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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