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Using Fluorescent Light Energy for Dermatologic Therapy

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Board-certified veterinary dermatologist, Dr. Ashley Bourgeois, joins Dr. Andy Roark to explore cutting-edge developments in veterinary dermatology. The focus is on Fluorescent Light Energy (FLE), also known as photobiomodulation (PBM), and its revolutionary applications in addressing diverse dermatological cases. Dr. Bourgeois demystifies the workings of this light energy, and provides insights into seamlessly integrating this innovative technology into veterinary practices.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Referenced Article: https://todaysveterinarynurse.com/dermatology/fluorescent-light-energy-therapy/

Phovia: https://www.phoviausa.com/

The DermVet: https://thedermvet.com/

Uncharted Veterinary Podcast: https://unchartedvet.com/uncharted-veterinary-podcast/

Uncharted Veterinary Conference

Dr. Andy Roark Charming the Angry Client Team Training Course

ABOUT OUR GUEST

Dr. Ashley Bourgeois is a board-certified veterinary dermatologist passionate about providing practical knowledge to general practitioners to help itchy pets! She completed her bachelor’s degree at Iowa State University and graduated from the University of Missouri’s College of Veterinary Medicine in 2010. She then completed a one-year small animal internship at Purdue University. Upon finishing her internship, she accepted a residency position with the Animal Dermatology Clinic’s Tustin, California location in 2011. She became a Diplomate of the American College of Veterinary Dermatology in 2014. Dr. Bourgeois moved to Portland, Oregon in 2016 to help expand the company. She is an owner within the company and on the board of directors. She has a strong interest in autoimmune skin diseases, allergies, cytology, and otology.

In her leisure, Dr. Bourgeois enjoys outdoor activities, traveling, and watching sports. She and her husband stay busy with their daughter, son, and rescue Lab/Boxer/Pit mix. Dr. Bourgeois is passionate about educating veterinarians in dermatology and work/life integration through her podcast, lecturing, and social media presence (The Derm Vet).

EPISODE TRANSCRIPT

Dr. Andy Roark: Welcome, everybody to the Cone of Shame veterinary Podcast! I am your host, Dr. Andy Roark. Guys, I got a fun one here for you today. I’ve got my friend, Dr. Ashley Bourgeois here. She is a boarded dermatologist and this is a, this is what our conversations are like. I was reading through my magazines as, I explain in a moment and I found an article on fluorescent light energy in dermatology. And I was like, this feels like voodoo. This feels like just, just some hand waving medicine that gets recommended in drum circles. Like that’s what it sounds like to me and I texted her, I was like, “is this legit?” And she was like “Totally!”

And I was like, ou gotta be kidding me. And she said, yeah, I’ll tell you about it. And I said, great. Let’s, let’s turn the, let’s turn the microphones on. And so that’s what happened here. There’s not a sponsored episode at all. I just, it was something I am not familiar with. I’ve not gotten to use this and Ashley was great about running me through it. So anyway, if you are familiar with FLE or Phovia. is the brand name that she refers to then you’re going to learn about it here. But anyway super fun stuff. Gosh, what an amazing time to be alive. Let’s get into this episode.

Kelsey Beth Carpenter: (singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark. 

Dr. Andy Roark: Welcome to the podcast, Dr. Ashley Bourgeois. How are you?

Dr. Ashley Bourgeois: I’m so wonderful. How are you doing?

Dr. Andy Roark: Man, I’m good now that you’re here. It’s good to see your face again, old friend. For those who don’t know you, you are a boarded veterinary dermatologist. You practice at the Animal Dermatology Clinic in Portland. You do a bunch of stuff online and things like that, but that’s not where I know you from.

We met way back in vet school. When we were doing the VBMA stuff and have sort of kept in touch ever since. And I get to see you at conferences and you are just a, you are just a gift to our profession. And so I just, I love having you here and I really appreciate you taking time and I will say here’s.

Here’s a feather for your cap, when I was reading an article, and I was like, I don’t know what this is, I need to talk to someone who could explain this to me, you were the person I texted. I was like, I’m gonna ask Ashley, hey, is this legit? And I texted you, and that started our conversation that led to this podcast, so, I will get into what that means in a moment. How are you doing?

Dr. Ashley Bourgeois: Yeah, I’m doing well. It is. It’s really funny to think about when people ask me, like, oh, do you know Andy Roark? And like, I mean, I knew Andy Roark he was Andy Roark. I will say, you know, National VBMA, which when we were on the national board was young, right? VBMA was really just going.

I never had any doubt. Like when you started being well known. I’m like, that makes sense. So it’s really cool to surround yourself with people, right. That you either went to school with, or were involved in certain organizations. And as we were talking about before we started recording, we’re getting old now that we can start to say like back in my day, like, you know? Over a decade ago when we were on the VBMA together, it’s pretty, it’s a cool journey to really see people blossom.

Dr. Andy Roark: Oh, yeah, it absolutely is. It absolutely is. It’s funny how you, it’s a small profession and it’s funny people who hustle and do stuff tend to kind of turn up again and again and I really, I think you end up, you just, you sometimes you meet people early on and then they just never go away.

You’re just kind of around. And so that’s been great. But it has been wonderful watching your journey. I, texted you because, and let me just say it front, this is not a sponsored episode at all, or  anything like that. I was just, I was reading through my journals and I came across an article in Today’s Veterinary Nurse about using fluorescent light energy for dermatologic therapy.

And I texted you because this was kind of a new concept for me as far as in practice. And I’ll, be honest. It sounds like voodoo. I was like, yeah. Is this like, you know, is, this like, you know, using salt crystals you know, things like that? I texted you like is this legit? And you were like, yeah, it’s pretty legit, Andy.

And so I was like, okay, I’m sure I’m not the only person who’s not very familiar with FLE. Can you just give me, give me a primer, start at sort of a mile high, what is this? And then we’ll sort of dig into how is it useful in practice, potentially.

Dr. Ashley Bourgeois: Yeah, definitely. And I’ll say anything, anytime something comes out in dermatology, because we are very right. Product heavy specialty. The first thing is that sounds cool, but show me the research. So I think it’s pretty normal when you hear something that’s different that you want to say, but, prove it to me.

So you’ll hear it called a few different things. FLE, like you mentioned, you’ll hear it called photobiomodulation. And primarily the unit within the veterinary field is Phovia. And the idea behind this is that there’s actually a gel. So it’s not just a light. What’s really important is it’s a chromophore gel that you put on lesions, which we can talk about specifics.

And then the idea is that light unit is a blue light. But what’s important is when that light actually hits the chromophore gel, it creates almost a rainbow effect of different wavelengths and lights. And why that’s important is it kind of hits different layers of the skin, so different wavelengths go different depths.

But then each light, like there’s red, green, blue, each light actually has different benefits too. So whether it’s anti-inflammatory, it’s encouraging different growth factors, which can help with wound healing, or being antibacterial, you get kind of that cascade of events just by putting one light on it because of that gel.

And so it is a pretty interesting technique and they actually do have literature behind it for deep pyoderma, superficial pyoderma, even things like perianal fistulas. So I think it’s a pretty cool tool. Yeah.

Dr. Andy Roark: That’s so perianal fistulas have a personal place in my, and I don’t, it’s not in my heart. It’s the opposite of my heart.

Dr. Ashley Bourgeois: No, I don’t think anyone’s in love with the disease.

Dr. Andy Roark: No, it’s the opposite. If I had a hate organ, that’s where it would be, but yeah, that’s fascinating. So the gel itself, is something that come in and gets applied in the clinic just for the transmission of a light? It’s not something that you would continue to apply at home anything like that? There’s no benefit to that, correct?

Dr. Ashley Bourgeois: Yeah, correct. It’s like photo activated. So the way that we do it is usually the protocol is twice a week, but you can do it back to back. So what I usually do is if I know I just did a Phovia treatment, I think last week in the clinic for like a very focal pyoderma. And so we’ll put the gel on, well we’ll use chlorhexidine if it’s a pyoderma, wipe that off, put the gel on.

The light is, once you press the button, it goes for two minutes. So it goes for two minutes, super simple. And then the light goes off. Then what you can actually do, because we all know clients are busy, if we can make it less hectic for them to have to go back and forth to the clinic, you can do the second treatment in a row.

So then I just reapply the gel. You want to wipe it off. the stuff that’s already used up, reapply, and then you just do another treatment, and then I’ll have them come in once a week, depending on what I’m treating.

Dr. Andy Roark: Okay. So give me some, examples of the things that you would be treating. I mean, so is this, does this have post operative functions? I mean, I, is this is this classic, you know, like deep pyoderma? I, what, walk, me through this. It kind of sounds like kind of sounds Like, like too good to be true?

Like, you just use it on everything. Like allergies, limping, storm phobia. Like it sounds like there’s a lot. Hey, give me, start, to ratchet this down for me a little bit and say, okay, this is when you would start to kind of think about FLE.

Dr. Ashley Bourgeois: Yeah probably not storm phobia, probably not trying to get the light energy to the brain for like anxiety, but I, you know, I’d say a lot of skin applications, I’d say the limitation is if it’s a really diffuse disease, right? Like if I diffuse pyoderma, that’s probably not gonna be really realistic. So I do need it to be focal or multifocal in a realistic manner, like two to three lesions, whatever makes sense. 

I would say primarily, and as we’ve had this technology longer and longer, we’re finding more and stuff we can use it for. But I’d say where the most supportive things in the literature would be wound healing. So you certainly could use it post operatively.

I use it in things like I’ve had non healing wounds that get referred to me. So My first application of it was a benign mass that a primary vet had taken off, like the dorsal paw of a dog, and it just would not close. It had struggled for like six months. We cultured and did all the things we needed to do, but that had been done before too.

But when we treated the infection plus used Phovia, it was the first time that lesion ever fully resolved. So I’d say focal lesions like that, I’ve used it in acral lick lesions. because those are often infected and inflammatory. I’ve used it in focal deep pyoderma and focal superficial pyoderma. And there are actually our studies, true studies available showing that either you can use it as a sole therapy and something like a superficial pyoderma.

Again, if it’s more focal. Or you could use it with a deep pyoderma concurrently with an antibiotic. And with deep pyodermas, we often have to use several weeks of antibiotics. They were able to shorten the duration of antibiotic use by implementing something like FLE.

Dr. Andy Roark: Okay. Are there cases that you do not use this on? Something where you’re like, yeah, this either there’s contraindications or, yeah, or, concerns that you have? Anything that you would say, this is a case I would specifically not reach for?

Dr. Ashley Bourgeois: Yeah, so I would say that what I am cautious of, though, I’ll talk about a couple things that maybe it’s different is traditionally when it came out, we were really cautious of anything that could be cancer, like a neoplastic process, because you are encouraging growth factors. So if it was just like a nodule sitting there and I didn’t make sure it wasn’t a mast cell tumor, there was some uncertainty, like we could not make it worse.

But I actually have had colleagues, because in DERM, sometimes we are the Wild West, right? Like, we have lots of options, we deal with lots of things. I’ve had some colleagues actually use it on focal areas like skin lymphoma, and have seen results with it. So, we’re cautious of that. I think that’s one I’d still be a little bit, you know, weary of before I got more information, but hopefully we’ll see further studies and information come out as we have it longer.

Dr. Andy Roark: Gotcha. What you said, you know, you can do the treatment sort of back to back. What is the standard sort of treatment period? Is this a fairly short session? I guess what I’m, thinking about here when I think about like, laser therapy for joints, arthritis, things like that. is it that, that’s kind of what’s in my mind.

How comparable are those in the actual performing of the therapy?

Dr. Ashley Bourgeois: So I would say kind of depending on what you’re treating. If it’s a superficial pyoderma on average, I probably do it about, you know, three weeks and then I recheck them. And the nice thing about it is it’s something that you can train. I’m all about utilizing my assistants, my technicians. So this is something that once we have the treatment protocol set up, then they come in for treatments with them.

You know, they know how to do it. It’s very straightforward. So it’s something that we can actually have the staff do. It’s really good as far as utilizing their skills and their techniques. So I’ll usually have them do like three treatments and then we’ll recheck. That wound I was talking about that was non healing, I think we did that one for probably about like six weeks, but I was rechecking kind of every couple weeks in between.

So there’s not really a contraindication going too long. There’s even some that will use it for maintenance, like things for perianal fistulas, but it just depends on, you know, how convenient it is for the owner to come in for treatments and how much they’re willing to keep up with it.

Dr. Andy Roark: Do owners tend to get it, you think? I mean, I couldn’t, it kind of, I don’t know, it seems to me like it would be hit and miss. Like some owners would be like, that’s too, that’s woo woo You’re going to shine a special light on my pet and he’s going to get better. Versus others that are like, oh yeah, I am here for this, for this specific therapy. Yeah.

Dr. Ashley Bourgeois: I find it hit or miss. I mean, to be frank, I, mean, I think that’s true for anything that I do in dermatology. Some people really get it for some people if we’re already going to have to utilize something like say an antibiotic. You know, maybe cost is an issue, right? Because of course we have to charge for that service.

So, I have had some people, I am in Portland, Oregon. So some people are really excited about anything that’s not traditional. So, and I think there’s something to be said for that. I mean, I still have to use a lot of antibiotics and dermatology, but I’m totally game for anything that gives me the ability to be a steward of antimicrobials and try to use less or shorter durations.

So I would say it is hit or miss. Certainly I give estimates out for it and people don’t do it. But I think if you really explain it like, “Hey, there’s studies showing this can not only help with infection, but stimulate, you know, wound healing properties that we might be able to shorten the duration of antibiotics.”

A lot of people really do buy into that. If you can say that it truly has support behind it.

Dr. Andy Roark: Are there things that you wish you knew when you started playing around with FLE? Were there lessons you kind of learned along the way?

Dr. Ashley Bourgeois: I think just the confidence and actually recommending it, right? So very similar to you when things come out, you know, I’m, pretty cavalier. Like I, I’m always up for innovation and trying new things. I think that’s the beauty of veterinary medicine. I never want to be the person that’s just like, “Oh, well this has worked for 30 years. That’s what I’ll do.” Like, I always want to try new things because that’s the beauty of our specialty, but of course, like I’m like, there’s this cool way like we could try it. I don’t know. So I think the important thing is the studies right? To be able to say there are truly studies that show the benefit of this, but I also am totally fine if people say it’s not for them.

Like I, you practice long enough. You kind of, you know, you get used to like, that’s not for you. That’s okay.

Dr. Andy Roark: Hey guys, did you know that I have another podcast? I am the host of the Uncharted Veterinary Podcast with my dear friend, practice management goddess, Stephanie Goss. We, we have been answering questions for years. We started a year before Cone of Shame. I started doing the Uncharted Vet Podcast with Stephanie.

We take questions from our mailbag. We have listeners who write to us and they tell us about what’s going on in their practice and we try to answer their questions and they are all about. Communication, leadership, management, things like that. It’s about working with clients. It’s about working with staff.

It’s about working with your boss. It is about all of those sorts of things. We have everything from, trying to establish some trust in your team when you’re a brand new baby doctor, fresh out of vet school to, managing an employee with mental health issues to, how to. How to give notice without the guilt if you are in a place, you just can’t be there anymore. We’ve got all that stuff. We’ve got hiring, firing, working together, working with clients, reviewing your systems, getting your practice to run smoothly and efficiently, how to manage your time. All that stuff is there. Check it out. I said 250 episodes.

You can see what everyone is about, from the title because it’s what, it’s basically the question that we’re being asked. But anyway, it is a very popular podcast. I hope that you’ll check it out and enjoy it and love it. I just love making it. So anyway, I just want to tell you it’s there. Guys, let’s get back into this episode. 

Yeah. No, that totally makes sense to me. I’m with you too. It’s- I never want to be like, “that’s how we always did it”. And, at the same time, I take people’s trust in me really seriously, which means I don’t want to be in there like, “Hey, here’s some stuff. I just, I got it in the mail. I don’t know if it works.

It might be toxic. Let’s do it.” I, you know, I don’t want to be that too. So it’s it’s building that confidence, which is why I wanted to sort of talk to you about it and sort of say, okay, tell me about this as I, sort of look at it.

Dr. Ashley Bourgeois: And to your point real quick, it is totally fine to say stuff like that. Like I do get samples of stuff and I’m in Durham, right? So I have clients who’ve seen me for years and years and half the time, half the appointment is talking about like, what are your kids doing? So I will tell people like, there’s this new product out.

I don’t know much about it, but it’s supposed to do this. Or, you know, I saw some studies, just a couple of studies. So I’m really honest with owners. Like this is new. I don’t know much about it. I don’t have a lot of experience about it. Cause they appreciate that to your point.

Dr. Andy Roark: Yeah. when I’m thinking about sort of new derm therapies and new derm approaches, and you and I are talking here and it’s kind of, it’s still near the, first of the the first of the year, the beginning of 2024 setting FLA sort of stuff aside, what’s in derm right now that you’re excited about?

Like, what are you, what other tools are you looking at? I’m just fishing to be like, are there other things I should be really thinking about? But what are you Ashley interested in, excited about, optimistic about for the coming year?

Dr. Ashley Bourgeois: You know, I’m always optimistic that there is good research coming out just about learning more about what allergies really are. I think that in the last decade, we always think of itch, right? Like, Oh, they’re itchy. Stop the itch. And that’s so important, but I’m also really optimistic that there are being more studies looking at right?

Like when certain medications like apical and cytopoint came out, like they were not out when I started doing my residency. And it was kind of like now, you know, wow, they’ve been game changers, but I love also some of the attention that’s going into things like microbiome, like the differences in some of our allergies, right?

Like how come Westies are always little elephants? How come German Shepherds tend to have like ulcerative, crazy, nasty, like dermatitis, like there has to be phenotypic differences between some of these pets? So Itch is important. I think we’re going to continue to have more allergy medications that come out, which is great because we still have some cases that don’t respond to even the tools we have now.

You know, I always, we all cross our fingers more stuff for cats will come out. Like, I don’t think that will ever change.

Dr. Andy Roark: I know that’s exactly where my head was talk to me about allergies and cats.There’s such an opportunity there. I was really hoping you would have something you were like, oh, this is

Dr. Ashley Bourgeois: Everyone’s always like, you must know. Here’s the thing I’ll say about cats. There is a reason we don’t have as much, right? Like, of course, like, there’s, we see more dogs than cats, and you can get down to that. But the big thing is, think about the differences in cat allergies that we see. So, you see anything from an eosinophilic granuloma, Right.

To an indolent ulcer completely eating its lip to a cat who’s just itchy to feline asthma. Like there’s so many different presentations of allergies in cats. So of course, I don’t think it’s as easy to figure out and fine tune all of these things with cats because they have such wildly different presentations.

So there has to be some difference between the mechanism of action and pathophysiology of those diseases, right? So. We all want more stuff for cats. All I can tell you from the little I do know is it’s not for lack of effort from companies. It’s just that they can’t figure it out because cats are cats and they like to make our lives complicated.

Dr. Andy Roark: Yeah. No, they don’t. It sounds like there’s not going to be a cat allergy off switch that we can just find and flick. That would be nice.

Dr. Ashley Bourgeois: That would be so, even for us, people are like, Oh, but derm. I’m like, we have the same tools as you.

Dr. Andy Roark: Yeah, exactly right. There’s not a secret derm medicine cabinet that you guys aren’t aware of. Like we have the same stuff that you do. Oh man. Ashley Bourgeois, thank you so much for being here. What before, before I, yeah. I’ll let you go. So jumping back to FLE real quick. If people are interested in this, if they want to learn more, I will link the original article that I just was happened to be reading when I decided to text you.

What are the resources that you really like that you would kind of point people towards if they wanted to learn more?

Dr. Ashley Bourgeois: Yeah. Honestly, what’s a really good resource is just going to the Phovia website. Like if you just Google Phovia. I think it’s like Phovia.us or something like that. We could look it up. But the Veto Kenal True website has their literature. their actual research there, and it links it to, like, these have been published, like, in VetDerm and other places, too.

So they’ll actually have the true studies there, and you can look at how they design them, you can look at the results of that. So it is worth checking out, and I do think we’re going to see more to come.

Dr. Andy Roark: All right. Sounds good. I will link to that in the show notes as well. Ashley, you do as I said at the beginning a bunch of stuff on online. You, you’re always telling Derm stories and lessons and pearls sharing. And anyway, where can people find you online?

Dr. Ashley Bourgeois: Yeah, you know, I’m a simple person, so it’s all under the DermVet. On Instagram, on Facebook. And then I have my own podcast that is just Derm Nuggets tips. A mix of just me chatting in your ear for 15 minutes and then a mix of interviews with other dermatologists cause I truly am a believer that we all do things differently and that’s okay.

And we should learn from each other. So I love to hear about people who do things differently than I do, but I put everything under the DermVet cause you know, I’m a tired mom of two. And so I just keep it all under the same name for simplicity’s sake.

Dr. Andy Roark: I love it. I will link to all that stuff, including the podcast and the show notes as well. Ashley, thank you so much for being here, guys. Thanks so much for tuning in and listening. Take care of yourselves, everybody.

Dr. Ashley Bourgeois: Thank you.

Dr. Andy Roark: And that’s it. That’s what I got for you guys. I hope you enjoyed it. I hope you got something out of it. Thanks so much for being here. Thanks to Ashley for being here as well. Gang, take care of yourselves. Be well. I’ll talk to you later. Bye. 

A Pentobarbital Problem: Post-Euthanasia Risks are Real

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In this episode of the Cone of Shame Veterinary Podcast, host Dr. Andy Roark discusses the post-euthanasia risks associated with pentobarbital injection. Dr. Warren Hess, the first author on a notable paper in JAVMA on the subject offers valuable insight as their conversation dives into the environmental and legal implications veterinarians may face after performing euthanasia using pentobarbital. Dr. Hess emphasizes the importance of understanding the drug’s impact beyond the act of euthanasia, addressing issues such as liability, rendering, and potential impacts on food and feed. The conversation explores the need for better education among veterinarians and clients, and the importance of documentation to protect practitioners. Dr. Hess also mentions ongoing efforts by the AVMA to provide resources and education on this critical topic for veterinary professionals.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Article Referenced: https://avmajournals.avma.org/view/journals/javma/261/11/javma.23.03.0161.xml

AVMA Axon: https://axon.avma.org/

2024 Uncharted Veterinary Conference: https://unchartedvet.com/uncharted-veterinary-conference-2024/

Dr. Andy Roark Charming the Angry Client Team Training Course: https://drandyroark.com/charming-the-angry-client/

Dr. Andy Roark Swag: https://drandyroark.com/store/

ABOUT OUR GUEST

Dr. Hess is an associate director in the American Veterinary Medical Association’s (AVMA) Division of Animal and Public Health and as AVMA’s Disaster Coordinator.  He provides technical and scientific expertise to the Committee on Environmental Issues (CEI) , the Aquatic Veterinary Medicine Committee (AqVMC), the Council on Veterinary Service (CoVS), and the Committee on Disaster and Emergency Issues (CDEI).

Dr. Hess graduated from Colorado State University in 1989.  He worked in small animal practice with an emphasis on birds and other exotic animals until 2004 when he began working for the Utah Department of Agriculture and Food (UDAF) where he served as a field veterinarian, assistant state veterinarian and 18 months as acting state veterinarian.  He began working at the AVMA in 2016. 

Dr. Hess became involved early in his career with organized veterinary medicine and was elected president of the Utah Veterinary Medical Association (UVMA) in 2000.  Dr. Hess has led several state and national organizations including serving as president of the National Alliance of Animal and Agricultural Emergency Programs (NASAAEP).  Dr. Hess was voted Veterinarian of the Year in 2014 by the UVMA.  He was the recipient of the NASAAEP Service Award in 2017 and the American Veterinary Medical Foundation (AVMF) Paws Up Award in 2018.  He is married to his high school sweetheart (Lori), and together they have 5 children and 14 grandchildren.

Dr. Hess has enjoyed the companionship of horses, dogs, various birds, and marine fish.  He enjoys fishing, rowing/kayaking, and motorcycles and has completed a motorcycle trip from his home state of Utah to Alaska and back with his 87-year-old father in tow.

EPISODE TRANSCRIPT

Dr. Andy Roark: Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here today with Dr. Warren Hess. He’s the first author on an interesting paper that I saw in JAVMA. It was about pentobarbital and what happens after the injection. And I’ll, be honest, it was something I was not really aware of. I genuinely don’t really think about what happens after we perform euthanasia. And it turns out there’s a number of things we need to at least have some eyes on. There’s some liability for veterinarians. There are there are some environmental impacts.

There are impacts around rendering and feed and food. And it’s just, it was something I had not really considered in a long time. And so it was a really good refresh. So anyway, this is a short conversation where we get right into it and just talk about what do veterinarians need to know?

What do they need to remember? What should we be talking to pet owners and animal owners about before we do euthanasias using pentobarbital? So anyway, that’s what it is. Let’s get into this episode.

Kelsey Beth Carpenter: (singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark

Dr. Andy Roark: Welcome to the podcast, Dr. Warren Hess. How are you?

Dr. Warren Hess: I’m great, Andy. Thanks for having me.

Dr. Andy Roark: I am very excited that you are here. For those who don’t know you, you are a veterinarian. You are also the American Veterinary Medical Association’s Disaster Coordinator, which I think is the best title you could possibly have. You are also an associate director in the AVMA’s Division of Animal and Public Health.

And I just became aware of some of your work quite recently. I was actually reading through the JAVMA issue that came out earlier this year. And you were the first author on a paper called Survey of Veterinarians Who Use Pentobarbital for Euthanasia Suggests Knowledge Gaps Regarding Animal Disposal.

It was actually an interesting survey that you did about what veterinarians know and don’t know, about what happens with animal disposal after we use pentobarbital. And it was funny because I looked at this and I thought I would check every “no, I am unaware box” on the whole survey. And so I actually found this survey quite interesting.

One, in what veterinarians know and don’t know, but also in the like, why would we do this survey? What are we supposed to know? What is important to know about animal disposal when we use pentobarbital and drugs like that? So let me just start at a really high level and just say, when I looked at this article at first, I was like, I had no idea that there was anything I need to be concerned about in this regard.

Why should we be aware? What should we know?

Dr. Warren Hess: Andy, you’re similar to most of us, I think, especially if we come from a small animal background, which, I do. We go through vet school, we’re taught pentobarbital is one of the choice agents for euthanasia and we’re taught how to use it but we’re not really taught much more than that.

And what we’re learning about pentobarbital is, it doesn’t break down very well after it’s injected into the body for, euthanasia purposes. And that can create quite a bit of a problem, the scope of the problem is multifactorial.

Dr. Andy Roark: Okay.

Dr. Warren Hess: It ranges from issues with traces of pentobarbital ending up food and feed through a variety of processes. It impacts renders and it also impacts scavenger animals that might get access to a carcass or animal remains.

And it also impacts the environment, when pentobarbital leeches out of animal remains into the ground it can reach waterways. It can impact microbial life in, the surrounding area, and it can get into waterways and impact aquatic life as well.

Dr. Andy Roark: What motivated you to start to do this survey and look at this? Do you get the impression that it is an increasing problem? Is it something that has just been around and you feel like it’s lingering without getting any attention or unawareness? But what made you decide that this was the thing that you were gonna look into?

Dr. Warren Hess: Back in 2018, there were a couple of incidents where pentobarbital was detected in pet food.

And that started a discussion between AVMA and the FDA about why was that happening and what could we do to bring better awareness to, not just veterinarians, but other industry professionals out there as well.

Dr. Andy Roark: How does that happen? how do we end up with pentobarbital in pet food?

Dr. Warren Hess: The FDA would probably be the best one that answer that accurately but my understanding is that there were two different scenarios. One where there was enough pentobarbital in some meat products that were used for pet food that it actually impacted the animals that were consuming it.

Dr. Andy Roark: Okay.

Dr. Warren Hess: The other scenario was and I don’t even recall what organization it was, but after that event happened where animals where their health was impacted. An organization just grabbed some pet food off the shelf and ran had a lab run pentobarbital levels and detected it in those products even though it wasn’t causing clinical signs in animals. So that, brings up the issue that, probably rendering products were involved and the more sensitive our tests become, the easier it is to just pick up minute amounts of pentobarbital. And, any amount of pentobarbital in a food or feed product is what FDA considers an adulteration, and would be cause for a recall.

Dr. Andy Roark: Are there guidelines or precautions that veterinarians should be taking when they use pentobarbital that you think that veterinarians don’t know or they’re not aware of?

Dr. Warren Hess: The first thing I would say is that veterinarians should understand that their responsibility about the drug, pentobarbital, that they use doesn’t end when they inject it. Their responsibility continues for any impacts that occur from that animal after it leaves their clinic or after they leave the farm or anything like that. That would be the first thing to be aware of. There have been veterinarians that have been prosecuted for the impacts that pentobarbital had on protected species of animals that ended up having access to those animal remains and being impacted by it. 

Dr. Andy Roark: There were veterinarians that were prosecuted because, I’m guessing you’re saying are we talking about endangered species or protected species scavenged something? What does that look like?

Dr. Warren Hess: Yes. They euthanize a horse, for example, and leave it with the owner to take care of. And the owner doesn’t take care of it, just leaves it out in the field. And eagles or something like that come along and feed on it and either die or are severely impacted from the pentobarbital that they’re getting from the meat that they’re eating.

Dr. Andy Roark: I’m looking at my career and I’m going, “where did I mess this up?” And so the first thing I say, do I have concerns if I’m using cremation service, something like that?

So your standard small animal veterinary and, we’ve got pets, we’ve got, we’re going to, we do our injection, we send the pet off to be cremated. Is there anything that I should be thinking about that? Is, should I give that a second thought or is that an acceptable disposal that does, is not gonna have any problems?

Dr. Warren Hess: As far as we know, cremation is probably one of the best ways to dispose of animal remains that have been euthanized with pentobarbital. There really hasn’t been a lot of study. Along that line, but the temperatures that the cremation services reach to cremate animals should degrade the pentobarbital.

Dr. Andy Roark: Hey guys, is your clinic slowing down? Are you having more open appointments than you had in the past? Are you wondering a little bit about what you need to do to get clients to, one, come into the building, and then, two, listen to your doctors and your staff when they get there? Well, you, my friend, might need to head over to the Uncharted conference in April.

That’s right! It’s in Greenville, South Carolina. It is April 18th through the 20th. This is the granddaddy of the Uncharted Veterinary Conferences. This is the one that we started with. This is our marketing and strategy conference back to our roots. I love this stuff! The theme of this conference is ‘Standing Out In A Sea Of Noise’

It is all about strategic communication. It is about getting heard. This is going to be a lot about your brand identity is understanding the modern consumer who is getting more price conscious because things are getting more expensive. We are going to need to up our marketing game, our communication game, our client bonding game, our trust building game, we’re going to have to turn the volume over on that stuff.

Guys, we didn’t have to do that for the last couple of years. People have been coming in, the pandemic was a surge in business. A lot of us are trying to keep our head above water. It’s not going to be that way going forward. It’s time to re-engage with our clients in a motivating, educating way to get them coming back into the building.

Guys, Uncharted is not a bunch of lectures. You are not going to come here and sit in lectures. You are going to work on your business at this conference. You are going to be surrounded by butt-kicking, positive people who love vet medicine, who love pet owners, and who want to create a great experience and make a wonderful place for, pets to get the care that they need.

They want to have a positive workplace. They want to have a place where people smile when they come to work and they’re working on making that happen. And so if that sounds like you, or if you want to be surrounded by those people, you got to come to the April conference. Also, this is the last time for a while that the April Uncharted conference is going to be in Greenville, South Carolina.

This is our birthplace. It’s our home base. It’s our nest, this is kind of a big deal for me. At least I, you know, I, I have loved this conference in Greenville. I still love it in Greenville. I think Greenville will always be our home, but guys, we’re spreading our wings. We are going to be moving out and doing new things and going to new places.

And it is going to be amazing. But if you want the original Uncharted experience, if you are like, man, I’ve heard so many people talk about Uncharted in downtown Greenville and how the conference just fits into that community and how amazing it is, this is your chance. You want to be here. Also, if you have been an Uncharted member, if you’ve come to our conferences before, if you loved it, you always thought there’d be a chance to come back to the old Westin Poinsett and downtown Greenville you should grab a spot.

I think that there will probably be a chance in the future, but it won’t be for a while. I think there’s going to be a lot of people coming back because they want to do it one more time at the Westin before we move on and check out some new places and do some new stuff.

So I do expect this event will sell out. Guys, go ahead, head over to UnchartedVet.com and grab your registration spot right now. I’ll put a link down in the show notes. Again, you do not want to miss it. This is an investment in yourself and in your practice and your future. It is an investment in skills that you will have and use again and again, and it’s an investment in connections.

You are the average of the people you spend time with and you’re about to be surrounded and spend time with some really amazing people. Anyway, let’s get back into this episode. 

Do you think that veterinarians need to not allow pet owners to take the body of pets’ home? Or do you think that we should not allow, say farms to dispose of bodies without some sort of supervision or some sort of a waiver or, what does that look like? Are we going to not yield access back to pet owners after they have this drug in the body?

Or are we going to legally protect ourselves? What does that look like in your mind?

Dr. Warren Hess: AVMA hasn’t come out with a position on that. My personal opinion is that I hope we don’t get to the point where people are afraid to send animals home, or leave animals at a farm, but hopefully better education, better awareness by the veterinarians, better education to the clients, and maybe some forethought about how things are going to happen rather than an afterthought of, “now that we’ve euthanized this animal, what are we going to do?” Because you want, you hopefully want with forethought, you can plan ahead and, let people know what really needs to happen if the animal’s not going to go for, stay with the veterinarian under their control and that probably will solve a lot of problems. Certainly, the number one message that’s out there that not all veterinarians apparently are aware of is that pentobarbital should not be utilized in animals that are going to go for intended for food or feed products. So that means either directly to a to be processed for meat or to go to a renderer and have rendering products. It’s a big issue right now in the rendering industry and a lot of people that deal with cattle and horses know that there’s been a major shift in the rendering industry over the past five or six years. And it’s much more difficult to a lot of renders will not even pick up horses anymore.

So that’s really limiting the options for horse carcass disposal, and some renderers won’t even pick up cattle anymore off of farms. The only products that they will pick up are from slaughterhouses. They’ll pick up unused product from slaughterhouses. And that’s all they’ll do because it costs tens of thousands of dollars to do a cleanup in a rendering facility once pentobarbital has been detected. 

And most renderers are now, because of this issue, most of them are routinely scanning doing spot tests for pentobarbital residues in their products.

Dr. Andy Roark: Do you think there’s fallout for veterinarians if you’re called out to the farm and you’re going to put cattle down or something and they go, oh, no, we’re not rendering this and then they change their mind or you’re like, is there anything that we need to do to protect ourselves is this going to come back on me when I go and I do a euthanasia and I, this is not what I thought was going to happen and maybe the story that I get is not accurate or the intentions change after I leave, do I need to cover myself in this significant way

Dr. Warren Hess: I’m not a lawyer, right? But my, my suggestion would be to document. Document your discussion, what you talked about with the owner. Make sure it’s in the record and that way you’ve probably protected yourself as best you can.

Dr. Andy Roark: if, I have a just a, dog or a cat come in and they come in for a euthanasia appointment or I go and I do a house call and I’ve had plenty of clients who say, I have a spot in the yard where I’m going to bury, Capsy and that’s, it’s her spot. I, do you have concerns about that other than maybe to talk about?

I don’t know, proper burying techniques where we’re not going to have problems with scavengers, things like that. I don’t mean to be morbid, but, those are the ones that I have done. I’ve a hundred percent used pentobarbital to put pets to sleep and the owner said, you know what? I, want to, bury, I want to bury her out by the, by the tree.

Yeah. Do, does that, does my approach to that need to change? Do I need to be having a different conversation?

Dr. Warren Hess: I, think there needs to be, there should be a conversation now that stresses the importance of the drug that was used the ramifications on if, if that carcass is accessed and also just be paying attention to what the regulations are in their location obviously a lot of these regulations are local they fluctuate from city to city, so it’s really difficult for veterinarians to know what those regulations are going to be, but if there’s shallow water tables that, leaching of that pentobarbital can certainly impact It’s not going to be treated by water treatment plants, and it’s not and it can, if it’s not going to a water plant, but going directly to a stream or something like that, it can impact the aquatic life there.

Dr. Andy Roark: If there are veterinarians out there who are just sitting and processing this and they would say, I’d like to think a little bit more about this, what resources do the AVMA have? What, would you recommend for people who wanted to learn a little bit more and, maybe start to process but what exactly they’re going to say or how this might affect the way that they practice. Where would you send them?

Dr. Warren Hess: AVMA is in the process of developing some resources, Andy, I wish I wish I could point you to an exact spot right now, but what I would say is be looking for information on AVMA’s website concerning this in the coming six months. And also, our digital education platform, which is called Axon we’ll be developing a, a webinar for veterinarians and, further education about this, expanding on what we’ve discussed today, pointing them to local resources. If you have specific questions about handling pentobarbital in larger animals certainly check with your state veterinarian, they might be a great first point of contact to understand if there’s any developing legislation in the state around this or anything like that.

Dr. Andy Roark: Good. All right, that sounds good. Dr. Warren Hess, thanks so much for being here today. I really appreciate your time. Guys, thanks for tuning in. I will put a link to the original JAVMA article in the show notes. I’ll also link up to Axon the educational portal for AVMA and hopefully you guys will be aware when they release new information there.

Dr. Warren Hess: Thanks, Andy.

Dr. Andy Roark: Hey, thanks a lot. Thanks everybody. Talk to you later.

 And that’s it guys that’s what I got for you. Thanks for being here. Thanks to Dr. Warren Hess. I hope you guys learned something from this. I hope you got something to think about I’ve been thinking about a little bit since the interview and just going, you know How would I say this and when pet owners want to take their pets home to bury them at home? What’s my communication strategy going to be? So I’ve been rolling it around. It’s definitely been a good conversation for thought provoking purposes Anyway guys, thanks for being here. Take care of yourselves everybody. I’ll talk to you later.

Understanding the Role of Nutrition and the Microbiome in Overall Pet Health

by

Dr. Caroline Mansfield, registered specialist in internal medicine and honorary research professorial fellow at the University of Queensland and clinician at James Cook University, joins Dr. Andy Roark to discuss the role of the gut microbiome in the health and disease of dogs and cats. Caroline provides an overview of the importance of the microbiome in general pet health, the impact of antimicrobials, and her thoughts on what future research in this area might find.

This episode is made possible by Purina Institute!

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Purina Institute CentreSquare

Get the new Purina Institute Clinical Nutrition Handbook for free!

The Purina Institute

Microbiome Forum

WSAVA Nutrition Toolkit

JCU Vet

Dr. Andy Roark Resources 

Dr. Andy Roark Exam Room Communication Tool Box Team Training Course

Dr. Andy Roark Charming the Angry Client Team Training Course

Dr. Andy Roark Swag

ABOUT OUR GUEST

Professor Caroline Mansfield is a registered specialist in small animal medicine and is recognised as an international leader in veterinary internal medicine, as evidenced by frequent invitations to present at international conferences, requests to provide expert opinions and current and previous roles in the profession. She is a past Board member and President of the Australian and New Zealand College of Veterinary Scientists and has been a member of the Board of Examiners for the National Veterinary Examination. Her expertise is recognized outside of the sphere of clinical veterinary medicine by participating in the peer review process for Australian Research Council Discovery Early Career Researcher awards (DECRA) and Discovery projects from 2015 to present. She is currently Chief Editor for the Australian Veterinary Practitioner, on the Editorial Board for Animals, a member of the Purina Institute advisory group and received the 2019 Award for Scientific Excellence from the Australian Small Animal Veterinarians. She is currently an honorary research professorial fellow at the University of Queensland and clinician at James Cook University, located in tropical far north Queensland. Her research is focused on the interaction of the gut microbiome in the health and disease of dogs and cats, and the role diet and environment play in this. She also researches in areas of clinical gastroenterology that can result in tangible improvement in the health and welfare of our pets. She has published over 90 peer-reviewed papers plus multiple textbook chapters and conference presentations. To date, she has supervised over 30 post-graduate students and clinical residents to successful completion.

EPISODE TRANSCRIPT

Dr. Andy Roark (00:07):
Hello and welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one today. I am here with Dr. Caroline Mansfield. She does a lot of things that I will talk to you about when she comes onto the podcast, but her main emphasis is in research on the interaction of the gut microbiome in health and disease in dogs and cats. And so I think she’s fascinating. I think gut microbiome research is fascinating. I am really amazed and odd as you will hear about what we are learning about gut health and how gut health interacts with health in the rest of the bodies and how basically every organ system can be tied back in some way, shape or form, probably to the microbiome and into gut health. And so anyway, we start talking about cognitive dysfunction and the role that the microbiome plays in that we start talking about where prevention and treatment of a variety of the illnesses might go in the future and what research in gut microbiome looks like in that.

(01:08):
If you just don’t know much about sort of the gut microbiome research and why people are talking about it and why it’s becoming a big deal in nutrition in general animal health, this is a great episode. I talked to her a little bit about the wellness industry and about the noise that’s generally around nutrition and things like this and how to kind of separate out what is worth talking about and what is not, and try to get our head straight so that we can be a valuable resource when we talk to pet owners. So anyway, it is a sprawling conversation about a topic that I think is incredible, and so you’ll hear my wonder and excitement when you get into this episode. I hope you’ll like it a lot. I have been thinking a lot about this episode since we did it. Anyway, that’s enough. Let’s get into this episode with Dr. Caroline Mansfield. Also, I got to say thanks to Purina Institute, they are making this episode possible ad free for you guys, and so shout out to them. Let’s get into it.

Kelsey Beth Carpenter (02:01):
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark (02:17):
Welcome to the podcast, Dr. Caroline Mansfield. Thank you for being here.

Dr. Caroline Mansfield (02:22):
Oh, thank you. You’re welcome.

Dr. Andy Roark (02:23):
Oh, it is a pleasure to have you here. You had to get up really early for this podcast. I really appreciate it. You are. For those who don’t know, a registered specialist in internal medicine, you are a past board member and president of the Australian and New Zealand College of Veterinary Specialists. You are the chief editor for the Australian Veterinary Practitioner. I could just keep going and going have, but you have over 90 peer reviewed publications. My wife is a college professor. I don’t know if people know how amazing that is, that incredible amount of work. You have supervised over 30 graduate students. You have done absolutely incredible things. And so I really just, I appreciate making time to be here. I want to talk with you about nutrition and there was something I was really sort laxing philosophical about as I was sort of preparing for our time together and I was thinking about having you come on and stuff like that.

(03:20):
And so I’ve got this idea that we do not look at life and especially at medicine with the wonder that it deserves. And so I look around at our world and just simple concepts like our physiology, our immune system. It is absolutely astonishing that we have this system that works as well as it does. And I just think about so much of what we do in medicine and we just take it as, oh yeah, well, we have this and we know that and we know that the body works this way in that way, but I really don’t think that we just look at life with the wonder that it deserves. And so your research really focuses on the interaction of the gut microbiome in health and disease in dogs and cats. And so I’m thinking about this idea that the gut microbiome has this role that is so large and sort of ubiquitous through our body and through health in dogs and cats, but also in humans. And I don’t know that people really process what that means. And so let me just sort of open up here at just a high level paint for me sort a picture of how you look at the gut microbiome and its role in healthcare in general, if you don’t mind.

Dr. Caroline Mansfield (04:38):
Sure. I guess it’s kind of interesting that you talk about that wonder and that excitement about medicine and physiology. I feel super excited every time I learn something new about the microbiome or the way that it interacts with the body. I think it’s incredibly fascinating area. It’s probably like having a whole other organism within an organism. So it has an interaction with virtually every organ system is affected by the gut. And the gut is from an immune perspective, is probably one of the most important interfaces with the environment. The gut is usually where we are exposed to multiple antigens on a daily basis. So the gut microbiome influences that immunity, that immune system. It influences the way the brain develops as a child or as a puppy or a kitten influences behavior. It influences kidney disease, influences development of uroliths. It’s fascinating all of the interactions that it potentially has.

(05:54):
And probably what’s even more fascinating is that we didn’t understand how much was there because we didn’t have the technology to identify all of the organisms that were in the gut microbiome until recently. And even now, I still think we’re a little bit limited in how we understand or basic in how we understand because I think each bacteria has the capacity to have different functions. And so there’s this kind of redundancy or fail safe system. So it’s not enough just to know what bacteria are there, it’s what they’re doing, whether they have their buddies there to help them or not. It’s justs just super fascinating.

Dr. Andy Roark (06:35):
I completely agree, and I appreciate you saying that this is fairly new in coming to light because it does feel fairly new. We didn’t have this sort of insight when I was in veterinary school. And so I’m seeing this sort of research coming out and I, I’m trying to get my sort of hands around it and I’m thinking about it in a lot of different ways. So first it’s just my basic understanding of the physiology and how this affects my patients. But then also we start to get into therapeutics. We start talking about wellness care, and then we also start talking about addressing disease states. If you’re talking to, I don’t know, just say a doctor who didn’t have a robust understanding of this coming out of vet school and has been sort of trying to catch up, how do you help veterinarians, veterinary technicians, nurses, how do you help them think about this microbiome just at a systemic level if they say to you, this is all really new to me and I’m trying to get my head around it so I can start to understand and start to talk in a way that’s helpful for my patients.

(07:29):
Where do you start?

Dr. Caroline Mansfield (07:31):
I guess, I don’t know. Well, it’s a little bit lyrical. I sort of talk about the fact that the microbiome, it’s not equally divided. It’s not good or bad, but to have a really healthy community, just like a healthy human community, you need diversity and you need the bacteria or the participants in that community are doing different functions and they’re all contributing together to work towards a particular goal. So I guess the things that we need to be thinking about is that when we talking about nutrition, we can talk about basic nutritional requirements like protein and carbohydrates and fat and so on, but we also need to be aware that any diet that we feed affects that community. And so if we want to enhance a particular function, I’m really loathed to talk too much about particular bacterial species because I think I was alluding to before, particular bacterial strains or species will only be effective if other bacterial strains are present.

(08:40):
And they do have a redundancy in their roles. And so I think it’s better to think about the functionality. And so most diets provide some kind of prebiotics, which it’s kind of like a fertilizer, I guess, to promote growth and diversity of that microbiome. And we also have the capacity to influence it positively by using prebiotics or what post-biotics, which are probably the new emerging fields. So those are the metabolites that bacteria produce, but we also have the capacity to do it a lot of harm. So I think particularly with the use of antimicrobials indiscriminately, we often think, well, we’re treating that urinary tract infection or we’re treating that ear infection or pyoderma, but we’re not doing absolutely no harm to the animal and the animal’s microbiome when we use those antimicrobials,

Dr. Andy Roark (09:45):
When we disrupt that way, when we use systemic antibiotics for cystitis or for, that’s the classic one, is we better safe than sorry. And so we use antibiotics when we have cystitis or even a pyoderma that we could maybe treat topically and we don’t. Talk to me a little bit about the recovery period. How does that manifest clinically? What does the fallout that we see?

Dr. Caroline Mansfield (10:10):
So I think that’s a really good question, and I wish there was a really simple answer, but there’s probably not because each individual microbiome is going to respond really quite differently. And even within an individual there, microbiome might respond differently at different times. I use the analogy of an elastic band. And so if you’ve got a really healthy, fresh, new elastic band and you stretch it, so you give it se antimicrobial, so you disrupt it, you give it for a short period of time and then you release it, the elastic band’s going to go back to normal pretty quickly. But the more that you stretch it, or if it’s an old elastic band or it’s a little bit sick when you stretch it, it just doesn’t go back as normal the next time. So it is highly individualized, and I think we probably don’t, A lot of the analysis that’s been done, a lot of the studies that have been done, the way that the microbiome has assessed probably doesn’t completely answer that question because it doesn’t completely answer the functional capacity. But we know that, for example, metronidazole has impacts for a very long time. We’re talking weeks to months after it’s been discontinued, but again, it’s really highly individual. Some animals will revert back to normal more quickly and some will take longer.

Dr. Andy Roark (11:30):
I think about sort of looking at diets this way and sort of processing what the microbiome means to overall animal health. And we’ve already got people, we’ve had pet owners for decades now who have been very attuned to what their pets are eating. They are very interested in the nutrition and what they feed their pets. It’s something that pet owners can see. They have a feeling of control about what they feed. I can also see this being an area for a lot of confusion. I can see a lot of people trying to do what’s best for their pets and kind of heading off in a sort of misguided directions. Let’s start to take this focus on the microbiome into a more sort of practical clinical conversation. How do we start to advise pet owners on diet selection and what’s important and what are sort of the pitfalls that we might fall in or areas where we might see pet owners kind of going off in a way that’s not productive?

Dr. Caroline Mansfield (12:26):
Yeah, I guess part of the problem with, part of the problem with the microbiome or it’s I guess the downside for its increasing popularity is that there’s a lot of increasing noise around about it and a lot of noise about how to manipulate it. And that kind of corresponds with, I guess that sort of whole wellness industry that I think is being translated into the veterinary pet owners. They take themselves very seriously. I think we have, the advantage with pet food though is that we can control what they eat to a certain degree. And I think as long as it’s a well-balanced diet, I mean it’s been proven and the dog is healthy or the cat is healthy, there’s probably not a lot of benefit in manipulating the microbiome in those animals. So the times, I guess when we start to think about it are once they’ve actually developed disease and particularly gut disease, that’s probably more when we know that manipulating the microbiome is likely to be effective. And also there’s some emerging things that are happening like with cognitive dysfunction in dogs and epilepsy and manipulating the microbiome in those may be beneficial. And I guess also when we think about it with some conditions like hepatic encephalopathy or liver failure, we’ve been manipulating the microbiome for half a century with lactulose, but we didn’t really aware that’s why we were doing it. So I don’t know that I’ve actually answered your question very well though.

Dr. Andy Roark (14:09):
No, no, I think you did. I knew exactly where I was going is the wellness industry is definitely spilling over into pet health, and this is when we start talking about gut microbiome. I hear this in the wellness industry all the time of people talking about protecting yourself against Alzheimer’s, people getting joint health from the supplements that we take and things like that. And there are supplements that are hugely valuable and wonderful, and there’s a lot that’s not. But I think you put your finger right on it. When I said I anticipate the noise of this, I hear a lot, and I don’t mean to start a controversy about this, but there’s a lot of people who put forward raw foods or things like that specifically because they say, oh, the microbiome is important and this is a more robust way to increase diversity in the microbiome and things like that.

(14:57):
And again, I’m not trying to start the raw food, not raw food debate at all, but there are a lot of people who have strong opinions. And so I think I just want to be, I appreciate you answering in sort of an even-handed way. Really what I was looking for is I want to have productive conversations about this and not just jump to conclusions or overstate what is available and what patterns need to look for in their food. So I think you asked it well, are there, the second part of my question was really how does this go off the rails? Are there areas of misunderstanding that you see where either doctors or pet owners, I don’t know, they take part truths or they have common misunderstandings or things that kind of derail these conversations?

Dr. Caroline Mansfield (15:50):
I think personally and probably in my experience not so much. I mean, I think I’m privileged that I work in a referral population. So normally the people are coming to me for advice, and so usually are quite happy to take advice. It’s interesting that there are some people that are very resistant to some diet regimes, but when you start talking about manipulating the microbiome and that there are other ways to do that, so we can use prebiotics, we can use fiber, we can use, probably not so much postbiotics anymore at this stage. They’re not really developed, but we can use probiotics to a certain extent. I find that people are really quite willing to take that on board. They’re probably not, if they’re very set in their ideas about what they want to feed their animal. And I do come across those people. They have really strong beliefs. I tend not to try and work against them. I tend to try and work with them and just to make sure that the diet is appropriate for the animal if it’s not what else they need to have to make that appropriate or if we can help in any way. But I tend to find if I’ll alienate them if I tell them that I disagree with ’em or I think that their diet choice is wrong and then you lose them.

Dr. Andy Roark (17:21):
Right, yeah.I think we’ve all kind had to do that math at some point and to say, is this the hill I want to die on, or do I want to continue on so that that’s right. We can work on the future. Yeah,

Dr. Caroline Mansfield (17:32):
Pick your battles.

Dr. Andy Roark (17:34):
Yeah, definitely. Talk to me a little bit about where you see this field going. I got to tell you, going back to the statement of wonder I had at the beginning, when we start talking about the microbiome and its impacts on cognitive dysfunction, that’s magical to me. That is so beyond what we ever used to think. And the idea that there’s something we can do for cognitive decline or things like that is amazing. Where do you see this sort of research going? How do you see the science here manifesting out into healthcare into actually treating dogs and cats in the future? What’s this going to look like?

Dr. Caroline Mansfield (18:17):
So what I’d love it to look like, so there’s a few things in the human field. So there’s something that was called the American Gut Project. It’s a bit of a misnomer because they do get samples from around the world, but where they’re basically screening people and looking for, I guess if there’s geographical differences, seasonal differences and so on. And we don’t really know that that well in dogs yet, partly because of the costs of sequencing. So a lot of it has been done with the method called 16S, which takes the ribosomal RNA gene that’s ubiquitous in bacteria, and then it amplifies that, and then you get your sequencing data, but it does miss a lot of stuff. It doesn’t go down to a species level, and there’s just a lot of noise that surrounds 16S. So using different methodologies is really expensive.

(19:20):
It’s coming down in price now, so it’s probably more useful, but it’s still expensive. So where I would love to see it is I’d love to see similar situations in veterinary medicine where we’re actually tracking it. We track cohorts of animals across the world, different breeds, and we then are able to also track their health. And so we can actually see whether there’s a preceding marker or a flag or a change in the microbiome that actually precedes the development of any clinical disease. And to me, that’s where the magic would really happen. So if we could have it as part of our health check and we go, well, hang on, we’re seeing this shift in the microbiome, and that suggests to me that if we can intervene here, we may prolong or prevent the development of this particular disease. That’s where I think the real magic is going to come. But that’s a long way away because we need to be tracking these animals and we need to be doing all of those and correlating them to the diseases. But you talked about cognitive dysfunction. One of the cognitive dysfunction can’t talk properly. I’m getting too excited. One of the really interesting things with Alzheimer’s disease is they have actually shown that changes in the microbiome proceed any detectable change by one to two years in people. So I know like, wow, isn’t that amazing?

Dr. Andy Roark (20:49):
Well, think about, I mean, that is amazing. One of the things that we have going for us in veterinary medicine is our patient’s lifespan are much shorter, which is bad, but the beautiful part is starting to gain that type of whole lifespan knowledge. We can do it much faster than if you were following cohorts of people that started in their twenties and age into their eighties and nineties. So anyway, this is super exciting. If people want to learn more, do you have favorite resources? Are there places that you would send veterinarians, nurses, even engaged pet owners? What do you like for general educational growth in this topic?

Dr. Caroline Mansfield (21:29):
Yeah, so the problem is that there is so much information coming out. So if you put microbiome in, you’ll have 25,000 hits. So sometimes I think there’s almost, there is almost too much information. I do find the Purina Institute Center Square, they’ve got a lot of really good resources. They’ve recently had a microbiome forum, which I think it may still be available online and the recording, which don’t quote me on that. So I think that breaks it down and it also breaks it down quite nicely into bite-sized pieces that are good for speaking to clients about particular conditions as well. So I think those resources are really good for more general nutrition. I think the WSAVA, the World Small Animal Veterinary Association has some amazing resources. So nutritional toolkits and diet history forms. They also run some modules on nutrition, which are free, which I think are really useful for techs and new grads to do as well. And then I guess it kind of depends on what condition you’re talking about, then you kind of go more specific websites. But I think those are probably good places to start.

Dr. Andy Roark (22:55):
I love that. I’ll put links to the Purinas Institute Center Square in the show notes. If the Microbiome Forum is still up, I’ll link to that as well in the notes. And then the WSAVA, I’ll definitely link to that. And their nutrition toolkits are excellent and their nutrition modules as well. So I’ll put links to all that stuff. Caroline, thank you so much for being here. I thoroughly enjoy talking with you. Where can people find you online if they’re interested in you and your work and just kind want to keep up with you?

Dr. Caroline Mansfield (23:24):
So at the moment, I’m working at James Cook University, which is in far north tropical Queensland. So JCU Vet, it’s probably the best link for that. It’s a pretty cool place to be. It’s just right near the Barrier Reef and get to go snorkeling and hop up and see some crocodiles. It’s pretty cool.

Dr. Andy Roark (23:47):
That’s amazing. Oh man, thank you so much for making time and being here. I really appreciate you.

Dr. Caroline Mansfield (23:51):
No worries.

Dr. Andy Roark (23:51):
Guys, thanks for tuning in today. Everybody take care of yourselves. Thanks for being here. And that’s it. That’s what I got for you guys. I hope you enjoyed it. I hope you got something out of it. Thank you so much to Dr. Mansfield. She got up before six o’clock in the morning, her time to do this podcast, and that was wonderful. Thanks to Purina Institute for making this episode possible. Thanks to you guys for being here. And yeah, that’s it. That’s all the thanks. That’s the thank and night. Thanks to me for also being here. Thanks to my dog Skipper who came and sat with me when I did the podcast, thanks to my mom and my dad. And I’m just going to fade out. I’m just going to fade out on that. And that’s where we’re going to end the episode. Thanks so much everybody. Take care of yourselves. Be well. Bye.

HOF: Anesthesia Crash Cart Course

by

Dr. Andy Roark dusts off this Hall of Fame episode in which he discusses the essentials of anesthesia crash carts with Veterinary Anesthesia Nerd, Tasha McNerney. Together they talk about what tools should be in your anesthesia crash kit and what kind of common pitfalls they’ve seen in practice.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Veterinary Anesthesia Nerds: https://www.facebook.com/groups/veterinaryanesthesianerds/

RECOVER Resources: https://recoverinitiative.org/category/resources-and-tools/

Upcoming Webinar (Free RACE CE): https://drandyroark.com/headcases

Dr. Andy Roark Resources 

Dr. Andy Roark Swag

ABOUT OUR GUEST

Tasha McNerney is a Certified Veterinary Technician from Pennsylvania where she works as a educational consultant and relief anesthesia technician. Tasha is the founder of the Veterinary Anesthesia Nerds, while also a Certified Veterinary Pain Practitioner and board member of the International Veterinary Academy of Pain Management (IVAPM) to educate the public about animal pain awareness. In fact, Tasha was the thought leader behind the now celebrated “Animal Pain Awareness Month” within the veterinary industry. Tasha became a veterinary technician specialist in anesthesia in 2015. Tasha loves to lecture on various anesthesia and pain management topics around the globe and was previously named VMX Speaker of the Year.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary podcast. I’m your host, Dr. Andy Roark. Guys, I am pulling one out of the vault for you, just blowing the dust off of it. This is a Hall of Fame episode with my good friend, the one and only Tasha McNerney, the original anesthesia nerd. We are doing the anesthesia crash cart crash course. It’s just a box of pearls. That’s what it is. It’s just knowledge, pearls, and I just put ’em all together in this box and here you go. From me to you. Happy holidays. It is a great episode. It is one of our most popular episodes of the last year, and you’re going to see why when you check it out, even if you heard it when it came out, it’s time to brush it up again. There’s so many mind gemstones here that you went through and you put some in your brain the first time, and I promise you there’s a lot more room. You’re ready for other ones. Now you’re ready for the next level of mind stones that go in. I don’t know what this metaphor is, but I think you’re just going to enjoy this episode. Let’s just do it.

Kelsey Beth Carpenter:
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast, Tasha McNerney. How are you?

Tasha McNerney:
I’m good. How are you?

Dr. Andy Roark:
I’m so good. It’s so good to see your face again. You’re one of my favorite people. You and me go way back. I’m like way back, way back. You were here visiting my house when the pandemic hit, and I’ll never forget you and I started the pandemic together.

Tasha McNerney:
Yes, yes. I have great memories of visiting four different stores, looking for canned goods and then finally buying all the beans at a CVS in some random South South Carolina town. Still have those beans.

Dr. Andy Roark:
I still have those beans a hundred percent. I’m like, these are my survival beans.

Tasha McNerney:
Yeah, well you save them.

Dr. Andy Roark:
My wife, she was like, “we’ll never eat these.” And I’m like, look, as long as they’re there, I’ll sleep well at night, but as soon as you throw away my emergency beans, I’m going to be like, what are we going to do if society ends? Yeah.

Tasha McNerney:
Yeah. It was a good time.

Dr. Andy Roark:
I felt, you know what? When the world went sideways, you and I took action. That’s all I’m going to say. And most people, a hundred percent did not, but we did.

Tasha McNerney:
No, people were like, is this happening? And we both looked at each other and be like, oh, we better stock up this pantry. Even though it wasn’t my pantry. I was like, I’ll help you stock up this pantry. You were with me. I had gotten a call from my husband at home saying, everything is off the shelves. It’s kind of pandemonium here. And at that same CVS, I bought two boxes of pasta and took them back in my luggage with me because I was so worried that I wouldn’t be able to find pasta when I went home. So yeah.

Dr. Andy Roark:
Oh man. That’s great to be with an anesthesia specialist because when the world goes haywire, they take action and I felt like that was instinctual for you.

Tasha McNerney:
Oh, 100%. I think I always joke with the anesthesia is that we are very cool, common, collected. When everything is crashing in the ER or in the OR wherever we are, it’s very much, okay, here’s the problem, where do we go next? Alright. And we start this kind of checklist. It’s very much cool, calm and collected in anesthesia. And the joke is that we’re dead on the inside. And sometimes I would agree with that in that we’re not going to be the people freaking out like, oh my God, everything is crashing. Go get this for me. Really that actually with me that things are real bad if I get very calm and monotone. And if I say, okay, what I need you to do next is turn off that vaporizer and can you hand me the epinephrine? Okay. Things are going down. Things are going down.

Dr. Andy Roark:
Yeah. Oh man. Yeah, you are a bit dead on the inside though. That’s just inside baseball from an old friend.

Tasha McNerney:
Yeah. And you know what? Listen, I got a therapist. We’re working on it. We’re good.

Dr. Andy Roark:
I think a lot of people could stand to be more dead on the inside. I think it would probably be, we all know a people who should be a little bit less alive inside. It would help them.

Tasha McNerney:
Yeah. Just calm down.

Dr. Andy Roark:
Totally. Alright, for those who don’t know you, you are a veterinary technician, specialist in Anesthesia. You are the founder of the Veterinary Anesthesia Nerds Group. It’s a Facebook group, it’s a website, it’s a conference. This thing has grown to how many people are involved engaged with the Anesthesia nerds group now?

Tasha McNerney:
Oh, we have about 65,000 members around the world right now. Yeah.

Dr. Andy Roark:
It’s awesome. It’s super awesome. It’s super bonkers. And I could sit here and sing the praises of the anesthesia nerds. I’m all about practical education. I really like to learn stuff that I’m like, I’m actually going to use this. And that is what you guys are all about. So I really love it. I’m super glad that you’re here. I thought of you recently when I had a pet under anesthesia and I can’t remember why. It was an emergency of some sort. And I had this pet under anesthesia and it just kind of dipped there for a second. And so when you pause for a second and you’re like, is this going to be an issue? And then it kind of stabilizes and comes back out and I thought I could use a refresher on the crash cart. That’s exactly what I took away from that specific instance was it was an emergency that came in. I can’t remember what it was. It went under anesthesia to get fixed. And I thought, you know what? Let’s just freshen these skills back up. And so I wanted to get you in and just say, run through the crash cart with me real quick. Let’s do a hundred percent refresher on what’s in my crash cart, what’s it do, what do I need to know about it? And just make me feel like the dust has been blown off my crashing patient knowledge. Is that okay?

Tasha McNerney:
Oh yeah, let’s do it. So, ooh, there’s probably a lot to cover, but we’ll kind maybe put it into categories when you’re looking at your crash cart. And again, just want everybody to know that I’m talking about this in the context of an anesthetic crash cart, not necessarily your ER crash cart, which is probably going to be a little bit different, but when we look at our anesthetic crash cart or what we want to have in that top drawer of our anesthesia machine or on hand during any anesthetic event, that’s what I’m going to talk about here. That’s cool with you. All right. So first of all, any emergency, again, when I say to you, Hey, things are not looking good, can you turn off that vaporizer? And then one of the first things that I want you to do is pull out our real emergency drugs.
And when I say emergency drugs with anesthesia in mind when I’m talking about are our emergency things like atropine and epi and then our anesthetic reversals. So these are really the two big things in our crash cart. We know that we want to have atropine or anticholinergic that we will use in emergencies because it has a very fast onset, shorter duration of action than glycoparalate. But again, in an emergency, we want that fast onset. Now there’s some stuff, and I will let you guys listening at home do some research because I think this is very, very interesting. Looking at the newer research that has come out in the past couple of years asking, especially starting in human medicine, asking is there really any benefit to using atropine during a code or a CPR event? And the human medicine, human literature has actually found that there isn’t, and they actually don’t really use atropine anymore during emergencies.
And if you look at the newest recovery guidelines, they actually state that atropine is not necessarily beneficial, but they don’t know if it’s really going to do any harm either. So if you feel like you still want to keep that in your back pocket, you’re probably not doing any harm. But it’s a little different than we thought 10 years ago that we don’t necessarily know that it’s really doing a lot during our CPR events or our code events. But I still will get it out. And I will say that my anesthesiologist will still have us give it during an emergency. Our next is epinephrine, right? And that’s because we want that basic constriction. We want to make sure that our blood pressure stays tight. We want to make sure that we are delivering oxygen to the tissues to where it needs to go. So again, our emergency drugs, then we need to get rid of whatever anesthetic.
Again, if this is a true anesthetic emergency, we want to make sure that we have reversals in our crash cart to reverse every single drug that can be reversed. Now, most of the time with anesthesia, we are administering opioids. So that means that we need naloxone first and foremost in our crash cart. So if we have an opioid on board, we want to make sure that we reverse that opioid with naloxone. Second most common drug class that’s used are benzodiazepines, things like Midazolam or things like valium, and we have a reversal for those. A lot of clinics don’t even carry the reversal, but I would say if you’re utilizing things like medazolam or Valium in your clinic, you need to carry the reversal just in case things get crazy. And the reversal for those is a drug called flumazenil. It’s a little more expensive than naloxone.
And again, a lot of people don’t keep it regularly on their shelves. But I would say that if you have an emergency, you want to have at least one bottle of flumazenil or at least one in your, or if you have an anesthetic emergency, the next reversal agent that is very important would be antisedan or anapamazol. So this is going to reverse your dexmedetomidine or if you’re in a practice that is still using xylazine, you would want your reversal to be yohimbine, although you could use anapamazol as well working on those receptors. So you want to have antisedan for your dexmedetomidine, right? So if we came into a urgent situation, we want to make sure we have access to atropine and epi and the reversals for all of our drugs. Now, if you’re utilizing ketamine in your protocol, you don’t have a reversal agent for ketamine.
So just realize that if things get crazy and you start reversing everything, that Ketamine is still going to be on board. We don’t necessarily have a reversal for that. Now, this is just for an emergency. I will say that there are a couple other drugs that I do think of as always having in my crash cart, one maybe for some anti-arrhythmogenic effects, and then one for if we start to see maybe some irritation or something like that under anesthesia. And one of these is lidocaine and the other one is diphenhydramine. I like to keep these on board because especially with our patients that are not hemodynamically stable certain breeds, if we see a ventricular tachycardia under anesthesia, so again, this is a ventricular tachycardia, and when I say that, I mean a beat that is greater than 160 beats per minute. So if we see something like this, again, that is going to be not great for forward movement of blood and cardiac output, which delivers oxygen.
So we always want to make sure we have lidocaine available as well. Especially in these more critical patients, you might need to give like a two meg per kg lidocaine bolus if you see that your patient is in vtac. Now again, the reason I mentioned the rate is because sometimes I’ve gone into clinics where they’ll see what they describe as a slow vtac or a ventricular escape beat, or they’ll see it, but maybe the rate is still only around a hundred beats per minute or 110 beats per minute. We don’t treat those with lidocaine. That could actually make it worse. So lidocaine is for those ventricular tachycardic emergencies. And then diaphenhydramine, I usually like to have it on board because sometimes my surgeons will note, Hey, I see that this patient has had a reaction to either maybe they have severe clipper burn or they’ve had a reaction to the chlorhexer iodine that’s been used to scrub their skin and now they have hives.
So if we see something like that, we want to make sure that we can administer some diaphenhydramine to them. Okay, that makes sense. Those are some emergency drugs. And so what I like to have in my anesthesia crash cart, now, these are kind of adjunct drugs that I’ll talk about really quickly, and this is more blood pressure drugs because we know that inhaling anesthesia along with a lot of the drugs that we are going to administer like ace premises, like propofol, like afaxolone, these drugs are going to cause a decrease in cardiac output and vasodilation, which is going to lower our blood pressure. We know that hypotension is going to happen, we want to be ready for it. Now, most of the time you have a normal healthy hemodynamically stable animal. Something like lowering your vaporizer setting or administering a fluid bolus. A five ml/kg is going to get you where you need to go for some animals.
But for other animals, especially if you have a longer procedure in mind, we want to make sure that we’re not just letting that blood pressure and that mean arterial pressure dip consistently below 60 because then we know that oxygen delivery to really important tissues, it’s going to be compromised. And that’s why I always like to have some blood pressure drugs ready and available. Now, I’m not saying that every clinic has to have all of these blood pressure drugs, but the three that I keep on me at all times are going to be dopamine, dobutamine, and ephedrine. And dopamine is a mixed alpha and beta, and that’s why I really like it. If you have a patient that just a cat that’s under anesthesia for, and we know that we’re going to do 12 extractions, it’s going to be a long procedure, but their blood pressure is already not doing so great and they are also a elevated kidney value patient and I want to make sure that they don’t get too hypotensive, then I’m going to start dopamine on this patient again, we’re going to have alpha effects and we’re going to have beta effects, which means the beta is going to help to increase the heart rate and the contractility and the alpha is going to give you a little bit of a squeeze on those vessels similar to another alpha active drug dexmedetomidine.
Now dobutamine, and the reason I like to have dobutamine around is because for some animals like your mitral valve disease patients like your chronic heart failure patients, these little shih tzus that come in and they have heart disease, these guys, if we’re about to do a lung procedure on them and they get hypotensive, they’re going to do better with dobutamine. And that’s because dobutamine primarily acts at disease, can’t handle the vasoconstriction that comes along with alpha activation and dopamine. So we will go with dobutamine for these guys because it’s like it’s having a party at the beta receptor. It’s like all beta all the time. And that’s why I want to have dobutamine for those specific heart cases. And then I also like to have a ephedrine, and ephedrine is one of those because it is very, very versatile. You can give ephedrine as a one-off and it’ll last for about 30 minutes.
So I find a phedrine very helpful. It’s an alpha and beta, very similar to dopamine, but unlike having to set up a concentrate infusion like you do with dopamine, you can give a one-off of ephedrine. Now you have to dilute it out. So make sure if you’re getting a vial of ephedrine, you are diluting this out. So you have maybe a one meg per mil concentration, but then you could give a dose of it. And sometimes if I say to my clinician, well, I’ve already tried the vaporizer, I’ve maybe tried giving, I don’t think the heart rate is an issue, and you’re telling me we still have 30 to 40 minutes left of this dentistry, but I need to do something about the blood pressure. If I don’t have access to dopamine or I don’t want to take the time to set up a CRIsad, I can maybe just do a one-off of ephedrine.
And that’s really effective because again, ephedrine like dopamine effective at the alpha and beta receptors, and we get about 30 minutes of activity. So that’s what I keep in my back pocket if I just need a quick something that I don’t want to set up or I don’t have access to set up a syringe pump and an infusion and et cetera. And then some other things, just like equipment that I like to keep with me at all times is an extra endotracheal tube, an extra laryngoscope. And if you are at a practice that has access to it, certainly paddles for fibrillation. Now again, remember if we are going to use paddles, this has to be a rhythm that’s a shockable rhythm. So we’re not going to shock vtac, but if you see it’s really critical things go south and crazy and your patient is in v fib, then we can shock that rhythm.
But I will also tell you that I’ve worked in plenty of places that don’t have access to paddles and they’ve done okay with that. But this is just equipment. And the reason I’ll go back to the laryngoscope in the tube really quick is on the off chance your patient during movement from induction into the theater gets extubated during the off chance that moving the patient around on the table, they get accidentally extubated. I want to make sure that I can quickly re-intubate that patient. And again, a laryngoscope is going to be the best way to do that because it’s going to give me visualization of where I’m going with the tube. If there are any problems, et cetera, I want to be ready for those problems. And that becomes especially, especially especially important if you’re dealing with brachycephalic patients, you always have an extra tube and laryngoscope ready to go.

Dr. Andy Roark:
Yeah, that totally makes sense. This is amazing. I did not have this as clearly broken down for me in vet school as you just did. This would’ve been so helpful 15, 20 years ago. This is amazing.
Hey guys, I just want to jump in here real quick and let you know about an awesome free one hour of RACE ce webinar that I’ve got coming at you real, real soon on December the 13th at 1 p.m Eastern Time. I am working with my buddy, Dr. Simon Platt, who’s a neurologist and a really interesting person. I just had him on the podcast. If you didn’t hear his episode on Spectrum of Care neurology, check it out. It’s a great episode. It’ll give you some idea of what we’re going to be talking about. But man, he is super fun and fascinating, interesting, and I cannot wait to get in and host this webinar for him.
Anyway, it’s called Head Cases, A Spectrum of Care Approach to neurology in general practice. It is made possible generously by Nationwide. There’s no fee to you. It does have RACE CE is going to be a great presentation about neurology in general practice and keeping neurology accessible to people in times when maybe people don’t have as much money as they would like or they don’t have the ability to just throw down and do the most aggressive treatment options possible. So anyway, it’s going to be fantastic. I would love to see you there. I’ll put a link to register in show notes. Let’s get back into this episode.
Alright, wonderful. Talk to me about some dosages. So are there dosage calculators that you really like because there you are and you’re doing the procedure and this is a stressful time and things start to go off the rails. What do you do to keep those things top of mind for you in a useful way where you say, okay, this is what we need. It’s not just epinephrine to effect, but although that works, but how do you track that information? How do you keep that in a very handy format? Or do you just know it, you’re just like, I know you know it, but is that the best way to approach this?

Tasha McNerney:
It’s probably not the best way to approach it because again, unless you’re really dead on the inside and you can block everything out and just go to your rolodex of drug dosages, nevermind the things beeping and people yelling again, I can do it, but I think that’s just because I don’t know, my brain functions a little bit differently, but

Dr. Andy Roark:
I’ve had people say, how much? And I show ’em with my fingers like this much, and they’re like, that’s not science.

Tasha McNerney:
Nope. Yeah, don’t do that you guys at home. But certainly I would say for anybody who’s interested, look at the vex website. They have a lot of really great things. Look at the RECOVER initiative that’s going to give you a really nice dosing chart. And I do know that if you go to RECOVER and look at the RECOVER initiative and their website, they also have posters that a lot of clinics will use that give you the dosages of based on weight. They have a quick wait chart. So a lot of ERs and emergencies will have this just hanging in their practice where they have a really nice weight chart that’s busted down between atropine, epinephrine reversal drugs, things like, again, if you’re in an ER setting and things get really crazy, you want to bust out the vasopressin, things like that. So I really would recommend recover because that’s probably the most up-to-date guidelines as far as what the research is saying, new updated dosages and having it easy and accessible.
Another thing that I do recommend that every practice does is take those dosages and make an excel spreadsheet or an emergency drug calculator, print that out based on the patient’s current weight and have that ready to go. The time to print it out and put it into the excel spreadsheet is not when everybody’s screaming and the dog’s losing a lot of blood. We want to make sure that we do that beforehand. And again, because it’s a really stressful time, it’s nice to have this printed out and checked beforehand because again, when things are really crazy and you’re really stressed out and your clinician says to you, okay, I need you to give a certain mg/kg dose, and then your brain is like, wait, how much does this patient weigh? What’s the concentration? And you’re trying to do this quick math doesn’t usually work out well. Those precious seconds that you’re taking to calculate out this drug can make a huge difference.

Dr. Andy Roark:
Yeah, yeah, that’s fantastic. I’ll put a link to the RECOVER initiative drug doses in show notes, so people could check that out. I don’t think I need a link to Microsoft excel, but um

Tasha McNerney:
I usually say because people can make their own excel, again based on what they have in their clinic, because I don’t think that every clinic maybe has vasopressin ready to go for their patients.

Dr. Andy Roark:
Yeah, no, no, I love that. I think that makes a ton, a ton of sense. What are the most common pitfalls that you see? What are the things that people either putting together a crash cart or using what’s on their crash cart?

Tasha McNerney:
I think that most common pitfalls, at least from an anesthetic perspective that I see, is that there’s not a regular checking of the crash cart and whether or not the drugs are expired or whether or not we have enough volume of the drug ready to go. So for instance, I would give you, yeah, to actually do what we need to do. Yes, I may have a bottle of atropine in there, but if there’s only 0.4 mls, that might not get me where I need to go. So having somebody check that before the procedure, and I’m a huge fan of checklists, and you guys know me. I love checklists. I love anesthesia checklists. If you haven’t read the Checklist Manifesto, please do yourself a favor and read this. It’ll change the way you practice. But certainly having checklists in anesthesia and having somebody to go in before the anesthetic event even happens, check that anesthesia machine, check that cart, make sure the lidocaine is in date. Make sure that you have a bottle of glycopyrrolate ready and available. Make sure that if you’re going to use dopamine, again, you have enough volume to make up your cri because I’ll just give you an example. I was helping out anesthesia on a 62 kg

Dr. Andy Roark:
Wow.

Tasha McNerney:
Great. Dane. Yeah,

Dr. Andy Roark:
That’s 140 pound

Tasha McNerney:
Great Dane in for a CT procedure. And I went to look at the crash cart and our anesthesia machine in Ct and I looking at it, and I was like, yeah, we only have 1 ml of atropine in this bottle. So yeah, I have atropine and it’s in days, but again

Dr. Andy Roark:
That’s not going to make one side of his mouth dry.

Tasha McNerney:
Something goes crazy with this patient. Now I have to run to a whole other side of the hospital to get more atropine because that one ML is not going to be enough for that dane.

Dr. Andy Roark:
Yeah. Yeah, that totally makes sense. Awesome. Tasha McNerney, thank you so much for being here. Where can people find you online? Where can they learn more about anesthesia nerds?

Tasha McNerney:
Yeah, so the Veterinarian Season Nerds is currently a Facebook group, and that’s where we do a lot of our discussion and case-based stuff. But you can also find us on the website. And on the website we have links to the Veterinary Anesthesia Nerds podcast as well as a calendar of events. So you can see where all of us are speaking. And when I say all of us, I don’t just run anesthesia nerds by myself. I am joined by Darcy Palmer, who’s a VTS in anesthesia, and she works out in Alabama. And then I’m also joined by Steven Sital, who is a VTS in, again, not only a VTS in lab animal, but also a surgical research anesthetist and just a wealth of information there. So we have a calendar, so you can see if you wanted to come hear us talk or lecture, we have a calendar on there as well. And then we have a contact form as well. So if you have something that you wanted to ask the anesthesia nerds or you wanted to request some help for something, you can get us there.

Dr. Andy Roark:
That sounds fantastic. Awesome. Thank you so much for being here, guys. Thanks for tuning in. Take care of yourselves. Have a wonderful rest of your week.

Tasha McNerney:
Thanks for having me.

Dr. Andy Roark:
And that’s it. That’s the episode, guys. I hope you enjoyed it. I hope you got something out of it. I said, you can see now why this is the Hall of Fame episode for us, and why so, so many people loved it when it first dropped. Guys, take care of yourselves, everybody. I’ll talk to you later on.

A Spectrum of Care Approach to Neurology

by

Dr. Simon Platt and Dr. Andy Roark dive into neurology’s challenges, emphasizing individualized care and accessible diagnostics. Dr. Platt introduces a forthcoming neurology resource aimed at providing comprehensive information for neurology enthusiasts, all in the pursuit of demystifying neurology and prioritizing accessible patient care.

This episode is brought to you by Nationwide Pet Insurance.

LINKS

Spectrum of Care

Nationwide’s Pet HealthZone

Web-Vet Neurology

Dr. Simon Platt on LinkedIn

Upcoming Webinar with Dr. Simon Platt

Dr. Andy Roark Resources 

Dr. Andy Roark Swag

ABOUT OUR GUEST

Dr. Simon Platt, a distinguished European and American veterinary neurologist with 23 years of academic expertise, embodies a passion for teaching, research, and clinical excellence. His extensive contributions encompass over 240 published scientific papers, including 70 chapters in renowned veterinary publications. Notably, Dr. Platt has co-authored five authoritative textbooks in veterinary neurology, showcasing his commitment to advancing the field’s knowledge base.

A trailblazer in academia, Dr. Platt has secured over $3 million in grant funding, led NIH translational research teams, and held pivotal roles within committees for ECVN and ACVIM. For over two decades, he has mentored neurology residents globally, while his dedication to education extends through the management of educational websites, notably featuring a pioneering 3D virtual-reality dog model for practical neurological examination teaching. Additionally, as the founder of SEVEN, a not-for-profit group, he established an annual southeastern regional clinical neurology conference, fostering collaboration and knowledge exchange within the field.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one for you today I am here with Dr. Simon Platt. He’s a veterinary neurologist. I did not know him before we sat down to record. This is my first time meeting him. His resume is amazing and so I just start off with that. But he has done so much and he is so smart and man is he approachable and easy to talk to and I could listen to him talk for hours and hours. So anyway, I was thrilled to get to talk to him. He has this really interesting way of looking at neurology, this genuine desire to bring it to general practice and to make it not intimidating to GP’s and just to help keep care affordable and accessible for people. And you’re like neurology and affordable don’t tend to go together.

You got to hear what he has to say. It’s just been really good. It is a great conversation. Anyway, I’m actually doing a webinar. I am hosting Dr. Platt for a webinar December 13th. It is made possible by Nationwide. It is totally free for you guys. I’ll put a link in the show notes to register. It’s got RACE CE attached to it. It is a sweet deal. I am really looking forward to it. After our conversation today, I’ve got pages of notes. I’ve got a bunch of questions from our conversation that I’m sitting on until we get together. So anyway, that’s coming up. This is a great episode. I have talked long enough. Guys, this episode is made possible ad-free by Nationwide. Let’s get into it.

Kelsey Beth Carpenter:
This is your show. We’re glad you’re here. We want to help you in your veterinary. Welcome to Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast Dr. Simon Platt. Thank you for being here.

Dr. Simon Platt:
Thank you very much. It’s an honor and thanks for the invitation.

Dr. Andy Roark:
Well, it is a huge honor to have you here. For those who do not know you, you are a board certified European and American veterinary neurologist. You have published over 240 scientific papers. You have co-authored five veterinary neurology based textbooks. You have gotten a bajillion dollars in different research grants. You have have trained neurology residents for 22 years. This podcast is beneath you, sir. That’s what I think.

Dr. Simon Platt:
No, I’m still the poster child for imposter syndrome and after listening to all of that, I wondered it “Was that me? Where have those years gone?”

Dr. Andy Roark:
It’s a blink of an eye. But anyway, it is an amazing resume. I am happy to have you here for a number of reasons. The first one is I am going to be hosting you in a webinar. You and I are doing a webinar together on spectrum of care neurology cases on December the 13th. It’s made possible by Nationwide, which is very lovely of them. So it’s free for everybody, but I’ll be hosting you. It’s a one hour webinar. It’s got an hour of RACE CE on it. I’ll put a link in the show notes. It’s for people to register for that, but you and I are going to get to talk then. And before we did that, I always like to talk to people in sort of a more conversational format. And so I thought this would be a good opportunity for us to start to talk about something that I’m really interested in and that’s accessibility and it’s spectrum of care.

So what I mean when I say that to lay out some terms, I have concerns about keeping veterinary medicine available and affordable for pet owners. And so one of the things that is really interesting to me is looking at people like yourself who have such deep expertise in specialties and saying, what does this look like at the general practice level to do right by the patients? And it’s always that balance of advocating for patient care and for doing what’s right for the pets and educating the pet owners and also trying to meet pet owners where they are. And neurology is a particularly intimidating specialty to me when I look at it from this standpoint because it feels like very quickly we get to the multi-thousand dollar MRI machine. And I also have felt, I’ve had the feeling as a general practice doctor before looking at neuro cases of like, I can’t cut this, I can’t cut this. My medications feel fairly limited. It can feel like there’s not a lot of options when I’m looking at a neurology case. And so anyway, let me just pause there and open that up to you. What is your general philosophy when you look at neurology in an access to care capacity?

Dr. Simon Platt:
Yeah, I mean you touched on a lot there. I would have to admit neurology is very intimidating. That’s the first problem, not just to us as veterinarians. I mean, I remember starting out and to me I really hated neurology. We got taught by a stand-in neurologist who was our cardiologist. She admitted she hated it. She said, I’m not really sure what I’m doing here. I’ll teach you some neuroanatomy and then we’re away. And it didn’t really make sense. I thought, well, everything I see seems to circle, get steroids and die. This doesn’t really make sense. And so I was a bit scared of it. Now it’s intimidating on every level. The clinical exam is intimidating. Look at some of the other specialties and some of those are intimidating, but the clinical exam part, that’s not dermatology to me, very intimidating. But the clinical exam doesn’t seem that intimidating.

But for neurology, very intimidating check sheet based, you check these things, you don’t really know what does that mean, but I’ll just check it. No one’s watching and it doesn’t really add up. And so we need to get rid of that. That’s the first thing. But then it goes on because as you said, it seems like you can’t do neurology without expensive tests, invasive tests, and it seems that you can’t do neurology without surgery. And so I’ve approached it from the general practice background that I had where I was frightened of it, intimidated of it, trying to work out how on earth I could actually do it without some of those tests where we came from a background where MRI wasn’t actually being used. And so the spectrum of care approach was something that I kind of adopted early but didn’t really know how to articulate it, didn’t really know to say, well, this is spectrum of care.

To me it was all about individualized medicine, individualized for the client and for the pet. So for the client, you are individualizing it based on their personal circumstances, obviously finances, their geographic location, could they get places to do further tests? What’s going on in their life? Are they working 16 hours a day? So we’re making some decisions around that. And then we’re making some individual decisions around the patient as well. Because a patient that’s two years old that has condition A would be treated very differently from a patient who’s 19 years old that has condition A maybe has exactly the same signs. And so we’ve got to take those into consideration and that’s what all of us, I think, in this profession do. And so all of a sudden then it had a name of the spectrum of care. And I felt that’s helped because I feel right at the start we talked about poster children, but poster children.

I think for spectrum of care, one of them is neurology because we have to be able to offer a stepwise approach in diagnostics and a stepwise approach in therapeutics. And the problem that we have many times is that other specialties, other areas of veterinary medicine can do this based on a lot of evidence in terms of what the disease is. And we never get there because without a biopsy of the brain or of the spinal cord, we never have a precise answer. Whereas obviously if you’re dealing with liver disease, you may have a biopsy, you’re going to have other areas of veterinary medicine where it’s a little easier, a little cheaper, a little safer to get a diagnosis. For us, we’re always even spending thousands of dollars MRI type, you’re always guessing. And so I’ve encouraged our students to stand up and have a mantra and say, I’m a veterinarian. I love to guess. And that’s not playing down evidence-based medicine, because you need the evidence to piece together the facts that are given to you. Let me see this dog with this signal and these presenting signs and this neurologic exam piece, those pieces of the evidence together and come up with, well, what could it be and how would they respond to the treatment? So the evidence is out there for those aspects of the case, but not really of what exactly does it have.

Dr. Andy Roark:
So lemme jump in here because a couple of things that struck me. First of all the, for a moment I thought if I ever wrote about a book about neurology, I would call it circle get steroids and die. But now I think I would change that. I think I’m a veterinarian. I love to guess is a better title for the neurology book that I would write.

Dr. Simon Platt:
And the follow-up would be, I am a neurologist, I love steroids. And now some people will be tuning out and going, can’t believe he said that, but I know when the lights get turned out. That’s what the dogs and cats, that’s what we’re using. It’s just about appropriate use. So circling steroids and maybe doesn’t do so well, you need to know the dose of steroids. That’s the evidence in there.

Dr. Andy Roark:
I love it. I always love specialist secrets where they’re, I will tell you I have a hundred percent referred patients to a specialist because, and I knew they were going to give steroids, but I didn’t have the guts to do it. And so I gave it to them and they took the liability and they did it. So it sounds to me like what you’re saying. I just want to clarify that. So first of all, I love the fact that you come from a place in the general practice background and this was intimidating and neurology was scary. I can resonate with that. And I think a lot of other people, it sounds to me like what you’re saying is because getting an actual indisputable diagnosis is so hard, that makes it much more challenging to break neurology down into sort of a clear diagnostic step to a clear diagnostic path that we could walk through because we don’t end up with enough evidence because we don’t often get all the way the diagnosis. And so the fact that we don’t come with that diagnosis makes it harder to teach doctors. This is step one, this is step two, trust your instincts. This is step three. Is that sort of what you’re getting at there?

Dr. Simon Platt:
Yes. But there has to be still somehow a step one, step two step here. And I think therefore with neurology it’s going to be different. What we will use is the evidence behind the presenting signs, for instance. So our presenting signs could be sudden onset or slow. They could be accompanied by pain or not. They could be progressive or static. And so we’ll look at neurology as a series of presenting signs that will help us try to narrow down what the problem is. And so one of those other presenting signs will be, is it asymmetric or not? And so for us, if we’ve got asymmetry, however we see that either just on observation or on taking it further with a hands-on exam, that’s a factor we’ll throw into speed of onset progression of disease, presence of pain or not, because those things will help us narrow down our differential diagnosis list.

I dunno about you, but originally I was taught to think about neurologic diseases using that pneumonic damn knit V and I didn’t know I remember that what that was. So we shuffle the letters around and we’ve come up with vitamin D and I used to teach at Georgia and no one knew what that was. And so I shuffled that around and said vitamin D, and then everyone got it. And what we’re talking about here is the letters, right? Those letters of that acronym there, those letters V for vascular will go down all of those mechanisms of disease and look at, well, what would you present? So if you are vascular that’s in the brain, that would be a stroke. You are sudden onset, you are asymmetric, you are non-progressive. And so now I look at the dog and say, could you be that next thing eye for inflammatory?

You are subacute to chronic, you are progressive, you are often patchy, multifocal, you’re asymmetric. Could you be that? So our step-by-step approaches is let’s answer some questions. Question one is are you really neurologic? Right? That seems like an odd question because many of the times we know straight away they’re dragging their legs or they’ve got a head tilt, but sometimes we’re obviously presented with a case that can’t jump into the car anymore or go up the steps. And so is that orthopedic or neurologic? So step one, are you neurologic? Step two, where’s your disease? And I don’t want then people to become intimidated further by neurology and say, oh no, this is where neuroanatomy comes in because really we’re looking for is your disease in the head or out of the head? That’s where the separation of disease types occur. So our next question then, where’s the disease in the head out of the head?

And then the third question is using this clinical reasoning approach where we try to look at how you are presenting asymmetric, progressive and sudden onset. For instance, we’re going to look at those differentials, V for vascular, I for inflammatory, T for trauma and toxin A for anomalous. We go down the list. And so our step three is what could you be? And at that stage we can communicate with the owner and say, here’s two, maybe three possibilities. And of those we could maybe narrow those down with some further tests and we’ll show you how we’ll do that. So we might not need to advance all the way to the most expensive and invasive tests. And if the owner says “We haven’t got any money for any of those tests,” then we look at those two or three possibilities with an eye for treat for the treatable, and again, stepwise go with the least invasive, maybe the cheapest, maybe the most effective potentially medication. If that doesn’t work, we’ve got a plan for step two and three. So yeah, diagnosis and treatment will still have that stepwise approach without really knowing what they’ve got.

Dr. Andy Roark:
Do you find that walking through this process and you get down to, is it in the head? Is it out of the head? And then sort of going to the owner and saying, all right, here’s a bucket. And I guess that’s kind of how I think of it is I can’t tell you what it is, but I can kind of tell you what bucket it’s in. That allows me to start to have some realistic conversations about what treatment wouldn’t involve or what further diagnostics would involve. We can start talking about prices of things and what options are going to be available to them. I don’t have to know what the answer is, but I have to tell them where I think this path ultimately probably goes or what that journey looks like. And then we can start to talk about where they are, what their resources are, what their intentions are, what their feelings are. Is that kind of how you of look at this and how this sort of shakes out into helping guide people and give them insight when you don’t have a diagnosis?

Dr. Simon Platt:
Yeah, we’ll have those two or three possibilities or buckets where we can say if you have disease, a bucket one, let’s say it’s possible stroke. If we do nothing, this is what happens if we treat, what are we treating with? What’s the advantage and disadvantage of doing tests? For instance, if it’s a stroke, there is no specific treatment. And although with tests such as MRI, you can gain more confidence, there’s nothing definitive and they’ll get better many times in the next two or three days. And so we’ll offer owners, well that path takes you down, do nothing for two or three days. If they get better, you’ve got your answer. And then bucket B, this case will get worse if we do nothing. So again, then we’ve got some help there by just using time on our side as a diagnostic, and this is what you’ll get with bucket B.

Let’s say it’s inflammatory. If we do just blood tests, this is what we’ll get. If we do an MRI, this is what we’ll get If we do C, S, F, this is what it’ll cost, pros and cons of each of those things. And again, we can often help the owners feel comfortable with not going to the extent of doing all of those tests by saying this is the difference it will make if we do the tests. Because ultimately this whole thing about I’m a veterinarian, I’m a neurologist, I’d like to guess MRI sounds like it should give you the answer, but it doesn’t. It’s not often definitive, it just improves your confidence level. And so many times we’re still looking at it and saying, I don’t really know. Is that a tumor? Is that inflammation? And so then we’re still guessing and we’re still then going to treat for the treatable. So I know in a may say, well, what was the advantage of even doing that? And that’s a killer comment because that means we haven’t communicated upfront that you might actually get no benefit of doing these tests.

Dr. Andy Roark:
Do you have or have you had any sort of apprehension about sort of trying empiric therapy when you don’t have those types of diagnostics? When I look at the sort of medications we reach for in our neuro cases, I think I always worry, what if I’m wrong? What if I put this dog on an anti-seizure medication and that’s not the right play? Or what if I reach for steroids and this is not the right play? I don’t tend to have nearly that much apprehension in internal medicine cases or dermatology cases and I don’t necessarily know why, but it’s something scary about, I don’t know, maybe it’s just those, my experiences with those medicines, they still kind of feel like voodoo to me in some ways. Maybe that non-steroidals don’t feel like voodoo to me or antibiotics don’t feel like voodoo. Does that make any sense at all?

Dr. Simon Platt:
Absolutely. Because I think in the past we’ve been taught to be scared of neurology because if you don’t know all of your neuroanatomy inside out, then you can’t do neurology. Not true. If you don’t have an MRI, you can’t do neurology. Not true. And therefore you feel, well if I don’t really know what the disease is, how can I come up with treatment and the brain and the spinal cord, they shouldn’t be messed with. If I get this wrong, they die. Well, I think that’s the same with multiple diseases. I’d be scared of treating a dog with cystitis. So I mean it depends where you come from. So for me, I have no problem with empiric therapy as long as I’ve had a completely transparent discussion with the owner to say this is what I think’s going on. Two possibilities, three possibilities. This is the best thing for the dog right now.

If we are aiming to see if we can get some improvement, how far will it go? Maybe we don’t know what happens if it doesn’t work. We need a plan B. What’s the worst that could happen if it doesn’t work? And then the owner has a chance to come back and say, well, I don’t like the worst option. What would I do to avoid that? And we can discuss whether tests at that stage are going to help or not. And sometimes they say, well that’s great that you say now an MRI will help but I still don’t have any money. Well, so we’ll address the discomfort that comes from the fact that empiric therapy is an unknown by saying, well if we do nothing, I’ve got more of a known for you. And that is there’s going to be progression potentially or there’s going to be pain. So the empiric will focus on quality of life and so making sure they’re comfortable above all else. But then also looking at, well if you have something that’s treatable, what could it be? If I’m looking at inflammation in the brain versus the tumor in the brain, I’m going to go with treating inflammation because that’s likely to have a more positive effect than anything I can do for the tumor regardless of how much money that you have. And there’ll be some collateral benefit for the tumor if I use anti-inflammatory steroids.

Dr. Andy Roark:
Yeah. Simon, before I let you go, I want to jump back and do the vitamin D with you. And so just to run through it, it’s funny, the acronym is one that I heard back in vet school and it’s been so long and you bring it back up and we start to go through it. So just for our listeners to have it, vitamin D, we’re talking about the origin of a neurologic problem. V is vascular, I is inflammatory, T is trauma or Toxin A is anomalous.

Dr. Simon Platt:
Yeah. So anomalous being, yeah, you’ve been born with something. So in the brain that’s hydrocephalus in the spine. Then if you’re a frenchie, that’s a vertebral malformation. And then we’ve got M for metabolic. So that most of the time is a brain problem rather than a spine problem. Hepatic encephalopathy is a good example. And then we move to I for idiopathic, and that again is on the top 15 list of why people hate neurology because idiopathic, well isn’t that when I find nothing? So isn’t that everything? And so we have to get across that. Yes, you’re right. But idiopathic is for specific conditions. They’re loner conditions where there’s nothing else. So epilepsy, facial paralysis, vestibular, so they’re loner conditions, you’ll find nothing else. And then we’re down to N for neoplasia. And again, we’ll use all of our factors like the average age for brain and spinal neoplasia is eight, so we’re going to throw that in.

If you’ve got a two year old patient, then neoplasia is dropping lower on your list. And then N also is for nutritional, which for a while in my career fell off the map and now is right back on it because people think you should feed raw meat and bones. And so now we’re seeing a lot of nutritional problems hit the brain. And then lastly, D is degenerative in the spine. That is disc disease and myelopathy. And then in the brain really we’re dealing with old age degeneration, a little like Alzheimer’s, a cognitive dysfunction. So we use that list, that sort of acronym there to help us remember what exists in the brain and the spinal cord and we can just cross those off based on how you’ve presented. And so of that list based on your age, based on was it sudden or not based on is it asymmetric based on is if there’s pain, I could cross them off and say, I’ve got one thing left for you, two possibilities.


And maybe one of those isn’t treatable. And now we’ll talk about tests as to whether they will really help or not. And sometimes we won’t perform tests. If I have a seizure inpatient, for instance, 50% of them meridia pathic, and my evidence-based medicine is going to tell me that if you’re idiopathic, you’re pure bred, your age is between six months and six years, you have no neuro deficits. So if I see a two-year-old golden retriever with no neuro deficits having had a seizure, I’m probably not going to be advising MRI tell people, spend your money on the medication. If we need to start treating, if things start coming out of the woodwork in the next few weeks and things change, that may be the time to talk about being more aggressive.

Dr. Andy Roark:
I have about seven follow-up questions and I’m, I’m going to sit on them, I’m going to sit on them until your lecture in December. I could talk to you all day. I really appreciate you being here. Where can people learn more? Do you have favorite resources? And then where can people find you online?

Dr. Simon Platt:
Well, I’m on LinkedIn and so you could find me there. We’ve just actually opened, if that’s what they say, I’m sure it’s not a new website published. Is it? We’ve just released

Dr. Andy Roark:
Launched?

Dr. Simon Platt:
Launched. That’s best.

Dr. Andy Roark:
Unveiled?

Dr. Simon Platt:
What do people say that? launched is good? Yeah, we’ll go website, which is under construction, but you can start to get a feel of it. It’s for neurology for all ages, so to speak. And it’s called web-vetneurology.com. And so we’re going to expand that into hopefully extremely useful resource. We’ve got cases on there, we’ve got some literature on there right now. It’s not as useful as it’s going to be because we’ve got a lot of nuts and bolts, grassroots, grassroots information to add to it.

Dr. Andy Roark:
Perfect. That sounds fantastic. I’ll put links in the show note to all of that. Guys, thanks for tuning in and listening today. Simon, thank you for being here, gang, take care of yourselves, everybody.

And that’s it guys. That’s our episode. I hope you enjoyed it. I hope you got a lot out of it, man. I genuinely, I love this episode. Thanks to Simon for being here. Thanks for talking. I am looking to our, looking forward to our webinar together in December when we’ll be breaking this down in more detail and probably uses the visual aids and some slides and some things like that. So anyway, I would love to see you there. I’ll put a link in the show notes if you want to come to that free webinar, get some RACE CE, hang out with me and Simon. It’ll be a good time anyway, take care of yourselves, everybody. Have a good day. I’ll talk to you later.

Veterinary Cardiology Myths, Legends and Fears

by

Veterinary cardiologist extraordinaire Dr. Kristin MacDonald teams up with Dr. Andy Roark to debunk the myths and unravel the legends swirling around cardiology. From heart attacks in dogs to the controversies surrounding grain-free diets, they dissect it all. Tune in as they sift through the maze of modern ideas floating on the internet, separating fact from fiction, and shedding light on what holds true in the world of pet heart health.

This episode is brought to you by CEVA Animal Health!

Important Safety Information: Do not administer in conjunction with non-steroidal anti-inflammatory drugs (NSAIDs) in dogs with renal insufficiency. Do not use in dogs with hypoadrenocorticism (Addison’s disease), hyperkalemia or hyponatremia. Do not use in dogs with known hypersensitivity to ACE inhibitors or spironolactone. The safety and effectiveness of concurrent therapy of Cardalis™ with pimobendan has not been evaluated. The safety of Cardalis™ has not been evaluated in pregnant, lactating, breeding, or growing dogs. Cardalis™ administration should begin after pulmonary edema is stabilized. Regular monitoring of renal function and serum potassium levels is recommended. Common side effects from a field study include anorexia, vomiting, lethargy, diarrhea and renal insufficiency.

LINKS

Cardalis Resources and App

CEVA Connect

Upcoming Webinar (Free RACE CE)

Dr. Andy Roark Resources 

Dr. Andy Roark Exam Room Communication Tool Box Team Training Course

Dr. Andy Roark Charming the Angry Client Team Training Course

Dr. Andy Roark Swag

ABOUT OUR GUEST

Dr. Kristin MacDonald earned her doctorate of veterinary medicine in 1998 from Auburn University, and then completed an internship in small animal medicine and surgery at Michigan State University in 1999. She finished a residency in veterinary cardiology at University of California, Davis in 2001 and became a board certified veterinary cardiologist in the American College of Veterinary Internal Medicine in 2002.  She continued her education by earning a PhD at UC Davis Comparative Pathology graduate group in September 2005 on hypertrophic cardiomyopathy in Maine Coon cats, and the effects of ACE inhibitors.  Dr. MacDonald taught on faculty at UC Davis for a year, and then became the clinical cardiologist at the VCA Animal Care Center of Sonoma County in Rohnert Park, CA, where she continues to have a busy cardiology practice. She has been an active author of book chapters for highly respected textbooks, served as section editor for Handbook of Small Animal Practice, published a multitude of original research papers, and is coauthor of The Textbook of Feline Cardiology, the only text of its kind available.  Dr. MacDonald has participated in clinical trials involving treatment of canine congestive heart failure, and enjoys being the lecturer for the VCA Cardiology Series in the United States. Living in Sonoma County, she enjoys spending time outdoors hiking, skiing, and being mom of two daughters, two Tonkinese cats and a Labrador Retriever.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark. Guys, I am here with veterinary cardiologist, Dr. Kristin MacDonald. Today we are talking about cardiology myths. We are walking through a little bit about heart murmurs, a lot about heart failure, a lot about communicating the heart failure to clients, a lot about managing heart failure. We talk a bit about Spironolactone and why it has become so popular in cardiology and it’s all sort of presented in the format of myths and legends that I have heard and mostly I’ve seen online with pet owner groups, things like that, pet owner discussions, and I’m just putting that out to her and seeing how she communicates about these things and really what the truth is. So anyway, this is a super fun episode. It is a great bite-sized chunk episode. We just clip from one subject to the next subject to the next subject. It’ll definitely hold your attention. You’re definitely going to pick up some pearls along the way. Kristin is amazing, was so glad to have her. Guys, this episode is brought to you by Ceva Animal Health. Let’s get into this episode.

Kelsey Beth Carpenter:
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast Dr. Kristin McDonald. How are you?

Dr. Kristin MacDonald:
I’m great. How are you, Andy?

Dr. Andy Roark:
I am so great. I am so glad that you are here. I have been looking forward to getting to sit down and talk with you a bit. For those who do not know you, you are a clinical cardiologist at VCA Animal Care Center in Sonoma, California. You are a huge outdoorsman, which I love, and you live in a beautiful place for it. You are also have two daughters just like I do, and you are teaching one of them to drive just like I am. I feel like we’re living parallel lives except for the whole cardiology thing. You are also a lecturer. You are doing VCA lecture series all across the United States. People can find you all over the place in your presentations. So yeah, thank you. Thank you so much for making time to be here. I’ve got a fun game and it is, I wanted to share with you some cardiology myths. I want to make some bold statements and I want you to shoot ’em down. So yeah, I want to go ahead and lay out some things that I am starting to hear or things that have kind of floated around the internet and I just want you to weigh in on some of the modern cardiology legends. Is that okay?

Dr. Kristin MacDonald:
That sounds great.

Dr. Andy Roark:
Alright, great. So first thing I’m going to start with is talk to me a bit about pet owners that are concerned about their dog having a heart attack. And so I see a lot in people. I’ve heard people say that dogs don’t have heart attacks. They’re like, dogs have heart attacks. I’m like, well, they do. And then people talk about heart failure and they’ll use heart attack interchangeably. Like, oh, well the doctor says he’s going to have a heart attack, and I’m like, nobody did that. Talk to me a bit about heart attacks in dogs and that terminology, if you don’t mind.

Dr. Kristin MacDonald:
Well, most clients actually equate heart disease in dogs to what they might suffer in human cardiology, which is a heart attack and it really is not the same thing. So dogs have a lot of different heart diseases, some that are in common with people, but they don’t have coronary artery disease and atherosclerosis. And I’m guessing it’s because we probably feed them better than we eat ourselves. Looking at my diet lately of lots of pastries and french fries on vacation, my dog eating way better than me. So there are certain things that may look like a heart attack that they may clinging to in severe forms. Their pet might be short of breath or breathing hard or coughing or collapsing. And so those things look like a heart attack, but it’s actually a very different process to a severe process. So we try to explain the actual heart disease that we think is going on with their pets so they can better understand it.

Dr. Andy Roark:
A couple of years ago, the grain-free heart disease was everywhere. It was huge thing. It blew up. There was much conversation about grain-free diets and their interaction with heart disease and things like that. That seems to have quieted way down. We don’t hear a whole lot about grain-free diet associated dilated cardiomyopathy anymore. Is that over? Is grain-free diet, heart disease a thing of the past?

Dr. Kristin MacDonald:
It is not over. It’s just not front and center on people’s minds. And unfortunately there are still cases of this. This was first described back in 2018 when we started seeing dogs that weren’t supposed to have dilated cardiomyopathy like little dogs that never get that disease. And we were looking at common threads and sure enough it was these grain-free diets that seemed to be emerging as this common factor. So there was this frenzy of learning and reporting to the FDA, which was a very arduous process for clients. It could take 30 minutes for them to have to fill out all this information and there gets to be fatigue in the process and fatigue with investigators. So there’s still ongoing active research, but I think that maybe the word has gotten out and maybe there’s been some reformulation of different diets, but there’s also very sneaky ways that companies are sorting the term grain free. And so they may call it grain friendly, but they still may have the same potentially toxic ingredients. We’re learning that it’s the legume family like peas and so they might call it green friendly where it’s more approachable. They still kept the peas in it. So we still are finding dogs with this and they can die from it. Changing the diet and treating for heart disease in these dogs can make a dramatic improvement in their outcomes. So it’s still around.

Dr. Andy Roark:
I can’t fathom. I’ve seen grain friendly and I’m like, oh, clearly they have addressed the concerns. But you say, but not necessarily.

Dr. Kristin MacDonald:
You have to look at now. It’s harder. You can’t just look at the title of the diet. You actually have to look at the ingredients list. It’s very complicated.

Dr. Andy Roark:
Oh man, I’m going to have to sit with that. That’s amazing. Talk to me about having seizures with heart problems. So I’ve had pet owners, I’ve seen posts on the internet where pet owners are like, yeah, my dog have heart disease and now he has seizures. How do you talk to people about seizures when their dog has heart disease?

Dr. Kristin MacDonald:
This is something or

Dr. Andy Roark:
Perception of seizures. Yeah.

Dr. Kristin MacDonald:
Oh, yes. This is something. Now full disclosure, I’m married to a veterinary neurologist, so this is a sensitive subject here. And we also happen to work in the same practice. So we’re often jockeying for whose case is this?

Dr. Andy Roark:
Well, hold on to jump in. Your father is also a veterinary dermatologist. Is that true’s like Oh, Thanksgiving’s at your house? Yeah.

Dr. Kristin MacDonald:
There was one actual Ettinger textbook that the three of us all had chapters in it and the table of contents had us in sequential order.

Dr. Andy Roark:
That’s got to be a record. That has to be a record. That’s super cool. Okay, I’m sorry. I didn’t mean to interrupt.

Dr. Kristin MacDonald:
So back to every time an animal has something where it looks like they collapse, they may lose consciousness, they may have some tonic CLO movement. They almost always call it a seizure, and it’s very difficult even in the best trained eyes and education to differentiate them. I’ve actually seen a dog in the ICU with an EKG on that went into horrible vtac, collapsed and fainted, and then had myoclonic movements that looked exactly like a seizure. But I had the EKG on and he had minimal blood flow and it was syncope. So of course an untrained client would think it’s seizure, but you’ve got to think twice about that and it’s hard for the GP because they’ve got to decide completely different directions to go, is this a really malignant cardiac event, cardiac or is this neurologic? Who do I send this to or what treatment should I start?
So it can be tricky because they can have similar appearances, but there’s a few things that I’m going to look for. I’m going to look at is there an inciting cause for syncope? It might be that it’s excitable or exertion related or triggered by a cough, or maybe it’s a small breed dog with chronic respiratory clinical signs in murmurs where for seizure it may be more likely at night when they’re resting and they may have different behaviors before and after, but it can be super tricky. But generally when a client says it’s a seizure, I would urge you guys to dig in deeper, get a little more info, look at your patient signalman and decide which direction should we go. And if there’s any questions, I’d be dialing up your favorite cardiologist or neurologist and tell them about it. Ask for a video.

Dr. Andy Roark:
Yeah. Well, I love the video suggestion, and this is always interesting because it really is the clinical history and asking the questions and kind of digging in. Do you still put halter monitors on dogs that you are playing around with syncope? Is that still a standard of care that you reach

Dr. Kristin MacDonald:
For? Oh yes. So for sure the first thing we’re going to start with is in my cardiology practice is we’re going to do a really comprehensive echocardiogram. We’re going to look for pulmonary hypertension, especially in small breed dogs, really common cause of syncope we’re going to have an EKG on, but you never luck into that aha moment. That’s when we really lean on the Holter monitor where we may place it for a day or even up to seven days to try to document arrhythmia and maybe we can catch the event and actually show whether it is from an arrhythmia or not, and then that will implicate your treatment because we have many great drugs out there, anti-arrhythmic meds, or even pacemakers we’ll use in dogs to really cure the problem.

Dr. Andy Roark:
Yeah, there’s a lot of conversation when I look online and I look at pet owners that are talking about their pets with heart disease and things like that. There’s a lot of fear. So one of the questions I’ve honestly seen online is people say, my dog has a heart murmur. Does that mean he’s going to die? Again, I think I bring this up because I think all of us in vet practice, we see heart murmurs all the time and we know that, but I think sometimes we take it for granted that the pet owners, they’re going to understand when we don’t act like it’s a big deal, so they’re going to understand it’s not a big deal. But I don’t think that’s necessarily true. How do you talk to pet owners about heart disease, about their heart murmur, which can hit them like a hammer when they go, what do you mean my little dog has a heart? What do you mean her heart has a valve that’s not working the way it should? What is that conversation like with you?

Dr. Kristin MacDonald:
Well, actually you catch it first, so I feel for you very much because you’re the revealer. And then I have clients that come in and they’re on the ledge. They are holding their breath, they are wringing their hands. You can see every bit of body language is fear. The dog’s not afraid, the cat’s not afraid as much, but the client’s terrified. So I love it when I can come back into the room after we’ve done our workup literally 25 minutes later and say, one of my first things is we’re okay here. And so it’s really disgusting that a murmur doesn’t mean your dog is going to die. And in fact, the odds are greatly in your dogs or your cat’s favor that they’re going to be okay. But this can get worse over time. And if we’re talking about the number one cause of murmurs in dogs, it’s going to be mitral valve disease, which yes, this can get worse over years of life, but again, if you’re a betting person, two thirds of dogs are going to live full lives with mitral valve disease. So it’s kind of giving them a little bit of reassurance and also committing them to the fact that things can go wrong and we need to stay on top of this. And that means we need to proactively prospectively watch these dogs and really monitor them to know when do we need to get worried and when do we need to start medications because certainly heart disease is not always benign and it can really progress to become problematic.

Dr. Andy Roark:
How do you handle the pet owners who, I mean again, so we talked about heart murmurs. When we start talking about heart failure, I have had clients come up to me or people who aren’t my clients, they talk to another vet and it’s almost like they have a question they’re embarrassed to ask their vet. So they say heart failure, that means he’s going to die, right? Heart failure is you can’t live if your heart fails and he’s in heart failure, does that mean he’s dying? And so unpack that for me.

Dr. Kristin MacDonald:
I literally had that happen to me last week. I kid you not right before this podcast. I was like, oh, this is it. This is definitely a myth that we need to dispel that heart failure is concerning. It’s a scary word because oh, it’s terrifying. This is a big deal. I mean, this is not a benign process typically, but it doesn’t mean your dog is dying on the floor in front of us. It means that your dog has severe heart disease severe enough that it cannot function properly, such that fluid will build up in the lungs or in the abdomen, or maybe they have really low blood flow so that they’re really tired going on walks or they’re coughing and breathing hard in that yes, heart failure, there are medications do help it just in people and think they may relate to that. They know like, oh, I have a lot of clients that go, well, I have heart failure.
I’m on that med. And so it almost makes them a little more comfortable to know we can treat this. But yes, overall there is a accelerated time course compared to people that can live with heart failure for 10 years, 20 years in dogs. I mean, it’s sad about most dogs with mitral valve disease and heart failure may live on average a year. Then again, we have some great success stories for longer and for dilated neuropathy, it’s even shorter. So there is this, in my approach, it’s an honest, gentle preparation for them so that we’re not sugarcoating things. We’re not trying to diverge from the truth, but we’re trying to support them, trying support and let them know what might happen, what it might look like. They always want to know what’s it going to look like, what’s the end going to look like? And I think it’s really helpful to discuss what it could be like with breathing difficulty that maybe it’s a phone call, kind of things are getting worse or maybe it’s a crisis and you need to get help urgently.

Dr. Andy Roark:
Do you think that you can have those honest conversations about what heart failure looks like and then still have sort of a voice of optimism?

Dr. Kristin MacDonald:
Yeah, absolutely. I think that I try to talk about that this is treatable and kind of a plan for what this looks like, but then we do have to talk about when things don’t go right. But also the fact that even if we have a dog that represents with heart failure, it doesn’t mean that we can’t make more adjustments and get more quality time. And I also think it helps with buy-in for medications because in veterinary medicine we don’t have so much success or there’s not as much availability of valve replacement. So really the mainstay of treatment cross country is medical therapy. And so if they know this is a deadly disease and we worry most about how they feel that medications are going to help deliver that improvement as best as we can, and we need them to be compliant and follow up and know what to look for that are concerns to let us know so we can be proactive.

Dr. Andy Roark:
Okay. Well, speaking of medical therapy, one of the things that I have seen in the last 16 months I have never seen since I was in vet school and learned about spironolactone, I have not put much thought into spironolactone until about 16 months ago when I started to really hear an uptick about conversations about Spironolactone. And so the debate that I’ve seen online, which is actually again, this isn’t pet owner for, but it’s interesting, but people are like, if you’ve got Lasix that’s so much stronger, you don’t need spironolactone if you got Lasix. And so let me put that to you as a potential myth that’s out there. How do you feel about that?

Dr. Kristin MacDonald:
I too was educated that it’s a weak diuretic. And really at that time until about a year and a half ago, I’ve been waiting for the data. I like data. I think it’s reassuring. It helps me to know is this worth it or not? And so we’re looking at effects within oftentimes like mitral valve disease and heart failure. And really we’re thinking about spironolactone is not a diuretic. We’re thinking about it kind of like an ACE inhibitor where it’s more of a renin, angiotensin, aldosterone system blocker. So it’s blocking aldosterone receptors. And so we think of it more in that neurohormonal antagonism rather than its effect on increasing urinary output. And there are definitely benefits that have been shown when you add spironolactone to benazepril that these dogs, they had a lot longer time before heart failure worsened and they lived longer and they had less time to what they call at all cause removal or all cause problems. So it’s very safe and effective and we’re learning that it’s not all about just how much urination they’re going to have in diuresis to have an actual benefit. But again, it’s not a one or the other. The beautiful part is that we can use multiple medications at each, have their own job to cumulatively get the benefit.

Dr. Andy Roark:
Well, tell me more about that. Talk to me a bit about quad therapy. So I’m hearing the term quad therapy in our cardiac cases and things. Can you define that for me, is what that means to you and then start to make the case for a quad therapy approach?

Dr. Kristin MacDonald:
Yeah, when I think we all talked about triple therapy, when PMO Bendin became available, we had of course our standard puric amide loop diuretic pulls the fluid from the lungs. We’ve got ACE inhibitors which are blocking the conversion of angiotensin one to two. And earlier studies showed improvement in heart failure class and double survival time. So that was back in the eighties to nineties. Then came pob Bendin, this revolutionary drug that has honestly changed the face of cardiology. It’s made us have a lot more fun and a lot better outcomes.

Dr. Andy Roark:
It should be in the water,

Dr. Kristin MacDonald:
A lot of happy, happy dogs and clients with this drug being an inod dilator. So what we’re looking at is I describe it to owners as this is the one that helps the heart function better and dilates vessels both going out the body and back to the lungs. So this really helps heart failure, many causes. And of course that one demonstrated again, improvement in survival, time and time to heart failure, recurrence, all of that is really something we’re looking for. So now comes on the scene spironolactone, and we just had this best clinical trial that I kind of honestly was waiting for. And what that is looking at is blocking aldosterone receptors with spironolactone and what aldosterone, it’s a toxic neuro hormone. And unfortunately when dogs or cats are placed on ACE inhibitors, we want to believe that there will be less angiotensin too made, which then lessens production of aldosterone. Well, that’s logical, but the body has different workarounds. And so about 40 to 50% of animals people, they have this aldosterone breakthrough where we still have elevated toxic aldosterone circulating in the body that’s wreaking havoc on the cardiovascular system. So we’re looking at now blocking both the ACE system and aldosterone, and I think of it as kind of like peanut butter and jelly, or actually it’d be more like chocolate and peanut butter. For me, the perfect combination really for more comprehensive blockade.

Dr. Andy Roark:
Is it hard to get clients to buy into quad therapy? I mean, we’re talking about giving a number of different medications. If some were to make the case and they were like, it’s better to do fewer things the client will actually do. How do you feel about that?

Dr. Kristin MacDonald:
Very

Dr. Andy Roark:
Tricky. Shoot that down for me if you can.

Dr. Kristin MacDonald:
It’s a tricky, tricky thing. And unfortunately a lot of these dogs are coming to me and have never even seen POB bendin yet. And so they may be on no medications and they come in for a little cough, they think they’ve got kemal cough, things are great, and then I’m telling them their dog is congestive heart failure and may live for a year. This is a lot to handle. So then we start talking about quad therapy, four different drugs. And some clients will get worried like, well, is it safe? Is it toxic drugs might be toxic? Well, yes, we do have to follow kidney values and all, but they are very safe. But then comes the reality of implementation. So how compliant might a client be able to be with four different medications given often twice a day? And unfortunately, doctors, they want to believe they have the perfect pupils that will do everything perfectly.
But I think we may be perfect cases that humans are going to mess up and they’re going to be busy and going to a lot of other stuff on their plate looking at a lot of clients say they cannot handle giving more than three meds. They say, I can’t even do two meds a day. And about 30% said they could give at most three meds a day and that they couldn’t handle more. So I often look at, there’s a nice combination tablet where we have both the NPR and Spironolactone and one tablet given once a day. And so I don’t sneak it in. I just say, well, we’ve got three medications your pet’s going to go home on little. And I sort of say, by the way, one of them happens to have a two in one, so it makes it a little easier for them to handle.
And it’s even easier if they’ve already come in on PMO bendin for preclinical, say, heart enlargement. And then I say, well, we’re just going to add two more medications that are going to help the heart failure part of things. But it’s very tricky. The other part is will the pet take the medication? Maybe the client is absolutely on board. They are dependable. They know they’ve been educated to say, this is how your dog is going to have a good life and live longer, but we have to give the med or it’s not going to work well talking pet language. Your dog or cat may not agree with that, so we’ve got to make sure they know how to give the med. Maybe they may need reminders or training on that. So there’s some great apps out there. I mean there’s apps for everything these days. But I do love the Cardis app because it helps them monitor breathing rights and it has medication reminders and you can have multiple pets. And I do have families that have three animals and heart failure all at once. So just giving them the tools to help them with the delivery.

Dr. Andy Roark:
I love it. Dr. Krista McDonald, thank you so much for being here. You are so wonderful. Where can people learn more from you? Where can they find you online or in the future?

Dr. Kristin MacDonald:
I might be a bit of a dinosaur, but I have a LinkedIn. I don’t check it that much, but really VCA Animal Care Center of Sonoma and LinkedIn. But overall, I also go incognito because online I have a Facebook that’s my own personal Facebook with last namely. Oh, okay. Yeah. But probably through VCA. I am actually going to have a really fun time weekend before school starts. My daughters and I are going to go to Vet Girl U down in Scottsdale at the Princess, and we’re going to have a great time with my mom-in-Law. Oh man. Yeah, you guys should check it out.

Dr. Andy Roark:
Yes, vet Girl u Justine Lee and Garrett Pater are good friends of mine’s founder of Night Girl. Just wonderful people. They’ve got a great event. They have a great culture. I think the world of them. That’s fantastic. Yeah. Awesome. Thank you. Thank you guys. Take care of yourselves, everybody. I’ll talk to you soon. Thank you. And that’s it. That’s what I got for you guys. I hope you enjoyed it. I hope you got something out of it. Real quick before you go, I got to give you a fast heads up. I have a Ray CE webinar coming right at you very soon. It is called The Practical Guide to the Mitral Valve Patient. This is with my friend Dr. Natalie Marks. It is on November 29th at 4:00 PM Eastern. That’s 1:00 PM Pacific. It’s sponsored by Ceva Animal Health. Guys. I’ve worked with Natalie many times. She’s been on this podcast many times. She’s absolutely great, super practical, a really wonderful doctor to learn from. This is going to be packed full of pearls, like I said, free hour race, ce. Jump in and grab it. Link is in the show notes. Get on it fast because this is going to pass us by real quick. Anyway, coming at you. I’d love to see you there, and that’s what I got for you today. Take care of yourselves, everybody. See you later.