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Tuesday, July 16, 2019

Advancing the art of veterinary medicine through essential handling skills


 Essential handling skills advancing the art of medicine
lidocaine cream to lateral saphenous, for a less stressful blood draw
observe, respond, integrate 


Veterinary medical education has been focused on evidence based, medical science for the last thirty plus years.  The advancement of ultrasound, radiology, clinical pathology and pharmacology from the 1980’s to present has provided this evidence-based approach to medicine.  Client communication is one of the social sciences in our curriculum to aid in client communication.   We have phone apps to help us wade through the sea of medical knowledge to treat these conditions.  The hands-on application of our knowledge, also known as the art of medicine, is currently weak in our education.  

The art of medicine integrates the observation of the animal’s behavior, response to therapy, hands on care, and knowledge of the home environment.   Listening to the client’s ability and needs allows creation of the treatment plan for this animal.  In short, the doctor takes all the science and puts it into real life use for this patient and family.  To observe the way an animal stands, walks, responds to in the clinic and at home is the foundation of animal behavior knowledge in veterinary medicine.
hands on examination - a comfortable environment, rewarding for touch, observation of patient response 

 
In our age of science, the intuitive skills of observation have fallen away from our educational experience.  Many veterinary professionals gain these skills through experience. Unfortunately, the experience is derived from increasing patient anxiety during care.   For example, the diagnostic exam causes pain; pain triggers aggression; the animal bites and must be sedated.  The sedation allows the radiograph to be performed; the radiograph displays   the severe arthritis that caused the pain that triggered the bite.   Now the veterinary professional has learned – pain increases anxiety which leads to aggression.  In future exams, more time is spent watching the animal move, and interact in the exam room.  Consideration of anxiety and possible pain before initiating care or diagnostics is now standard.  The patient’s behavior is considered with response to therapy as an option for care if performing diagnostics on this day would harm welfare, and all of this is communicated to the client.   This is the integration of knowledge that creates the art of medicine.

It is essential for all veterinary professionals to have the ability to observe and interpret the behavior of any animal presented to them for care.  From this knowledge the appropriate techniques for approach, touch and triage for care can be applied.   The interaction with the animal is where the art of medicine lies.   The number of colleges offering education in the fundamentals of animal behavior is increasing, yet most of us need to gain education through conferences, webinars, articles and certification programs. 

Presently, there are three major veterinary animal behavior programs focused on improving the veterinary care experience.  Each of these programs contains fundamental animal behavior education.  The effect of environment, correct reading of body language of anxiety and aggression, methods of approach and touch to reduce fear and stress are addressed in each program.   Expertise in specific areas of veterinary care provide the focus of each program.  It can be overwhelming to complete each certifying program.  Integrating the parts of each program, choosing which program best fits with your practice perspective is often best.  Sharing collaboration and referral to other veterinary professionals certified in different programs is also a good way to enhance patient care.

  In my experience as a veterinarian, speaker and educator I find that learning the core fundamentals of multiple programs helps me create a well-rounded approach to care.  I can think more critically about a situation and apply this knowledge efficiently.  My presentations often blend the knowledge of the three behavior based veterinary care programs to encourage critical thinking.  I head Dr Sophia Yin’s Low Stress Handling® Certification program.  I was a contributing author to the first level of the Fear Free® certification program and support the Cat Friend Practice® program.  My strongest foundation of knowledge comes from the Low Stress Handling® certification program, yet I would be deficient in applying this knowledge without the benefit of education from Cat Friendly Practice® and Fear Free® Certification. 
wet lab presentation at Humane Alliance Asheville NC 

Each piece of our education is a tool in our tool belt.  The fundamental use of these educational tools may be similar, yet there are special features that make each unique.  Recognizing this uniqueness is most helpful when it is uses properly without judgement.   Please be kind with your colleagues.  No one is less than another as they are learning these less stressful care skills.  Start with the essential skills and encourage your co workers to learn and expand in the art of veterinary medicine. 

I am presenting the Essentials of Low Stress Handling at Anti Cruelty Society in Chicago Sunday Sept 15.  6 hours CE. Register here  I hope to see you there! 

Sally J Foote DVM, CABC-IAABC    July 2019 


Friday, April 19, 2019

Dampening the Din - reducing noise through design in veterinary reception areas

Since I have sold Okaw Veterinary Clinic,  I have been creating webinars, speaking at seminars, and providing in clinic consultations to general veterinary practices.  The clinic consults are fun.  I call this my " Super Nanny" service.  Like the TV show,  I follow the staff around for the first hour to assess where they are  with Low Stress Handling skills,  where additional training is needed and any physical changes to the practice environment to reduce patient stress.  I present to the staff and demonstrate the Low Stress Handling skills that need polishing up, do some hands on coaching,  and will discuss cases.  I round out the day by meeting with the practice manager to outline what  protocols I will develop for this practice.  Email and video chat support is included in the consultation to support the process of staff development.
This is the back wall to the vaulted ceiling line, over the reception desk


  One of my " Super Nanny" visits was focused on a noisy reception area.   This clinic was advanced in reducing waiting area noise from the patients.   They created a " Kitty Concierge" service to prevent the  stressing feline patients  in the waiting area.  Special parking spaces were reserved near the front door, and a staff member would come to the car to directly escort the client and kitty directly to the exam room at appointment time.  Barking dogs were quickly moved to exam rooms or waiting outside to reduce patient agitation and noise.  The staff still noticed how loud one barking dog, even for a moment would be in the waiting area.   Even without any patient noise, the staff sensed a lot of reverberation of echo.  It was clear that there was something about the design of the reception area that was adding to noise problems.  This practice  moved to this newly constructed building less than 10 years ago.  A staff member commented that the " old building" was not as noisy as the new office.  High vaulted ceilings, covered in dry wall graced this new property.  The old property had typical flat ceilings with acoustical tile covering.
this is the free app from the National Institute for Occupational Safety and Health (NIOSH)


  I downloaded a decibel meter on my phone and took measurements at my visit.  In my pre visit research, I learned that noise over 85db  in an 8 hour day can cause hearing damage (OSHA guide)  Also spurts of noise over 115 db are painful, and can affect worker welfare.



 The waiting area had a high vaulted ceiling that met at a back wall to the reception desk.  With few clients in the waiting area, sound  measured  65  to 95 db   When I stood talking in a conversational tone with three other people, the sound increased to 90 db.  Upon showing the readings to the practice manager, she responded " Now I see why it is unbearable when just one barking dog is in here).  I discussed some general ideas for noise reduction and promised to research more solutions.

The very next day, I was at another clinic,  built 2 years earlier.  The lovely reception area had a peaked, vaulted ceiling, with many of the same hard reflective surfaces as the previous clinic.  I took out my phone and covertly checked the decibel levels.  This clinic was averaging 50 db and did not spike over 75db.  I commented to the reception staff that it was fairly quiet for a vaulted ceiling reception area.  The staff immediately responded " It was awful until we had the acoustical panels installed".  They pointed out lovely fabric panels, high on the walls that  absorbed the sound in the waiting area.   I took photos, and the the info of the installer which I  sent that night  to the other clinic.   It felt good to be able to use the experience from one clinic to help another.

 A closer look at the  fabric acoustical panels that helped with noise problems 
Last week I presented at a clinic in Kansas.  This property was about 40 years old, and the owner is planning on building a new clinic.  The present property has a vaulted ceiling, with ceramic tile floor, yet the noise level was generally low.  75 db was the highest recorded level, during  a busy time of  client traffic, phones ringing, and staff conversations.  I noticed the popcorn ceiling finish. This style is dated, yet absorbs noise better than plain drywall. The reception desk area had an 8 foot ceiling with acoustical tile, which also helped reduce noise there.  I strongly advised the practice manager to  review the design, focusing on  the reception area to avoid noise problems.   Many modern clinics are styled with vaulted ceilings, hard flooring, counter and wall surfaces which increase noise problems.  They look lovely but can literally create headaches for our staff and patients.

 The impact on staff stress due to  noise reflection is significant.   Various medical groups have  studied the reduced productivity of office workers due to  noise (noise studies ref).  Strained facial expressions in our staff trying to hear  a client on the phone, or talk to a client across the counter  affects the animals in care too.  Carefully considering the ceiling design, surfaces, and flooring before new construction or remodeling can save a lot of problems.

Solutions are easy and not very expensive for existing practices.   Acoustical panels range in price and effectiveness panel resources .  At first,  I suggest you measure  your noise levels.  Download a decibel meter to a smart phone or i pad at the office.  Measure and record at different times of the day to see the range.  If you have a large reception area, and are at high levels, hire an acoustical consultant and installer.  They can create a plan for you, working with your budget and needs.  If you cannot find an installer in your area, reading some of the info at the resources link above may help you create a plan for yourself.  Simple choices such as cloth upholstery for chairs over hard plastic, fabric wall hangings or canvas paintings are some solutions.   A combination of ideas can create the noise reduction you need.
A comfortable cloth chair, about $50 is an inexpensive furniture fix 

 If you are building new,  be aware that expertise in acoustics can vary.  In my experience, few builders understand  the levels of noise, the intensity of our work and the need for conversations in a practice.  An architect  specialized in veterinary clinical design tends to have this expertise and understanding.  Some of these architects may offer review services for building plans, if they are too far away.  Take time to visit  other clinics and measure the sound level in their reception areas.  Notice  the flooring, ceiling and furnishing choices, especially in the quieter offices.  You may be departing from a popular design style to not opt for a vaulted reception space, yet you may appreciate the quiet environment it helps provide.  One of my friends did these site  visits when he built a new practice building.  When I stopped by the  office, the noise level barely raised about 60 db.  Opting for a flat ceiling in the reception area was a departure from the popular style,  but an important choice for the function of the space.

I look forward to more clinic consults aka " Super Nanny" visits.  Meeting the veterinary staff, clients and seeing the change in veterinary medicine that incorporates the understanding the animal in front of us, right now for care is so exciting.  If you would like to know more about a clinic consult, please email me at dr.sally@mchsi.com.

Thanks!
Sally J Foote DVM, CABC-IAABC, LSHC-S




Thursday, February 7, 2019

Certifications - what's in a name?

yummy treats, wagging tails, padded tables - these is all part of
low stress veterinary care 
Over the past 7 years there has been a focus on creating a less stressful care experience at the veterinary clinic.  A number of  certification programs now exist to help both the practice and the consumer provide this experience.  I have witnessed the growth of the Cat Friendly Practice from the American Association of Feline Practitioners ( https://www.catvets.com/cfp/cfp  )  the Low Stress Handling Certification program from Cattledog publishing, the legacy of Dr Sophia Yin https://lowstresshandling.com/, and the Fear Free Certification program https://fearfreepets.com/my-courses/ . 

These programs are one way for veterinary staff to learn these skills. There are seminars, webinars, text books on handling and interactive handling labs as well.  A practice may approach bringing a less stressful care experience to you combining some of these resources - certified by a program or not.

At Okaw Veterinary clinic, a small animal practice in rural central Illinois which I owned, my staff and I created a low stress culture before these certification programs started.  Dr Yin was a friend, and asked if I would have my staff take her program to evaluate it and become one of the first clinics certified.  We did and it was a good investment of time and knowledge that elevated my staff's skills to a new level.  This program was intense in the behavior education and specific handling techniques.  The other programs covered material and standards that we already had in place, so it was not worth the expense to do these.  These are great programs, yet we were already at the certified level, so paying for these programs and associated costs was not going to gain anything for my practice in my community. 

As the 3 certification programs have become established in veterinary medicine, there is broad choice for clients to find practitioners who create a less stressful care experience.  I am also witnessing some practices becoming certified, only to  the branding that certification can bring.  It is a tricky business to be sure that one who carries a certification is following the standards.  You may find non certified practices following positive care standards very well.  

hands on teaching of Low Stress Feline handling 
So, you are a pet owner.  You want a veterinary practice that is competent with medical care, knows how to be nice to your pet, keeps their costs at an affordable level for you, has convenient hours, reliable staff, and a well maintained operation.  As a past practice owner, I can assure you this is no small task.  It became much easier for me to provide all these things as I took the steps to create a low stress clinic.  For some practices, the cost of certification and maintaining that cost may be a factor in whether or not you see any logos from certification.   In a more populated area, having this certification can make a distinction for a practice - a way for clients to choose and that is important.  In smaller areas, a practice may not be certified yet they may be providing a positive care experience.   Each program has a cost ranging from a one time fee of $330/person, to annual fees upwards of thousands of dollars per year in a large practice.  Some programs have corporate sponsorship and others do not.  So like anything else, there needs to be a return or value for the cost of the program for a practice to take part.  In a competitive environment, there may be practices who are certified in name only, to market themselves.

The good news is that all 3 of these programs are working towards the same goal - improve the experience of the animal in care.  As I say Every Day, Every Way with Every Animal - Low Stress.
There is a bit of overlap, so as a consumer or professional how do you pick?  I work for Dr Yin's company that publishes the Low Stress Handling Certification program.  I was an author for the Fear Free program.  When veterinary staff ask me "which one should I chose to take?"  I ask them  " What do you see as your primary need for reducing patient stress?  What do you want to focus on for your practice?"  If one wants to  improve the feline experience  - take the Cat Friendly Practice program.  If you have a large staff, and want to quickly provide  everyone with fundamental  understanding of fear, and the benefits of pre visit meds, take the Fear Free program.   If you need  improved handling skills for the animal in care, with less dependence on pre medication, take the Low Stress Handling program.  There is overlap to these programs, and if a practice is certified in one, there are resources, articles and educational materials that are available to blend some of the advantages of each.  In the end, it is the experience for the patient that matters most.

As a consumer, how do you choose?  I suggest you look at each website's directory of certified professionals as a start.  No matter if you find a certified professional or not, always  ask these questions when investigating  the clinics in your area.

Do you do everything in the exam room or take them to the back?    Providing care in the exam room is the best way to provide a positive experience.  If they always " go in the back"  that can increase stress.  Find a clinic that avoids this.

Do you provide treats for my pet or should I bring my own?  If the clinic is surprised by suggesting food for exams, they are not a low stress practice.  You can also ask about bringing a toy or favorite blanket - the attitude should be one of appreciating your efforts to reduce your pet's stress.

Can we split up care if my pet is getting stressed?   You should hear a plan for the most important care first, with an eye for possibly splitting up care to help prevent increasing fear.  The days of "getting it all done " are not the focus now.  Taking care of the most important needs, while keeping it pet friendly is the focus now.

Does certification matter?  Yes, but it is not everything.  The particular  program is not as important in my opinion  compared to  holding  the standard of less stressful care.  I have seen non certified practices holding a higher standard than those certified.  In the end, it is the care experience that matters - does your pet like coming in? Are they  becoming more calm and relaxed with every exam?

 Helping your pet have a positive veterinary  experience requires your participation as well. Every practitioner involved in low stress care encourages happy visits, where  your dog gets a quick treat at the reception desk,  can step on the scale, get a reward and go home.  You are encouraged to keep your cat carrier out in the living room to help your cat like it.  Being open to giving your cat  supplements and medications to reduce anxiety for your helps tremendously.

I hope this articles helps you with providing or receiving a kinder,  positive experience that is centered on knowing your pet.

A favorite photo of me, Butterscotch and Bella outside Okaw,  which has passed on to Dr Kyla Kuhns, an
excellent veterinarian.  I now travel speaking, consulting and creating webinars to continue
build the low stress veterinary care experience  





Sunday, January 13, 2019

Cool Cat Room at Indy Humane

The wonderful staff at Indy Humane who helped make my
Essentials of Low Stress Handling Seminar possible 

I traveled to Indianapolis last week to present a full day seminar on Low Stress Handling at Indy Humane.  Colleen Benson, director of shelter behavior,   gave me tour of the facility when I stopped by the day before my event.  Indy Humane is the central Humane society of Metropolitan Indianapolis.  The facility has grown since  the founding in 1905,  with  a vaccine clinic, behavior program for dogs and cats, and assists  other humane societies by taking on transfers .

As I walked into the seminar room,  I noticed that someone was painting small crates a lovely lavender color.  Colleen then explained Dr Liz Rose, one of the shelter veterinarians,  was busy hanging shelves, painting the crates and creating an enriched space in a second feline open room. I met Dr Rose, drill in hand, working away transforming a basic room into cat wonderland.
Like Vanna, Dr Liz Rose  points out the optimal spacing for cat launching
from shelf to shelf 

This central room, which is kind of a traffic zone for staff , was needed to create more space for the well socialized cats to play while they were awaiting adoption.  Brett Kruger, the feline behavior lead  recognized the need for extra space and worked with Dr Rose on the design. The ideas implemented here, using  color and fabric are not difficult to use in your home if you have a little time, money and are a bit handy . 
A simple wall hanging using the custom fabric
in the signature lavender color and logo 
 Lavender is the signature color for the humane society.  It is appealing, and easy on the eyes for both humans and cats,  so it works well in the décor.  I loved the fabric.  I am not sure of the specific company Indy Humane used, but I found  https://www.spoonflower.com  as a resource.  Fabric was custom printed with the color and logo of the humane society. I saw this fabric in other areas, such as the  cage covers for the the cat habitat cages.  This controls contagion from upper respiratory disease, they are easy to wash, and livens the decor up in the ward areas.  


easy cage covers to control
congation 


 One wall has many shelves strategically placed  for stepping and jumping between them.  This is important – watch how your cats stretch, and the space and height between shelves to be easy for them to navigate.    The bridge over the office doorway is creates the  “ off the floor runway” most cats want.  Central  floor areas  can be a competitive traffic zone,  so having the ability to walk around the room off the floor is essential in an enriched space.  The litterboxes are located here , so providing this off the floor runway also reduces the “ stare down” between cats when the box is in use.  
bridge for a cat runway - note the crates
pretty and functional 

The cubbie organizer shelving units are great and can alternate between cat storage and actual product storage for the area.    The pretty lavender crates so carefully painted the day before, now hung from the walls near the shelving areas.   These crates provide that hiding space but with some peeping cracks so the cat can see out.  I love this idea – they can hold the weight of the cat, are lightweight themselves, and can be painted or stained to match the décor of the home.  Tee pee tents, cat trees and an open floor space round out the enrichment area. ( picture)   There is plenty of room for people to go about their work, for the cats to be safe and happy.
nice tee pee, scratching pad - they can be moved
about as the cats like 


 As far as costs go – I did not ask, but looking at the crate, shelving, and cubbie cases I would estimate it was under $200 for all the materials new.  You could save some money by asking at a construction site if you can take scrap shelving or go to a Habitat for Humanity store for materials. Not handy with a drill?  Maybe a friend can help or a few hours paying a  handy person.  With your plan in hand, it would not take more than a few hours to get everything up and in place.   If you do not sew, use fleece for cubbie and shelf pads. Fleece does not fray,it  comes in all sorts of patterns and colors and cats love it.  Staple guns and hot glue guns make quick short cuts of creating framed wall hanging, and upholstered pads. 

 I post hope this gives you some ideas for creating a “ Cattastic” space in your home.  Cubbies, shelves and runways can resolve a lot of cat problems in a home.  Enriching the home does not mean it has to look like a cat house – it can be fun and creative for both of you.  So, share some of your stories of how you made your home more enriched for your cats – I would love to see your creativity!
Ranger, my office cat now retired loved his perch at our office of course with all his toys! 
  
Take care, 
Sally J Foote DVM                                                  Jan 2019 


Sunday, December 9, 2018

How to get the bouncy, rowdy dog calm for exam

The bouncy, fidgety, active dog in the veterinary exam room

I have been posting some Face book live events at Low Stress Handling of dogs and cats face book page   for the past two weeks.  We have had some great ideas and I am   answering the comment requests as they come in.    About a week ago, there was a request to show how to handle the bouncy, active but happy dog presented for care.   This is a common situation in veterinary clinics and shelters.   Often there is no time for clicker training, or setting up training visits, and you have to provide care that day.  So the question was how does one get this dog to calm down, especially if the dog is not medicated, and cannot be rescheduled?

The scene is this -  you have a happy,  very animated dog who is jumping up on you, taking treats  in a grabby way, and full of life.  We all value this happiness, but  the dog becomes more agitated when held, or an examination begins.  The caregivers - DVM or technician need to do their job, but the touch  can increase agitation which can result in the dog flipping it's head and aggressing.  What the heck is going on here????   The dog seemed happy but now he is biting me?

targeting to a bowl with shoulder hold - less agitation with focus 
It is important to understand That there are four F's to anxiety.  Fight, Flight, Freeze and Fidget.   Some of this bouncy, rowdy agitation is fidget.    The dog may be bouncing between approach for treats and avoidance of  exam.  The anxiety stems from sensory overload at the clinic from people, other animals, smells and noises.  It may also be from a memory of firm restraint to limit the bounciness as painful injections are given .  An  approach - avoidance behavior unfold before you.  The dog may also be grabbing the treats, and indication of lack of impulse control.  In short - the dog is over the top with joy, resulting in a lack of the ability to slow down mentally to carefully approach or accept a food reward.    The dog grabs and increases agitation due to the desire for the item.

All of this physical animation increases adrenaline, the fight or flight hormone.  A dog may not be negatively stressed but  bouncing around  so much they are preparing their body and mind to react.  That is why when you start a non painful exam with a  stethoscope, they flip their head and try to snap.  That touch is the one extra stimulus on an already amped up body responding with fight.  While a stethoscope is not  threatening, the touch is enough to be the added stimulus to have the dog react against it.

cowl hold to minimize handling but safe for the dog and handler 

reward directly to the dog's mouth, with cheerio sized treats 
How does one handle dogs like this? You want them happy but you need some calm for the exam.  Knowing the Low Stress Handling specific collar holds or cowl holds are essential to handling dogs like this.  Secondly, have  paper bowls with spreadable rewards like baby food, squeeze cheese, or liver paste immediately available for targeting.   Now  you can lure the dog into position and mix classical and operant conditioning to condition calm body postures for exam. 

Be aware of what ramps this dog up.  Often, people coming in and out the exam room door adds to the agitation.  Bring the dog in the room after you have set up all the needed medications, vaccinations and items for examination.   Every time you open and close that door, the dog may run to the door, jump up at you coming in and out.  You can leave the door open to avoid the opening and closing stimulus. 

Do not allow the dog to investigate the room.  Keep the dog on leash,and limit the amount of area that the dog can pace or wander around.  This limits the physical agitation that starts the continuum leading to handling aggression. (1)    In my office, we had a carribiner clip to attach the dog' s leash to to help hold that dog in place.  If the dog has a flexi style leash, have some thick nylon 6 foot leashes to attach then tether the dog. 

 If the owner is not helping the dog to calm,  have the technician take the dog from the owner and start rewarding for calm behavior.  Small tidbits of treats taken softly for sitting or standing calm can immediately be instituted.  A food puzzle held for targeting when sitting then removed when any focus is broken can also be immediate target training that will help the dog to calm.    This often demonstrates to the client how to handle the dog at home for times when the dog is agitated.

Use the mother dog calming pheromone - Adaptil immediately.  About 5 sprays on a bandana applied in the waiting area and re applied in the exam room will calm the dog within  5-10 minutes.  Diffusers are helpful,  but do not work as quickly as the spray.   Target to  a bowl and lure the dog into place.  The staff must know the collar and cowl handling techniques to minimize the amount of physical contact with these dogs.  Often, dogs of this nature have had 2 or more people holding them down forcefully to restrain.  Many dogs like this are  not conditioned to struggle against body holds, so you must have a lower amount of hands holding them but some point of restraint for safety.  If you increase the amount of holding, often the dog will struggle against the restraint and aggress.
With these dogs you go the opposite direction with handling - have an anchor such as a collar hold or cowl hold but less physical restraint.  Use a target in addition to the collar hold to focus the dog's attention away from the examiner and stimulus of any injection. 



The Low Stress Handling certification program goes into specific details of positioning dogs like this, how to handle them on leash to lead them for exam as well as positioning them for radiography or blood draws.  All of these situations are high risk for aggression because the dog is physically primed for reacting.  In the " less is more " approach, you need to have a hold on these dogs but one that is not forceful.    The Low Stress Handling, Restraint and Behavior Modification of Dogs and Cats by Sophia Yin DVM covers these techniques.   This is a youtube video demonstrating how to use the cowl hold in a dog. https://www.youtube.com/watch?v=z5L6f9f365M&t=101s

Please join me at low stress handling of dogs and cats on facebook.  I am hosting weekly facebook live events to demonstrate ways to reduce stress to dogs and cats in care.

Thanks!
Sally J Foote DVM



https://www.psychologytoday.com/us/blog/canine-corner/201801/can-dogs-suffer-adhd

 https://pethelpful.com/dogs/Understanding-Sensory-Overstumulation-in-Dogs 


Sunday, November 26, 2017


Dancing around thresh hold
I have recently returned home from a week of presenting at  the Veterinary Congress of Quebec,  and to the Pet Professional Guild in Orlando Florida.  At both conferences, I educated on less stressful handling during veterinary care.  The Quebec audience was veterinarians and veterinary staff while the Orlando audience was primarily dog trainers and other non veterinary animal behaviorist who also offer counter conditioning animals to veterinary care.

In french - translation -  less stressful handling of companion animals 
 One concept that I needed to emphasize was knowing the thresh hold for panic or aggression for the animal in front of you, in situations.  For example, for a particular dog, the prick of the needle for an injection may be the trigger that causes this dog to stop taking a reward and start to struggle.  This dog may be eating treats, relaxed but as soon as it sees the veterinarian moving close and feels the needle, then snapping, or lunging occurs quickly.  It is difficult to counter condition a trigger so deeply related to fear so how can one administer needed care, like a rabies vaccination, or insulin injection?  Knowing this animal's  triggers to anxiety and understanding this animal's signals are  individual.   Yes, it is best to reschedule an appointment using pre exam medication but at times this is not feasible.  If the patient is vomiting and needs an anti emetic injection to control vomiting, or an overdue rabies vaccine on a dog with a bite history - that will need to be taken care of immediately.

 So,  how do I keep care  low stress knowing the injection will cause stress?  The answer is keeping the care short and sweet.  You remove as many stressors as you can, giving rewards to counter condition for all parts of the exam and when the moment of stress comes, you give the injection quickly and remove your hands and move the dog away praising and giving rewards from the handler, then the vet to help them settle.  You have crossed over the threshold for aggression, but quickly removed triggers to help the dog come down below threshold and take the reward.   This stimulus - stop - reward  is dancing around threshold.

Allow the handler to evaluate, communicate and reduce escalation 

I call this technique dancing around threshold ,because it is like stepping  over and under the threshold line.  The action is quick administration of stressor, then removing the stressor,  to bring them down.  You wait a few minutes with reward to prevent further escalation,  before another stimulus .  Think of some one doing the cha cha where they step forward and back over an imaginary line.   This technique is reserved for needed care, not elective.   It takes clear communication between the handler and the person administering an injection,  to co ordinate rewarding then watching the body language of the animal as the care administrator ( veterinarian or other technician )actually gives the injection. If we sense  the animal will snap, the handler will quickly hold the animal as the injection is given, then lead the animal away or give  a rewards as the veterinarian moves away for a few moments,  The key points are that the stimulus has to last less than 1 second, and the time for hold - stimulus - release - reward or lead away had to happen in less than 3 seconds.  So this is fast work.    Just like in dancing you are moving back and forth around the threshold line, not staying on the high side very long.

What is good about this technique is that the animal learns that the high stress point is going to be short, they are not stimulated to escalate up the ladder of aggression from where the present high point is, and the warnings they show us are heeded for reducing stress and anxiety.  By heeding these warnings, the animal learns to warn and give more time before escalating to panic or biting.

Knowing the animal in front of you for their triggers, and their body language is essential.  Even if you are  not certain if a nervous animal will escalate higher, bet on the side of fast escalation. So keep the stressor short and sweet with lots of rewarding before and after.  Understanding that both the handler  and care administrator must communicate that the animal is approaching thresh hold is of utmost importance.  If the threshold for panic or aggression is not recognized, and the animal is triggered for more than 1 second, it will escalate - you are taking too long and are forcing the animal to react.  This is a video of a dog who is nervous but we keep the actions short and sweet that would trigger him up to panic  . video of nervous dog dancing around threshold 


 Clear understanding of the animal indication that it is over  thresh hold takes experience and education.  The lab 3 and 4 of the Handling, Moving and Restraining modules of the Low Stress Handling Certification program demonstrates this very clearly. Dr Yin works with an aggressive dog pointing out the threshold for stress during a counter conditioning session.  For many pets, they may shut down just arriving at the veterinary office.  If care can be rescheduled, then have a house call for this pet.  Another idea, is to do the exam or care in the car or grounds outside the building.   As a practitioner in a rural community, I have seen many a farm dog less agitated in the bed of the farm truck for exam or vaccination or standing on the grass outside of the building.  It may seem crazy, but I had yellow Lab patient who would be very nervous in the waiting area, and attempt to aggress in the exam room.  Outside, he was calm and happy.  So I would do his exam and vaccinations standing in the grassy area to the side of my building.   When he needed more advanced care, I would give him the sedation injection outside and then take him into the building when he was sedate. It may have looked weird to see me outside listening to a dog's heart , or giving a vaccination but it prevented this  dog from escalating. I was willing to make it less easy for me  for the dog's benefit.  That is what I like about reducing fear and aggression during veterinary care -  you get become  creative in  handling, see a more relaxed patient and deliver more care.

Quick use of a blanket to hood allows an injection to be given with less stress then move the dog away and reward immediately


Dancing around threshold is a skill that veterinarians, technicians, assistants and trainers must learn to prevent escalation of anxiety and stress during needed care or events.  Understanding this animal's body language for escalation, how to block or minimize the trigger to stress and work quickly to lower the stress through rewards and movement away from the trigger is an essential skill.  I look forward to hearing from my readers and attendees to  know how they are starting to use these skills
Thanks
Dr Sally J Foote DVM 

Sunday, October 22, 2017

Tactile learning with positive veterinary care - from learning to doing

ranger and  Emily
Hands on practice only takes a few minutes

 As I am leading handling labs in Low Stress Handling, I have come to realize the tremendous impact hands on learning has to actually feeling confident using Low Stress handling techniques.  This type of learning is also called tactile learning - because you literally feel the process of what you are learning.  When I think about providing health care to animals, it is primarily based on touch.  One must touch an animal to lead them to an exam area, to listen to their heart,examine their skin, look in their mouth and more.  For many of us, touching the fur, feathers or scales of an animal is very calming to ourselves.  This is part of what attracts us to veterinary practice, shelter care or training.   Through Low Stress Handling, we can now be more aware of how we provide a calming effect through our touch to any animal.  The knowledge  of an  animal's body language, past and new memory,  physical and emotional health lay the foundation for delivering low stress care.  The next step is actually handling the animal using this knowledge.  
 
That is where the handling labs come in - the opportunity to actually try out the knowledge you have gained from seminars, webinars and certification programs.  As I am leading these labs to various groups, I am realizing some important elements to have in place for a good learning experience.   This list is based on my experience training faculty who are certified in Low Stress Handling, staff at a large shelter who while not certified have been using the skills, and general veterinary staff who are starting to learn to use these techniques.   While this is a diverse range of students,  there are some common needs in learning  to feel confident to use these skills:  
 
Technique check Am I doing this right?
teaching blood draw  
technique points for low stress jugular blood draw
  - students need a coach who actually uses these handling techniques, and directly observes the student for hand placement, body position and approach.  The coach needs to think  of ways to adapt these techniques based on the animal's body or the handler.  In leading a session,  I found reminding the students of the anatomical points of placement  for head holds, cowl holds, blood draws, or positioning from standing to lateral and had them compare touching on their own body these points. That small step helped them recognize how important bony points are in handling and not holding against soft tissue.  This  improved their confidence immediately.   As I would see the " gaposis" as I call it - arms splayed out along side a cat in a towel wrap where the cat might wriggle free - then move the handlers arms in and remind them to close the gap - BINGO!  They understood how thier body placement of both the handler and animal  mattered.   I use the Low Stress Handling, Restraint, and Behavior Modification et al book by Dr Sophia Yin  as my guide, as well as some of the instructional DVD's from Cattledog publishing.   With these resources at everyone's side, they too can quickly look up a point for review and use these resources at home.  
 
Stuffed animals - fun support from  peers.
having fun in handling lab  
Laughing is part of handling labs
  When you have a stuffed animal you have the security of knowing if you mess up it won't hurt anyone.  You have peers who are also practicing technique first on the stuffies then moving onto real animals. The group collaborates, sharing how the holds and  body placement feels and what they find works in their situation.  It is safe to make  mistakes and even the most skillful will share what they find difficult.  With the live animal in this practice environment,  the stress is off if you miss the vein on a blood draw, or the animal is escalating  and you are not recognizing it.  Certified coaches  will kindly point it out an  alternative approach for the second try.  Often here is where fellow students  will share the stories of animal stress escalation that they did not see or appreciate.  Now they can see it, the coach can point out what touch,noise or is particular to this patient has been part of the escalation to make a better handling situation.  I love these moments because it is like we are all on even ground learning in the moment.  
 
Special situations - Not every practice, shelter or animal care setting is the same. Often we discuss  ways to organize space, or manage an animal holding area to decrease stress.  With each presentation, I have found more and more ways to help animal care providers create a less stressful handling situation based on the behavior knowledge that is the foundation of Low Stress Handling. It is when the students are sharing ideas and stories that solutions are thought of and tried out.  Staying in contact with these students to hear how the ideas work out is what continues development of more Low Stress Handling techniques.   
spay scar check  
figuring out a less stressful way to check for spay scar
 
I will be leading a handling lab at the Illinois State Veterinary Medical Convention in Lombard Il November 3.  The lab is full, but I am working on dates for handling labs in 2018. Below I have a survey I would like for you to fill out.  There is an opportunity for me to develop a place to have handling labs in an actual practice setting.  We would have lectures, and practice animals in exam rooms, treatment areas and run areas just like a practice.  The point of a space like this would be to learn in a space that is close to where you actually have to do these skills - in a practice.       
 
Thanks !  
Sally J Foote DVM CABC-IAABC