Fearless columnist Natalie L. Marks is an educator, consultant and practicing Chicago veterinarian. Dr. Marks is a leader within the Fear Free movement, was a member of the original Fear Free advisory board and is Fear Free Certified Elite. She passionately believes that all veterinarians should be committed to the physical and emotional health of their patients.Read Articles Written by Natalie Marks
Cortisol is a well-intentioned, very powerful hormone. It is a normal part of the physiological stress response when the body perceives something fearful or threatening. It initially acts as a strong anti-inflammatory and temporarily reduces the pain response when the body experiences an acutely painful episode. In veterinary patients with chronic pain, the cortisol release becomes maladaptive and dysfunctional, and it allows widespread inflammation to continue.
Understanding the hormonal response is essential to understanding how patients react in the exam room, especially during episodes of pain. It explains why a patient suffering from an acute anterior cruciate ligament tear might appear only slightly uncomfortable and have subtle lameness while a chronically affected large-breed dog diagnosed with severe osteoarthritis might hobble, appear paretic and be extremely reluctant to permit passive range-of-motion exercises.
It also explains why we should rethink the process for orthopedic examinations and diagnostics. Not only do we want to create an environment that supports the early and accurate diagnosis of disease, but we also want to prevent additional pain and stress.
Just like fear, pain becomes a permanent memory in the amygdala of the brain. These imprinted snapshots are part of the protective mechanisms of the body so that it avoids future danger. However, if our patients experience pain while in the hospital, we become the future danger and a patient’s reaction can destroy a client’s trust.
A Different Approach
I’d like to propose a new way to think about the orthopedic exam to prevent additional pain and fear. There are three components.
1. Pre-Exam Telehealth Assessment
I have begun to recommend the use of telehealth consultations before orthopedic exams for dogs and especially for cats. This sounds like added work for busy veterinarians, but I’ve found that telehealth appointments save time when implemented appropriately.
Telehealth visits can occur in real time, but they don’t have to. What’s often just as helpful is a client’s use of asynchronous tools like email to send still images, videos and even slow-motion clips of a pet sitting, walking, standing, climbing stairs or running — and any other behavior in which something seems “off.”
When the patient is in a relaxed environment, changes in standing and sitting conformation, muscle mass, weight bearing, head bobbing, gait lameness and grooming are easier to notice. While we don’t want to diagnose before the in-person exam and diagnostics, initial observations allow us to focus on an area of interest and notice subtle changes that are often masked during cortisol release.
When the in-hospital exam is scheduled, the veterinary team should share with the client a document explaining how to prepare for the appointment. The information should include tips on car travel, relaxing music, pheromone use, compression garments, and the timing of any previsit medications and fasting.
Once the patient is in the hospital, many strategies are available to help a mildly painful dog or cat to become more comfortable. They work best in patients that respond positively to oral anti-anxiety medications administered at home.
To create a relaxing environment, eliminate the waiting room by bringing the patient directly to the exam room. The more a patient is in one setting, free from new team members walking in and out, the more successful the visit. Dim the lights, play soft music and plug in pheromone diffusers or spray pheromones onto towels and stethoscopes.
Many canine patients who are in pain feel much better on a secure support mat placed on the ground compared with being lifted onto a slippery exam table. Feline patients might feel much better inside a top-loading carrier. If you use an exam table, try to make sure it has a soft, preferably warm, treaded cover.
As the exam starts, the same tenet of fearless exams rings true: Start with the least painful step and leave the most painful aspect for last. When heading into more directed palpation of the skeleton, allow the patient to be in natural body positions instead of in forced, restrained positions like lateral recumbency, especially with cats.
If significant reactive behavior is witnessed during a telehealth appointment or disclosed in medical records or by the client, I strongly recommend that previsit sedation be done at home and in-hospital sedation start immediately upon arrival. Not only do drugs assist in achieving safe and effective diagnostics, but they also prevent adding to an animal’s fearful response or having to reschedule the exam because of the patient’s high emotional stress level.
One question pet owners frequently ask is whether currently prescribed pain medications should be given before the exam. Many veterinarians previously felt that anti-inflammatories and other classes of pain medications would mask an injury or disease, preventing an accurate diagnosis.
If any part of this article should be prioritized, please remember this: Telehealth technology creates another tool for assessment and diagnosis. Pain medications need to be given to support a patient’s physical comfort and to prevent pain from being a trigger for fear.
Capture Better Images
This brings me to diagnostic imaging and a concept that might seem medically aggressive. I strongly suggest that all patients undergoing diagnostics such as radiographs and joint taps be sedated. For some patients, previsit medications might be enough, but others will still have elevated pain and fear at the time of the exam and might resist proper positioning.
A short-acting, reversible sedation choice is often utilized, but protocols should be based on the patient’s health, biochemical profiles and risk factors. Proper monitoring is essential for any patient undergoing injectable sedation. Also, consider using local nerve blocks or continuous rate infusions to supplement for focal disease and to maintain continuous pain control.
Veterinarians can create a more successful orthopedic experience for their canine and feline patients if telehealth technology is first used to assess a pet in its relaxed home environment. Doing this also allows for the better planning of at-home and in-hospital sedation and for the support of a pet’s emotional health.
A relaxed, comfortable patient is what clients want to see and what veterinary teams want to achieve. An idyllic state allows for the most accurate diagnosing and treating of orthopedic patients.
WHAT’S IN YOUR TOOLBOX
Essential elements in the ultimate orthopedic exam room include:
- Nonslip floor mats
- Exam table with a nonslip surface and warm, soft bedding
- Dim lighting
- Soft music
- Pheromone therapy
- Pheromone-impregnated towels
- Laboratory supplies for
- biochemical testing
- Reflex hammer