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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

https://www.cliniciansbrief.com/article/esophagostomy-feeding-tube
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
https://www.kittykollar.com
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.

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.

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.

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/

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.

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.

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.

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.

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.

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.

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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Fear Free Shelters: Why Natural Lighting Is Important

Heather E. LewisAs we have learned this year during the pandemic, outdoor spaces are healthier for people than indoor spaces. It isn’t just ventilation that is better outside; daylight provides physiological benefits for people and animals that artificial lighting will never replace.

For dogs in shelters, the best you can do for their welfare is to get them outside for enrichment. This must be emphasized before we talk about improving indoor spaces, as even the best indoor space cannot replace outdoor time. Nevertheless, bringing natural daylight into the shelter has benefits for all animals, including homo sapiens.

Reinforcing Circadian Rhythms

Circadian rhythms are the hormonal and physiological cycles our bodies go through, day and night. They tie to our general health, our quality of sleep, and our patterns of eating and resting. Circadian rhythms are also important for reinforcing seasonal patterns such as the growth of winter haircoats.

- Bringing daylight into shelters and allowing dogs and cats indoor/outdoor spaces helps them maintain crucial biological cycles throughout their stay. Circadian rhythm regulation is particularly important for animals who must stay longer in care; for example, dogs with medical conditions requiring continued care.
- As one example of the importance of circadian rhythms, human hospital patients with disrupted day/night cycles suffered poorer cognitive functions, had delirium in greater frequency, and recovered more slowly than they would have without these disruptions.

Boosting Morale for Staff

Animals in the shelter pick up on the morale of staff and volunteers. Sheltered animals are often fearful, and one way we can reduce fear is to provide compassionate and gentle care. Lack of natural daylight in human workplaces contributes to stress, fatigue, anxiety, and depression-related illnesses such as SAD (Seasonal Affective Disorder) and makes compassionate care more challenging. Bringing daylight into the building counteracts these effects and helps support a healthier, more upbeat work environment, which is better for the well-being of all.

Unfortunately, many shelters, especially older ones, are constructed with few windows and little natural daylight. However, there are ways to add natural lighting without huge expense. Here are a few tips:

Construct inexpensive outdoor spaces such as catios, dog exercise yards, and a covered patio or pretty garden pergola where staff can relax and take their lunch or breaks. These are easy to get donations for (relatively speaking), or they can be built on weekends by handy volunteers.
Consider adding “Solatubes,” which are tubular skylights. These introduce daylight from roofs down to the ceiling, and work even in structures that are high overhead. They are relatively easy to install, and they are not as prone to leaking as traditional skylights.
Speaking of which, we have been to several shelters that used to have skylights but covered them when they leaked. Uncover your old skylights and put the effort into fixing them – it is worth it!
Swap out solid doors for glass doors. Adding a glass door adds daylight with very little effort. If you’re worried about security, put an alarm on the door and frost the glass – the soft daylight coming in will be worth the risk of the glass, in most cases.
Add windows. Windows can be harder to add because this involves cutting holes in an outside wall, so add them where they would provide the most benefit. For example, if you have a cat isolation room on a blank outside wall, adding a window will vastly improve the wellbeing of the cats housed in that room while being treated. If you do go to the trouble of adding a window, put a heavy-duty screen on it and design the window to be operable. That way it can be open in nice weather, which provides even more benefit.

Don’t settle for a lightless bunker. It’s not good for you and it’s not good for the animals. As we head into the dark of winter, look for fundable opportunities to get animals and staff outside, as well as for ways to bring daylight in. Everyone will be happier and healthier!

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.

Fear Free Management of Feline Diabetes

Julie Liu, DVM
Before learning about Fear Free handling techniques, one of my biggest fears about my cat, Puff, was that he would someday become diabetic and require insulin injections. While he is a friendly cat, he is so resistant to restraint that even applying topical parasite preventive on him monthly could be a struggle, not to mention the nightmare of bringing him to the clinic and handling him for labwork (picture a 12-pound white and orange bucking bronco).

I have encountered a similar level of panic in a number of my clients faced with the diagnosis of diabetes in their cat. Beyond the stress associated with costs of initial diagnosis and treatment, many clients have a high level of anxiety at the thought of giving their cat injections and may even consider euthanasia for a disease that is often ultimately manageable. We can provide a huge service to our patients by educating both clients and our fellow veterinary professionals on Fear Free methods of handling diabetic cats.

Insulin Administration

Fear of needles is nothing new in the veterinary clinic. We see it develop all the time in pets when they jump with the poke of a vaccination. Over time, they begin to anticipate that when their skin is touched, pinched, or lifted, a needle will follow. You may even observe this occurring within the course of the same appointment when you have to give several vaccines. While we set a goal for diabetic remission in our feline patients, unfortunately this won’t be possible or permanent for all cats, so getting clients comfortable with handling their cat for injections is vital.

Prepping Pet Owners

The good news about managing diabetic cats is twofold: insulin needles are tiny and most diabetic cats love food. I normally ask owners to administer insulin while their cat is obliviously munching away on breakfast or dinner. For those with a cat like Puff, taking time to desensitize and countercondition the baby steps leading up to the injection is recommended since these types of cats always seem to know when their owners are up to something.

Start with having the owner find a comfortable location in the house for feeding and insulin administration and practice remaining next to their cat while the cat is eating. Next, have the owner desensitize the cat to being petted between the dorsal shoulders while eating, followed by desensitization and counterconditioning to the owner gently lifting and releasing the skin. For needle-reactive cats, practicing fake injections with the tip of a pen. Using the Fear Free vaccination technique of applying numbing cream a few minutes before injection will help ensure that the process remains more positive and less like a horror movie where the owner is chasing the cat around the house with an uncapped needle.

Blood Glucose Monitoring

Have you ever taken a blood glucose reading from a cat in the clinic while he’s growling and hissing and wondered how accurate your 391 value was? Similar to Doppler blood pressure, if your feline patient has an FAS level of 4 or 5, you may not be able to trust those blood glucose numbers.

To minimize stress hyperglycemia, all of the normal Fear Free recommendations you would make for reducing FAS associated with vet visits apply to in-clinic blood glucose curves: desensitization and counterconditioning to the carrier, low-stress handling at the clinic, and most of all, pre-visit pharmaceuticals. Unfortunately, even with taking all of these precautions, your feline patients will likely experience some stress. If you rely on serum fructosamine you’ll get a general idea of their level of blood glucose control over the preceding week but miss the nadir and other parameters. As a result, home blood glucose monitoring has become a much more common and Fear Free method of assessing diabetic control.

Historically, I’ve asked owners to purchase their own AlphaTRAK™ glucometer kit online and scheduled a technician appointment for a demo with their cat on how to obtain the needed microdrop of blood from the marginal vein along the haired portion of the ear pinna. Similar to desensitization and counterconditioning to handling the cat for insulin injections, the same approach can be used for blood glucose sampling. Using a cotton ball to stabilize the non-haired portion of the pinna and a 27-gauge needle will improve patient comfort.

Clinics can create a standardized home blood glucose curve form containing patient information, current diet, current insulin type/dose, blood glucose level prior to the start of feeding/insulin, and readings every 2 to 4 hours over a 12-hour period. Once this is completed and emailed back to the clinic, a blood glucose curve consult fee can be charged to the owner prior to having the doctor contact the client. While you may get some pushback from clients regarding this fee, keep in mind that the fee is typically a fraction of the cost charged for an in-clinic curve, and client education on home blood glucose sampling will empower owners to verify hypoglycemia if symptoms are seen and seek veterinary care if indicated.

Recently, continuous glucose monitors (CGM) such as the Abbott Freestyle Libre™ glucose monitor have provided another option for Fear Free management of diabetes. While these products are used off label in pets and require an in-clinic visit to apply the device, they can provide continuous interstitial (subcutaneous) glucose sampling for 10 to 14 days on feline patients where an at-home curve is not possible.

Once the small sensor is applied to the skin, the owner simply scans the device with their phone periodically to transmit the data, which can also be shared with the clinic. A glucose curve consult fee can be charged to the owner at the time of application of the CGM that will cover the consult with the veterinarian at the end of the two-week period. CGM can also be used to reduce FAS at the clinic for hospitalized diabetic cats such as those receiving treatment for diabetic ketoacidosis or pancreatitis.

Caution must be used to avoid overinterpretation of glucose readings by the owner, and even when placed correctly the sensors may fail to obtain data. However, the ability to avoid multiple needle pokes at home or in the clinic makes these devices an appealing Fear Free alternative to how we traditionally monitor diabetic patients.

Telemedicine

In the age of Covid and curbside veterinary care, many clinics have ventured into teleconsults, which are a great addition to the Fear Free toolkit. What could be more Fear Free than helping your patient from the comfort of their own home?

Once a veterinarian-client-patient relationship is established based on the rules of your state, clinics can offer paid video teleconsults with an experienced technician or a veterinarian to guide a client through low-stress handling for insulin injections and blood glucose sampling while they are working with their own cat. Teleconsults also allow for education on signs of FAS that the owner may not pick up on such as a flicking tail tip or flattening ears that necessitate a change in handling.

Feline diabetes can be a challenging disease for owners as well as veterinary staff, and as always, we need to consider the client’s lifestyle and the patient’s symptoms in our recommendations. Whether your patient is at home or at the clinic, tailoring your treatment plan to include Fear Free techniques will help build confidence and increase success with disease management.

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.

Boxing Down: The Wrong Choice for Animals… and People

Boxing Down: The Wrong Choice for Animals… and People

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.

Join Clinical Behavioral Medicine Resident Alison Gerken, DVM, and Washington State University Adjunct Professor Tamara Grubb, DVM, PhD, DACVAA, as they discuss the science of why these techniques are no longer recommended and what you can do instead.

Pheromones to Help Pets Cope with Holiday Stress

Pheromones to Help Pets Cope with Holiday Stress

The holidays are often overlooked as a major time for stress in our patients’ lives. In this webinar, Valarie V. Tynes, DVM, DACVB, DACAW, will review the common triggers occurring from October through the end of December and how to equip your clients with the best information to make it a happy holiday season for everyone.

Brought to you by our friends at Ceva Animal Health

Design Solutions to Tackle Stress in Treatment Areas

Heather E. LewisMany veterinary practices have developed effective solutions for Fear Free exams and for low-stress patient housing. The next important area to tackle, the treatment room, is an inherently stressful space. Why are treatment rooms so stressful and what can we do to reimagine them?

Treatment rooms are stressful because they are generally designed to be a wide-open space, with many different functions occurring simultaneously. Treatment rooms are this way to ensure efficiency of staffing and safety for patients. For example, animals may be housed in treatment because this is the location where they can be monitored most easily. What if it were possible to maintain safety and efficiency, while de-stressing the treatment and other medical areas of your hospital? I know that it is! Below are a few of our favorite solutions for incorporating Fear Free design concepts throughout the medical areas of the hospital.

Separated Cat Treatment. One of the easiest ideas to implement is a separate cat treatment area located near cat exam rooms and ward. With this design, the cat areas of the hospital can function as a “mini clinic” space. This does not take a lot of room and removes cats from the chaos of the primary treatment space. Designs that include windows into the main treatment room allow for better communication between the cat area and other medical spaces.

Minor Treatment. This treatment space is located behind exam rooms and functions as a quiet area for simple procedures that might need more space or equipment than an exam room might offer. The client can step into this space as well. This minor treatment space is intentionally placed away from potentially frightening and unfamiliar sounds, smells, and activity associated with procedures and surgery. It can remain calmer and quieter because of its placement.

Treatment Curtains. Treatment curtains are borrowed from cubicle curtains used in human medical triage and emergency care. They allow for flexible visual privacy, and they also cut down on noise and visual stimuli, as we have learned anecdotally from using them. A curtain track can be placed in the ceiling around any treatment table to convert it into a semiprivate space.

Separate ICU and Recovery. Separating more critical patients behind glass in the treatment space does wonders. Even if you have few critical or recovering patients, separating them will help create a quieter treatment space and quieter patient space. If you like the idea of glassed wards for more critical patients, ensure that the glass goes to the floor so you can quickly glance in and monitor patients, to continue to keep them safe.

Better Materials and Systems. Once the design is reworked to make treatment areas more specialized, focus on the next layer of design: selecting better materials and systems. Here are a few of our favorite ideas:

Dimmable lighting. Lighting that dims allows you to de-stress the space when things are quiet, such as overnight for hospitalized pets.
Windows and daylight into treatment. Placing some outside daylight in the treatment room can make it feel more connected to the natural environment, helping to de-stress the space and make your staff feel a lot better.
Indoor/Outdoor options. As the Covid-19 crisis has taught us, having some flexible outdoor space can be very helpful for a veterinary practice. What about having a treatment porch, or if that is too ambitious, what about at least having a few operable windows, or a beautiful garden for walking post-surgical patients?
Noise control. Noise control is critical. Use good ceiling materials that cut down on noise. Use quiet casters on your chairs, and quiet latches on cages. Every bit of unnecessary noise is an opportunity to rethink design elements.

We have a long way to go with veterinary treatment spaces, but with Fear Free, we’re on our way to reimagining medical care that is far better for the emotional wellbeing of pets than it has been in the past. We are excited to see your ideas implemented in the treatment room of tomorrow, and we know that we will never look back.

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.

Navigating Your Practice’s Preventative Care Yellow Brick Road During a Pandemic

Vaccines, Clients & Curbside… Oh My! Navigating Your Practice’s Preventative Care Yellow Brick Road During a Pandemic

Join Dr. Julie Reck, owner and founder of Fear Free Certified Practice Veterinary Medical Center of Fort Mill, for a discussion on vaccines, how to administer vaccines in a Fear Free manner, and how to improve communication throughout your practice to navigate preventative care in a curbside environment.

Brought to you by Elanco.

Alone in the Wilderness

Course Overview

Are you the only person in your clinic who has a passion for Fear Free? It’s easy to get discouraged and frustrated when we are surrounded by obstacles. This course provides tools to achieve your Fear Free goals even when you feel like you are all alone in your work. Learn how to get buy-in, implement strategies from the ground up, and encourage your colleagues to join your heart’s work of protecting the emotional welfare of our treasured animal patients.

This course, approved for 1 RACE CE hour, was written by Monique Feyrecilde BA, LVT, VTS (Behavior).

This course consists of five lessons:

Lesson 1: The essence and importance of Fear Free Practice
Lesson 2: Understanding the dynamics of change
Lesson 3: Implementing change within your practice
Lesson 4: Addressing common push-back topics
Lesson 5: Thrive where you’re planted, or transplant to a new garden

5 Fear Free Experts Celebrate Their Wins

Kim Campbell Thornton
Blood draws, chemo, happy vet visits, even training veterinary students: Fear Free makes things work. Here are this month’s success stories.

Chemo for Indy

Indy was a middle-aged mixed-breed dog who developed Stage 3a lymphoma requiring weekly treatment under a CHOP chemo protocol. Only one problem: he was an FAS 4-5 patient who did not like to be touched, let alone restrained. How were we going to treat weekly with IV catheter-administered chemotherapy? Spent a lot of time in the early days fine-tuning a PVP protocol that allowed us to work on touch gradient approach so we could eventually hold his paw and use a regular or butterfly catheter to administer therapy. We always had myself and one specific technician available to work on desensitization with gentle restraint and forelimb holding. Lots of treats. For longer IV treatments, we preemptively sedated Indy. By the end of his treatment cycles, he would walk into the chemo room, sit or lie on a padded mat, and let us treat without incidents. Amazing! It works!

Jeffrey D. Palmer, DVM, Elite Fear Free Certified Professional, Burr Ridge Veterinary Clinic, Darien, Illinois

PVP, Tuna Lead to Successful Cat Exam

A new feline patient with a high level of fear, anxiety, and stress went home with gabapentin as a pre-visit pharmaceutical. The exam we performed two days later was great. He was readily eating tuna and happy to be petted. He did well for a complete exam, including radiographs and blood draw. The Feliway-infused towel was also a great help.

Matthew Hudson, DVM, Elite Fear Free Certified Professional, VCA Blum Animal Hospital, Chicago, Illinois

Cat Can Do

We have seen so many success stories with numerous patients, but the best for me is my personal cat. He is an uncontrolled diabetic, and the first year I owned him he had a lot of blood draws and vet visits. He was a wonderful-tempered cat at home, but at the clinic, while he never bit or scratched, he hissed and struggled every time he came out of the cage and became a difficult patient to handle. He is very food-motivated and after we started Fear Free practices and he got squirt cheese and baby food every time he was handled, he now purrs and rubs on everyone when he comes for treatments and is so much happier and easier to handle. I am overall so much more aware of a patient’s anxiety level the moment they walk in the door now, and it gives us a chance to start finding ways to alleviate their stress before it escalates.

Cheri Crane, Elite Fear Free Certified Professional, Customer Service Representative, Healing Paws Veterinary Clinic, Springfield, Missouri

Culture Change

For most of my practice career, I have been involved in student training. Some students embraced the things I taught them about the importance of minimizing fear, anxiety, and stress in patients, while others felt I was “too soft,” “only cared about giving the animals treats,” or “was crazy or misguided in my efforts.” Fellow faculty members sometimes shared these sentiments and even accused me of not being able to “get the job done” when I would elect to postpone or re-plan a procedure for an animal. The revolution of awareness that Fear Free has helped to create in our profession has changed the way I am viewed by students and colleagues. No longer the “crazy Dr. Griffin,” I am the one they ask to teach them about low-stress handling and Fear Free techniques. The art and science of Fear Free have become valued: this is truly a gift for all of us, our patients, and their owners. I look forward to the day when Fear Free is taught in all veterinary colleges and is fully embraced as an indispensable standard of care in veterinary practice.

Brenda Griffin, DVM, DACVIM, Elite Fear Free Certified Professional, Adjunct Clinical Associate Professor of Shelter Medicine, Maddie’s Shelter Medicine Program, University of Florida College of Veterinary Medicine, Gainesville, Florida

Happy Puppy, Happy Vet Visit

I took a client’s puppy to our veterinary office for a happy visit after the previous appointment did not go well for them. We played on the floor, showed off some of their tricks, ate some really yummy food. I was able to ask for a nose target to get up on the scale all on his own! We were able to leave with a calm, happy puppy and his next vet visit went much better.

Jenn Hauta, Elite Fear Free Certified Professional, Fairy Dogmother Training & Pet Care, Nanaimo, British Columbia, Canada

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 a Level 3 Fear Free Certified Professional. She has been writing about dogs, cats, wildlife, and marine life since 1985.

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