Tony Johnson, DVM, DACVECC Let’s just get this right out of the way first: animals feel pain.
They have different pain tolerances, just like people do (if I step on my pit bull Gwen’s toe, she never notices, but if I accidentally do the same to my Pomeranian, Turley, she’ll scream, run and hide, and not speak to me for days) but sensing pain comes hand-in-hand with having a complex neurosystem and a big brain.
The challenge for us as veterinarians is how we detect and react to their pain.
To address the complexities of animal pain and its management, the International Veterinary Academy of Pain Management (IVAPM) has declared September to be Animal Pain Awareness Month. (https://ivapm.org/animal-pain-awareness-month/) It’s also Pain Awareness Month for another group of big-brained animals – people.
Treating animal pain will always involve some guesswork until someone develops a way for dogs and cats (and horses and iguanas, etc.) to point to their anatomy and say “It hurts right here, doc.” Until that beautiful day, we have to tease out the sometimes-subtle signals of discomfort and adopt a trial-and-error approach, backed up by science whenever possible.
As an ER clinician, acute pain is what I deal with most. I do see animals with chronic pain, and try to help whenever I can, but for those patients I encourage pet owners to seek the counsel of their family veterinarian, since chronic pain will take a solid partnership spanning weeks or months – things that are impossible in the rushed setting of the ER.
With that as preamble, I’ll share some tips from 25 years of ER pain management.
If a condition is known to be painful, treat for pain. Blocked cats are painful. Pancreatitis is painful. Pyelonephritis hurts. Some diseases have pain baked in, and treating pain should always be part of the initial management plan, yet I very often see pets with diseases such as pancreatitis and urethral obstruction go without pain medication. Until the disease has calmed down, assume pain is present and treat for it.
Recognize the signs of pain. Is that cat sitting at the back of the cage hissing because he is afraid, or is it pain? Is the usually sweet and slap-happy Golden now snapping at the kids because his ears hurt? Recognizing an animal in pain is an important first step in managing pain. A trial of pain medication (perhaps even combined with appropriate sedation) can help tease out the complex web of animal pain responses and decrease the fear, anxiety, and stress of painful conditions and hospitalization. Using a validated pain scale (available at https://ivapm.org/, and many other places) can also help to quantify and track pain during treatment.
Use the right class of medication for the disease. Let’s look again at blocked cats and patients with pancreatitis. A blocked cat who is non-azotemic and going home might benefit from an NSAID used cautiously. A blocked cat with a K+ of 8 and a creatinine of 4? The medical board will be knocking at your door if you give an NSAID.
Same holds true for a dog with raging pancreatitis. If he’s vomiting every time the wind blows, an NSAID will only make matters (way) worse. Opioids have minimal GI effects beyond constipation (which I have not seen as a major problem), and we use tons of opioids in the ER and ICU to manage pain. Our brains (and those of our patients) are hard-wired to receive opioids – it’s a gift from evolution and nature. Use it.
Why do brains have receptors for chemicals produced by a poppy largely grown in the Middle East? I have no idea, but for the sake of my patients I am thrilled that they do, and I make use of it every day I am on the clinic floor.
The opioid crisis has certainly made giving opioids a challenge, with increased regulation and paperwork and changes in the supply chain making some drugs unavailable. Try to keep abreast of what’s on and off the market and do your best to make sure you always have a few options for good pain control on hand. I think every hospital needs to have a full mu agonist such as fentanyl, morphine, or hydromorphone on hand for treating severe pain. Butorphanol is great as an adjunct for sedation for minor procedures like lacerations, but it’s just not potent enough for cases of moderate to severe pain.
Sometime more is more. Treating pain with multiple different approaches can result in better pain control and lower doses of any individual medication. Using a lidocaine sacrococcygeal block to help unblock a cat, combined with a full mu agonist like fentanyl, or an opioid agonist/antagonist like buprenorphine, can treat pain from different angles, as well as make unblocking easier.
Look for creative ways to address pain, using different techniques such as local blocks, epidurals, and topical lidocaine patches. Combining classes of drugs such as NSAIDs and opioids, in carefully selected patients, can achieve results that higher doses of either drug can’t achieve.
I have found that learning new techniques can be a great way to fend off burnout and makes me feel as if I am growing as a clinician. Learning new pain management skills aids me in fulfilling my obligation to alleviate animal suffering. Enrolling in CE classes, attending online seminars, and even brainstorming with colleagues can open new worlds to the clinician who wants to learn and grow. It can also make great financial sense to a practice, as owners now accept and even expect advanced pain-control modalities.
The IVAPM offers consultations in pain management and pathways to become IVAPM-certified as a pain management practitioner. (More info at https://ivapm.org/).
We all want our patients to live long, pain-free lives. Learning about pain and learning new ways to manage pain and recognize it will serve our patients better and help us grow as doctors and people.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Dr. Tony Johnson, DVM, DACVECC, is a 1996 Washington State University grad and obtained board certification in emergency medicine and critical care in 2003. He is currently Minister of Happiness for VIN, the Veterinary Information Network, an online community of 75,000 worldwide veterinarians, and is a former clinical assistant professor at Purdue University School of Veterinary Medicine in Indiana. He has lectured for several international veterinary conferences (winning the small animal speaker of the year award for the Western Veterinary Conference in 2010) and is an active blogger and writer.
Alison Gerken, DVM, Lisa Radosta DVM, DACVB, Tamara Grubb, DVM, PhD, DACVAAHetch-Hetchy is the sweetest, most affectionate cat I have ever known. For the past 12 years, he has seen me through veterinary school, my father’s passing, my marriage, and most recently, a cross-country move to start a veterinary behavior residency. This guy has been the most devoted, loving companion, but he is not the bravest of souls. When Hetch goes in for a veterinary visit, he often leaves with a urethral obstruction (UO). While not fractious at the veterinary hospital, he becomes very stressed and has an impressive ability to wiggle out of any restraint.
The stress of veterinary visits frequently resulted in urethral obstructions for Hetch.
Hetch has had myriad health issues over the last year, necessitating four hospitalizations and at least 10 veterinary visits. Fortunately, pre-medication at home with buprenorphine and trazodone in addition to a quick injection of alfaxalone at the hospital has allowed for almost effortless hospitalizations and has prevented further UOs. Hetch had never needed to be boxed down.
When Hetch recently needed an anesthetic procedure, I researched veterinary specialists in my new area and dropped him off at a trusted specialty hospital. I reminded the staff that Hetch blocks when stressed and attached a note to his carrier requesting that I be called if he became stressed. I thought I was doing everything right to prevent another UO. However, when I picked Hetch up from the hospital after his procedure, I found my normally mellow cat panicking inside his carrier. When I inquired as to why Hetch was so distressed, I was astonished to learn that he had been “boxed down” that day. In other words, rather than being given a fast-acting injectable medication to induce anesthesia, he was stuffed into a box that was then filled with anesthetic gas – a prolonged and stressful way to be anesthetized.
When we returned home, Hetch began vocalizing and walking in and out of his litterbox. I panicked when I realized we might be facing another UO. Fortunately, Hetch wasn’t blocked, but for days after that veterinary visit, my normally social, loving kitty hid beneath the bed and barely ate. He was traumatized, and the only difference in that visit from all of his others was that he was boxed down. Not only was I incredibly saddened to think of my own cat being subjected to the inhalant chamber, I was also deeply troubled to learn that inhalant chamber use is not uncommon in veterinary medicine.
Why “Boxing Down” Animals Isn’t a Good Choice
Most of us who have been practicing for longer than a decade have used inhalant chambers to “box down” feline patients. It seemed to work, and the patient was able to be treated. Why throw away a potentially useful sedation protocol? Because the use of inhalant chambers or masks (also called “boxing” or “masking”) for sedation or induction to anesthesia is not considered standard of care for a number of reasons. (We should note, however, that mask sedation is commonly used for birds.)
Use of inhalant induction can be dangerous to pets.
In a study on anesthetic risk for death, Brodbelt (2009) showed that inducing and maintaining patients on inhalants alone added to the risk of anesthetic fatalities. The risk is secondary to the high dose (high percentage setting on the vaporizer) of inhalants required to achieve induction.
Inhalant anesthetics are appropriate for maintenance of anesthesia but not for induction.
The high dose can cause dangerous physiologic changes, such as hypotension and respiratory depression. In addition, mask or inhalant induction requires a prolonged period with an unprotected airway (i.e., no endotracheal tube) with an increased risk of airway compromise or obstruction. Because of this, inhalant induction can be dangerous in any animal and is contraindicated in brachycephalic animals.
The excitatory phase of anesthesia (Stage II; Table 1) is exaggerated and prolonged with this type of induction, further increasing the dose necessary to achieve induction. The excitement causes a release of catecholamines, which may cause tachycardia, hypertension, and hyperventilation and may increase the risk of arrhythmias and/or cardiopulmonary arrest.
Once the patient is induced, a higher concentration of inhalant is required for the maintenance phase of anesthesia when compared to the dose of inhalants required to maintain anesthesia in patients who also had premedications or injectable induction drugs.
Use of inhalant induction can be dangerous to humans.
The veterinary healthcare team and any pet parents who are present may be potentially exposed unnecessarily to anesthetic inhalants. No matter how tightly the induction chamber is sealed or the mask is fit, it is never totally leak-proof. There will be contamination of the environment with the inhalant gas. Although not consistently linked, health concerns due to exposure to anesthetic gases have been shown to range from reproductive effects such as spontaneous abortion (Shirangi et al. 2008) to genetic damage (Cakmak et al. 2019). OSHA states: “The waste anesthetic gases* and vapors of concern are nitrous oxide and halogenated agents (vapors) such as halothane, enflurane, isoflurane, and desflurane. Some potential effects of exposure to waste anesthetic gases are nausea, dizziness, headaches, fatigue, and irritability, as well as sterility, miscarriages, birth defects, cancer, and liver and kidney disease.” (https://www.osha.gov/SLTC/wasteanestheticgases/index.html)
*Waste anesthetic gas is inhalant anesthetic gas not metabolized by the patient and is exhaled back into the breathing system. It should be evacuated from the anesthetic machine by the scavenging system. Unfortunately, the gas often leaks from the machine or breathing system, causing environmental contamination and human exposure.
The view on dangerous results related to use of chamber inductions in animals is shared by both veterinary and human-health experts:
“Chamber inductions should never be routine but rather a ‘last resort’ and only when other approaches have failed.” (Robertson et al. 2018)
“Mask or chamber inductions can cause stress, delayed airway control, and environmental contamination and are not recommended by the authors.” (Grubb et al. 2020)
“Chamber induction in unpremedicated, agitated cats is the least desirable technique described in these Guidelines, since an agitated cat will require more inhalant anesthetic to achieve the desired endpoint. This increased inhalant anesthetic requirement results in severe depression of the cardiovascular system. Additionally, an increased release of catecholamines predisposes the cat to development of cardiac arrhythmias.” (Robertson et al. 2018)
“The use of an induction chamber with gas anesthetic as a method of restraint may mean less control of the patient’s airway and raises concerns about other safety issues for the cat and the staff.” (Robertson et al. 2018)
“A disadvantage of this technique is the unavoidable release of anesthetic gases and exposure of personnel when the cat is removed from the chamber.” (Rodan et al. 2011)
Stress has many definitions, but according to the National Research Council Committee on Recognition and Alleviation of Distress in Laboratory Animals, it is defined as a real or perceived perturbation that threatens homeostasis.
Inhalant chambers are not considered standard of care. Their use should be avoided for a number of reasons.
The stress response is a normal part of daily life but becomes harmful when triggered too intensely or for too long (Hekman, 2014). Different stressors cause varying levels of activation of these responses, but it has been shown that uncontrollable stressors from which an animal cannot escape and which cannot be mitigated activate the stress response more strongly across species (Dess, 1983).
Activation of the sympatho-adreno-medullary (SAM) axis in response to an acute stressor initiates an immediate response, often known as the “fight or flight” response. SAM axis activation leads to mydriasis, increased heart rate, increased blood pressure, cutaneous vasoconstriction, increased plasma glucose, and increased free fatty acid concentrations (Hekman, 2014).
A slower response to a stressor is mediated by activation of the hypothalamic-pituitary-adrenal (HPA) axis, with effects seen in minutes to hours to days. This response mediates release of glucocorticoids from the adrenal cortex. Glucocorticoids affect a wide range of physiologic functions including, but not limited to, metabolic processes such as protein, glucose, and fatty acid metabolism; immune function; gastrointestinal motility; growth; thyroid function; and reproduction (Hekman, 2014).
The overall effect of these responses is to mobilize energy stores, increase oxygen intake, decrease blood flow to non-critical areas, and inhibit digestion, growth, immune function, reproduction, and pain perception (Tynes, 2014).
Several studies have demonstrated that inhalant chambers are significant stressors. Reiter et al 2017 found that inhalant anesthesia increased concentrations of various hormones, including cortisol, corticosterone, and other glucocorticoids in mice, indicating activation of the HPA axis. The mice in this study appeared agitated and dug in the corners of the induction chamber. Similarly, a study by Flecknell et al 1996 found that induction of anesthesia in an inhalant chamber and an inhalant face mask caused all animals to avoid inhaling anesthetic vapor and to breath-hold, behaviors indicating that the induction was aversive. Another study by Flecknell et al 1999 evaluating the effects of induction of anesthesia with sevoflurane and isoflurane in an inhalant chamber found that most animals struggled violently during induction and breath-held, leading the study authors to conclude that both sevoflurane and isoflurane were aversive and should be avoided.
Furthermore, inhalant chambers cause increased struggling, breath-holding, and excitement because induction times with inhalant anesthetics are generally slower than intravenous agents such as propofol (Lester et al 2012).
Stress increases morbidity and mortality.
The consequences of physiologic and psychogenic stress on health and welfare outcomes have been documented across a range of domestic species.
Stress can increase susceptibility to infection and sepsis, reduce the rate at which wounds
heal, and increase the risk of gastric ulceration development (Hekman, 2014).
Westropp 2006 showed that cats with feline idiopathic cystitis (FIC) had altered bladder permeability, most notably during the initial period of stress.
Some cats may develop marked hyperglycemia secondary to an acute stressor, including struggling, with some cats having glucose concentrations in the diabetic range (> 200 mg/dL) over 90 minutes after exposure to the acute stressor (Rand et al 2002). This may lead some cats to be treated with insulin despite not being diabetic. Furthermore, struggling in an induction chamber may lead to injury of the patient.
Inhalant chambers perpetuate fear.
The animals considered candidates for use of the inhalant chamber or mask are often displaying aggression or fear and restraint is considered difficult or impossible.
Most animals visiting the veterinary hospital display signs of fear. A study by Doring et al 2009
Fear and stress during veterinary care can contribute to illness and injury.
found that 78.5% of clinically healthy dogs visiting a veterinary hospital in Germany showed signs of fear on the examination table. Quimby et al 2011 found that most cats hid more and had elevated physiologic parameters associated with stress (heart rate, respiratory rate, and blood pressure) when in a veterinary clinic compared to their home. In a survey of over 1,100 cat caretakers in Italy, most cats showed signs of fear during all stages of a veterinary visit, including 73% in the reception, 85% on the examination table, 55% during examination, and 58% after returning home. Restraint, pain, and anxiety led to aggression toward veterinarians and caretakers in these cats (Mariti, 2016).
Use of an inhalant chamber or mask will undoubtedly perpetuate underlying fear in patients already displaying fear. Koolhaas 1997 found that a single experience with a major stressor may have long-term consequences ranging from hours to days to weeks. Mariti 2016 showed that 34% of the cats’ stress following a veterinary visit subsequently worsened with handling in other situations. Landsberg 2013 supports that a single exposure to a stressor can be enough to cause a fearful response in the future. Therefore, the trauma of the inhalant chamber or mask is likely to increase the pet’s fear and anxiety at future veterinary visits. This will compromise the veterinarian’s future ability to provide the highest quality of care to these pets.
Increased fear, anxiety, and stress compromise patient care and veterinary staff safety.
Patients subjected to an inhalant chamber may display more fear and aggression. This can make administration of treatments and medications in hospital or at home following the procedure more difficult or unsafe for veterinary staff or clients.
Dog and cat bites as well as cat scratches are the most common cause of injury to veterinary hospital staff (Jeyaretnam, 2000), so increased pet fear and anxiety compromise the safety of staff.
Stressful veterinary visits have economic implications to the practice.
According to the Bayer veterinary care usage study, their pets’ stress is a leading reason pet parents fail to bring their animals to the veterinary hospital (Volk, 2011). Out of more than 1,000 cat caretakers, 58% reported that their cat hates going to the veterinarian and 38% of the cat caretakers reported that they themselves were stressed just thinking about taking their cat to the veterinarian (Volk, 2011). In a survey of 200 cat owners conducted by the International Society of Feline Medicine and Your Cat magazine, 20% of respondents said their most recent visit to a veterinarian had been sufficiently stressful that they would either avoid going back or would change veterinarians (Rodan 2005).
Cats are already underserved veterinary patients. In the Bayer usage study, 40% of cats had not been to a veterinarian in the last year compared to 15% of dogs (Volk, 2011). More than three-quarters of veterinarians in that study reported that care for cats is one of the most significantly missed opportunities in veterinary practice (Volk, 2011).
Stressful veterinary visits are likely to result in a further decline in cat visits, creating a greater obstacle to reaching the feline market.
Overall, the implications of using an inhalant chamber are far-reaching. For all of the above reasons, taking steps to decrease physiological and emotional stress is an essential medical goal, one that is significantly undermined by use of an inhalant chamber or mask.
Why Chemical Restraint Shouldn’t Be a Last Resort
Chemical restraint is often necessary for animals displaying fear and aggression and should not be considered a last resort (Grubb et al. 2020 Lloyd, 2017). According to the American Association of Feline Practitioners/International Society of Feline Medicine Guidelines on Feline Friendly Handling, indications for chemical restraint include the following:
–when an animal shows fear, anxiety, stress, or aggression;
–situations in which pain, discomfort or surgery is anticipated and where analgesia alone will be insufficient;
–when gentle restraint does not provide sufficient safety for the team.
Fortunately, many alternatives to inhalant induction exist to achieve chemical restraint, starting with premedication at home.
Evaluating Patient Fear, Anxiety, and Stress and Determining the Need for Pre-Visit Pharmaceuticals
Premedication at home may reduce the need for the inhalant chamber or mask and may reduce the need for injectable sedation or general anesthesia. It can make handling the patient more pleasant for all. Use of the FAS scale will aid in determining which pets may benefit from pre-visit pharmaceuticals (PVPs).
The FAS scale was created to rate a patient’s level of fear, anxiety, and stress in the veterinary clinic. It is a useful tool to determine if a PVP and/or injectable sedation is indicated.
A pet with FAS scores of 2 or 3 displays some lack of interest in treats, toys, and/or attention. This pet may fidget and have difficulty settling. This is consistent with moderate fear, anxiety, and stress, and a pre-visit pharmaceutical is recommended.
A pet with FAS scores of 4 or 5 displays little to no interest in treats; exhibits a fight, flight, or freeze response, and may display aggression. This is consistent with a high degree of fear, anxiety, and stress, and pre-visit pharmaceuticals combined with injectable sedation if needed is recommended. (Martin K and Martin D, 2007).
When scheduling veterinary appointments or procedures, ask clients about the pet’s behavior in the veterinary hospital. If the pet has a history of being fearful in the hospital, have the pet parent administer oral anxiolytics and/or sedatives such as gabapentin, trazodone, buprenorphine, transmucosal dexmedetomidine, and benzodiazepines prior to arrival.
Using PVPs
All pre-visit pharmaceuticals have variable effects in individual animals and should be tested prior to the veterinary visit to evaluate time to onset, effect, duration of effect, and possible adverse effects. This information will enable the veterinarian to evaluate the pre-visit pharmaceutical plan and make adjustments if warranted to ensure an optimal outcome.
Potential pre-visit pharmaceuticals include gabapentin, trazodone, benzodiazepines, some opioids, and some formulations of alpha-2 agonists. Oral acepromazine and melatonin can also be considered (Costa et al. 2019), keeping in mind, however, that acepromazine should never be used alone, as it is a tranquilizer but not a good anxiolytic. Before prescribing a medication as a pre-visit pharmaceutical, the attending veterinarian should consider the age of the pet, any interactions with other medications or supplements currently being administered, the pet’s overall health status, interactions with the chosen anesthetic protocol, and any other contraindications to administration.
Gabapentin
While not labeled for use for anxiety, gabapentin is increasingly used to reduce anxiety in humans and in veterinary patients. In a study by van Haaften et al 2017, 100 mg of gabapentin per cat prior to a veterinary visit resulted in significantly lower stress during transportation and examination as reported by pet parents, and increased compliance during examination as reported by veterinarians. Gabapentin also reduces neuropathic pain, which may benefit patients in which underlying pain may be contributing to fear and aggression.
Sedation is a possible side effect and may vary depending on cat size, so administer 50 mg to petite or geriatric cats. Large cats may require 200 mg for optimal effect. Other side effects of gabapentin include ataxia, hypersalivation, vomiting, and increased appetite.
Gabapentin should be administered three hours prior to the veterinary visit. The capsule may be opened and the powder sprinkled onto 1 tablespoon or less of wet food, tuna juice, Churu, or other tasty food. The effects of gabapentin may last for 8 to12 hours. When using gabapentin, administering an additional dose the night before the veterinary visit may be helpful.
Trazodone
This serotonin antagonist reuptake inhibitor is an anxiolytic and sedative. The dose of trazodone for cats is 50 to 100 mg per cat (not mg/kg). It should be administered three hours prior to a veterinary visit.
Side effects of trazodone may include drowsiness, variable mild gastrointestinal effects such as vomiting, diarrhea, decreased or increased appetite, and paradoxical excitation. When administering a test dose at home prior to the veterinary appointment, have the pet parent assess the pet’s level of sedation three hours after administration by calling the pet in a happy voice, shaking a treat jar, and/or getting out the pet’s favorite toy. If the pet readily rises and runs over to the pet parent, then the dose should be increased by 25% and another test performed at home. Duration of effect is 4 to 12 hours.
Benzodiazepines
These potent anxiolytics have a rapid onset of action with effects that last a few to several hours. They are reasonable options for patients with severe fear and anxiety, but their use is not recommended in patients with aggression.
Benzodiazepines may cause a paradoxical excitement reaction, so it is necessary that they be tested at home prior to a veterinary visit. Other side effects include ataxia, sedation, muscle relaxation, and increased appetite.
Commonly used benzodiazepines in cats include lorazepam and alprazolam.
Lorazepam has no active metabolites, so it is safer for geriatric patients and patients with hepatic disease. The dose of lorazepam for cats is 0.25 to 0.5 mg per cat (not mg/kg). It should be administered two to three hours prior to a veterinary visit.
Alprazolam has a different pathway for metabolism than diazepam, so it may have reduced risk of liver toxicity in cats. The dose of alprazolam for cats is 0.125 to 0.25 mg per cat (not mg/kg). It also should be administered two hours prior to a veterinary visit.
Injectable diazepam is used frequently in cats for anesthesia. There are a few reports of oral diazepam causing fatal hepatic failure when used at high dosages. Use it with caution in cats with hepatic disease and do not exceed clinical doses.
Buprenorphine
Buprenorphine is a partial mu agonist with analgesic and mild sedative effects. It is commonly administered with other sedatives and anesthetics, making it a reasonable option for balanced sedation or anesthesia in cats and dogs. Side effects may include sedation (which is the goal in this situation), hyperthermia, hypothermia, vomiting, and constipation.
Buprenorphine can be administered transmucosally in cats at a dose of 0.01 to 0.02 mg/kg, although a higher dose may be necessary since oral transmucosal uptake is low and variable (Steagall et al. 2014). Buprenorphine should be administered two to three hours prior to a veterinary visit. Duration of action is four to eight hours. Simbadol provides analgesia for 24 hours but efficacy of this duration has not been proven for OTM administration. (Steagall et al. 2014).
Sileo
Sileo, which is transmucosal dexmedetomidine, is FDA-licensed to treat dogs with noise aversions but is used off-label in a number of situations to reduce anxiety in dogs and cats. Sileo is fast-acting and minimally sedating. At a dose of 0.02 mg/kg, it can be combined with buprenorphine for use in cats with more significant fear and stress. In dogs, the dose is 0.01 to 0.04 mg/kg, and combination with buprenorphine is also an option. Sileo should be administered 60 minutes prior to a veterinary visit.
Not only will an effective pre-visit pharmaceutical plan decrease the animal’s fear, anxiety, and stress, it will also allow for easier and safer administration of intramuscular injections of premedications and anesthetics for all involved.
Transportation and Handling on Arrival
Request that the pet parent transport the patient in a soft, squeezable carrier or a carrier with a top that can be easily removed to facilitate low-stress handling. When the pet arrives at the hospital, immediately place the pet, still in the carrier, in a quiet room. Cover cat carriers with towels sprayed with Feliway.
Proper patient handling skills are paramount to minimizing stress and increasing safety during sedation or anesthesia (Yin 2009, Rodan et al 2011). Low-stress handling techniques are intended to minimize fear and pain experienced by pets during veterinary examination and increase safety of the veterinary team (Rodan 2010, Yin 2009). When handled appropriately with gentle restraint and Fear Free techniques, full anesthesia may not be necessary.
Removal From Carrier
Covering or wrapping a cat with a towel can help to decrease stress and increase a feeling of security.
Use gentle restraint when performing a physical exam and administering intramuscular injections. Do not grab and pull the pet out of the carrier and do not tilt to shake the pet out. For markedly fearful and/or aggressive pets who have arrived in a soft carrier, gently squeeze the sides of the carrier to administer an intramuscular injection through the carrier. For pets who have arrived in a carrier with a removable top, gradually remove the top half of the carrier while simultaneously placing a towel between the two halves of the carrier. Cover the pet with the towel, starting at the rear, and gradually move the towel up the pet’s body while removing the carrier top. This will allow for restraint under the towel for an exam and intramuscular injection.
Additional Sedation
If the pet needs a deeper plane of sedation, balanced sedation can be achieved with intramuscular injections of an opioid, dexmedetomidine or medetomidine, midazolam, alfaxalone, Telazol, and/or ketamine. If IV access is possible, propofol can be added to this list of drugs. When using injectable sedation, be aware that fear, anxiety, and stress may produce a more variable and less efficacious sedative response. The protocol may need to be adjusted. For all drugs, if the patient is deeply sedated or anesthetized, provide supplemental oxygen and initiate monitoring of physiologic parameters and support of normothermia.
For the opioids, mu agonists such as methadone, morphine, and hydromorphone provide the most profound analgesia and should be considered for patients undergoing surgical or other painful procedures. Buprenorphine is a partial agonist and may provide more analgesia than butorphanol but may also be less sedating. As previously stated, buprenorphine is absorbed after OTM administration, as is methadone.
Butorphanol provides mild, short-duration (60 minutes in the dog, 90 minutes in the cat) analgesia so is not optimal for painful procedures. However, butorphanol is a fairly effective sedative in both dogs and cats, especially in sick or aged patients. It is often combined with an alpha-2 agonist to increase the depth and predictability of sedation in healthy dogs and cats, as well as to enhance the alpha-2 mediated analgesia. Nausea and vomiting are the main adverse effects. Pre-treatment with an anti-emetic, such as maropitant, is recommended. Oral maropitant can be administered at home by the pet parent, thereby decreasing the likelihood of vomiting from the car ride to the hospital. Oral maropitant is approved for the dog at 2 mg/kg and used off-label in cats at 1 mg/kg (Quimby 2020). Other adverse effects include those listed above for buprenorphine. Naloxone can be used to reverse the effects of all opioids, although buprenorphine binds tightly to opioid receptors, making full reversal difficult.
Alpha-2 agonists, such as dexmedetomidine and medetomidine, provide fairly rapid analgesia and sedation and their effects can be reversed. There is a ceiling on the degree of analgesia, so further dosing acts to increase the degree of sedation, duration of sedation, and potential adverse effects. Alpha-2 agonists produce an initial hypertension and reflex bradycardia. Avoid using them in patients with most cardiovascular diseases. Alpha-2 agonists may also cause nausea and vomiting. Oral maropitant can be administered by the pet parent at home prior to the visit. Otherwise, administer maropitant SQ prior to the alpha-2 agonist if possible or administer maropitant SQ or IV once the cat is sedate.
Dexmedetomidine will markedly reduce the amount of induction and maintenance drugs required for anesthesia; use half or less of the standard induction drug dose. Wait at least 15 to 20 minutes after administering dexmedetomidine before induction to allow maximum effect to occur. Because level of sedation can be tailored to the patient by adjusting the dose and because the effects of alpha-2 agonists are reversible, this class of drugs is commonly used for sedation of pets admitted for outpatient procedures. The alpha-2 drug effects do not always require reversal, but reversal allows rapid return of a fully conscious pet to the pet parent.
Patients should be calm during both induction and recovery. Excitement should be avoided.
Alfaxalone is an anesthetic drug that can be used at low dosages for sedation or high dosages for anesthesia. It has a short time to onset and rapid duration of action with minimal adverse effects, which include dose-dependent minimal to mild cardiovascular and respiratory depression. It can be safely combined with other premedications such as opioids, dexmedetomidine, medetomidine, midazolam, and acepromazine. Alfaxalone can be administered intramuscularly (IM) and is a good option for cats but its volume makes it impractical for IM injections in larger pets. When used as a sole agent, recovery can be rough so balanced premedication protocols will help to diminish or eliminate this effect.
Ketamine is a dissociative anesthetic that is effective when administered intramuscularly and can be used at lower dosages for sedation and higher dosages for anesthesia. It provides analgesia when used at low doses and administered as an infusion. It is often combined with a benzodiazepine (midazolam or diazepam) for induction. Cardiovascular and respiratory depression are uncommon but could occur if the drug is administered to a severely compromised patient at an anesthetic dose.
Anesthetic dosages may need to be avoided in pets with a history of seizures or suspected intracranial disease, although recent data indicate that the drug may be used with caution in these pets. Anesthetic dosages should be avoided in cats with hypertrophic cardiomyopathy or pets with other cardiac diseases in which tachycardia could be detrimental. Use anesthetic dosages with caution in pets with renal disease. Ketamine is excreted unchanged by the kidneys in cats, and drug accumulation, with subsequent prolonged recoveries, could occur. However, low sedative dosages and the even lower infusion dosages used for analgesia are generally appropriate in all of these patients.
Telazol (tiletamine/zolazepam) is a combination of a dissociative agent (tiletamine) and a benzodiazepine (zolazepam) that can be administered IM and can be used at lower dosages for sedation and at higher dosages for anesthesia. Telazol is an excellent option for FAS-level 5 cats and dogs because the small volume needed to produce sedation or anesthesia can easily and quickly be administered IM. It has a quick onset and longer duration of action than ketamine, and it is not reversible. According to the product label, Telazol is contraindicated in pets with pancreatic disease or severe respiratory and/or cardiovascular disease; however, clinically these are precautions but not contraindications. Follow the same precautions as those listed for ketamine.
Conclusion
Taking steps to increase his comfort and reduce fear, anxiety, and stress have improved Hetch’s veterinary visits.
Overall, the use of inhalant chambers and masks is dangerous and stressful for both pets and anesthesia personnel. Stress causes deleterious effects on health outcomes and compromises mental wellbeing. Given the many alternatives that exist, use of an induction chamber or mask is a poor choice for sedation or induction and should be avoided for all patients. We as a veterinary community must prioritize practices that are both safe and stress-reducing for our patients and colleagues.
Hetch-Hetchy’s comfort for veterinary visits and procedures has increased substantially thanks to an effective protocol of pre-visit pharmaceuticals (0.02 mg/kg buprenorphine OTM and 50 mg trazodone PO 3 hours prior to getting into the car), an intramuscular injection of a sedative (alfaxalone) as needed, and low-stress handling. Having seen how swiftly he responds to this approach has highlighted the recent use of an inhalant chamber to sedate him as an archaic, inhumane practice that needs to be eliminated from our practices.
Table: Stages and Planes of Anesthesia
Stage
Description
Details
1
Disorientation, sedation
Occurs following premedications
2
Delirium, excitation, uncontrolled movement
Occurs during induction and recovery. Anesthetic plans should be designed so the patient spends minimal time in this phase. Induction should be rapid (use injectable drugs) and recovery should include sedatives if excitement/dysphoria occurs.
3
Unconsciousness, surgical plane of anesthesia
Plane 1: Light anesthesia, depth inadequate for moderately-severely painful procedures unless local anesthetic blocks are part of the protocol.Plane 2: Moderate anesthesia, adequate for painful procedures with administration of appropriate analgesia.
Plane 3: Deep anesthesia, required if analgesia is not part of the protocol. More physiologic depression occurs in this plane than in previous planes.
Plane 4: Excessively deep anesthesia, dangerous physiologic depression. Turn the vaporizer off and start ventilating for the patient to speed inhalant elimination.
4
Too deep!
This stage is between respiratory arrest and circulatory collapse. Take the patient off the anesthetic and prepare for CPR.
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This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Photos of Hetch Hetchy courtesy Alison Gerken, DVM; inhalant photo courtesy Tamara Grubb, DVM, PhD, DACVAA; cat inhalant chamber from Advances in Anesthesia; fearful cat from Napa Valley Holistic Veterinary Services; cat wrapped in towel courtesy Tamara Grubb, DVM, PhD, DACVAA.
Dr. Julie Reck, Owner, Veterinary Medical Center of Fort Mill, Fort Mill, South CarolinaMore than ever, pet owners have a strong bond with their pets. That means they are expecting their pet’s experience at the clinic to be enjoyable. Fear Free provides that excellent “customer” experience for both the pet and the pet owner. However, a client’s first Fear Free experience will likely be different from previous veterinary visits and could seem strange. It is important to ensure that each client fully understands that Fear Free considers both the medical and emotional well-being of their pet and realizes the significance of taking both aspects of the pet’s care into consideration.
Three Key Messages for Our Practice
We believe in the power of positive reinforcement. Patients will be treated kindly and receive lots of treats and verbal encouragement.
Fear Free is reinventing the definition of a successful veterinary visit. It is no longer acceptable to “just get it done.” We take into consideration where the patient is emotionally and proceed appropriately, which may mean that some things will not get done during a visit. For example, toenail clipping may have to be done another day if the patient elevates to moderate signs of fear, anxiety, and stress (Level 3 FAS).
Our hospital has a consistent approach to handling and treating our patients: Everyone is practicing Fear Free techniques with every patient.
Below are tips for successfully communicating the benefits of Fear Free to your clients.
Maximize Your Social Media Presence
Currently I have owners seeking out my clinic specifically for the Fear Free experience, but in the beginning this was not the case. It became obvious to me that the benefits of the Fear Free visit needed to be stated clearly in all my communications.
For the pet owner, the Fear Free journey begins before they get to the clinic. I want my clients to be educated consumers, so they “know before they go,” or, in other words, they know what to expect when they arrive at my clinic. My website and my clinic’s Facebook page fully communicate this to pet owners. We take a proactive approach to prepare the client for a positive experience. This includes stating our philosophy on what a good veterinary experience looks like for the pet and the pet owner using videos, testimonials, news feeds, or stories to keep pet owners informed and prepared for that great Fear Free experience.
The Customer Service Representative (CSR) Prepares the Client and Pet for the Visit
Our CSRs are the next line of communication. They are trained to answer any questions about Fear Free and are critical in making sure that the pet arrives safely and prepared for the visit.
Safety includes recommending that the pet is either in a carrier or harnessed/seat belted while in the car, and that they have a collar and leash if walked into the clinic or stay in the carrier until in the exam room. The carrier can provide the pet a sense of comfort.
Being “prepared” for the visit means making sure the pet arrives hungry and that we have their favorite treat ready for them when they arrive. A day or two before the visit, we send the owner a reminder email and/or text with these same instructions.
Continuing to Communicate During the Examination
The examination provides an opportunity to have a conversation with the pet owner, allowing them to feel more involved with the entire process. I will explain what I am doing, such as standing behind the patient instead of examining their head and face first. I will also describe the patient’s emotional status based on the patient’s body language and my physical findings. This prepares the owner for any diagnostic and/or treatment recommendations that I make, and they are more likely to be compliant with my plan.
Additionally, if the patient’s level of FAS does not allow the completion of the exam or planned procedures, such as nail clipping, the client will be more likely to understand because of the ongoing conversation about the patient’s behavior and emotional status.
It is also important that the pet owner understands their pet’s level of fear, anxiety, and stress will change, based on the situation. A dog who typically loves coming to the clinic may behave differently when coming in for examination and treatment of a painful ear infection. Where we may have never needed to sedate in the past, it is necessary now to ensure that the patient had the best possible experience because the dog’s pain has exacerbated his level of fear.
For patients with a history of severe veterinary visit FAS who we are seeing for the first time, we will inform the pet owner that the first visit will be a consultation. We take the patient’s history, perform a visual examination, but forgo the physical examination to keep the FAS level as low as possible. We may prescribe PVPs and/or schedule a series of “Happy Visits” where the patient arrives, receives treats, then leaves before we ever get to the hands-on physical exam.
What About the Client Who Fails to See the Benefits of Fear Free?
For clients who are more interested in “just getting it done,” I will inform them that the goal is to consider the long-term emotional wellbeing of their pet rather than the short-term approach of “just getting it done.” Some clients will understand and comply. For those who do not, we will agree to disagree and part ways.
It is important that the clinic owner and staff back this decision and uphold the values the Fear Free team has agreed upon. This is especially true if the pet owner is loud and unpleasant. Professional affirmation for the decision and support from colleagues can reinforce that one negative encounter with a client cannot undermine all the positive feedback and improved patient outcomes that comes with being Fear Free.
I have found that it is the small consistent changes that accumulate over time that get you to Fear Free. You might start with pheromones and see a subtle difference, then add in Considerate Approach and Gentle Restraint with liberal use of treats and see more of a change. As you continue to master the techniques and communicate the benefits of Fear Free, you will find that you and your staff are emotionally enriched, your clients have a renewed feeling of trust and bonding to you, and your clinic and your patients are actually happy to see you!
Sponsored by our friends at Zoetis Petcare. NA-02292
Heather E. LewisNoise is a notorious problem in shelters. When we reduce noise in shelters, we also moderate factors that cause fear, anxiety, and stress. Controlling noise is both an art and a science. Here are some helpful tips:
Create a calm environment and reduce mental stress. Because dogs cause the noise, it is important to ease dogs’ mental stress, so they feel less prone to barking. Regular exercise, outside time, supervised play groups, and walks help them to use their energy in positive ways. Creating feeding, cleaning, and bedtime routines in the shelter whenever possible so dogs know what to expect can also reduce their stress. Limit unpleasant stimulation as much as you can given your means. For example, for some dogs with barrier anxiety, it can be helpful to place a partial barrier on the fronts of their runs, so they have a choice of retreating from visual stimulation. And although it is sound, specially composed calming music may help to relax dogs and promote less barking. When played at low volume, it is meant to create calm rather than to mask noise.
Reduce the reverberation. Once you have done everything you can to lower stress through behavioral means, this is when building materials become more effective. Your best place for noise reduction is the ceiling! Choose a ceiling material with a high Noise Reduction Coefficient (NRC). The material should also be cleanable and antimicrobial. This is not impossible, as ceiling materials have improved. We like the Rockfon Medical Plus ceiling panel. This product achieves an NRC of .9, which means that 90 percent of reverberant noise within a tested frequency range is absorbed by the material.
Absorb the sound. In addition to the ceiling, you can place sound-absorbing panels high on the wall to reduce noise in the space. Please note that these sound panels are not enough on their own; they must be paired with the ceiling. Choose a panel with a high NRC and choose the thickest product offered as this one will absorb noise in a broader frequency range. Sound-absorbing panels do not need to be ugly! We use products that can be printed with a photo or image for a custom look.
Contain the noise. Beyond absorbing noise, it is also important to prevent it from affecting other shelter occupants, especially cats. We do this by ensuring that rooms containing dogs also contain the noise. The best way to do this is to build a wall with heavy mass (concrete block, etc.) around the dog housing. You can achieve the same result by layering materials. For example, a stud wall with sound insulation and two layers of drywall on each side will be much better than a stud wall without those materials. Keep in mind that a sound wall is only as good as its weakest point. To design an effective sound wall, do the following:
Build the wall up to the structure, so no sound “flanks” over the top of the wall.
Seal penetrations through the wall, such as duct and conduit penetrations.
Install gasketing around doors into the room, and a sweep on the bottom of the door.
If there are windows into the room, provide double glazing in the windows.
Separate dogs from other spaces. Despite doing the above, dogs are still loud. We recommend having more than one wall between dogs and cat spaces, or dogs and other quiet spaces such as offices. If the cats are right next to the dogs in your shelter, consider moving them to another room in the building, if possible.
Mask the noise. As a last resort, you can use masking noise to make your shelter feel more pleasant. An example of masking noise is soft white noise. While these sounds can be effective, we put this at the bottom of the list to encourage you to truly solve your noise problems first.
Your shelter does not have to be noisy! With a multifaceted and rigorous approach that begins with reduction of mental stress for dogs, you can create a much more peaceful, Fear Free place for animals and people.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Heather E. Lewis, AIA, NCARB, is a principal of Animal Arts, an architectural firm that has exclusively designed animal care facilities, including veterinary hospitals and animal shelters, for more than three decades. She has worked on dozens of projects across the country, both large and small in her 19 years with the firm. Heather is a member of the Fear Free℠ Advisory Board and assisted in creating the Fear Free facility standards for veterinary hospitals. Heather is a regular contributor to various veterinary industry magazines. She has spoken on the design of facilities for the care of animals at dozens of national and regional conferences including Fetch Hospital Design Conferences, the UC Davis Low Stress Animal Handling Conference, and the Humane Society of the United States Animal Care Expo.
Rachel Lees, RVT, KPA CTP, VTS (Behavior)We’ve all seen the many animal-training programs on cable TV and streaming networks. Some of the concepts depicted in these programs are appropriate for veterinary behavior cases and some are questionable. This article will discuss the learning theories and training philosophies demonstrated in these programs and review why veterinary behavior professionals are using alternative protocols.
Whether you are a veterinary team member working in general practice or interested in behavior, it is important to recommend up-to-date Fear Free information for patients and clients. Giving outdated information can potentially damage the human-animal bond and potentially end with the patient being rehomed or even euthanized.
The first part of this blog post looked at punishment. Punishment is not recommended in treatment as it can slow learning and cognition, suppress behavior, increase fear and fear-based aggression, create damaging and unintended associations with owners and other environmental stimuli, and damage the human-animal bond.
This blog post discusses “dominance” theory, a commonly used training philosophy recommended by many traditional trainers. We will dive into the origins of this concept and discuss current recommendations.
Do You Really Need to Be Alpha?
The word “dominance” is one of the most misunderstood terms in veterinary behavior. The dictionary defines dominance as “the predominance of one or more species in an animal community.” The word predominance is defined as “possession or exertion of control.” When reviewing these definitions, it is hard to imagine that some trainers use them to describe how to train domestic animals. When an owner shows “exertion of control” over a pet, it increases the likelihood of behavior suppression, increased fear and anxiety, and can make owners and their actions conflicting to the pet. This can damage the human-animal bond and even increase owner-related aggression.
Here is the question veterinary professionals and owners have asked for years: If this training is so aversive, why did we start using it in the first place? In 1947, a Swiss scientist, Rudolph Schenkel, published a paper suggesting parallels between domestic dog behavior and that of wolves. In 1970, wildlife biologist L. David Mech built on that notion in his book “The Wolf: The Ecology and Behavior of an Endangered Species,” reinforcing the “alpha wolf” idea Schenkel had promoted (a concept Mech recanted later in his career after studying wolves in the wild). The adapted theory had gone as far as to assume that the human family makes up the dog’s pack, and if behavior problems are present, it is because dogs are working to raise their social rank in the “pack.” But as science has advanced, so has our understanding of canine behavior. Schenkel’s and Mech’s research had significant flaws, including the following:
Their original research was based on captive wolves. These captive social groups show little resemblance to the normal behavior of free-living wolves. Free-living wolves are all related to each other, which is quite different from artificial colonies of captive wolves.
Dogs and wolves may be from the same “genus” but are not the same. When these theories were published, they did not take into account the 15,000 years of domestication that separate modern dogs and wolves. These theories were generalized to the human-dog relationship and resulted in increased human-related aggression and behavioral problems. Comparing a dog to a wolf is like comparing a human to an ape. We are similar but not the same.
The original ritualistic body language displays were misinterpreted as forcible dominance displays. For example, it was reported that the “dominant” wolf will place the subordinate onto the ground. In reality, the subordinate or more fearful wolf will voluntarily assume this position to avoid conflict in a ritualistic appeasement behavior, which is the opposite of the original findings.
Meghan Herron, DVM, DACVB, at Ohio State University, published research concluding that use of forceful techniques can increase the likelihood of aggression toward owners. Unfortunately, the conflict inherent in the alpha-dog theory makes for appealing television, so the idea has been widely disseminated. Veterinary behavior professionals are now working to teach updated concepts that will enhance the bond between humans and dogs instead of putting a barrier between them.
As veterinary professionals it is important that we ask questions about training recommendations and behavioral concerns at each physical exam to confirm that clients are getting the most up-to-date behavior and training information. Clients value your opinion and recommendations and your advice can be lifesaving. Observe training classes you may recommend to ensure that they use Fear Free techniques.
Recommended Reading for Owners or Veterinary Professionals
From Fearful to Fear Free
Author(s): Marty Becker, Lisa Radosta, Wailani Sung, and Mikkel Becker
Decoding Your Dog
Author(s): The American College of Veterinary Behavior
Dog Sense
Author: John Bradshaw
Other Resources
Herron, Meghan E. Shofer, Frances. Reisner, Illana R. 2009. Survey of the use and outcome of confrontational and non-confrontational training methods in client-owned dogs showing undesired
Shaw, Julie K. Martin, Debbie. Canine and Feline Behavior for Veterinary Technicians and Nurses. John Wiley & Sons, Inc. 2015.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Rachel Lees, an Elite Fear Free Certified Professional, is a veterinary technician specialist in behavior, a KPA certified training partner, and lead veterinary behavior technician at The Behavior Clinic in Olmsted Falls, Ohio. She loves helping people create and maintain a strong human-animal bond.
Linda Lombardi Fireworks and other loud noises are a common cause of fear and anxiety in dogs. A recent study provides some insight into the progression of this fear over time and provides evidence of the effectiveness of training and the importance of preventive training before fear develops.
“Not a one-way road—Severity, progression and prevention of firework fears in dogs” by Stefanie Riemer, published in PLoS ONE in September, analyzes the results of an online survey of dog owners who answered questions about the severity and development of fear, demographic factors, other behavior issues, and efforts made to address the problem. Out of 1,225 responses analyzed, 52 percent of dogs were affected by this fear to some extent. The severity of the fear was assigned a “Welfare-impaired score” based on the question “Please rate your level of agreement with the following statement: The overall welfare of my dog is strongly compromised by fireworks,” answered on a five-point scale from “disagree strongly” to “agree strongly.”
This fear often showed up early: in 45 percent of cases, at under one year. However, it also developed later, although in almost all cases before six years of age. Responses also showed that this fear can change considerably over time, both for the worse and the better, even if nothing is done to address it. Great improvement was reported for 10 percent of dogs and almost one-third of dogs tended to improve; just under one-fifth reported the fear had gotten worse, and 8.5 percent, much worse. One-third of dogs were reported to have shown no change.
Improvement was not always due to training or medication. For the subset of dogs whose owners had not sought advice for the problem and were not professionals such as trainers or veterinarians themselves, there was slightly less improvement, but also less deterioration – about half reported no change.
Owners of 530 dogs (43.3 percent) reported doing some training to prevent or treat firework fears. Preventive training was most effective: the median Welfare-Impaired score was 1 (lowest possible) in dogs trained in puppyhood and 2 in dogs trained as adults, compared to a median score of 4 for dogs with no training before the onset of fear. Statistical testing showed no significant difference between preventive training as a puppy and as an adult. However, there was a significant difference between having preventive training and having training only after fears had developed.
Training after fears developed was nevertheless shown to be worth doing, as those dogs were significantly more likely to show improvement. The effect of training was independent of whether the dog was treated with medication, as there was no difference in the proportion of dogs in groups that did and did not receive training.
The importance of some other factors investigated, including potential correlations with health problems and other behavior problems, were unclear, but one finding was that certain breed groups were more likely to suffer from this fear, including herding dogs. At the same time, one of the two most significant risk factors was being a mixed-breed. These results may seem contradictory, but they suggest that both genetics and upbringing are relevant. “Mixed-breed dogs originated from shelters or from the street more often so, on average, mixed-breed dogs probably had less positive socialization experiences,” says author Stefanie Riemer.
The other significant risk factor was older age. Again, at first glance this might seem to contradict the finding that fears develop at an earlier age, but fears are not static with aging. “While in over 70 percent, firework fear was noticeable before the age of two years, firework fear often does not disappear on its own, even though it may be improved, as I found in my study,” says Riemer. “Therefore, the longer the dog has been in the world, the more likely it is to have developed a fear of firework at some point in its life. Moreover, often the fear gets worse over time, which may lead to higher average fear scores in older dogs.”
The high number of owners who sought help for the problem (45 percent overall and 70 percent of owners of fearful dogs) was large compared with what has been found in other research. Riemer says, “I am sure the owners in the sample were above-average motivated to work with their dog. I don’t think this invalidates the finding regarding the effectiveness of training but of course a higher level of experience might make them more effective trainers.”
The results suggest that because preventive training is most effective, it’s a good idea to do some training with dogs who are not showing fear, but even after fear develops, it’s not too late. “This study shows that if your dog is afraid of fireworks or other loud noises, it’s important to do something about it, because it can make a difference,” says Zazie Todd, PhD, author of the blog Companion Animal Psychology. “There are several ways to help dogs who are afraid of fireworks, including gradual desensitization and counter-conditioning using a recording of the sound.”
Todd notes that Riemer’s recently published followup study on the effectiveness of various training methods found that owners reported that both ad-hoc counterconditioning and relaxation training helped.
She also observes that while some dogs’ response to noise is too obvious to miss, owners may need to be educated to notice it in others: “Other research has shown that sometimes people miss the signs their dog is afraid of fireworks, so it’s important to be aware and look for them.”
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Linda Lombardi writes about the animals that share our planet and our homes for magazines including The Bark, websites including National Geographic and Mongabay.com, and for the Associated Press. Her most recent book, co-authored with Deirdre Franklin, is The Pit Bull Life: A Dog Lover’s Companion.
Linda Lombardi Taking your dog training business online might seem hard to imagine, but even before the pandemic, some trainers were doing it successfully. Far from being a last resort, there are advantages for trainers, clients, and dogs. Here’s how to succeed.
The Learning Environment
Working in the home environment can be a big positive for dogs.
“I have found that dogs are less distracted when working in their home environment. Foundations are learnt quicker in general,” says Laura Ryder, head trainer at Morley Vet Centre in Perth, Western Australia.
Jessica Ring, a Fear Free certified trainer in Maryland who recently started teaching group classes online, cautions that there are some exceptions. For clients with chaotic homes, the class environment was less distracting. And as students become more advanced, creating training distractions at home can become more challenging. But in general Ring finds it’s a positive: “It seems like dogs are getting through the material more quickly in the session.”
Ring has also observed that without the distraction and stimulation of other people and dogs, it’s possible for students and dogs to take a real break when she’s focused on someone else. “Especially for little dogs, they don’t fill up as quickly if they can take a break,” she says.
Fear Free certified trainer Kate LaSala says some kinds of training, such as for separation anxiety, have long been done remotely. It also has advantages for fear and aggression cases. “Often, with aggression, it’s less stressful for the dog not to have a stranger there,” she says. “If I’m dealing with a stranger-danger case, the fact that I’m going there to talk to the person automatically brings that dog over threshold in most cases. It makes the dog anxious, makes the person anxious, makes me anxious.” Online consultations eliminate all of that and are no obstacle to the work she needs to do.
“A big part of what I do in fear and aggression cases is educating and coaching the client. If the dog is a stranger-danger case, I’m not going to be hands-on anyway.”
Online training has the same advantages for dogs with similar but less extreme issues. “I’ve had some people take online classes who probably couldn’t bring a dog to a group class,” says Ring. “Dogs who are reactive to other dogs, excited, or worried can participate.”
Client Convenience
LaSala finds that online training has advantages for scheduling, since she no longer must factor in commuting time or setting up and cleaning a facility. “I can accommodate appointment times I’d never do before,” she says. “Eight a.m. on Saturday — that was not going to happen. But I can do that remotely, and I can accommodate much later appointment times, too.”
For the same reasons, Ring can offer shorter sessions and single-session classes. “I only have to commit to half an hour when I can fit it in,” she says. She now offers 30-minute classes, including basic skills and tricks. “Some of them are to jump-start people in their training and give them an idea of what it would be like to work this way,” she says. She still offers standard hour-long classes as well, but it’s useful for clients have more options. “It’s a lot for people and dogs to stay focused for that long, so the half hour is enough for some people,” she says.
Another benefit of online training is that platforms such as Zoom allow sessions to be recorded. LaSala makes the video available to clients. “If they want to be able to refer back to our session, they can do that, unlike an in-person session, which is fleeting,” she says.
Business Considerations
LaSala finds that a benefit of taking her business online is that she can take on more work. “I can fit more clients into a day because I’m not spending hours commuting between appointments,” she says. Partly due to this, she has reduced her fees for sessions. “Because I’m not spending money buying cheese and steak and hot dogs, and with the time and money I’m saving not having to commute, I roll that into my price, so it is less expensive,” she says.
Not all trainers have made the same calculation about fees. Ring says that although she is saving commuting and setup/cleanup time, she finds that she spends more time communicating with clients between sessions, so thinks it evens out.
A new challenge can be attracting business in the first place. “How to market to this new audience is still something I’m trying to figure out,” says Ring. She’s starting to get clients from farther away than in the past, but she sees a new need to educate potential clients.
“This is a shift for people, to get over the traditional thinking that the dog trainer needs to come and work with the dog,” says LaSala. “Once they’re on board, everyone loves it – it’s cost-effective, it’s less stressful, we can get the same results – but now there’s an extra step where you need to sell the person on the idea of how this is going to be effective and efficient.”
LaSala has pages on her website explaining procedures: what an initial consult consists of, what remote learning looks like, how to prepare for a session. Much of this hasn’t changed. An initial consult is still two hours of talking. And training a dog who’s fearful on walks, for instance, involves instilling a number of behaviors at home before taking them on the road – just like before, except now she needs to explain in advance that she doesn’t need to be there for the walk. “It’s a lot of dispelling preconceived notions of what the owner thinks dog training looks like,” she says. “I don’t need to see your dog be afraid outside. I know what that looks like, I don’t need you to show me that.”
Along with clearly explaining procedures on your website, don’t forget the power of online reviews.
“A couple of well-written testimonials from clients, I feel, are the best way to convince other dog owners that online learning is effective and worthwhile,” says Ryder.
One of hers reads in part: “I honestly wasn’t sure how online training would work for me, but it really was a wonderful experience. Participating in dog training has always been a bit of an outlet for me, especially when the rest of life can get so crazy and busy. Now more than ever, to feel connected and supported by such wonderful dog professionals does wonders for your own wellbeing as well as your dog’s.”
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Linda Lombardi writes about the animals that share our planet and our homes for magazines including The Bark, websites including National Geographic and Mongabay.com, and for the Associated Press. Her most recent book, co-authored with Deirdre Franklin, is The Pit Bull Life: A Dog Lover’s Companion.
Heather E. Lewis As veterinary practices implement Fear Free design for their patients, it becomes more important to cater specifically to felines. Even if you have a smaller facility, at least one exam room should be properly outfitted to care for cats. Many ideas are easy and inexpensive to implement. Here are some favorite cat exam room ideas:
Room Placement and General Features
Choose a room in a quiet spot. Reducing noise, traffic, and activity is a great way to sculpt a quieter and calmer experience for our feline friends. Ensure the walls around the room have sound insulation in them, if possible, to screen noise coming from other spaces.
If possible, use a room with a window. Cats see well in low-light conditions. Cats will prefer the room if artificial lights are lowered and the room is flooded with soft natural light. It is useful to have lights on a dimmer switch so they can be brighter for a proper physical exam and then lowered again for client consultation.
Furnishings, Cabinets, and Finishes
The exam table should be comfortable. Ensure that your table will have a non-slip surface for cats and that it can be outfitted with something soft. Any exam table is potentially acceptable and can be updated with a yoga mat for slip resistance and a towel for a soft surface. This said, we prefer a smaller table for less awkward maneuvering when working with a cat.
Create appropriate retreat spaces. Cats often need to hide to feel comfortable. Avoid designing trash access holes or flaps in cabinets or your feline patients will end up in the trash can! Extend upper cabinets to the ceiling to prevent cats from being able to get into ceiling panels (yikes)! Avoid chairs cats can get underneath; solid-fronted benches work better for seating. Create an appropriate space in the room for retreat, such as a wall-hung basket or a box in an appealing location in the room. The cat can enter this retreat space at will and coaxed out gently or examined there.
Choose light colors. We prefer to paint feline exam rooms with lighter colors, so they will function well when the lights are dimmed. However, avoid bright whites as sometimes these appear even brighter to a cat. Calming colors can help reinforce your goal for the room to be a retreat.
Equipment
While equipment may appear to be a small consideration, the right accessories will help your cat exam room become the Fear Free space you envision. Consider the following:
Feliway dispensers in the room.
A towel warmer to warm blankets and towels for use during examinations.
Non-figural artwork and no photorealistic images of cats. Cats can react negatively to this type of visual input. Use soft abstracts and landscapes.
Quiet casters on the stool so it does not clatter when rolled.
Feline exam rooms are easy and rewarding to design and finish. We consider cats to be our best architectural students; they tell us when we have executed spaces well. We create for them. Pair good spaces and good operations, and your feline patients will be happier and calmer. Happy patients make for happy clients!
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Heather E. Lewis, AIA, NCARB, is a principal of Animal Arts, an architectural firm that has exclusively designed animal care facilities, including veterinary hospitals and animal shelters, for more than three decades. She has worked on dozens of projects across the country, both large and small in her 19 years with the firm. Heather is a member of the Fear Free℠ Advisory Board and assisted in creating the Fear Free facility standards for veterinary hospitals. Heather is a regular contributor to various veterinary industry magazines. She has spoken on the design of facilities for the care of animals at dozens of national and regional conferences including Fetch Hospital Design Conferences, the UC Davis Low Stress Animal Handling Conference, and the Humane Society of the United States Animal Care Expo.
Photo courtesy Loyal Companions Animal Hospital & Pet Resort, Tim Murphy / Foto Imagery.
Tony Johnson, DVM, DACVECC It is a frustrating condition with many names: Feline Lower Urinary Tract Disease, Feline Urologic Syndrome, Feline Interstitial Cystitis, even the rather whimsical Pandora Syndrome. Anyone who has treated it knows the stress and anxiety it can induce in those treating the disease, as well as in patients suffering from it, not to mention their anxious owners.
That same stress and anxiety also contribute to the disease process itself. As an ER vet, I know the plumbing aspect of the disease very well and can usually get them unblocked and on more stable footing in short order. What I don’t usually have to deal with are the softer aspects of the disease – softer, but no less important. That usually falls to general practice veterinarians, who have to take the reins from ER vets like me and manage their patients long-term.
In the spirit of adhering to the Veterinarian’s Oath and reducing animal pain and suffering, I’d like to offer up some points to consider when either treating a cat with a urinary obstruction or managing a non-obstructed cat with signs of lower urinary tract disease.
Are you incorporating appropriate analgesia and sedation in your treatment protocol?
This is a painful condition. Pain causes stress, which can exacerbate the disease – and make future trips to the vet even more stressful. Making sure you have incorporated appropriate analgesia when unblocking a cat, and when managing a catheterized cat in the hospital, is a vital part of treatment – and one that is often overlooked. Proper (and safely chosen) sedation, and incorporation of a sacrococcygeal block while unblocking, good pain control with buprenorphine or a full-mu opioid agonist, and home analgesia for three to five days after discharge will help to minimize the pain and anxiety of an episode of urethral obstruction. Owners will appreciate advanced pain control protocols and knowing that you are taking their pet’s emotional wellbeing into consideration. It also makes cats easier to handle in the hospital and more likely to come back for future visits – everybody wins!
Suggested Protocols
Sacrococcygeal block:
Use 0.1 mL/kg of either lidocaine or bupivacaine
Unless the cat is very sick and moribund, this is typically done under heavy sedation or anesthesia
Move the tail up and down in a “pumping” motion, palpating the sacrococcygeal region.
The first movable space at the caudal end of the sacrum is either the sacrococcygeal or intercoccygeal space. Either site is okay and there’s no need to differentiate which site you are in.
Insert a 25-ga needle through the skin on midline at a ~45° angle.
If bone is encountered, withdraw the needle a few mm, redirect slightly at a steeper or flatter angle and reinsert. This is known as “walking” off the bone.
Repeat this process until the needle is in intervertebral space. A “pop” may be felt and there should be no resistance to injection.
Note: Since many cats who are blocked may also have some degree of acute kidney injury, NSAIDs should be used cautiously or not at all in acute obstructions. They may be helpful in cats with normal renal function for non-obstructive episodes.
Are you reducing stress in the household? In your hospital?
Imagine you are a hospitalized blocked cat: fluorescent lights, a painful catheter, Elizabethan collar, barking dogs – sounds awful, right?
Do everything you can to reduce the stress of hospitalized cats. Put yourself in the patient’s position and imagine what their existence in your hospital is like. If you don’t have a “cat room,” try and keep cats in the quietest part of the hospital, out of sight and sound of dogs. Allow time for rest and a break from medical procedures and provide a box or other structure in the kennel where the cat can hide.
Both at home and in the hospital, use of feline facial pheromones (Feliway®) may help alleviate stress and anxiety. Consider installing one in your ICU and changing it regularly. A few sprays of Feliway® on your patient’s bedding may also help. The Feliway® diffuser can be particularly helpful at home.
Make sure cats at home have distractions and safe spaces to hide from dogs, children, and other cats. During stressful times (moving, boarding, redecorating, addition of new pets or children to the home) consider advising clients to spend extra time with their cats or discuss safe sedation and anti-anxiety protocols and environmental enrichment to reduce fear, anxiety, and stress.
Stress can bring on this condition, and the things we have to do to treat it are often stressful and uncomfortable, creating a continuous positive feedback loop. Owners are stressed, vets are stressed, and (most of all) patients are stressed. Do everything you can to reduce the anxiety and discomfort of feline urologic conditions and you will not only be keeping up your part of the Veterinarian’s Oath, you’ll be practicing better medicine as well.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Dr. Tony Johnson, DVM, DACVECC, is a 1996 Washington State University grad and obtained board certification in emergency medicine and critical care in 2003. He is currently Minister of Happiness for VIN, the Veterinary Information Network, an online community of 75,000 worldwide veterinarians, and is a former clinical assistant professor at Purdue University School of Veterinary Medicine in Indiana. He has lectured for several international veterinary conferences (winning the small animal speaker of the year award for the Western Veterinary Conference in 2010) and is an active blogger and writer.
Heather E. Lewis While the best place for a dog or a cat is a loving home, a shelter can be a lot less stressful if the design considers the social, physical, and physiological needs of each animal. One important topic for creating Fear Free spaces in a shelter is lighting. Below are some practical ideas every shelter can incorporate:
Sunlight Is Best. No matter what we do with artificial lighting, we cannot replace the benefits of natural sunlight. Regardless of the age and quality of your shelter, it’s possible to find ways for the pets to experience daylight. For dogs, outside play time or walks will make a positive difference for behavior and well-being. A catio can be a great addition for adoptable cats; they will enjoy sunbathing and exploring a safe outdoor environment. Even if your shelter is extremely limited, look for ways to add a glass door or a tube skylight to let in natural light. Daylight benefits:
Reinforces natural circadian rhythms.
Improves staff and volunteer productivity and mood.
Natural UV disinfection for spaces receiving direct sunlight.
Energy savings for spaces that do not need to rely on much artificial lighting.
Creates an environment that feels more natural.
Replace Fluorescent Fixtures with LED. If you’re building a new shelter, this is required by energy codes, but many people do not know to replace older fluorescent lighting in their current shelters. Fluorescent fixtures buzz and flicker, and these disturbances are more obvious to dogs and cats than to people because of the way pets see and hear. Properly designed LED lighting converts alternating current to direct current at the fixture, which eliminates buzzing and flickering. As a bonus, LED fixtures use far less energy than fluorescent ones, so lighting replacement projects pay for themselves quickly.
Go Dimmable. LED lighting fixtures are easy to specify with dimming controls. This is a wonderful feature as it allows shelter staff to brightly light spaces when they are being cleaned or during adoption hours, but to turn down the lights during quieter times so dogs and cats can rest more easily throughout the day.
Keep It Dark at Night. If it is necessary to keep a light on at night for staff safety, specify a fixture that emits red light. Because dogs and cats do not see colors on the red end of the human visible spectrum, a red light creates a darker space for pets at night, allowing them to sleep normally in the shelter.
Use Cool Color Temperatures. Lighting can be designed to balance beautifully with natural daylight. Fixtures that are color balanced but tuned toward cooler color “temperatures” will feel more like daylight. We specify fixtures that emit light in the 3500 – 4000 Kelvin range. These are cool but not so cold as to feel institutional. The goal is for spaces to feel clean and crisp! Be careful to specify all fixtures in a similar color temperature so they blend well together.
Light Adoptable Animals Well. While we like animals to rest well during non-adoption hours, we also want them to leave the shelter quickly and go to their forever homes. Adoption spaces should be lit more brightly than circulation areas where people are viewing, so the animals show well and gain the attention of potential adopters.
A good lighting design can help reduce fear, stress, and anxiety in a shelter setting and can help the pets go home more quickly. It is well worth the investment!
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Heather E. Lewis, AIA, NCARB, is a principal of Animal Arts, an architectural firm that has exclusively designed animal care facilities, including veterinary hospitals and animal shelters, for more than three decades. She has worked on dozens of projects across the country, both large and small in her 19 years with the firm. Heather is a member of the Fear Free℠ Advisory Board and assisted in creating the Fear Free facility standards for veterinary hospitals. Heather is a regular contributor to various veterinary industry magazines. She has spoken on the design of facilities for the care of animals at dozens of national and regional conferences including Fetch Hospital Design Conferences, the UC Davis Low Stress Animal Handling Conference, and the Humane Society of the United States Animal Care Expo.
Sponsored by our friends at Zoetis Petcare. NA-02292
