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Using Fear Free Principles to Improve Anesthetic Safety In Complicated Patients

Using Fear Free Principles to Improve Anesthetic Safety In Complicated Patients

Decreasing fear, anxiety, stress (FAS), and pain leads to safer anesthesia by allowing a lower dose of sedative and anesthetic drugs needed for anesthesia premedication, induction, maintenance, and recovery. Lower drug dosages are especially critical in complicated patients with underlying disease and physiologic compromise. In this discussion, Tamara Grubb DVM, PhD, DACVAA, will explore the role of Fear Free principles in anesthetic safety, especially in the compromised/complicated patient.

Brought to you by Zoetis Petcare.

Placing Cats With FeLV: What to Know

Kim Campbell ThorntonAt University of Florida, Julie Levy, DVM, DACVIM, DABVP (Shelter Medicine) focuses on the health and welfare of animals in shelters, humane methods for cat population control, and feline infectious diseases.

One of her successes in the latter area is determining the most reliable and effective way to test cats for FeLV, a disease for which approximately three to four percent of cats in the United States test positive each year. The diagnosis affects an estimated 60,000 cats in animal shelters annually. And until recently, the diagnosis has frequently been a death sentence for cats.

In a study published last year in Journal of Feline Medicine and Surgery, the researchers—who included Dr. Levy—state “Overpopulation of cats in shelters, combined with limited shelter resources, apprehension about viral transmission and preconceptions about how FeLV infection may impact quality of life or adoption potential often lead to routine euthanasia for shelter cats following a single positive FeLV test.”

But their findings suggest a high national demand for a lifesaving option for cats diagnosed with FeLV and have made a difference for cats in several ways. One is that the recommended options for testing have been pared down to a small menu of the most accurate and cost-effective tests.

“In the past, veterinarians and shelter managers were confused about what kind of sample they should collect from cats, what tests they should run, and how much they could trust the results. There are so many point-of-care and laboratory options that it could be overwhelming,” Levy says. “Our work with naturally infected cats in animal shelters has helped us address outdated dogma and to streamline testing .”

That’s important because more and more shelters are working to place FeLV-positive cats in homes. Levy’s interest began because in the past, cats who tested positive for FeLV were often routinely euthanized. Because of that dire consequence, she says, testers were so fearful of misdiagnosing cats that they often ran multiple tests, sometimes with varying results.

And the disease, which suppresses a cat’s immune system, does not run a straight course. It affects different cats in different ways and at different times. Levels may change over time depending on a cat’s immune status. Some cats live with the disease with little problem. It may flare up if the cat is stressed or has a comorbidity such as an upper respiratory infection and then die back down. It’s not possible to run a test once and then expect the cat to remain the same throughout life. Accepting that screening for FeLV is often fraught with a level of uncertainty, Levy suggests pairing a simplified testing process with a goal for saving cats regardless of the results.

“Let’s just identify these cats as infected or not infected as best we can and then get them into the right homes and support them and not try to achieve some level of control or absolute knowledge that isn’t attainable,” Dr. Levy says.

But why would shelters place cats infected with a disease that is commonly considered a death sentence?

Because life-saving protocols and good guidelines for adopters mean that FeLV is not necessarily a death sentence. And because people are willing to adopt cats with FeLV and give them the care they need.

The adoption study showed high national demand for a life-saving option for cats diagnosed with FeLV. In it, researchers state: “The majority of cats referred to the FeLV program were adopted, demonstrating that programs centered on adopter education and post-adoption support can create lifesaving outcomes for most FeLV-infected cats, despite uncertainty regarding their long-term prognosis.”

The study also noted that FeLV infections could not be confirmed in approximately one in five cats referred to a large FeLV adoption program, a reminder of the risk of basing a cat’s fate on a single positive test result.

That FeLV adoption program, begun by Austin Pets Alive!, was the springboard for Levy’s research to identify the most practical testing protocols.

In collaboration with IDEXX and APA, which places hundreds of FeLV-infected cats from around the country each year, University of Florida researchers enrolled 130 infected cats who were fostered, tested monthly, and then followed over time. Previously, many small studies had evaluated one test at a time, but none had compared so many different tests at the same time, in the same cats, repeatedly.

“That has allowed us to determine what the more reliable tests are and to evaluate how the status of cats changes over time,” Dr. Levy says. “It changes a lot more than we expected.” They were also able to evaluate the survival rate of cats in relation to their test results.

Originally, the study was not expected to run for more than a year, a year funded by $160,000 from Maddie’s Fund, plus professional time contributed by researchers, testing donated by IDEXX, and discounted testing from other laboratories. But the researchers recognized the value of the information they were gathering and knew they would never be able to repeat it. They didn’t want to lose track of the cats or of the very engaged group of cat owners who wanted to help.

Support from ECHF allowed the study to continue beyond that first year. Vicki Thayer, DVM, then executive director of ECHF, thought the work was important enough to support and put through an out-of-cycle proposal to ensure they could continue the work. The funding allowed staff to spend time staying in touch with the cats and to complete another two rounds of testing for a year for some longer-term results.

“ECHF has always been so tuned in to the emerging needs of cats and the emerging research opportunities,” Levy says. “This is a great example of recognizing a critical moment in time for cats on a critical disease that was killing a lot of cats, either medically or because of inappropriate euthanasia.”

Four years later, the cats are part of the largest group of infected cats that have been followed for the longest period of time. They are real-world cats under real-world conditions.

The result is a new test available through the IDEXX commercial diagnostic lab that can not only provide confirmation of infection but also information about the cat’s prognosis. Using a new quantitative PCR test, shelters can now identify whether a tested cat is likely to be a long-term survivor or develop disease and mortality early. The study also found that whole blood is the best sample for testing, rather than serum or plasma. That’s good news because whole blood doesn’t have to be processed before it’s tested.

Levy recommends using a high-quality point of care test in a “one and done” screening process for most newly acquired cats and then managing the cat appropriately according to the test results. Shelters or practitioners who want to go to the next level of testing—to follow up on a positive screening test or to screen blood donor cats, for instance—can choose the quantitative PCR, a DNA test that identifies the extent to which a cat is affected by FeLV. The long-term follow-up study by the University of Florida study showed that if there’s a lot of FeLV when cats are first diagnosed, they are more likely to develop early disease and to have a shorter lifespan.

And “manage appropriately” doesn’t mean euthanize. But that message still needs to get out to veterinarians. Too often, cats with FeLV are stigmatized as poor risks for adoption when in fact their condition can be supported like other chronic diseases. The retrovirus is impossible to cure, but a cat with FeLV can live for many years without illness and without spreading the disease to other cats if they are adopted into single-cat homes or with other FeLV+ cats.

“We need to do a better job of sharing the life-saving paradigm with veterinary practitioners,” Levy says. “It is very frustrating to place an FeLV+ cat with an informed adopter,  only to have their veterinarian  convince them that the cat should be euthanized,” Levy says. “That’s just very old school thinking.”

In fact, the Association of Shelter Veterinarians and the American Association of Feline Practitioners do not support euthanasia based solely on a cat’s infection status.

The assumption is that people won’t want to adopt cats if they don’t know how long they’re going to live or if they might require expensive treatment toward the end of their life. That’s frustrating to Levy.

“People adopt old dogs or dogs with medical conditions all the time,” she says. “They’re like, ‘Yes, this animal needs a home. I like him. Nobody knows what the future will bring. And even if he has only a few years left in life, he’s a good dog for me, and I want to be there for him.’”

They feel the same way about cats with FeLV or other diseases such as FIV, she believes. Those are often young cats who are healthy in the moment, enjoying life, and are great companions. In an adopter satisfaction survey, 74 percent of respondents had a “very positive” experience living with an FeLV-positive cat adopted from APA and 21 percent had a “positive” experience; 73 percent were “very likely” to adopt a FeLV cat again and 11 percent were “somewhat likely” to do so.

The shelters that are starting adoption programs for cats with FeLV are proving Levy’s point, using creative and fun programs to place the cats.

“Very often, the thing that tips a shelter over to trying it is when a favorite cat turns up positive or a foster home ends up with a positive cat and they can’t possibly euthanize it,” Levy says. “So they take this ‘dangerous’ step of adopting it out and it goes so well. They’re like, ‘Oh my gosh, why didn’t we do this sooner?’”

That’s what happened at Tree House Humane Society in Chicago. A foster caregiver raised some neonatal kittens who tested positive later and no one could bring themselves to euthanize them. They adopted them out and the adoptions were so successful that they now feature FeLV cats at their new cat café. They are popular adoptees thanks to good education and public relations. A cat café in Seattle has a similar program, focusing on FeLV cats from local shelters.

The Austin model provides good data on the viability of such adoption programs, especially when they are combined with the education and support of local veterinarians, as well as how to put them in place. The programs create optimism and enthusiasm for saving cats who could be considered some of the most vulnerable in the shelter system.

“We need to be better at providing the continuing education to private practitioners, so they also feel this optimism about caring for these cats,” Levy says.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Kim Campbell Thornton is content manager for Fear Free Pets and is an Elite Fear Free Certified Professional. She has been writing about dogs, cats, wildlife, and marine life since 1985 and is a recipient of multiple awards from the Cat Writers Association, Dog Writers Association of America, and American Society of Journalists and Authors. When she’s not writing or editing, she’s snuggling with Harper and Keeper, her Cavalier King Charles Spaniels.
 

Study Suggests Simple Cage Modification to Reduce Stress in Hospitalized Cats

Linda LombardiThe veterinary clinic or hospital can be a stressful place for cats, full of strangers and strange noises and sights. A recent study suggests a simple and inexpensive way to reduce this stress by use of plexiglass sheets hung over the front of the cage.

In the study, thirty pet cats were placed in one side of two connected cages (the starting side, left or right, varied randomly) for 70 minutes. There were three conditions: open cage vs a cage-front covered by clear plexiglass; open cage vs opaque plexiglass; and clear vs opaque plexiglass. Observers calculated stress scores from the cat’s behavior during the first and last 15 minutes and recorded how much time was spent in each cage.

The cats who were most stressed in the first 15 minutes spent significantly more time in the cage that blocked the most incoming stimuli: they preferred either type of plexiglass to the open cage, and preferred opaque plexiglass to clear.

Coauthor Kyle G. Mathews, DVM, MS, DACVS of North Carolina State University says the idea behind the study was to find an affordable way to make clinics less stressful, while still allowing a full view of the patient. The opaque plexiglass is “like looking at the cat through a pair of sunglassses,” he says, which is much better than other inexpensive possibilities. “When you put a towel over the cage, or you give them a hiding box, you can’t see the animals.” When staff need to open the door to look at the hidden cats, that adds stress; if there’s a problem, staff might not notice in a timely fashion.  “They may have IV lines, and that makes giving them a hide box difficult, because they could get their lines tangled up,” he adds.

Other possibilities are more expensive. For example, louvered windows, such as those used for privacy in conference rooms, would probably work. “You’re looking down at an angle and can see the cat, but the cat looking straight out can’t see the room,” he says. “But these are very expensive and have to be custom made.” In comparison, inexpensive plexiglass cut to order can be bought fairly cheaply and all that’s needed is to attach hook and loop fastener strips to hang it from cages.

If you’re wondering why not a one-way mirror, they ruled that out immediately for good reasons. “A one-way mirror only works if there’s light on one side, and dark on the other. So the person in the dark room can see the person in the light room, but the person in the light room can’t see the person in the dark room,” he says. “So we’d need the light in the cage with the cat and the room would need to be dark.”

While they may be a start, barriers won’t solve all the problems that stress cats. In particular, while plexiglass sheets block light (a 74.4 percent reduction for opaque and 13.9 percent for clear), they do little to block noise (only a 4.5 percent reduction). Although no one has specifically studied the effect of noise on cats, it’s almost surely a problem, especially in an echoing stainless steel cage.

“Eventually, if people don’t want to rebuild a room for cats, we may need to design a cage that has insulation around the outside of it, but still stainless inside that you can clean,” he says. “But noise reduction is going to be a more expensive alteration. So this was our first attempt at looking at, is there something relatively cheap that a practitioner could use to retrofit their clinic that would make it feline friendly.”

Further research also needs to be done in a real hospital setting: this study was done in a special room, with video of the sights and sounds of a veterinary inpatient ward projected onto a screen. But in the meantime, the results suggest that it’s worth trying and doesn’t appear to have any downsides. “The indication is that it probably is helpful, especially in the most stressed-out cats,” he says. “It’s not going to hurt them – they’re not going to move away from it, there was no indication that was the case.”

Board-certified veterinary behaviorist Margaret E. Gruen, Assistant Professor of Behavioral Medicine at North Carolina State University and a Fear Free Certified Professional, agrees that this is worth trying, noting that odors, separation from owners, lack of hiding places, and sounds of people talking and monitors beeping are all stressors for cats, making hospitalization and recovery more difficult for them as well as increasing morbidity. They may refuse to eat or be hesitant to use the litter box. And anxiety is often difficult to differentiate from pain in cats. Looking at ways to mitigate these stressors while still being able to easily observe feline patients, especially when they are ill or recovering from procedures, benefits both veterinary teams and the cats themselves.

“The cats, and their people, will appreciate it,” she says. “And having happier cats in the hospital is a win for everyone.”

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.

The Link Between Pain and Problem Behavior

Linda LombardiFor some animal behavior issues, the need for a medical workup is clear. While a cat who stops using the litter box certainly may be under stress or have social problems in the household, the first step is to rule out bladder or kidney issues.

But there are also medical issues where a potential connection to a behavior problem may be less obvious. One that can be tricky to diagnose and that affects behavior in a wide range of ways is pain.

A recent article published in the journal Animals reviewed records of 100 dogs seen by the 13 coauthors and found that conservatively, a third of them involved some form of pain, and in some cases possibly up to 80 percent.

Coauthor and board-certified veterinary behaviorist Margaret E. Gruen, DVM, Ph.D., of North Carolina State University says, “We want to raise the consciousness that there are a lot of things where pain can be a contributor.” When clients come in with behavior issues, she says, “we want to be really specifically looking for discomfort, even if it’s behavior where we’re not immediately thinking, oh, that could be pain.”

It can be tricky, because pain in animals is not always obvious. “Unless you are really well versed in pain, it can be hard to pick up a painful animal in the exam room,” says Mike Petty, DVM, CVPM. “They put on a show about how well they feel. We will see dogs limp across the parking lot and then quit limping when they hit the front door.”

This means that knowing how to look for it is critical. “Primary care providers must keep an open mind that absolutely any change in their patients’ behavior that the client reports can be related in some way to pain. That means doing a good pain palpation as a part of every examination,” says Robin Downing, DVM, DACVSMR. “Only by including a pain palpation in every examination will a practitioner become proficient in identifying even subtle pain in patients.”

It’s also important to be aware of the many demonstrated connections. An increasing number of behavioral effects of pain and discomfort are being found in research. As more of these are studied, what’s “obvious” changes. “Compulsive licking in cats is a fantastic example,” says Dr. Gruen. While this was once commonly assumed to be a result of stress, after research revealed that approximately three-quarters of cats with compulsive licking actually had an underlying dermatological issue, such cats are now more likely to be treated correctly.

A less well-known example involves compulsive behaviors such as stargazing, fly-snapping, and pica. Research has shown that these can result from gastrointestinal problems in dogs.

And while inappropriate elimination as possible evidence of pain is well known in cats, it’s perhaps less frequently considered that pain can also be connected to housesoiling in dogs. “Oftentimes it’s too much effort for the dog to go and find their owner, or they dread going down the three steps into the backyard,” says Dr. Petty. “So they will sometimes go to the door and urinate or defecate there, or sometimes won’t even go to the door and just do it wherever they are.”

Problems of Aging

It’s often not easy to tell the difference between pain and cognitive decline, both of which can happen as pets age — and the two can interact as well.

“If a dog is acting weird, it might not be simple cognitive decline; it might be cognitive decline driven by pain,” says Petty. “Sometimes animals are in so much pain they can’t even think straight, so they’re much more likely to have behavioral issues.”

A sign such as apparent disorientation could be due to physical issues: a dog who seems to be stuck standing on a rug might be reluctant to cross a slippery floor because walking on it hurts. An apparent decrease in sociability could also be due to undiagnosed pain: “If you’re getting up and moving around the house, they’re less likely to follow you from room to room,” says Petty. “I always say to these clients, let’s make sure there isn’t a pain issue that pushing your dog over the edge, while we look at this cognitive issue.”

Petty thinks that teasing apart these potential causes is especially important because they often push people toward the decision to euthanize, since the dog doesn’t seem to be enjoying life and the pet-owner bond can be affected. Treating pain can help, as well as encouraging owners to modify their expectations for an aging pet. It may not be that the dog doesn’t enjoy his favorite activities anymore so much as they need to be modified: say, rolling the ball a short way instead of throwing it across the yard. He tells clients, “Think of what the dog used to like to do and tone it down.”

Looking for Changes

Because pain isn’t always obvious on examination, listening to the owner’s observations is crucial — but these may also need to be guided.

“When I speak with my clients about the possibility of pain in their pets, I alert them that any changes in behavior must lead us to at least consider pain as the culprit,” says Dr. Downing. “So, this means changes in eating and drinking, changes in getting onto furniture/beds, reluctance to ascend or descend stairs, decreased grooming (cats), restlessness at night (or the converse – – sleeping excessively), decreased interaction with human or animal family members, “grouchiness,” any changes in housetraining or litter pan use, objections to petting/brushing, decreased stamina on walks, or any other changes they may witness.”

But even for owners, these changes can also creep up so slowly that they almost don’t notice them. “It’s very common with chronic pain issues that once they’re treated, the owner says, ‘I just realized it’s been two years since he jumped on a couch,” Petty says. He strongly recommends using a questionnaire such as the Canine Brief Pain Inventory starting when pets are six or seven years old. “If you give this to every dog owner that walks in for their annual exam and have them answer these questions, you’ll be amazed at the red flags that come up.”

Lack of change where it can reasonably be expected can also be a hint, where behavior modification isn’t working. “If we have a patient who is working with someone, and they’re doing lots of appropriate things and not making progress, that’s when you want to think, let’s look even closer,” says Gruen. “Are we seeing anything that could be pain?”

Treating Both

Finally, it’s also important to remember that even when an underlying medical issue is identified, both medical and behavioral treatment may be needed.

“We need to know what the medical conditions are but that doesn’t necessarily mean treating that will solve the behavior problem,” says Gruen. “A good example is noise phobia.” In a dog who has some pain along with some fear of fireworks, for example, tensing up at the frightening noise may also cause physical discomfort. “That gets associated with the noise, so worsens the behavior problem.”

Similarly, when cats have urinary tract issues or pain that causes them to start avoiding the litter box, simply solving the medical problem may not be enough. “You can treat the infection, but the aversion is set up and persists,” she says.

Likewise, simply treating the behavior isn’t going to work if an underlying medical issue has been missed. “Making changes in those other pillars of the treatment plan is important and will be helpful, but it’s an uphill battle if you have an untreated medical concern,” says Gruen. “Particularly if it’s pain and discomfort, because that affect so many things.”

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.
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Top 10 Treats to Win Pet Hearts

Mikkel Becker, CBCC-KA, KPA CTP, CDBC, CPDT-KA, CTCFor pets, treats are like currency. Just as few of us will expend much effort to pick up a penny, but would risk ripping the seat out of our pants for a dollar, pets too crave high-value treats. Let’s face it; not all treats are created equal. There are certain flavors, textures, and even temperatures pets prefer over others.

It’s crucial to use “the good stuff” when it comes to treating effectively and gaining a pet’s keen appetitive interest in the face of distractions and change that are beyond a pet’s comfort zone, as happens when they are removed from the comfort of home and taken into the veterinary hospital environment.

Many Fear Free Certified Professionals have their own “tricks of the treats” to persuade even the most finicky of pets to chow down and lick their lips. Dr. Marty Becker,  founder of Fear Free and a Fear Free Certified Professional himself, is rarely in the exam room without a ready supply of top-shelf treats that he and his team generously hand out as pleasant distractions and high-currency mood boosters to help deliver a more optimal emotional experience for pets during veterinary healthcare.

Here are his top 10 pet-preferred treats for Fear Free veterinary care.

For Dogs

– Baby shrimp

– Beggin Strips (broken into tiny pieces)

– Canned salmon or tuna

– Warm deli turkey

– Easy Cheese Cheddar & Bacon

– Freeze-dried meats from Pure Bites

– Honey Nut Cheerios

– Kong Squeezable Peanut Butter

– Peanut Butter Captain Crunch

– Slices of turkey hot dogs

For Cats

– Albacore tuna or salmon

– Anchovy paste

– Baby shrimp

– Bonita fish flakes

– Easy Cheese Cheddar & Bacon

– Fancy Feast: Foil packs of any flavor

– Green olives

– Marshmallows

– Vegemite

– Whipped cream

Dr. Becker and the team at North Idaho Animal Hospital pay special attention to economical means of delivering tasty treats by ordering many of the above options in bulk for a lower price. They keep treats fresh and easy to pull out for individual patients by dividing the bulk size into smaller portions when possible, placing them into small, treat-size Ziplock bags and storing in a refrigerator or freezer until needed. The team will pull out treat options from the freezer to thaw in the fridge overnight. Warming the contents in a microwave-safe container for 7 to 10 seconds prior to the exam releases fragrant aromas and heightens flavors.

Pets with allergies and other special dietary needs receive treats specially chosen treats. Oftentimes the owner will bring in a pet’s favorite treats, such as blueberries, apple pieces, or green beans. An alternative is to warm the pet’s regular hypoallergenic food or treats in the microwave to enhance scent and flavor. A canned version of the pet’s regular food or a compatible alternative soft food and treats can be delivered through means of a food-dispensing toy. Or fill small paper cups with dilute beef bouillon or tuna juice and freeze to make a long-lasting popsicle the pet can lick. Remember, pets are coming in hungry, so even their regular food warmed up can seem like manna from heaven.

Deliver tiny tastes or portions. The pet may receive dozens of treats or continuous licks of a treat during the exam, but their appetite is maintained through small amounts (think Cheerio-size or smaller) or slow delivery methods such as from a food puzzle.

How do Dr. Becker’s favorite Fear Free treats stack up with your own go-to treats? What would you add to the list?

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Mikkel Becker is the lead animal trainer for Fear Free Pets. She is a certified behavior consultant and trainer who specializes in reward-based training that’s partnered closely with the pet’s veterinary team. Mikkel is the co-author of six books, including From Fearful to Fear Free.

 

 

 
 

Why Fear Free Is Better Medicine

Tony Johnson, DVM, DACVECCFear limits options.

When a patient is fearful of seeing me at a veterinary hospital, their world shrinks to two options: flee or fight. Neither one is fun for them or helps me do what I’m supposed to do for the patient and the family who loves them: find out what’s wrong and make it better.

With patients who are driven by fear, their natural instincts kick in and they resist everything we need to do to get them well.

I’m sure you’ve all been there when trying to treat a fearful patient. Patients displaying aggression are driven by fear. The vast majority of them don’t display this type of behavior at home – so why do they revert to aggression when we are trying to help them?

Think of their first few visits to the hospital and try to see it from their perspective. The car ride. They are likely apprehensive when loaded into the car or carrier. Their owner may try to soothe them with calming words, but fear takes hold.

The sights and smells. When they arrive at the hospital, they can smell the fear from dozens – hundreds – of other pets before them. They can smell the odors of the hospital – cleaning and disinfecting products, the cautery unit in surgery, the parvo dog in isolation. Their heightened sense of smell, many thousands of times what ours is, wafts all of these to them: smells of sickness and death. They sense that this is a bad place.

After this – needles, restraint. The inability to move. The fear of being atop the exam table with no place to run.

Is it any surprise, then, that they would grow to dislike this place and its occupants?

We know that we want to help them. We know that a vaccine will prevent deadly diseases, that a spay will prevent unwanted pregnancies and pyometra…but they don’t.

Lest I be misunderstood – I am not saying that a veterinary hospital is a bad place – not at all. I love them and I know the good that veterinarians do each and every day to protect and preserve animal health and promote healing. We just need to find a way to explain it to our patients.

Since we can’t use words (or my favorite means of communication – interpretive dance), we have to show them by our actions. We have to note the aspects of our places of work and our way of handling them and convey the concept that this is not a bad experience. We have to make their perception of this is a bad place become Hey, this ain’t half bad.

I know it can’t happen each and every time – I can’t take the time to cozy up to the Great Dane that just came crashing into my ER with a GDV – but I can take the time to make sure his post-op stay is as free of pain and anxiety as I can safely make it.

Fear Free is a mindset. It’s a new way of looking at our interactions with patients to suss out aspects that can be improved, spikes of fear that can be dulled, practices and protocols that can be improved.

Why?

You can look at it as a moral imperative – we have taken an oath. It’s the right thing to do. No patient should be worse off for seeing us.

You can look at it practically, as well.

Imagine the stress of trying to do a toenail trim or a heartworm test on a 90-pound dog displaying fear and aggression. That dog is probably recalling all sorts of memories, stretching back to puppyhood, of nauseating car rides, stressful physical restraint, triggering smells.

Now imagine a dog who saw each visit before this one as a chance for treats, pets, and gentle interaction. Happy visits – just in and out the door, and he didn’t even notice the DHLPP jab because he was too busy licking peanut butter off of a kind hand and the veterinarian giving the shot used a brand-new needle. Imagine a dog who received safe sedation for a laceration instead of being held down and receiving nothing but Brutacaine.

Which dog do you think will let you trim his toenails with less stress – for all of you?

Fear Free isn’t just about the patients. How many times do you think your top-tier tech will wrestle with that dog before she hears the siren call of nursing school? How many times will you look at the chart of the FAS 5 dog and feel your heart sink? Feel burnout creeping ever closer?

This doesn’t happen with a calm pet who knows that a visit to a veterinary hospital is a good thing, not a terrifying experience. In my 20 years of emergency practice, I’ve seen fear quite literally kill many patients – patients who are barely coping with illness at home, who then take a lethal turn when the fright of a car ride or veterinary visit tips them over the edge. Fear Free could have saved many of them.

If you take a patient who’s comfortable with the whole process in a veterinary hospital – check-in, physical exam, diagnostic tests, and going back home – you have a patient who doesn’t want to flee or fight me or my team. They’re cooperative and calm – they might enjoy the whole thing if we give them love, confidence, and, of course, plenty of treats). And judicious use of sedatives and analgesics can help offset the fear, anxiety, and stress of visits and procedures. Fear Free patients will let me run the tests and do the physical exam that gets me the answers I need to deliver the best care I can.

Without fear – when pets are Fear Free – it’s not only easier for everyone, it’s better medicine. It’s less stress – for everyone. It’s fewer shots in the dark. Fewer guesses, fewer misdiagnoses, fewer “let’s-see-if-this-fixes-it” treatments ending in lost time, bad outcomes, and problems like global antibiotic resistance. Fear Free practices mean more pets go home faster, and you and your staff are happier and more productive.

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.
 
 

Fear Free CSRs: How You Can Help Prepare Pet Owners

Course Overview

The CSR is the client’s first point of contact with the veterinary clinic. They play an important role in communicating the Fear Free concept and helping the client prepare their pet for a Fear Free vet visit. This module will help CSRs better understand how to “Speak Fear Free” to clients. It will provide sample scripts and tips. It will also provide them with a better understanding of the FAS scale, an awareness of their surroundings, the knowledge of what steps to take to ensure a positive experience for each pet, and more.

This course was written by Louise Dunn.

This course consists of three lessons:

  • Lesson 1: The CSRs Role for the Pre-Visit
  • Lesson 2: Creating the Fear Free Environment
  • Lesson 3: How to “Speak Fear Free” to Clients

Esophagostomy Tubes: Fear Free Tools for Disease Management

Julie Liu, DVMSeveral months ago, my senior Bichon mix, Dorie, developed severe gastrointestinal issues. She was trembling with pain and nausea, stopped her favorite pastime of body slamming her toys against the couch, and eventually became inappetent.

Medicating Dorie has always been a challenge because she can sniff out anything no matter how well I try to hide it, but during her illness it became impossible. Even worse, the fear, anxiety, and stress (FAS) she experienced during my attempts to medicate her were almost as traumatizing to me as a pet parent as they were to her. When she didn’t respond to hospitalization I brought her to a specialty hospital for endoscopic biopsies, and during her anesthetic procedure the internist placed an esophagostomy tube (E tube).

The sense of relief I felt at having the option to medicate her and feed her through the tube without causing FAS was immense. Dorie was ultimately diagnosed with inflammatory bowel disease and required weeks of immunosuppressive doses of steroids before she started body slamming her toys again, and without her E tube I wonder if she would have recovered.

As Fear Free practitioners we always try to consider a pet’s wants vs. needs, but when treatments are medically indicated for an unwilling sick pet, we have to find a different approach. The use of E tubes provides a compassionate solution to disease management that should be considered for a variety of illnesses and not only as a last resort.

Indications for E Tube Placement

Historically, many veterinarians have recommended E tubes for gastrointestinal diseases such as feline hepatic lipidosis, cholangiohepatitis, IBD, and pancreatitis. These pets can have a prolonged road to recovery and the conversation about E tube placement should be started with clients early–when their pet has had anorexia reported for a few days. At best, syringe feeding an icteric cat with hepatic lipidosis can fall short of the caloric needs required for their recovery. At worst, it can result in aspiration pneumonia, fear of the client, and injuries as the client struggles with the pet.

Conditions that cause oral pain, such as facial trauma and significant dental disease, are additional indications for E tubes when we consider the role of pain in contributing to FAS.

Rather than sending a pet home after full-mouth extractions with some canned food and oral pain medications and hoping for the best, we can have a proactive discussion with the client about an E tube at the time of surgery. This is particularly important in cases where the pet has already had decreased appetite preoperatively and adds minimal time and cost to the procedure. In cases of oral neoplasia where the client is not ready to pursue humane euthanasia, placement of an E tube to deliver nutrition and analgesia may provide at least some relief to the patient until the next quality of life discussion with the client.

In pets with chronic kidney disease, an E tube can make a huge impact on long-term management and maintaining the client-pet bond. I remember attempting to give subcutaneous fluids to my first cat with kidney disease and managing exactly one poke before she jumped off her cat perch and ran away while the fluid line whipped around, spraying fluids everywhere. Some clients are also uncomfortable with handling needles and having to inject their pet with fluids and can inadvertently poke themselves in the process. An E tube can allow a client to administer daily fluids and anti-nausea medications easily without causing FAS or discomfort.

In addition, many pets with CKD find renal diets unpalatable and develop nausea, inappetence, and weight loss as their azotemia worsens, leading their owners to feed them whatever they will eat. Placement of an E tube ensures that their pet will receive both adequate nutrition needed to maintain their body weight as well as the recommended prescription diet to try to slow progression of their disease.

While there may be an increased level of anesthetic risk for patients with CKD or other underlying health conditions, placement of an E tube1 is very quick (typically less than 30 minutes for placement and radiographic confirmation of location) and can provide weeks to months to even years of benefit. Once the stoma heals, it may be possible to exchange the tube through the same stoma site without general anesthesia by using topical anesthesia and the techniques outlined by Dr. Sheri Ross in 2016, in which she describes one feline patient with CKD whose stoma site was maintained for almost 5 years using E tube exchanges2 .

Client Education

Perhaps one of the challenging aspects of E tubes is overcoming the perceived stigma attached to the tube itself. Some clients may agree to several days of hospitalization for their pet but draw the line at an E tube because they associate it with end-of-life care. While this may be true with some conditions such as oral neoplasia, in others an E tube can actually save their pet’s life or improve management of a chronic disease. Most pets with an E tube also don’t seem to notice it at all, and will eat, drink, groom, and even body slam their toys with their E tube in place.

Some clients may also feel squeamish at the prospect of handling and using an E tube for their pets. Washable, patterned neck wraps such as the Kitty Kollar3 or Kanine Kollar have been amazing at minimizing the “medical” aspect of E tubes, and their website provides a great starting point for educating owners when initiating an E tube conversation. Once the E tube is placed and the pet is ready to be released from the hospital, provide written discharge instructions4 with a recommended schedule for medicating, watering, feeding, and cleaning based on that pet’s calculated water and caloric requirements to ensure that the pet is getting everything they need. Scheduling a teleconsult the following day and printing a weight chart for the patient at every recheck will provide additional guidance and positive reinforcement. When your client realizes how easy it is to treat their pet with the E tube, you can consider asking them to be a resource for others who are on the fence about having one placed for their pet.

Summary

E tubes can be used successfully for a variety of acute and chronic illnesses, and their ability to remove the FAS associated with treatments is significant. Weighing the risks vs. benefits of the brief anesthesia needed for placement is important, but when routine medical management is inadequate, we need to be proactive in advocating for our patients and work together to destigmatize these invaluable tools.

Resources

  1. https://www.cliniciansbrief.com/article/esophagostomy-feeding-tube
  2. Ross, S. Vet Clin North Am Small Anim Pract. 2016 Nov;46(6):1099-114.doi: 10.1016/j.cvsm.2016.06.014. Epub 2016 Aug 5. Utilization of Feeding Tubes in the Management of Feline Chronic Kidney Disease
  3. https://www.kittykollar.com
  4. http://vhc.missouri.edu/small-animal-hospital/small-animal-internal-medicine/diseases-and-treatments/esophagostomy-tube-information-and-care

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Julie Liu, DVM, CVA (Certified Veterinary Acupuncturist) is a small-animal veterinarian who practices in Austin, Texas. In addition to advocating for Fear Free handling of pets, she is passionate about feline medicine and senior pet care.
 

Dispelling Dental Myths

Mary L. Berg, BS, RVT, RLATG, VTS (Dentistry)Did you know that approximately 80 percent of adult dogs and 70 percent of adult cats have some form of oral disease? Dental problems in dogs and cats are among the top three pet owner concerns, and many have misconceptions about how to provide good oral care. Here is a list of the most common myths your clients believe about pet dental health or questions they have and what to know to answer them.

  1. White teeth equal a healthy mouth.

Not necessarily. The health of the gums is more important than the color of the teeth.  Red, swollen gums are a sign that infection is lurking below the gumline. Infection can lead to bad breath, tooth loss, and heart, liver, and kidney disease in pets. The best way to ensure that every pet has a healthy mouth is to have your veterinarian perform a regular oral examination and professional tooth cleaning procedure on at least an annual basis.

  1. Bad breath is normal in pets

Not true. Bad breath is an indicator of an infected mouth. The odor is often caused by by-products of bacteria in the mouth that form plaque and lead to dental disease. Pets with halitosis need a thorough dental exam and cleaning procedure.

  1. Anesthesia is scary, so non-anesthetic dental cleaning is the way to go.

There is always a risk when an animal is anesthetized, but a thorough pre-op examination and blood work along with individualized anesthetic protocols and monitoring reduces pets’ risk during anesthesia. An anesthesia-free dental cleaning provides no benefit to the pet’s oral health. Scaling or scraping the teeth with an instrument only makes a tooth whiter in appearance. Think of the tooth as an iceberg; we see only about one-third of the tooth with the remaining two-thirds below the gumline. Bacteria below the gumline quickly become pathologic and begin to destroy the tissues surrounding the tooth. It is not possible to eliminate bacteria beneath the gumline where damage is done. Scaling without proper polishing roughens the tooth surface, leaving more surface area for bacterial plaque to attach to the tooth surface. Anesthesia-free dental cleanings are dangerous because they give a false sense of security that the pet has a clean mouth, allowing periodontal disease to go undetected and untreated. See more at: http://avdc.org/AFD/pet-periodontal-disease/#sthash.EGBX3IuT.dpuf and http://avdc.org/AFD/

  1. Tooth brushing is too difficult, and my pet hates it and it really doesn’t help anyway.

While not all pets are willing to accept tooth brushing, it is the gold standard for good oral care.  It does take time to teach pets to accept tooth brushing. Have a detailed explanation and demonstration for the pet owner such as this: “Start slow, with your finger and some pet toothpaste. Hold the muzzle with one hand and gently insert your finger between the cheek and the teeth and ‘brush’ the teeth.  Reward pets with a favorite treat, praise, or game when they accept brushing! You may need to do this every day for a week to ensure your pet learns that it’s okay! Once the pet accepts your finger, begin using a toothbrush but introduce it slowly over several days. You only need to brush the outside of the teeth.” You can also refer clients to this video from Maddie’s Fund.

  1. Feeding hard kibble will keep my pet’s teeth clean.

Most dogs and cats swallow kibble whole, getting no dental benefit. Even if pets chew kibble, the kibble is too hard and breaks apart when the tooth hits it, offering no benefit. Some dental diets are designed to solve this problem. The kibble is larger and softer, comprising a fiber matrix that allows the tooth to penetrate the kibble, thus wiping plaque off the tooth.

  1. 6. Bones, chew toys, and tennis balls will help keep his teeth clean.

While your dog will love you for the bone, his teeth may not. The canine jaw does not shift side to side like a human jaw, so when dogs bite down on a bone they often fracture the carnassial teeth. These fractured teeth hurt and can lead to infections and abscesses if left untreated.

Here’s a good rule of thumb when choosing a chew toy: if you can’t easily bend it with your hands or if you wouldn’t want to be hit in the knee with it, don’t give it to a pet. Wild dogs and wolves often have multiple fractures in their mouths due to chewing on bones.

Playing fetch with a tennis ball is a great way to bond with your pet but put the ball away when done. The rough surface of the tennis ball can abrade tooth enamel over time. Dogs who constantly chew on tennis balls often have severely worn teeth that can become painful.

  1. Dogs and cats do not feel pain.

Our pets can’t tell us about the pain they feel, and they often want us to be happy, so they mask the pain. An infected mouth or a fractured tooth hurt and require treatment. Pets need to eat to stay alive so they will often figure out a way to do so that causes the least amount of pain.  If clients notice their pet dropping food or only chewing on one side of the mouth, their pet has a problem.

  1. It doesn’t bother me if my pet’s teeth aren’t pretty.

Pets with dental disease have an infection that should be treated just as an infected ear or wound would be treated. This infection is in the oral cavity and every time the animal chews, bacteria is released into the bloodstream, causing a detrimental effect on the heart, liver, and kidneys. There are even new studies linking joint issues to the oral cavity.

  1. Oral disease is an inevitable part of aging.

Pets who receive good oral home care and routine professional cleanings are much less likely to develop dental disease as they age. Many veterinary professionals believe that good oral care can add an average of two years to the life of a pet. Just as age is not a disease, dental disease does not have to be an issue in aging pets.

  1. How can I know if a dental product will really work for my pet?

The Veterinary Oral Health Council gives dental products a seal of approval for either plaque reduction or tartar reduction. The VOHC recognizes products that meet pre-set standards of plaque and calculus (tartar) retardation in dogs and cats. Types of products include special diets, toothbrushes, treats that may contain enzymes to help clean teeth, and treats or toys that can be filled with enzymatic pet toothpaste. Items awarded the VOHC Seal of Acceptance have been proven to work based on scientific studies and protocols. Bright Dental chews and toothpaste are currently in the midst of trials to earn VOHC certification.

References

Pavilica, Z., Petelin, M., Juntes, P, Erszen ,D., Crossley, DA, Skaleric, U,  “Periodontal Disease Burden and Pathological Changes in Organs of Dogs.”  J Vet Dent 2008 Jun:25(2):97-105.

DeBowes LJ: The effects of dental disease on systemic disease. Vet Clin North Am Small Anim Pract 28:1057. 1998

Debowes, LJ, Mosier, D. Association of periodontal disease and histologic lesions in multiple organs from 45 dogs. J Vet Dent 1996; 12: 57–60.

Maresz, KJ, etal, “Prophyromonas gingivalis facilitates the development and progression of destructive arthritis through its unique bacterial peptidylarginine deiminase (PAD)” .  PLos Pathog. 2013 Sep;9(9):e 1003627

Tang, Q, Fu H, Qin B, etal,”A possible link between rheumatoid arthritis and periodontitis: A systemic Review and Meta-analysis.” Int. J Periodontics Restorative Dent 2017, Jan/Feb, 37(1):79-96

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Mary is a charter member of the Academy of Veterinary Dental Technicians and received her Veterinary Technician Specialty in Dentistry in June 2006. She worked in research for over 28 years, specializing in products aimed at improving oral health of companion animals and continues to work with companies to evaluate the efficacy of their products. Mary is the founder and president of Beyond the Crown Veterinary Education, a veterinary dental consulting service.  She was named NAVTA Veterinary Technician of the Year in 2020 and received the AVDT’s Excellence in Dentistry Education award in 2019. Mary is a speaker and wet lab instructor at numerous state and national conferences. She lives on a small farm near Lawrence, Kansas, with her husband, Doug, and has two sons and three grandchildren.

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