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
I vividly remember a Tuesday morning many years ago. I woke up incredibly sore and tired, and I had no recollection of why I felt that way. I hadn’t worked out recently and, although I had two heavy toddlers, the previous days were the same routine — no heavy lifting or theme park toting.
And then I remembered. The day before, several technicians and I had been lying down and restraining a large German shepherd named Bear who needed a heartworm test and nail trim. For over 10 minutes, Bear thrashed, vocalized, expressed his anal glands and fought to the point of exhaustion. The feeling of exhaustion carried over into the next day for me and the team. All I could think was, “If I’m this sore, how does Bear feel?”
Sadly, we probably all have a Bear story, a patient who exhibited incredible stress and fear during a diagnostic test or treatment, yet we continued without pausing, regrouping or planning an alternative.
I encourage you to take the pledge to not let that happen again.
Let’s discuss some helpful strategies to use to not only lessen triggers during diagnostics but also to obtain more accurate results in the interest of best medicine and best business.
It’s widely accepted that stress responses can influence the complete blood count through stress leukograms and some chemistry panel results such as blood glucose. Patient restraint is one of the most important keys to success. A jugular blood draw is always preferred, especially when large volumes are needed for specific endocrine or metabolic testing, but other accessible vessels should be taken into consideration for patient comfort.
Allow large dogs to stand and use a lateral saphenous vein for wellness screening and heartworm testing. They can be distracted with a high-reward treat, and restraint can be minimal.
In patients with face sensitivity, utilize less-intrusive restraints like Zen collars to safely hold the head elevated and distract the patient.
In patients with reactivity, strongly suggest pre-visit anxiety medications and, if needed, a basket muzzle filled with peanut butter or squeeze cheese for distraction.
With cats, so much is new and exciting in the area of gentle handling to decrease their stress. In today’s veterinary practices, cats should never be scruffed. Instead, use a pheromone-infused towel to wrap cats like a burrito, exposing either just the head or one rear leg. This allows safe and gentle access to the jugular or medial saphenous veins. Consider use of a vacutainer and butterfly needle collection set for reduced handling of the focused area.
In feline patients with known significant anxiety or reactivity, I recommend 100mg of gabapentin the evening before and the morning of the appointment for easiest handling and most accurate testing.
A urine sample truly is liquid gold if and when it is obtained properly and analyzed in a timely fashion. The sample also is commonly the missing piece of diagnostics in many small animal hospitals. We know we cannot diagnose kidney disease or diabetes without the sample, and many breeds, such as Shar-Peis and Wheaten terriers, show disease here first.
While drop-off urinalysis from home should be encouraged for a senior screening test, we know that sterile urine collection is often important for the diagnosis of infection, inflammatory disease, crystalluria or other systemic disease. Think creatively in the restraint of these patients. Some patients enjoy being in a dorsal recumbency position for cystocentesis. However, this is a significant trigger for others. Be open to allowing a patient to stand, and position yourself differently.
I encourage all veterinarians and technicians to always use an ultrasound for cystocentesis, if available. Not only will this allow immediate visualization of the bladder, but it also identifies uroliths, polyps and tumors and is another source of revenue. Portable ultrasound units now attach to tablets and move with you throughout the hospital.
Always suggest sedation if the patient’s body language demonstrates ongoing anxiety.
Encourage a pet owner to bring a patient in early and acclimate to the exam room for at least 30 minutes before a blood pressure reading. Activate pheromone diffusers, play quiet classical music and dim the lights to encourage relaxation.
For some patients, being allowed to stay in a carrier with a removable top or even rest in the owner’s lap can significantly reduce stress-induced hypertension.
I always recommend using the Doppler method with blood pressure readings. Not only is it most accurate, but it can be done in most patients by using a pedal artery and not having to use a clipper to shave and stress the patient. Obtain three readings and use the average for the medical record.
If this plan still does not allow the patient to be in a relaxed or less anxious state, postpone the reading and regroup. Consider prescribing an anxiety medication to be given two hours before the visit.
Blood pressure is an essential vital sign, especially for senior and renal patients, but a false reading of hypertension due to stress offers no benefit, just confusion.
One of the hottest topics in veterinary medicine today is the advent of hands-free radiography. It offers many advantages, not only in reducing radiation exposure to the medical team but also in helping obtain the most accurate and focused images for diagnostics, and lessening the triggered anxiety and fear caused by repetitive restraint on a radiology table.
Courses are offered online and at conferences to help educate and train on this subject matter. Until it becomes the standard of care, this is an area of diagnostics where we should not hesitate to sedate, especially in any orthopedic or neurologic case and with any patient demonstrating anxious or fearful behavior.
As I mentioned, ultrasound is becoming an invaluable tool for tasks as simple as obtaining urine through cystocentesis, but thankfully ultrasound is becoming more widely used in general and emergency practice for FAST scans of free fluid and tumors, full thoracic or abdominal studies, and to aspirate or biopsy collections. Ultrasonography can be an important and rapidly growing profit center for your practice if you have properly trained users and quality machines.
Diagnostics is truly an essential part of veterinary practice, not only for best medicine and wellness screening, but also to drive continued improvement and growth within the business. We all know that great medicine generates great business. Our patients’ physical health has always been at the forefront for practitioners, but we are long overdue in protecting our patients’ emotional health as well.
On behalf of Bear and all other patients you recall while reading this article, tomorrow we will be better. I promise.