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 

Why I tie- dyed my lab coats -  Stop  white coat syndrome in pets!

This little dog would only allow me to touch him without my lab coat on

Have you ever seen white coat syndrome with pets?  You know what I mean - the pet is calm, relaxed or even happy with the staff until the doctor walks in with the white coat.  I have seen this at my office, although the pets who have come in since  so used to rewards at the clinic from me as well as the staff, my uniform does not affect them much.  For other pets, the white coat means trouble.  Time for needles and poking around that is not fun.  When you remove your coat, the animal is less anxious. 

  We note on the medical record what pets have  white coat anxiety so I can remove my lab coat before I come into the room.  This has helped a lot  to keep the pet less anxious.   The problem now is,  how do I keep my clothes clean?  Personally,  I like the lab coat look for the doctor.  It distinguishes the doctor  from the rest of the staff.   So here is the quandary - how do I get the lab coat look without it  being white?  Would just a different color make a difference to these white coat syndrome pets?

In my search for non white lab coats, I found some  colored ones, and even rainbow tie dyed ones. They were too bold for my taste.  My tech suggested that I tie dye my old white coats  to experiment and make it kind of fun .  I have never tie dyed anything, but after reading a few crafting blogs on dyeing, it did  not seem  too  complicated.  I actually had fun doing it!

twisted up coat secured with rubber bands

I wanted to keep things as neat as possible and have a subtle dyeing effect.  The first coat I wetted down,  then using a paint brush I just brushed the dye, diluted to 2 ml dye to 1 pint hot water,  onto the coat.  I worked on this in a Rubbermaid under the bed storage box so the mess would be contained.  After I brushed the dye on, I let it sit in the covered tub for 8 hours, then rinsed it clean.  I had a neat, watercolor effect to my coat which everyone liked.  The second coat I used rubber bands to make the typical tie dye effect.  I used the same tub and a small squirt bottle to control applying the dye.  This one had more pattern but was still subtle. 

For others I twisted the coat around and held it with rubber bands - this has a star burst effect.   For these coats I kept the same ratio of dye to liquid but made a larger volume to soak the coat in. 

Use metal tongs to rotate the coats in the dye

   I began  wearing these coats, which  took a little for me to get used to.  I guess I am a traditionalist when it comes to lab coats.  I pursued, and  one day, a dog who is usually nervous for exams  was acting much better.  I was wearing the tie dyed coat and I noticed on the record this dog did not like white coats. I had forgotten to look at the record ( my bad!) and kept my tie dyed lab coat on.  He was much less anxious with the tie dye coat on.  I have made an effort to wear the tie dyed coats with white coat syndrome dogs and they are all acting a lot better. So now I have my solution - a lab coat that protects me,  and does not trigger anxiety in  the pets as much.  

A butterfly was born at my dad's funeral

June 10, 2014 my father John Foote passed away peacefully at his home in Jarman  Center Senior living, surrounded not only by his immediate family, but also a terrarium full of butterflies that lived with him in his final days.  These monarch caterpillars were gathered in from the outdoors to live and become chrysalis's  later to be released after emergence as part of the Monarch butterfly restoration project at Jarman Center.  Dad had released the first butterfly that was "born"   when the monarch butterfly restoration project started a few years ago. 

Dad is releasing the first butterfly born a few years ago

  To help put a positive spin on dad's final days, Cindy Pringle one of his care givers,  brought a terrarium with 5  developing caterpillars in to live in dad's apartment.  Dad was able to witness the first caterpillar actually transform into a chrysalis. All 5 of the caterpillars transformed into the chrysalis stage as dad declined.  By the time dad passed away, the first chrysalis was 6 days into the typical 10 day incubation period.  There were some hopes that a butterfly would be born before dad passed, but that was not to be.

Dad and I are admiring the j formed caterpillar ready to become a chrysallis

On the morning of dad's funeral, Cindy brought the terrarium to the funeral.  The chrysalis dad saw develop was just about  ready to emerge. She thought maybe it might happen at the funeral.  If not,  at least these developing butterflies could "attend" dad's funeral .  As Cindy said maybe it is wishful thinking to hope it will emerge, my sister Nancy and I said - " It will.  We just know it"   

The little  terrarium sat to  the side of the alter, just under the statue of the Virgin Mary .  I don't think too many people were even aware of it until my sister's closing comments pointed out the butterflies and how special it was to see the connection of dad's physical  transformation like the caterpillars.  We proceeded out of the church, following the casket down to the hearse.  As dad was loaded into the vehicle, Cindy ran outside and exclaimed " Sally, Nancy the butterfly is being born!"   I literally jumped up, and yelled at Tim the funeral director " The butterfly is being born!!  How fantastic" and ran back into the church.   Sure enough, there was the butterfly just hanging out of its old shell slowly unfurling it's wings.  Nancy grabbed the I pod  - I grabbed the laptop with my sister's family in Switzerland  on SKYPE, so they too could witness this miracle.   It was so wonderful to watch the little wings open up with friends  crowded around this little terrarium.  It only took about 6 minutes for the wings to fully open and to really see how beautiful it was.   The butterfly was invited to the funeral diner and  later that afternoon my sisters and I with residents from Jarman went to Wimple Park in Tuscola to release it.

Many of the residents came along for the release

Nancy, Barb, and myself with the butterfly at Wimple Park

There is an abundance of Milk Weed near the entrance to the park, by the small creek.  The butterfly  climbed onto  my sister's fingers lingering  for a few minutes before  resting on a nearby milkweed.  It was a female, fitting since dad had 3 daughters and 2 granddaughters as his offspring.  The butterfly flew off into the wind, strong, agile and knowing exactly what it was and where it needed to be.  

  This experience was so like my dad's  nature.  Positive, forward moving and in tune with nature.     Although dad is buried in Chicago, now I have a local place of remembrance also  filled with nature.   When I go here, I notice all the birds, butterflies and other creatures that make Wimple Park home.  It really helps me remember to be present in this moment with everyone I encounter.

 Maybe to some it was just a co incidence that the butterfly  emerged  at the end of the funeral.  I won't argue with them.    For me, I felt there was a reason for that timing, and it has been one of the most uplifting experiences of my life, helping me through my grief over losing dad.  As a veterinarian I have heard lots of stories from families about how their pets helped them spiritually.  One woman related how the family dog would find personal items of a daughter that had recently passed,  and bring them to a family member having particular difficulty with the daughter's loss.  This little dog was trying to help a person in grief take those difficult first steps of acknowledgement.  Another friend told of how the family cat laid with the dying elderly mother right up to the end, and then would not leave the body when the funeral home staff came.  The cat kept finding a way to get back in the room to lay right on the woman slowing down the transfer process as if on purpose.   Personally, I don't think any of these situations were just co incidence.

There are many more stories like these where animals - be they pets, butterflies or any other creature have appeared when someone  needed a  sign that a spirit is still here.  For many of us, this is a wonderfully strong affirmation of our belief in life after death.  Personally I don't think it is crazy - I think these connections of animals and the spiritual is  real.  The longer I am a veterinarian, the more often I witness that animals are angels among us.

Me and my dad

I hope for anyone in grief that you too have an affirming experience - your butterfly moment.   Be open to the world of nature around you, especially your pets.     I hope it gives you a sense of wonder and awe as it did me and my family.

Thanks, Dr Sally J Foote