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Medicine

Anesthetic Deaths Happen to Anesthesia Experts, Too

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As an anesthesia technician, one of the things we are told early on is that if you don’t have a death under anesthesia “you aren’t doing enough anesthesia.” This can be a hard fact to stomach, but it’s true. If like me, you’re performing anesthesia for 80 percent of your day at work you see death from many causes whether it be drug related or caused by a disease process unable to compensate for the changes in physiology caused by anesthesia. A 2012 study showed that an overall death rate for animals undergoing anesthesia was 1.35 percent.

So, what do you do when you and your patient fall into that 1.35 percent? How do you as a team leader guide your staff through the tragedy and all of the feelings associated? How do you pick up the pieces and move on to other surgeries and other patients that need your expertise? And how do you do all of these things when the patient belongs to one of your own team members?

About three weeks ago that’s exactly what was swirling around in my head as I tried to comprehend what was unfolding.

I have been in the anesthesia field for 14 years and I have to say it’s my love, it’s my comfortable bed in the clinic. I know the beep and hum of my monitors and am soothed by the swishing of a doppler. I have a respect for death because in anesthesia he is always waiting in the corner. But as I have become more proficient with this field, he has shrunk down. Over time, he has even started to blend in with the walls.

When this tragedy struck our hospital, I had all of the same questions I usually do as a supervisor: How? Why? When? Where? Trying to piece together details to come to an informed decision and explain how this could have happened. But the different thing was: this wasn’t another employee I was trying to rationalize with and talk down before they leave vet med completely forever… this time I was talking to myself. I was the technician in charge of this pet and I had failed.

I had missed something, I was incapable of fixing this problem. As other employees rallied around me I noticed how supportive they were. They could have easily come around with blame and anger and gossip but instead it was love. I received the most profound statement from my hospital administrator, a simple text message that read:

“I am so sorry you are going through this tragedy. We will process this together, we will heal together, and if a change needs to be made, we will do it together.”

If only all practice cultures could get on board with this! We are a team, we will do this together, we will have fun together, we will go through tragedy, and we will be a better team because we will do it together.

I still have so much self-doubt and guilt when it comes to this situation. I wish I could have done more. For a minute I questioned whether or not I should continue in vet med. But, I am an anesthesia technician. Death and I can share the same space. I just hope he doesn’t think I will leave my love when I become part of the 1.35 percent.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

Why You Should Consider “Drastic” Measures for Your Pet’s Cancer

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I hate osteosarcoma. This bone cancer is a cause of major pain for pets and heartbreak for their owners. Many dogs with osteosarcoma have a greatly improved prognosis with limb amputation.

However, the word “amputation” sends owners into a tailspin, and for good reason. They either have personal experience or they watch TV shows and movies where humans have amputation performed. Then they watch the amputee suffering through the mental and physical trauma as they adjust to missing a limb.

No one wants that for their beloved pet. What they don’t realize is that animals adjust rapidly in most cases. The pain they experienced in the cancerous limb is much worse than the healing pain of the amputation. My biggest problem with leg amputation is trying to keep my patients from running around while it heals!

In some cases, amputation is curative. Please, please read that again. Cancer can be CURED with amputation of a limb. Death can be warded off for months or even years in cases where a cure isn’t possible. Most importantly, quality of life can be restored to an acceptable level once the offending part is removed.

There are some cases where an amputation may not be the best choice. Pets whose cancer has spread can benefit from removal of the pain, but the cost of the procedure in relation to time left with good quality of life must be considered. If a pet has severe arthritis in their other limbs, removing one puts more pressure on the others.

However, with joint supplements and proper pain control, this may still be an option. I am still surprised and sad to see so many pets at the end of their lives that have never had any pain relief at all for their arthritis, but I digress.

When I worked in the shelter, I performed a large number of amputations. We didn’t have the funds to have fracture repairs done on pets. Amputation of a fractured limb was our only option. Animals with eye trauma or disease had eye removal (enucleation) performed. I vividly remember one of my enucleation cats rubbing her eye stitches against my hand while purring just a few hours after surgery!

If amputation isn’t an option for you, I completely respect your choice. I just want to make sure you are making a well-informed choice instead of having a knee-jerk response to the word “amputation”.

I’d hate for you and your pet to miss out on quality time together. If you have fears about the procedure, ask your veterinarian or veterinary nurse about their experiences (odds are, they’ve not only created tripods, they’ve owned them!).

This was my tripod, Jambie. He was injured badly as a kitten, and I amputated his leg. I was a young vet and terrified to perform the procedure, especially on such a small patient. He did extremely well. Sadly, I only had him for 3 years before a urinary problem from the trauma of the accident took him from me.

Still, I’m happy we got to love each other for 3 years and am grateful my boss was generous enough to allow me to operate on him. I took him home with me the night of his surgery to watch and worry over him, and he never left!  If you have a tripod (or tripawd), please share their story so we can save more lives and get more time with our pets because of this procedure. Don’t let fear steal your pet early!

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

5 Questions You Need to Answer Before Anesthetic Procedures

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Oftentimes our clients are faced with the decision whether or not to put their pets under general anesthesia for a surgical or dental procedure. Patients do not get the care they need when pet parents are scared of anesthesia.

During this time, they look to us, the knowledgeable veterinary staff, for answers. With so many advances in the field of veterinary anesthesia there are many reasons why anesthetic procedures are safer than ever!

Here are the 5 questions you should be able to answer before a pet undergoes an anesthetic procedure.

1. What pre-op testing is required?

Often pre-op blood work can give you early clues to potential diseases such as diabetes and hyperthyroidism. Also it is important to check the function of both the liver and the kidneys since they are the organs responsible for processing and clearing anesthetic drugs from the body.

If the pet is a senior more in depth pre-op diagnostics such as and ECG or cardiac ultrasound should be considered to ensure the patient’s heart is healthy enough for some anesthetic drugs. Getting a clear picture before anesthesia can ensure that the most appropriate drugs are used.

2.Who will be monitoring the patient?

Today’s technology allows people to do more tasks at the same time, and there is a strong myth that we can “multitask”. A 2008 study at the University of Michigan showed that we don’t do lots of things simultaneously. Instead, we switch our attention from task to task extremely quickly.

As the technician in charge of a case, I want to focus solely on the anesthetic event. So, it helps that many veterinary practices now have a technician whose sole job is to monitor the pet under anesthesia. This is very important because with a dedicated technician anesthetist, the doctor can focus solely on the surgical or dental procedure being performed.

3.What monitors will be used during the anesthetic event?

During anesthesia it is important to monitor changes in temperature, blood pressure, and ventilation. These changes can influence not only what drugs will be used in the post-operative period, but will help guide the quality of recovery for your patient.

In the age of Dr. Google and information symmetry, your clients know what’s available.  Be prepared to have a conversation with the client to explain why properly monitoring blood pressure in those senior pets is so important!

4.What should the pet parents expect during recovery?

Some surgeries will only require a short recovery time.  Orthopedic and dentistry procedures that have required multiple extractions may require a longer recovery time. After surgery patients may be unsteady on their feet and unable to walk up or down stairs.

If the pet usually sleeps upstairs in the owners’ bed, it’s important to set up a comfortable area on the first floor for the patient to rest in when they come home, or be prepared to carry that patient up and down the stairs! And be realistic with expectations.

5. What will the pain management plan be?

Almost every surgical and dental procedure will involve some level of pain. Be ready to talk with the clients about the expected level of pain and how this pain will be treated. Talk about the need for post-operative physical therapy.

Orthopedic procedures greatly benefit from post-operative physical therapy such as hydrotherapy, massage therapy, and low level laser therapy. Many pain medications have to be administered orally. If it is difficult to give those patients a pill, work on other options to ensure the pet stays comfortable in the recovery period.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

Are You Haunted By Negative Exploratories?

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A few years ago, I wrote an article entitled “No such thing as a negative exploratory.”* Shortly thereafter, I received an amazing email from a colleague on the other side of the world.

Dr. Andreane Daigle, who practices in Queensland, Australia, shared with me a story about an exploratory laparotomy she performed on a vomiting nine-year-old dog after x-rays revealed a possible foreign body. When she went in, however, she found nothing.

“Ohhhh, how disappointed and angry at myself was I, when all I found was an erythemic small intestine,” she wrote. “The client now has a bill of about 2K because of my lack of confidence… If I would have just waited another day, maybe none of that would have happened… So I was hoping you could guide me with your experience. What questions do you ask yourself? How do you decide to go to surgery?”

Wow, what an incredible email!

My reply was:

Hi Andreane,

I think that what you did is fine. This has nothing to do with confidence.

However, it has to do with the art of veterinary medicine, rather than pure science.

Sitting on a suspected FB can be a recipe for disaster, so I can’t possibly recommend it. On Monday, the intestine may be fine, and an enterotomy may be enough. On Tuesday, the intestine may be so angry that an R & A is necessary. And on Wednesday, the dog may perforate and end up with septic peritonitis!

So earlier intervention is usually preferred… but not always. I have a hard time believing that waiting another day would have changed much to the health of the intestine… but your biopsy will confirm that.”

A week later, the biopsy results confirmed that this 9-year-old jack Russell had IBD.

Young Andreane had made the right decision after all.

Still, as I wrote in the original article*, there should be no such thing as a negative exploratory. If you don’t find anything grossly abnormal or fixable or removable, then you should at least take multiple biopsies and submit them to the lab.

Of course, saying “you should” is a diplomatically correct way to say that you must…

At a minimum, biopsies should include the stomach, the duodenum, the jejunum (maybe 2 levels), and very importantly the ileum, often forgotten but a common site for IBD. Depending on the specific situation, you may also need biopsies of the liver, pancreas, mesenteric lymph nodes etc.

You may have heard this saying: “If you don’t have negative exploratory laparotomies, you’re not doing enough of them.” In other words, a negative exploratory laparotomy is perfectly acceptable. I respectfully disagree with this philosophy. A laparotomy can be negative if you throw your hands up in the air, cuss a few times, and close the patient on the spot. But it will not be a negative exploratory until you take and submit a bunch of biopsies.

When should we consider an exploratory laparotomy? By definition, when we are not 100 % convinced about the diagnosis. Arguably, this could be when a patient presents with:

  • Unexplained and unresolved hematemesis or melena.
  • Chronic weight loss of unknown origin.
  • A history of eating foreign bodies, especially in puppies and kittens
  • A history of eating foreign bodies, especially in older patients – a classic suggestion for IBD.
  • A questionable barium study.
  • A penetrating injury to the abdomen, such as a gunshot wound.
    Unexplained and unresolved gastric or intestinal distension with no radiographic or ultrasonographic evidence of obstruction.
  • A focal intestinal lesion seen on ultrasound, such as a mass or disrupted layers.
  • An increase in bilirubin without a logical explanation.
  • When partial thickness GI biopsies taken via endoscopy do not provide answers that may be provided by full thickness GI biopsies performed surgically. Studies show that surgical biopsies are more reliable than endoscopic samples because of the difference in depth.

If you are still in doubt based on the history, the physical exam, blood work and X-rays, ultrasound is a great, non-invasive modality to guide you. The secret: ultrasound should be performed and read by well-trained individuals.

What are the consequences of “closing” a patient after a negative exploratory without taking (and submitting) biopsies?

Here are at least 4 consequences:
1. We (still) cannot document whether or not there is GI or some other abdominal disease.
2. The patient, who may (still) be debilitated, may need to have another anesthetic episode to have endoscopic or surgical biopsies harvested.
3. You may need to admit to a disgruntled internist (or surgeon) that you didn’t take biopsies!
4. And you need to have the same tricky discussion with an unhappy client.

Over a year later, I asked Andreane for permission to use her name for this story. In her approval email, she wrote:

“Interesting timing, I was talking about you to my colleague 2 days ago. I had a cat with GI signs and I wanted to do a laparotomy. He was telling me to wait… but I thought of you and went in yesterday… I found an obstruction due to chicken necks.”

Way to go Andreane!

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

* “No Such Thing As a Negative Exploratory”. Veterinary Practice News. Published March 2nd, 2010.