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 

Tactile learning with positive veterinary care - from learning to doing

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?   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.   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.      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

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!

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 ( drsophiayin.com)  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