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Friday, August 18, 2017

Once bitten - twice shy Bite - near bite job stress in veterinary medicine

I recently attended the American Veterinary Medical Association Convention in Indianapolis.   This was pretty exciting for me as I was selected as a poster presenter for my  survey " Once Bitten, Twice Shy - bite/near bite job stress in veterinary medicine".    In addition to the poster presentation,  I  was also selected to lead a round table discussion on the same topic.    
Me and my poster at  AVMA  convention

Last summer, I ran a 10 question survey to veterinary  groups.  This was an effort  to gather data on our job  stress due to bite and near bite injury in small animal  practice.  As a speaker, I was often  asked by attendees who had been bitten, how to be less nervous at work.  In my research I found few surveys or research on this subject so I ran my own, independent of any sponsors or affiliations.  I have presented the findings at the Midwest Veterinary Conference in Columbus Ohio Feb 2017, and at my  Low Stress Handling Ce days in Tuscola Sept 2016. 
It can happen in a second - facial bites often creates the most stress on the job 
Creating the poster was a little bit of a challenge since I had never done this before ( !)  and the guidelines were very broad from the AVMA. So I felt  a bit lost creating the  poster.   Dr Paul Eubig from the University of Illinois College of Veterinary medicine was a huge help.  I present a  behavior lecture in his pharmacology course, and he responded to my plea for help.  Paul sent me a template,  gave  constructive criticism on my draft.  Nancy Oliver in the design group at Vet Med U of I printed  my poster with short notice,  and helped tweak the lay out as well.  A huge thank you to both Paul and Nancy.  I could not have had my poster ready without you.
The round table event was fun.  There was food, drinks and 30 different experts at tables to present a topic for 10 minutes,  then  lead discussion with the participants.  There were 3 rotations of 20 minutes each for the hour and a half of the event.  I had a full table at each turn, with different input from each group.   I presented this  summary of the survey results  which are as follows - responders were DVM, licensed tech and on the job trained with  over 5 years of clinical experience.  The scenarios for bite/near bite injury were greeting the animal ( 29% of injury risk)   Blood draw,nails, feet handling( 40.1%)  rectal, ear, oral, or painful exam ( 29%)  transfer while sedated (14%)
75% claimed the bite came without warning, yet 70% indicated that there were signs of anxiety and early aggression before the bite which was not recognized for the bite risk.
Methods to reduce job related stress included asking help from a co worker ( 55.5%) requiring use of muzzle, sedation or other safety measures ( 58.2%), or avoidance of fractious animals ( 36.4%)
42% reported prolonged stress post bite/near bite with an additional 33.4% who indicated stress" just for the day".
12% of responders consider leaving the practice they are at due to injury risk, with 1.46% leaving practice  ( career change) due to job related stress.
feline bites are common to the hands and arms often requiring hospitalization
From the survey comments, taking courses in less stressful handling,  behavior and having the support of the DVM for sedation and pre exam  medications is what reduced job related stress the best.  
Towel Wrap technique from Low Stress Handling text book by Dr Sophia Yin

At the round table discussions, there was  a mix of experienced DVM's, practice managers, technicians and veterinary students.  Much of our discussions centered on how to improve staff awareness of bite risk.  As one DVM stated " It seems they need to get bitten in order to realize there is  bite risk."  many agreed with this statement.  Taking the time to train new staff in handling and recognizing the body language of stress is also a challenge.   When a new person has been added to the  staff, they are  handling animals  before they have a received this training.  Ideas for training and handling protocols, was discussed.
Other points of discussion were how approach to the animal  when it is agitated, reduce travel stress and reduce the intensity of handling. The seasoned DVM's had the most input about the importance of not pushing through care. Many stated that it seems there is a focus on getting the task done, without paying attention to the animal's response so fear build and becomes aggression.  The veterinary students brought up how they feel a lack of preparedness for knowing how to reduce stress in an animal.  As one student said " So I can tell this animal is a yellow or red for stress, but what do I do now?"  

 In discussing  the technician programs,  while some are including behavior and low stress handling in the curriculum,  few are addressing handling aggressive animals in a less stressful way.   Considering the number of aggressive animals adopted out of no kill shelters, preparation for the aggressive animal is important. 
We all agreed more surveys  are needed to dig deeper into this topic.  At my poster presentation, people would wince at the bite photos,  acknowledging that these injuries happen, and we must have  more knowledge to reduce this.
It was a great weekend. I learned a lot, gathering ideas to write and create products  to help veterinary care be less stressful for patients, owners, and staff.    On a personal note, I was able to meet up for brunch with two of my Purdue suite mates.   We had a great meeting and it was hard to believe it had been 37 years since our "suite life" at Earhart hall. 
Jo Anne and Kathy - 2 of my old Suite mates from Purdue!

Wednesday, April 12, 2017

The cost of rough and tumble veterinary visits

Recently, a couple brought in their 2 pug dogs for check up.  I had not seen these dogs for care in a few years.  The couple moved about 3 hours north, and that would have been a bit of a drive for veterinary care!  Now the couple were living back in my area, and the dogs needed a check up.  " really bad breath - be sure to check teeth". was noted on one of the chart.  OK, dental exams are part of check ups so that would be fine.

The dogs were their usual happy, but  mildly anxious selves.  If you have ever  cared for a pug, panting  continuously is normal  for these dogs.  The pushed in face, small nose, long soft palate and big tongue makes creates a small airway.  This is the tricky part of examining  pugs, or any of the brachycephalic ( pushed in face) dogs for that matter.  When they start to fidget, paw, or struggle it can become very difficult for them to breathe.  Examination of the eyes, ears and mouth can be more challenging, because it  involves approaching them from the front.  Many dogs see  this as a threat, pulling away from the approach.   In pulling away, they start to struggle which causes them to breathe harder and pant more intensely.  It is more difficult for them to breathe now, so they continue to struggle trying to escape the restraint.

  In traditional handling, often a second or third person is called in to hold the dog  to  "just get the job done".   The dog will  become very agitated and even have severe difficulty breathing as they struggle.  Now the dog has  learned  to struggle for  any handling right  from the start.  The struggle is real - these dogs are fighting for air.  I am not here to discuss the breed, or breeding that created this health risk.   I want to have everyone understand from the animal's point of view why they resist handling in the first place, and how  traditional handling  creates a very rough experience.  Owners see this struggle,  and know it is not good for their pet.

Back to my story -  I reviewed the history for both dogs with my technician.  Both dogs were presented for nail trim, general exam and " bad breath" for one.  As I reviewed the history with my technician, she noted the dogs had not had veterinary care  since the last time I had seen them a few years before.  The breath was foul, and from the information that the dog did not want to play ball, or use the chew bones, she suspected  mouth problem had been present a number of months.  Why had they not sought care before this I wondered?  I put that in the back of my head and  entered the exam room.

I was  greeted by 2 active,  pugs  slathered with Adaptil ( mother dog calming pheromone) to help calm them in preparation for exam.  My technician knew the Adaptil helped these dogs be calm because we  a medical record system ( Bella Behavior Label System tm)  to record  the handling plan  for each patient.  We still had the medical records from years ago and the tech and I followed that plan  providing  a low stress exam and nail trim.  For the first dog, we used the calming pheromone, a cowl technique , and positioned the owner to continuously deliver baby food by syringe to her dog as I clipped the nails.  There was a little prancing at first, but with the right approach, rewards and low stress restraint the first dog was standing happily for care.
cowl technique - "Low Stress Handling, Restraint, et al" SYin 

When we started the exam on the  dog with the mouth odor, I could see he was more fidgety.  Fidget is a sign of anxiety and normal when there is pain.  Mouth odor usually equals dental disease and mouth pain so I knew I should be careful about examining his head and mouth.   We put the cowl on him and I used a pretzel stick  to lift his lip to avoid  excessive touch which would stimulate pain.
using a pretzel stick to lift the lip minimizes touch and pain 
 His gums  were inflamed with advanced periodontal disease,  to the point one of the first molars was just about ready to fall out.  He was always difficult for the owners to look in his mouth, so they could now see what was causing the foul odor.  I  carefully showed the owners the problem teeth, and the wife was especially upset that her dog was in pain and she had not realized the extent of it.  She could not see the extent at home, and had been in a quandary of what to do for him.    We set up his dental immediately, checked his blood work and started him on medication in preparation for the dental.

I was wondering why they had delayed care for his teeth.  They had smelled the bad breath, suspected dental problems for over 6 months but had not sought care.  My curiosity was not to accuse them of wrong doing but rather understand why they would delay care.  So I asked " From the records I saw that his last exam was from myself a few years ago.  Was it difficult to get him in for care at your new home or was there something else going on?  I was curious and just want to understand".  The husband immediately said " We could not find a vet who would care for them without hurting them. They were all too rough and I was not taking them back"  So I asked for more specifics and the wife added " They just called in more people to hold them harder, or took them to the back and who knows what was going on there.  Here you use the towel and some food and are kind in your care."  The husband added " If they are that rough around us, what are they like handling our dogs when we are not around."    I understood - they had seen the traditional handling which can often escalate fear and anxiety in our patients.  This couple had the money, had the knowledge of what their pets needed and were near a major metropolitan area so there were plenty of clinics around.  Yet despite that they lost trust in veterinary care due to their pet's experience.  

This had his dental 2 days later after being prepped with antibiotic and pain relief.  He had multiple extractions, deep cleaning and treatment to his gums for which he  immediately felt better.  Anesthesia went well and  we used calming pheromones in  cage, kept his area quiet and allowed him to go home early to reduce his stress.  The clients were happy that he was on his way to better health and that we cared for him in a way that was best for him.

The Bayer corporation ran a pet owner survey in 2011 which showed that approximately 35% of pet do not bring their pets in for care due to pet stress.  A repeated study was done in 2014 with not much improvement on this number.  As a veterinarian who has made positive veterinary care a standard in my practice, I am not surprised by these statistics.  I have had many seek my practice like this family because they saw the stress their pet was in during care and wanted to find a different approach.  Presently there is the  Low Stress Handling  tm Certification,  Fear Free sm Certification, and Cat Friendly Hospital programs to help veterinary staff learn specific ways to reduce stress and anxiety in care.  The text book " Low Stress Handling, Restraint , et al" by Dr Sophia Yin (  is the guide for all animal care professionals.  The American Veterinary Society of Animal Behavior has released a  positive veterinary care position statement.  I encourage all veterinary staff, trainers, groomers, and animal owners to read this statement and owners to seek veterinary professionals who follow these guidelines.  

Change is happening, and thank you to the  owners who make it clear that the animal's experience is essential to choosing  veterinary care. With vocal pet owners, more practices will embrace these standards .  Some veterinary clinics have followed this standards for years and I  applaud all of you. Practices new to  creating less stressful techniques, I am cheering you on as well.  I am especially thankful to the students who have taken the certification programs at the additional time and cost to bring this skill to the profession.  Hopefully it will become a standard for both  veterinarian and technical colleges.
Every day - Every way - Every patient keep it kind and low stress