Are you taking care of you? - cdn.ymaws.com€¦ · Are you taking care of you? The only chews with...

JOURNALDecember/January2019

V E T E R I N A R Y N U R S I N G I N A C T I O N

IN THIS ISSUE

24 What's Your Mission?

27 Work-Life Balance

38 Compassion is a Two-Way Street

Are you taking care of you?

The only chews with the power of delmopinol, ORAVET® Dental Hygiene Chews create a barrier against bacterial attachment—and when bacteria can’t attach, they can’t produce plaque bio� lms or the volatile sulfur compounds of halitosis. ORAVET Dental Hygiene Chews have been proven effective in multiple canine trials, including “clean mouth” and “dirty mouth” studies.1,2 They are also highly palatable,1 and the scrubbing action of the chew works in parallel with delmopinol to remove existing plaque and calculus. For full study results, contact your sales representative or visit oravet.com.

53% 42% 54% HALITOSIS PLAQUE CALCULUS

PROVEN REDUCTION IN KEY ORAL HEALTH INDICATORS1*

Defend against plaque, calculus, and halitosisFight the source of oral health problems with the science of delmopinol.

*Compared with dogs receiving dry diet aloneReferences: 1. Data on � le. 2. Data on � le.

Merial is now part of Boehringer Ingelheim.ORAVET® and SERIOUS ORAL CARE MADE SIMPLE® are registered trademarks of Merial. All other trademarks are the property of their respective owners. ©2018 Merial, Inc. Duluth, GA. All rights reserved. OVC17TRADEAD (02/18).

The only chews with the power of delmopinol, a barrier against bacterial attachment—and when bacteria can’t attach, they can’t produce plaque bio� lms or the volatile sulfur compounds of halitosis. Hygiene Chews have been proven effective in multiple canine trials, including “clean mouth” and “dirty mouth” studies.action of the chew works in parallel with delmopinol to remove existing plaque and

Defend against plaque, calculus, and halitosiscalculus, and halitosisFight the source of oral health problems Fight the source of oral health problems with the science of delmopinol.

ORAVET Dental Hygiene Chews are a Merial product.

CONTENTSIN

TH

IS I

SS

UE

Cover p

hoto

adap

ted fro

m iSto

ck.com

/ kemalb

as

NAVTA NEWS

2 NAVTA Executive Board Report

3 State Association Updates

6 Academy Updates

6 Student Updates

36 American Heartworm Society 2018 Canine Heartworm Guidelines

SPECIAL FEATURES

24 NAVTA Spotlight: What's Your Mission? Defining Personal Values, Vision, & Mission as a Veterinary Technician

34 Head to Tail with Steve Dale: Loss of Appetite in Senior Cats: Symptoms, Causes, and Treatments

38 Member Perspective: Compassion is a Two-Way Street

CASE STUDIES

19 Heatstroke in a Brachycephalic Breed with a Severe Coagulopathy and Tracheostomy Tube

VETERINARY NURSING EDUCATION

7 Gastric Dilatation and Volvulus

27 Work-life Balance in the Veterinary Industry

43 Raptor Anesthesia

CURRENT CONVERSATIONS

15 How Veterinary Insurance Might Save the Veterinary Technician

40 Conference Time . . . Get Unplugged!

PROFESSIONAL PULSE

50 Professional Pulse: Veterinary Support Staff Unleashed!

48

41

17

On the cover:In our profession, taking care of others often comes before self care. In this issue you'll find tools for evaluating and elevating your own self care.

VETERINARY NURSING IN ACTION | December/January 2019 | 1

NAVTA1931 N. Meacham Road Schaumburg, IL 60173

[email protected] | www.navta.net

2017 NAVTA EXECUTIVE BOARDPresident:

Kara M. Burns, MS, MEd, LVT, VTS (Nutrition), VTS-H (Internal Medicine, Dentistry)

President Elect: Erin A. Spencer, M.Ed., CVT, VTS (ECC)

Secretary: Beckie Mossor, RVT

Treasurer: Michelle D. Krasicki Aune, MBA, BS, CVT

Member at Large: Kenichiro Yagi, MS, RVT, VTS (ECC), VTS (SAIM)

Member at Large: Elizabeth (Beth) Green, RVT

Past President: Mary Berg, BS, RLATG, RVT, VTS (Dentistry)

COMMITTEE CHAIRSNAVTA Booth Representative:

Virginia Rudd, CVT, RVTNAVTA CE Committee:

Vicky Ograin, MBA, RVT, VTS (Nutrition)NAVTA CVTS Committee:

Ed Carlson, CVT, VTS (Nutrition)NAVTA Global Outreach Committee: Ken Yagi, BS, RVT, VTS (ECC, SAIM)

and Linda Markland, RVTNAVTA Membership Committee:

Jaime Rauscher, RVTNAVTA National Credential

and Title Change Task Force: Ken Yagi, BS, RVT, VTS (ECC, SAIM)

and Heather Prendergast, RVT, CVPM, SPHRNAVTA Public Relations Committee:

Jade Valasquez, LVTNAVTA SCNAVTA Committee:

Beckie Mossor, RVT NAVTA State Representative Committee:

Ken Yagi, BS, RVT, VTS (ECC, SAIM)NAVTA Veterinary Assistant Committee:

Dennis Lopez, M.ED, B.SCI, LVT

THE NAVTA JOURNALEditor in Chief & Website Coordinator

Heather Prendergast, RVT, CVPM, SPHRAssociate Editor in Chief

Kara Burns, MS, M.Ed., LVT, VTS (Nutrition) Editorial Board

Katie Larsen, DVMRachel Lutz

Betsy Hensley, CVTPat Telschow, BS, LVT

DesignPop! Creative Design | popdesigned.com

Printing and FulfillmentNextPage | gonextpage.com

Opinions and statements in The NAVTA Journal are those of the authors and not those of NAVTA, unless so stated. NAVTA assumes no responsibility

for, and does not warrant the accuracy or appropriateness of, recommendations or opinions

of the authors or of any product, service, or technique referred to in The NAVTA Journal.

Published advertisements in The NAVTA Journal are not an endorsement of any product or service.

JOURNALNAVTA EXECUTIVE

BOARD REPORT

FROM THE EDITOR

Happy New Year from the NAVTA board!

The start of each new year is a time for reflection and for reflecting and implementing (sometimes difficult) decisions to make ourselves better people.

In that regard, this last year has seemed like a never-ending “new year” for the NAVTA board. As we move into 2019, we believe that we have made some necessary changes to move forward with NAVTA’s mission “to advance veterinary nursing and technology.”

In an upcoming issue of TNJ we will be providing an in-depth report of the state of NAVTA. In this letter from the NAVTA board we will present a general overview of where we have been, and where we are going for the upcoming year. We would like to thank our fellow board members for their commitment and engagement throughout a demanding year, especially our Treasurer, Michelle Krasicki-Aune.

After Michelle took over as Treasurer in January, she began a deep dive into how NAVTA’s finances were organized. Michelle holds an MBA, enabling her to look at things from a true business perspective. Her focus was to ensure all of NAVTA’s financial information was up to date and accurate, while also streamlining processes to make things easier and more accountable. She succeeded in getting us to a place where NAVTA’s financial picture is clearer.

One of many financial decisions had to do with the NAVTA Journal. There has been both “cheers and jeers” in our

decision to offer a digital only version for the past several issues. This was a short-term decision, made for financial reasons, not a permanent decision. The NAVTA board had every intention of going back to a print journal. We began hearing from members who liked TNJ as a digital publication … and then we started hearing from those who want the print journal back. The NAVTA board is working toward the best option for all NAVTA members. It is exceedingly expensive to publish a print version of TNJ, so the board is evaluating the pros and cons, as well as feedback from members to assist in the decision making. Whatever decision is made will be in the best interest of NAVTA as a whole.

In 2018, NAVTA was faced with determining future management options for our association. The AVMA was extremely generous in funding an interim Executive Director from June through November. This allowed NAVTA time to determine its long-term plan, as well as provide an evaluation of our current systems. The NAVTA board would like to thank the AVMA for their generosity during this time and for their continued support.

Lisa Perius served in the role of interim Executive Director for that time frame. Lisa helped to identify weaknesses within our organization and areas for opportunity, while also working to clean up our database, brainstorm ideas for member recruitment, and handling day-

2 | THE NAVTA JOURNAL | NAVTA.net

to-day management. At the end of her tenure, Lisa provided a report which will allow us to continue to work on the areas with the most need for improvement. NAVTA owes Lisa a huge debt of gratitude for all she has done to keep us going over the past year.

Finally, this has all led to the board having to decide what our management structure will look like for the future. Unfortunately, as of publication time for this issue, we have not yet ironed out all of the final details, but are getting close. Most likely, by the time you receive this issue, you will have already received an update on this in the form of an email blast or news release. We would like to provide some background so each of you—our valued NAVTA members—understand how the board came to our decision. We were faced with 3 options as follows: 1) Have the board run the organization 2) Keep the current model with an independent Executive Director that works with a small team; 3) Contract with an association management group that provides support to a mutually agreed upon Executive Director. The board agreed it is not realistic, nor desirable, for the board to run the organization. The second option could work in theory, but NAVTA is not financially ready to support the salary of an Executive Director who has the expertise necessary at this time. The board agreed that the best way forward was with an organization that provides association management, could support NAVTA on many levels, and help identify an Executive Director that meets NAVTA’s needs. Potential partners submitted proposals to the board throughout 2018. The board then conducted phone and webinar interviews, follow-up questions, and many hours of discussion all leading to the decision.

So, what is ahead? This year promises to again be busy for the NAVTA board. We are looking forward to a year of getting settled in with our new structure, continuing to set protocols in place to hold our board accountable and allowing for the continued success of NAVTA. We look forward to continuing to grow and advance our organization and our profession. We look forward to a strong NAVTA.

Thank you all for sticking with YOUR organization through this past year. Your board appreciates it more than you know!

Respectfully,

The NAVTA Executive Board

Veterinary Health Care Team of Arizona

On Saturday, October

20, 2018, the Veterinary

Health Care Team of

Arizona (VHCTAz) broke

new ground by holding

its first conference.

VHCTAz’s Veterinary

Team Connection

Conference focused on each member of the veterinary practice

team. It was a dynamic group of attendees, composed of over

180 team members representing 70 practices across Arizona!

Veterinary team members attended specialized tracks focused

on advancing skillsets within their areas of expertise. There

were tracks for client services, kennel & veterinary assistants,

managers, and technicians. During the Technicians Track, Angela

Thorp, CVT, VTS (ECC, SAIM), presented on diabetes, Jessie

Nelson, CVT, VTS (Nutrition), instructed on nutrition basics, and

Erin Criswell, CVT, VTS (ECC), lectured on cardiopulmonary

resuscitation for technicians. Additional sessions centered on

learning strategies to combat compassion fatigue and caregiver

burnout, and how to make the routine visit remarkable for both

clients and patients.

There was a special awards luncheon held to recognize

individuals, teams and practices for their dedication to providing

exceptional patient and client care. Awards were presented

for Veterinary Team of the Year, Team Player of the Year,

Veterinary Leadership, and VHCTAz Leadership. There was

also a graduation ceremony for those who completed the 2018

VHCTAz Professional Veterinary Team Member Certificate

Program.

During the conference closing, VHCTAz leadership chairs

and veterinary professionals shared the exciting possibilities

of careers and advancement opportunities within veterinary

medicine.

VHCTAz is excited to announce its plans to hold another

conference next year, in the fall of 2019.

— Lisa Donimari, CVT, BS, M.Ed. NAVTA Arizona State Representative VHCTAz Leadership Committee Chair

The VHCTAz's Veterinary Team Conference brought together a dynamic group of attendees, composed of over 180 team members representing 70 practices across Arizona!


NAVTA NEWSSTATE ASSOCIATION UPDATES

Indiana Veterinary Technician Association

The Indiana Veterinary Technician Association (IVTA)

continues to actively work on the revitalization of our

state association. Our membership numbers our low but

we continue to do outreach to promote our organization.

We have elections approaching and are hoping for new

interest in our membership. In September, through the

generous sponsorship of Boehringer Ingelheim, we

offered four hours of CE focused on dentistry and lunch

that was free to our members. They have also offered

to sponsor another event this coming January/February.

The Indiana Veterinary Medical Association (IVMA) has an

annual CE event, and starting in 2019 will offer a discount

on registration to members of our state association. Both

the sponsorship and support from our IVMA is exactly

what we need in order to offer benefits to joining our

professional organization. We are always open to ideas

to increase our membership numbers so please email

us with any advice or ideas. The IVTA was asked to

recommend a member of our organization to serve on the

AVMA Committee on Veterinary Technician Education and

Activities (CVTEA). We are pleased that Sarah Summers of

Lafayette, Indiana will be a site team member and attend

an 2.5-day accreditation site visit of Purdue University’s

Veterinary Nursing Program this December. The IVTA has

made some big strides this year and are hoping for an

increase in interest this coming calendar year.

— Julie Commons, RVT, VTS (SAIM)

IVTA members Megan Anderson (L) of MedVet Indianapolis and Liane Shaw (R) of Purdue University Veterinary Teaching Hospital who were the featured speakers at our dentistry lunch and learn sponsored by Boehringer Ingelheim.

Georgia Veterinary Technician and Assistant Association (GVTAA)

On Saturday, November 3, the GVTAA hosted the

second of its major annual events, the Fall Technicians’

Conference in Athens, Georgia. The event was well-

attended by over 130 participants (this being a renewal

year for licensing). New for this conference, CE offerings

were divided into small and large animal tracks for the

morning sessions. Topics included equine colic work-up

and wound management, as well as cat husbandry and

animal hospice and palliative care. Several wonderful

sponsors made this event possible.

Big plans are underway for 2019, including working with

NAVTA on advancing the Veterinary Nurse Initiative (VNI),

as well as our traditional spring and fall conferences.

— David Shuey, RVT, CHPT Editor, Georgia Veterinary Technician

& Assistant Association



Missouri Veterinary Technicians Association Missouri Veterinary Technicians Association (MVTA) just wrapped up our annual fall

conference that was free to all members. Eighty-six registered technicians gathered at the

Humane Society of Missouri in Maryland Heights to hear Dr. Teresa Himebaugh, DVM, PCC,

CEGE, Dr. Julie Brinker, DVM, MS, Tatiana Yvette (Eevee) Watson, AAS, CVT, RVT and Mary

Berg, BS, LATG, RVT, VTS (Dentistry), speak on topics relevant to our field. We would like to

thank our sponsors at Idexx, Dechra, Rolling Acres and Loving Hearts for helping make this

conference a success.

MVTA asked Missouri Governor Mike Parsons to declare October 14-20th Missouri

Veterinary Technicians Week, as we have done in the past, we received our proclamation

and have shared it on our Facebook page.

MVTA is currently working hard on updating our website to improve membership and

conference registration for next year, as well as improving our social media presence for our

members. During VTW we ran a series of trivia questions and offered random daily prizes

with a grand prize of free membership for 2019-2020.

MVTA board members are busy planning for the MVMA conference for 2019, which will

take place in Columbia, Missouri on January 24th-27th, as well as our next annual conference

that will take place in the Kansas City area next fall. We hope to see a great turnout of

Missouri technicians there!

— Melissa Bartlett, RVT, MVTA Newsletter Chair

Kansas Veterinary Technician Association

In honor of veterinary technicians and

specifically the technicians of Kansas, the

Kansas Veterinary Technician Association

(KVTA) asked for and received a proclamation

from Governor Jeff Colyer, MD of Kansas,

who declared October 14-20, 2018, Kansas

Registered Veterinary Technician Week.

A KVTA group attended the proclamation

signing to meet the Governor and officially

declare the Kansas Registered Veterinary

Technician Week. We hope everyone

celebrated with your clinics or place of

employment. Technicians are an integral part

of the team and this is a great week to honor

what we do, especially for our patients.

— Vicky Ograin, MBA, RVT, VTS (Nutrition)

Proclamation of Kansas Veterinary Technicians Week

Meeting Kansas Governor, Jeff Colver, MD

Missouri Proclamation of Veterinary Technicians Week

Save the date for the 2019 MVMA Conference, which will take place January 24th-27th in Columbia, Missouri.



Academy of Dermatology Veterinary Technicians

The Academy of Dermatology Veterinary

Technicians (ADVT) will hold its biannual

Regents meeting and annual general

business meeting in April, 2019 in Austin,

Texas. This will coincide with the annual

North American Veterinary Dermatology

Forum. At this venue, we will officially

welcome our newest member, Amanda

Friedeck, at the members pinning ceremony

dinner. She makes the 11th member to

ADVT. We currently have 25 candidates

working on their application packet, and will

offer our third credentialing examination at

this event for those who are eligible.

Technicians interested in dermatology

can attend NAVDF (https://www.

navdf.org/) and look forward to a half

day technician continuing education

session with a renowned Diplomate

of the American College of Veterinary

Dermatology (ACVD). We will also offer a

technician’s roundtable session, chaired by

one of our ADVT members.

ADVT met with the World Association

for Veterinary Dermatology (WAVD) and

we are working on becoming an affiliate

organization with them! This will potentially

enable us to reach more technicians

interested in veterinary dermatology!

Please join our diverse group from all

over the world that share a passion for

veterinary dermatology! Visit us on our

Facebook page, website or listserv. We

hope to see you in Austin, Texas!

For more information:

http://www.vetdermtech.com/ or

https://www.navdf.org/

—-Jennie Tait AHT, RVT, VTS (Dermatology)

SCNAVTA Foothill Community College, Los Altos, California

Our class was presented with an opportunity to

support our community when Dr. Katharine Tyson, a

veterinarian at San Jose Animal Care Services (SJACS),

invited us to assist with the monthly Vets for Healthy

Pets (VFHP) Program. During the course of our first year

in the program, students attended eight of these events,

meaning we assisted in the continuing and acute care of

over 300 clients.

Students have the chance to practice skills learned in

labs at school in the real world. These clinics have to run

with great expediency and accuracy. The visits are fast

paced, and begin when a student finds their records,

determines what procedures and medications are due

and communicates with the client to determine medical

needs. The file is then sent to our “pharmacy” station,

where students work in teams to quickly and accurately

fill prescriptions.

Students draw up vaccines, prepare microchips,

calculate dosages, gather any anti-parasitic medications

and deliver these to the the students assisting the

veterinarians at the exam table. These students are

responsible for restraining the patients, performing nail

trims and administering vaccines and other medications.

These patients are frequently fractious, scared, and

owners are frequently stressed and anxious. The

program teaches students how to speak in a way that

calms clients, and how to educate them on important

points that they need to remember, and provide

treatments in a tranquil way.

This program is completely run and staffed by

volunteers. The Foothill Vet Tech Program did a donation

drive and collected numerous kennels, beds and medical

supplies such as e-collars and grooming supplies. We

encouraged our community to donate food, toys,

treats, leashes, beds and other supplies that are evenly

distributed to clients and their pets depending on needs.

Our program managed to collect four SUV loads of

donated, clean and sorted items.

For many of our clients, their animals are all that they have. Pets provide a deep

comfort, are non-judgemental, and provide warmth and security. Caring for a pet can give

them a sense of normalcy, however the inability to care for their pets can prevent them

from caring for themselves properly. Between 5-10% of homeless people have pets.*

In the future, we intend to continue to volunteer. As Foothill students, it is our

responsibility to be good citizens in our community. We have the unique opportunity to

use our skills to improve the lives of our Silicon Valley neighbors.— Emily Miller

* from the National Coalition on Homelessness

Foothill Vet Tech Students teamed up with San Jose Animal Care Center for Vets for Healthy Pets, 2017-2018 School Year


NAVTA NEWSACADEMY & STUDENT UPDATES

Pho

to b

y iStockp

hoto

.com

/ Seregraff

Introduction

Gastric dilatation and volvulus (GDV) is a life-threatening condition

primarily affecting large and giant breed dogs with deep chests. The development of GDV rapidly leads to multiple deleterious complications, including decreased cardiac output, decreased tissue oxygenation, respiratory distress, and shock, and is fatal without treatment. It carries a high morbidity rate, but mortality is low with fast intervention and surgical correction. Survival rates with appropriate treatment are reported to be approximately 85-90%.

PathophysiologyGDV, commonly referred to as “bloat,” is the distention (dilatation) and rotation (volvulus) of the stomach. Its direct cause is unknown, however there are widely accepted risk factors that raise an animal’s

likelihood of developing this condition. It is classically a disease of large and

giant breed dogs who possess a deep chest and lean body condition,

and is more prevalent in older adult dogs. Predisposed

breeds include the Great Dane, Irish setter,

German shepherd, Weimaraner, standard poodle, and Saint Bernard, as well as

mixed breeds displaying similar deep-chested

conformation. It can, however, occur in any breed, including small breed dogs, cats, and other small mammals.3 Environmental factors thought to be implicated in the development of GDV include eating a single large meal each day instead of

Gastric Dilatation and Volvulus Amanda Wyniarsky, LVT, VTS (ECC)

This program was reviewed and approved by the AAVSB RACE program for 1 hour of continuing education in jurisdictions which recognize AAVSB RACE

approval. Please contact the AAVSB RACE program if you have any comments/concerns regarding this program’s validity or relevancy to the veterinary profession.

LEARNING OBJECTIVE:Through this article, readers should be able to gain an understanding of the pathophysiology and treatment of gastric dilatation and volvulus, as well as gain the ability to recognize common clinical signs of the disease. They should also be able to counsel owners on what they can do at home to help lower the risk of a pet developing this life-threatening condition.

BREED DISPOSITION

> Great Dane

> Saint Bernard

> Weimaraner

> Irish Setter

> Standard Poodle

ENVIRONMENTAL

> Elevated food dish

> Single, large meal

> Dry food diet

> Stress

CONFORMATION

> Large or giant breed

> Deep chest

> Lean body condition

Figure 1: Table indicating widely accepted risk factors for developing GDV.

Veterinary NURSINGEDUCATION


multiple smaller meals, rapid consumption of food, consuming a strictly dry kibble diet, and eating from an elevated feeding dish.1 Other risk factors are an anxious or fearful demeanor, chronic delayed gastric emptying time, and having a first-degree relative that has developed GDV. It was previously thought that post-prandial exercise was a major contributing factor, but this is no longer supported as a potential cause (Figure 1, previous page).

When GDV occurs, the stomach expands and rotates on itself, anywhere from 90-360 degrees (but most commonly 180-270 degrees). This rotation is most often, though not always, in a clockwise direction. This allows for trapped gas to build up inside the stomach, causing gastric distention. Once this occurs, a series of complications begins. The expansion of the stomach puts pressure on the major veins in the abdomen, including the caudal vena cava, and portal and splenic veins. This in turn causes reduced blood flow to the heart, leading to decreased cardiac output, poor tissue oxygen delivery, hypotension, and distributive shock with relative hypovolemia. The expansion of the stomach also puts pressure on the diaphragm, leading to decreased intrathoracic volume and subsequent respiratory distress.

There are numerous complications that can be associated with GDV, including gastric necrosis from reduced blood flow, electrolyte abnormalities, acid-base derangements, regurgitation and aspiration, ileus, cardiac arrhythmias, and disseminated intravascular coagulation (DIC). Also, due to the proximity of the spleen to the stomach,

splenic torsion can occur. This can lead to tissue death in the spleen, resulting in the need to perform a splenectomy. In severe cases, gastric rupture or diaphragmatic herniation can occur due to the pressure of the expanding stomach (Figure 2).

PresentationCommon presenting complaints relayed by owners include retching or unsuccessful attempts to vomit, restlessness, distended abdomen, depression, and lethargy.

As the trapped gas in the stomach causes discomfort, the patient will try to eliminate it via the esophagus by attempting to vomit. This results in one of the classic symptoms: non-productive retching. Because the stomach rotates, it closes off the opening between the esophagus and stomach,

preventing gas and other stomach contents from exiting. With time, the stomach distention can also lead to the abdomen appearing bloated. This gives GDV its common name of “bloat.” This does not always happen—in dogs with certain conformation, the stomach naturally sits within the caudal ribcage, so the bloating is not as evident. The discomfort also typically leads to depression, ptyalism, and often the patient will stand with a hunched posture indicating abdominal discomfort.

As the condition progresses and blood flow to and from the heart and other organs is reduced, the animal develops distributive shock and a relative hypovolemia. Early signs of shock displayed while compensatory mechanisms have taken effect include tachycardia, injected or hyperemic mucus membranes, fast capillary refill time (less than 1 second), and normal to bounding pulses. As compensatory mechanisms begin to fail, shock

worsens. The decompensatory phase begins, which is characterized by tachycardia (followed by bradycardia

in later stages), weak peripheral pulses, prolonged capillary refill time, hypotension, cold extremities, and pale mucus membranes. The patient is often dull or obtunded, and sometimes presents laterally recumbent.

Due to the pressure of the expanding stomach on the diaphragm, and decreased thoracic volume, some patients will present in respiratory distress. They can display an elevated respiratory rate with increased effort, shallow breathing, open-mouth breathing, and muddy or blue mucus membranes.

DiagnosisDiagnosis of GDV is fairly simple, and should be made rapidly if clinical suspicion suggests it as a differential. The vast majority

Figure 2: A great Dane, displaying the classic deep chested conformation found in dogs prone to GDV.



4

4

4

4PREVENTS HEARTWORM DISEASE TREATS AND CONTROLS3 SPECIES OF HOOKWORMS TREATS AND CONTROLS 2 SPECIES OF ROUNDWORMS OWNERS PREFER IT1

AND DOGS LOVE IT2

TRUST.

IMPORTANT SAFETY INFORMATION: HEARTGARD® Plus (ivermectin/pyrantel) is well tolerated. All dogs should be tested for heartworm infection before starting a preventive program. Following the use of HEARTGARD Plus, digestive and neurological side effects have rarely been reported. For more information, please visit www.HEARTGARD.com.

®HEARTGARD and the Dog & Hand logo are registered trademarks of Merial. ©2018 Merial, Inc., Duluth, GA. All rights reserved. HGD16TRADEAD (01/18).

1 Data on file at Merial.2 Freedom of Information: NADA140-971 (January 15, 1993).

HEARTGARD Plus is a Merial product. Merial is now part of Boehringer Ingelheim.

xhg290624_HGTrustAd-VTB-CB-8.125x10.875_rsg.indd 1 12/6/17 4:46 PM

of cases are diagnosed via a right lateral radiograph of the abdomen. The stomach will be large and gas-distended, and the volvulus will be indicated by a cranially and dorsally displaced pylorus with a soft-tissue structure appearing between the pylorus and the fundus. This is known by many common terms, such as the “double bubble,” “reverse C,” “smurf hat,” and “Popeye’s arm” phenomenon (Figure 3).

If it is unclear on the lateral radiograph, a dorsoventral view can also be taken (this is preferred over a ventrodorsal, which can put more pressure on the major veins and lead to further compromise). In this view, the pylorus will be displaced to the left of midline.3

Note that gastric dilatation can occur without volvulus, and it is important to distinguish this before treating, as dilatation on its own does not warrant surgical intervention. Dilatation alone can be due

to either gas buildup, or an excess of food in the stomach, known as “food bloat.”

Intervention and TreatmentShock is considered to be the primary life-threatening complication of GDV, so early treatment goals are aimed at reversing its effects. Rapid intervention is necessary to give the patient the best chance at survival. The first step is obtaining venous access through the placement of a large bore intravenous catheter in each cephalic vein. This allows even the biggest dogs to obtain large volumes of intravenous fluids rapidly. A short, large bore catheter offers the least amount of resistance to fluid flow, and is therefore preferred over a long catheter. Aggressive fluid resuscitation with a balanced isotonic crystalloid fluid should be initiated immediately to combat hypotension, and other supportive care should be provided as indicated, including

oxygen supplementation, heat support, and analgesia.

The standard shock dose of fluids is a 90ml/kg bolus, with one-quarter to one-third of the volume given at a time and the patient reassessed, followed by additional one-quarter to one-third volume boluses as indicated.3 Colloids (such as hydroxyl-ethyl starch) and/or vasopressors (such as norepinephrine, dopamine, or vasopressin) are warranted in cases with protracted hypotension, once appropriate volume resuscitation has been achieved. Treatment of life-threatening arrhythmias (typically ventricular in origin) should also be performed if they are present. Anti-arrhythmic medications such as lidocaine can be administered if the arrhythmia is prolonged or severe. Note that shock cannot be completely reversed until surgical correction of the rotation is performed, so the main goal is to get the patient’s

Figure 3: Radiograph displaying GDV.

The vast majority of GDV cases are diagnosed via a right lateral radiograph of the abdomen. The stomach will be large and gas-distended, and the volvulus will be indicated by a cranially and dorsally displaced pylorus with a soft-tissue structure appearing between the pylorus and the fundus.



cardiovascular status as stable as possible in a short period of time, and quickly initiating surgery.

Once cardiovascular stabilization attempts have been initiated, gastric decompression should be attempted. This can be done in two ways. Trocarization can provide rapid decompression without the use of sedation or anesthesia, which is especially useful for patients who require additional stabilization prior to anesthesia. This procedure is performed by shaving and sterilely prepping an area on the right or left side of the abdomen, where it is the most tympanic. A large, short, over-the-needle catheter is then inserted through the abdominal wall and into the stomach, and the stylet removed. Confirmation of successful placement is indicated by the hissing sound of escaping gas. There are potential complications associated with this method, including perforation of the stomach and laceration of the spleen. The preferred method of decompression is the passing of an orogastric tube under sedation or anesthesia. A large, smooth tube is externally measured to the last rib of the patient, marked at this point, lubricated, and passed through the mouth and down the esophagus. It should not be advanced past the mark indicating the last rib. If successful, the escape of gas and stomach contents will occur. This can be done while surgical preparation is occurring. If orogastric tube

passage is not possible, trocarization should be considered, and the patient should be taken to surgery as quickly as possible.3

Additional diagnostics, besides abdominal radiographs, that should be considered are a minimum database including packed cell volume, total protein, electrolyte levels, and lactate. A complete blood count, biochemistry profile, and coagulation panel may also be considered. Elevated packed cell volume/total protein may indicate hemoconcentration, and can be used to help guide fluid therapy. Electrolyte abnormalities may be present, and should be corrected as appropriate. A pre-renal azotemia may be present and caused by a relative hypovolemia. Elevated hepatic enzymes (potentially indicative of hepatic damage) may also appear on serum chemistry. Hyperlactatemia is common with GDV, and is caused by decreased blood and oxygen flow within the body. A lactate level of >6.0mmol/L (reference range: <2.5mmol/L) can be an indicator of gastric necrosis, and is associated with a higher mortality rate.2

Once cardiovascular stabilization is complete, the patient is prepped for surgical repair. An exploratory laparotomy is performed, and the first step taken during surgery is to manually rotate the stomach back into its normal position, followed by the passage of an orogastric tube to empty the gastric contents. In some cases where orogastric intubation has been successful prior to surgery, the stomach may already be back in its correct position. The stomach should then be evaluated for any signs of necrosis, and a partial gastrectomy performed if any is found. The spleen should be evaluated for blood clots, torn vessels, or necrosis, and a splenectomy performed if indicated. The remainder of the abdomen should be explored for any abnormalities, and finally the stomach should be fixed to the body wall via gastropexy. This is a permanent fixation that will drastically reduce the risk of future GDV episodes. After a gastropexy, dilatation may still occur on its own, but

CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian.INDICATIONS: For use in dogs to prevent canine heartworm disease by eliminating the tissue stage of heartworm larvae (Dirofilaria immitis) for a month (30 days) after infection and for the treatment and control of ascarids (Toxocara canis, Toxascaris leonina) and hookworms (Ancylostoma caninum, Uncinaria stenocephala, Ancylostoma braziliense).DOSAGE: HEARTGARD® Plus (ivermectin/pyrantel) should be administered orally at monthly intervals at the recommended minimum dose level of 6 mcg of ivermectin per kilogram (2.72 mcg/lb) and 5 mg of pyrantel (as pamoate salt) per kg (2.27 mg/lb) of body weight. The recommended dosing schedule for prevention of canine heartworm disease and for the treatment and control of ascarids and hookworms is as follows:

HEARTGARD Plus is recommended for dogs 6 weeks of age and older. For dogs over 100 lb use the appropriate combination of these chewables.ADMINISTRATION: Remove only one chewable at a time from the foil-backed blister card. Return the card with the remaining chewables to its box to protect the product from light. Because most dogs find HEARTGARD Plus palatable, the product can be offered to the dog by hand. Alternatively, it may be added intact to a small amount of dog food.The chewable should be administered in a manner that encourages the dog to chew, rather than to swallow without chewing. Chewables may be broken into pieces and fed to dogs that normally swallow treats whole.Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes after administration to ensure that part of the dose is not lost or rejected. If it is suspected that any of the dose has been lost, redosing is recommended.HEARTGARD Plus should be given at monthly intervals during the period of the year when mosquitoes (vectors), potentially carrying infective heartworm larvae, are active. The initial dose must be given within a month (30 days) after the dog’s first exposure to mosquitoes. The final dose must be given within a month (30 days) after the dog’s last exposure to mosquitoes.When replacing another heartworm preventive product in a heartworm disease preventive program, the first dose of HEARTGARD Plus must be given within a month (30 days) of the last dose of the former medication. If the interval between doses exceeds a month (30 days), the efficacy of ivermectin can be reduced. Therefore, for optimal performance, the chewable must be given once a month on or about the same day of the month. If treatment is delayed, whether by a few days or many, immediate treatment with HEARTGARD Plus and resumption of the recommended dosing regimen will minimize the opportunity for the development of adult heartworms.Monthly treatment with HEARTGARD Plus also provides effective treatment and control of ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense). Clients should be advised of measures to be taken to prevent reinfection with intestinal parasites.EFFICACY: HEARTGARD Plus Chewables, given orally using the recommended dose and regimen, are effective against the tissue larval stage of D.immitis for a month (30 days) after infection and, as a result, prevent the development of the adult stage. HEARTGARD Plus Chewables are also effective against canine ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense).ACCEPTABILITY: In acceptability and field trials, HEARTGARD Plus was shown to be an acceptable oral dosage form that was consumed at first offering by the majority of dogs.PRECAUTIONS: All dogs should be tested for existing heartworm infection before starting treatment with HEARTGARD Plus which is not effective against adult D. immitis. Infected dogs must be treated to remove adult heartworms and microfilariae before initiating a program with HEARTGARD Plus.While some microfilariae may be killed by the ivermectin in HEARTGARD Plus at the recommended dose level, HEARTGARD Plus is not effective for microfilariae clearance. A mild hypersensitivity-type reaction, presumably due to dead or dying microfilariae and particularly involving a transient diarrhea, has been observed in clinical trials with ivermectin alone after treatment of some dogs that have circulating microfilariae.Keep this and all drugs out of the reach of children. In case of ingestion by humans, clients should be advised to contact a physician immediately. Physicians may contact a Poison Control Center for advice concerning cases of ingestion by humans.Store between 68°F - 77°F (20°C - 25°C). Excursions between 59°F - 86°F (15°C - 30°C) are permitted. Protect product from light.ADVERSE REACTIONS: In clinical field trials with HEARTGARD Plus, vomiting or diarrhea within 24 hours of dosing was rarely observed (1.1% of administered doses). The following adverse reactions have been reported following the use of HEARTGARD: Depression/lethargy, vomiting, anorexia, diarrhea, mydriasis, ataxia, staggering, convulsions and hypersalivation.SAFETY: HEARTGARD Plus has been shown to be bioequivalent to HEARTGARD, with respect to the bioavailability of ivermectin. The dose regimens of HEARTGARD Plus and HEARTGARD are the same with regard to ivermectin (6 mcg/kg). Studies with ivermectin indicate that certain dogs of the Collie breed are more sensitive to the effects of ivermectin administered at elevated dose levels (more than 16 times the target use level) than dogs of other breeds. At elevated doses, sensitive dogs showed adverse reactions which included mydriasis, depression, ataxia, tremors, drooling, paresis, recumbency, excitability, stupor, coma and death. HEARTGARD demonstrated no signs of toxicity at 10 times the recommended dose (60 mcg/kg) in sensitive Collies. Results of these trials and bioequivalency studies, support the safety of HEARTGARD products in dogs, including Collies, when used as recommended.HEARTGARD Plus has shown a wide margin of safety at the recommended dose level in dogs, including pregnant or breeding bitches, stud dogs and puppies aged 6 or more weeks. In clinical trials, many commonly used flea collars, dips, shampoos, anthelmintics, antibiotics, vaccines and steroid preparations have been administered with HEARTGARD Plus in a heartworm disease prevention program.In one trial, where some pups had parvovirus, there was a marginal reduction in efficacy against intestinal nematodes, possibly due to a change in intestinal transit time.HOW SUPPLIED: HEARTGARD Plus is available in three dosage strengths (see DOSAGE section) for dogs of different weights. Each strength comes in convenient cartons of 6 and 12 chewables.For customer service, please contact Merial at 1-888-637-4251.

chewables

®HEARTGARD and the Dog & Hand logo are registered trademarks of Merial. ©2015 Merial, Inc., Duluth, GA. All rights reserved. HGD16TRADEAD (01/18).

Color Coding 0n Dog Chewables Ivermectin Pyrantel Foil Backing Weight Per Month Content Content and Carton

Up to 25 lb 1 68 mcg 57 mg Blue 26 to 50 lb 1 136 mcg 114 mg Green 51 to 100 lb 1 272 mcg 227 mg Brown



volvulus is prevented. This procedure has a less than five percent failure rate.

Post-operative care should focus on continued cardiovascular support, monitoring for cardiac arrhythmias, pain control, and gastrointestinal support as needed. Cardiac ischemia may lead to arrhythmias, which are primarily ventricular in origin. This most often develops 6-24 hours after the insult. If the arrhythmia is mild, it may be self-limiting and require no treatment. In cases of persistent or severe arrhythmia, treatment with anti-arrhythmic medications such as lidocaine or procainamide is warranted.2

More severe post-operative complications can occur as well. Septic peritonitis is possible, often due to the leakage of stomach contents into the abdomen, and can be life-threatening. Disseminated intravascular coagulation can occur as a result of blood pooling in major veins and arteries, or thrombotic events.1 Patients should be monitored very closely after GDV surgery for any possible complications, so that rapid intervention can be initiated.

PrognosisPrognosis for GDV is fairly good if fast stabilization and surgical correction are executed. Survival rates in these cases are reported to be approximately 85-90%. Factors that cause higher mortality rates are protracted shock, gastric necrosis, and post-operative complications such as septic peritonitis leading to systemic

inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), and disseminated intravascular coagulation.1

PreventionWhile the exact cause is unknown, there have been some risk factors identified that can be controlled at home. Feeding from a floor-level dish and feeding multiple smaller meals throughout the day can reduce the risk of GDV. Keeping stress levels low can also be helpful. This can be accomplished by keeping stressful events to a minimum at home, and avoiding outside stressors such as traveling or boarding. Prophylactic gastropexy can be performed as well, typically in conjunction with ovariohysterectomy or castration, but could be considered during any abdominal surgery in an at-risk dog. In some hospitals this can even be performed laparoscopically. This is the most effective method of preventing GDV, carrying a failure rate of less than five percent.

It is also recommended that any dog

AMANDA WYNIARSKY, LVT, VTS (ECC)Amanda is a Licensed Veterinary Technician at BluePearl Veterinary Specialists in Michigan. She has a passion for emergency medicine, and received her VTS in Emergency and Critical Care in 2017. Her areas of interest include endocrine emergencies, trauma, and transfusion medicine. Outside of work, she enjoys spending time outdoors, camping, traveling, and off-roading. She shares her home with her husband, their dogs Blue and Hemi, and cat Nova.

Pho

to b

y iS

tock

pho

to.c

om

/ G

lob

alP



who has developed GDV, or with a first-degree relative that has developed GDV, not be bred. There is thought that a genetic component might exist, and that the risk may be lessened through selective breeding.

Technicians and veterinarians should counsel owners of at-risk patients on steps they can take at home to reduce the risk of developing this condition, as well as the signs to watch for.

ConclusionGastric dilatation and volvulus is a true and severe emergency requiring rapid action. Recognition of clinical signs leading to a swift diagnosis are of utmost importance, as is initiating treatment quickly. Early goals are aimed at cardiovascular stabilization in preparation for surgical repair. When recognized quickly and treated appropriately, the survival rates for GDV can be quite high. J

REFERENCES1. Gibson, TGW; Merck Veterinary Manual. 11th ed. Kenilworth,

NJ. Merck and Co.; 2016

2. Plunkett, SJ. Emergency Procedures for the Small Animal Veterinarian. 2nd ed. St. Louis, MO. Elsevier; 2000

3. Silverstein, DC and Hopper, K. Small Animal Critical Care Medicine. 2nd ed. St. Louis, MO. Elsevier; 2015

Let’s Review...1. What is the major life-threatening complication of gastric

dilatation and volvulus?

a. Gastric necrosis

b. Shock

c. Gastric rupture

d. Splenic torsion

2. Which diagnostic test gives us the most prognostic information?

a. Packed cell volume

b. Hepatic enzymes

c. Complete blood count

d. Lactate

3. What causes the shock seen in gastric dilatation and volvulus?

a. The expanding stomach compressing major abdominal veins

b. Fluid losses

c. Respiratory compromise

d. Pain

4. What is the preferred way to gain vascular access in a GDV patient?

a. Long, large bore IV catheter

b. Central venous catheter

c. Short, large bore IV catheter

d. Arterial catheter

5. What is the best way to prevent GDV from happening?

a. Prophylactic gastropexy

b. Using elevated feeding dishes

c. Feeding multiple, smaller meals throughout the day

d. Exercise restriction after eating

CO

NTI

NUING EDUCATIO

N

Q

U IZ O NLIN

E

Visit VetMedTeam.com and log in with your Vet Med Team Profile.

It is recommended that any dog who has developed GDV, or with a first-degree relative that has developed GDV, not be bred. There is thought that a genetic component might exist, and that the risk may be lessened through selective breeding.



NAVTA CAREER CENTERYour Job Search Resource CenterEverything you need to make your resume stand out, ace the interview, advance your career, and navigate the digital world through social media and digital communication

visit www.navta.net

Introduction

A retrospective study of the impact veterinary insurance has on veterinary

case and the implications on the veterinary economy in regards to paraprofessional compensation.

The Value Insurance BringsThe veterinary technician shortage has negatively impacted clinics and hospitals nationwide. Veterinary technician positions are being left vacant for months, leaving veterinary care teams short staffed and over worked. This leads to increased mistakes in patient care and poor client service. So, where have all the veterinary technicians gone? To a field of work where they are better compensated. With veterinary spending increasing every year, why hasn’t the veterinary technician wage kept pace? Because veterinary charges do not support the increased knowledge base, dedication or livelihood of veterinary technicians. A job that was once able to be filled by a pre-vet student during the summers now requires working knowledge of anatomy and physiology, anesthesia, performing advanced laboratory diagnostics, radiology, ultrasonography, parasitology, advanced CPR and life support, critical care nursing, surgical assisting and instrumentation, as well as mechanical maintenance and hospital inventory.

With the average veterinary technician leaving the field after twelve years, many hospitals struggle to find qualified

candidates for open positions, have high turnover rates accompanied by the costs associated with having high turnover, and suffer from lack of consistency with training (Dittmar, 2016). The average American has less than $1,000 in savings, which does not go far for non-routine veterinary care. This is a major factor in how veterinary hospitals can charge for services, as they are restricted to what the average American is capable of spending out of pocket. Veterinary hospitals pay the same price for medicine and diagnostic equipment as human hospitals do, lending to narrow profit margins thus keeping veterinary technician wages low. So, how do we increase profit? The short answer is increase profit margins. The long answer is increase profit margins via veterinary insurance.

How many clients would say yes to a specialist referral if the owner only had to pay $25 for a specialist visit instead of $140 (but, the clinic still received $140)?

Can veterinary insurance make the veterinary industry a sustainable career choice for veterinary technicians?

Tiffany Bartlett, LVT, BAS

How Veterinary Insurance Might

Save the VeterinaryTechnician

Pho

to b

y iStockp

hoto

.com

/ Peo

pleIm

agesVETERINARY NURSING IN ACTION | December/January 2019 | 15

current CONVERSATIONS

How many more dentals would be done if the client only had to pay $50, but the clinic was still able to get the full $450 necessary to perform the procedure? An increase in cases seen, increase in average transaction per client, and increased owner compliance generates more revenue. Increased profitability for a hospital supports increased wages of veterinary support staff. Which leads to the question, can veterinary insurance make the veterinary industry a sustainable career choice for veterinary technicians?

This led to the following hypothesis: veterinary insurance creates an environment where pet owners are more likely to spend money on veterinary care. To test this hypothesis, a retrospective study of 300 veterinary clients at a specialty and emergency hospital was completed in Houston, Texas. This study dated back three years starting, October 2017. These were cases that saw either an emergency veterinarian, an oncologist, surgeon, neurologist, or internist. Cases were reviewed for documentation of having veterinary insurance. Next, client selection of treatment was divided into fist recommendation, second recommendation, euthanasia, or leaving against medical advice. Finally, the case was evaluated for prognosis as assessed by the attending veterinarian as either excellent, good, guarded, poor, or grave. There were 34 cases that were discarded from this study because the patients either never showed up for their appointments, left without an examination through the emergency department, or were seen as out-patient ultrasounds for the radiologist and therefore, a prognosis was not given.

Of the 266 cases eligible for review, nine cases had documentation of veterinary insurance making the retrospective study skewed. In order to examine the two different groups, those with veterinary insurance and those without veterinary insurance, it was best to use percentages due to the large disparity in actual case number. None of the cases with veterinary insurance were given a prognosis of excellent; however,

it was still listed for analysis. More than 60% of the cases had a prognosis below good. None of the cases were seen for preventive care due to the nature of the veterinary emergency and specialty hospital so the patients and cases reviewed either had an accident, illness, or injury.

The only case with a grave prognosis to receive primary suggested treatment

was the case with veterinary insurance. For cases without veterinary insurance, as the prognosis declined so did the clients’ willingness (or financial ability) to move forward with the primary suggested treatment (Figure 1). However, that is not true for cases that had veterinary insurance- ability or willingness to move forward with primary treatment does not appear to have

Figure 1: As prognosis declines, fewer clients without veterinary insurance opt move forward with suggested treatment.They also leave against medical advice and euthanize at greater rates.

Figure 2: Clients who have veterinary insurance show greater willingness to move forward with suggested treatment plans.



a relationship with prognosis (Figure 2). Finally, this study shows that cases without veterinary insurance only follow initial treatment options 41% of the time and have a high rate of leaving against medical advice, 23%, or euthanizing, 15%.

This study suggests that when financial constraints are alleviated, owners will choose the first recommended course of treatment. It also correlates prognosis to treatment options. As prognosis becomes poorer, fewer owners will choose the initial treatment plan when there isn’t veterinary insurance. When veterinary insurance is present, this correlation does not exist.

When the clients are readily able to follow through with first recommended treatment plans client compliance increases, patient care is better, and profits increase. Increased profits would allow veterinary hospitals to increase pay of their veterinarians and paraprofessionals (veterinary technicians, veterinary assistants,

kennel staff, and receptionists). With pay being the number one reason veterinary technicians are leaving the veterinary field, an increase in pay/benefits would allow more veterinary technicians to stay in the field. Essentially, this could end the veterinary technician shortage and make veterinary technology a sustainable career choice.

This retrospective study could be performed on a larger scale with cooperation from several day practices in an area to see if this holds true in other areas throughout Houston, Texas, or any other area in the United States. At a minimum, a retrospective study using a larger pool of clients/patients is warranted to see if this can be repeated.

Education is KeyAdditionally, in a survey conducted in Veterinary Support Staff Unleashed, a Facebook support group, with permission

from the administrators, 51.7% of respondents have received zero training on the currently available veterinary insurance options. Of the technicians polled, 16.4% say they do offer wellness plans at their veterinary clinic, and that same 16.4% say they have received training on how to present the wellness plan to clients. This would indicate that hospitals focus on recommending their wellness plans, rather than discussing veterinary insurance. This is a problem because, from the same survey, only 17.2% of respondents believe that pet owners understand the differences between wellness plans and veterinary insurance (Figure 3). By focusing primarily on wellness plans we may have confused the consumer, and failed to educate them on their options. While wellness plans do offer financial benefits and promote regular exams and preventative procedures, they are not transferrable to emergency and/or specialty clinics, whereas veterinary insurance does

Figure 3: Only 17.2% of survey respondents believe that pet owners understand the differences between wellness plans and veterinary insurance.

In your opinion, do you believe that owners understand the difference between veterinary insurance and wellness plans? 169 Responses

Yes

No

82.8%17.2%

Surveys indicate that hospitals focus on recommending their wellness plans, rather than discussing veterinary insurance... By focusing primarily on wellness plans we may have confused the consumer, and failed to educate them on their options.

Pho

to b

y iStockp

hoto

.com

/ Tham

KCVETERINARY NURSING IN ACTION | December/January 2019 | 17


offer coverage for these important services. Many veterinary insurance companies offer plans to include wellness care and even breed specific conditions.

The bottom line is, clinics need to both investigate and educate technicians on wellness plans and veterinary insurance plans. It is our responsibility to be the best advocates for our patients’ health. Both wellness plans and veterinary insurance can be tremendously beneficial to our clients, as well as to the level of care they are able to provide for the pets. J

REFERENCES1. Carlson, J., CVT. (2017, September 22). Where

have all the technicians gone? Retrieved September 23, 2017, from http://veterinarynews.dvm360.com/where-have-all-technicians-gone

2. Dittmar, C. A., LVT. (2016). The Relationship Between Continuing Education and Job Satisfaction for Veterinary Technicians. The NAVTA Journal, (2016 Convention Issue), 20-22. Retrieved September 18, 2017, from www.navta.net.

3. Dvm360.com staff. (2014, May 30). The truth about the veterinary technician shortage. Retrieved September 16, 2017, from http://veterinaryteam.dvm360.com/truth-about-veterinary-technician-shortage

4. Dvm360.com staff. (2015, February 03). Veterinary Team Pay Report. Retrieved November 1, 2017, from http://veterinarynews.dvm360.com/team-pay-report?pageID=5

5. Dvm360.com staff. (2016, December 15). Pet insurance: Fact and fiction. Retrieved September 25, 2017, from http://veterinarybusiness.dvm360.com/pet-insurance-fact-and-fiction?pageID=1

6. Indeed.com. (2017, September). Salaries. Retrieved October 20, 2017, from https://www.indeed.com/salaries/Veterinary-Technician-Salaries,-Texas

7. NAPHIA. (2016). North American Pet Health Insurance Association State of the Industry Report (pp. 1-15, Rep.). Willis Towers Watson.

8. Rollo, A., Metzger, F., & Ward, E. (2015, November 09). The power of pet insurance. Retrieved November 1, 2017, from http://veterinarybusiness.dvm360.com/power-pet-insurance

9. Springer, J. (2017). The 2017-2018 APPA National Pet Owners Survey Debut: Trusted Data for Smart Business Decisions (pp. 1-50, Rep.). Greenwich, CT: American Pet Products Association.

10. Strutner, S. (2017, November 19). The Hourly Income You Need To Afford Rent Around The U.S. Retrieved November 20, 2017, from https://www.huffingtonpost.com/entry/how-much-you-need-for-rent_us_5942cc92e4b0f15cd5b9e2ee

Both wellness plans and veterinary insurance can be tremendously beneficial to our clients, as well as to the level of care they are able to provide for the pets.

Pho

to b

y iS

tock

pho

to.c

om

/ In

nerV

isio

nPR

O



SignalmentAxel, 5-year-old, neutered male, American bulldog, weighing 32.4kg.

HistoryAxel was traveling with his owners from Las Vegas to New Mexico in a covered truck bed. His owners discovered him unresponsive while at a rest stop about 50 miles from our veterinary hospital. Axel was cooled with water and ice and was moved to inside the truck. He vomited a large amount of bile, had a bowel movement, and then had 5-6 episodes of convulsions on the way to the hospital.

Initial Assessment/Physical Exam On entry, Axel was lateral and stuporous. He was normothermic at 99.6oF. He had a normal respiratory rate of 24bpm, but severe increased inspiratory effort with stertor (he was noted to have stenotic nares). His lungs auscultated clear and no murmur was appreciated. He was tachycardic at 180bpm with weak, synchronous femoral pulses. His mucous membranes were injected and tacky, with a CRT less than two seconds. Doppler blood pressure (BP) was unobtainable. He had brown diarrhea with sloughed intestinal content on rectal exam. A full neurological exam wasn’t completed due to his critical condition, but his pupils were equal and responsive.

Initial Interventions Flow-by oxygen was immediately provided. An 18g IV cephalic catheter was placed and sample collected for a venous blood gas (VBG). Stat blood glucose (BG) was 29mg/dL (66-115mg/dL), therefore he received 30mls of 25% dextrose IV as a bolus. Axel’s VBG showed an acidosis, with pH of 7.299 (7.34-7.42), pCO

2 of

33.6mmHg (24.4-39.3mmHg), pO2 of

81.2mmHg (30.6-57.4mmHg) and HCO3

of 16.6mmol/L (16-24mmol/L). PCV was hemo-concentrated at 61% (37-50%) with a TP of 5.4g/dL (4.8-7.6g/dL). Lactate and all other electrolytes were within normal limits. Due to his severe respiratory effort (RE), Axel was induced with 4.5mg/kg propofol IV slowly titrated to effect; he was intubated with a #8.5 endotracheal (ET) tube and continued on flow-by oxygen. During intubation, white foam was visible within the trachea (concerning for

Courtney Waxman, CVT, RVT, VTS (ECC)

HEATSTROKE in a Brachycephalic Breed with a Severe

Coagulopathy and Tracheostomy Tube

Figure 1: Axel intubated with flow-by oxygen and receiving a FFP transfusion in our critical care crib.

Due to the nature of his condition, Axel was placed in the critical care crib and had one-on-one nursing care.


Case STUDY

aspiration) and an elongated soft palate was appreciated. Continuous ECG monitoring was started and sinus tachycardia was noted. A 15ml/kg bolus IV crystalloids was started and an additional liter of crystalloids with 5% dextrose/L was started at 6ml/kg/hr. BP was still unobtainable; therefore three additional 23ml/kg boluses of plain crystalloids were given IV. Even after Axel received a full crystalloid shock bolus (90ml/kg), BP remained unattainable. Synthetic colloids are considered controversial in potential coagulopathic states (which are common in heatstroke cases). Colloids have been shown to decrease factor VIII, cause functional changes to platelets and decrease plasma clotting factors. To address hypotension, a second 20g IV cephalic catheter was placed (to have a dedicated line) and IV norepinephrine was started at constant rate infusion (CRI) at 0.1mcg/kg/min. Norepinephrine is a catecholamine, functioning as a hormone and neurotransmitter, which increases systemic vascular resistance (causes vasoconstriction) with minimal cardiac side effects. Using sterile technique, an 8Fr Foley urinary catheter was placed and connected to a sterile closed collection set (noted pigmenturia). Enough blood was collected from the second IV catheter placement for a CBC/Chem profile, but not citrated clotting times. CBC showed a normal white blood cell count and thrombocytopenia (PLT = 43K/uL; 148-484K/uL) that was confirmed with a manual platelet count. His chemistry panel showed a normalized glucose of 141mg/dL (74-143mg/dL), elevated liver enzymes and normal renal values.

Due to the nature of his condition, Axel was placed in the critical care crib and had one-on-one nursing care (Figure 1).

Further InterventionsAn IV fentanyl CRI was calculated and started at 10mcg/kg/hr. Fentanyl is a potent opioid analgesic with a rapid onset of action and short duration of action. Axel was also given 50mg/kg ampicillin-sulbactam IV q8h (for presumptive aspiration pneumonia),

1mg/kg enrofloxacin IV q24h (for broad spectrum antibiotic coverage), 1mg/kg maropitant IV q24h (to control nausea), and 1mg/kg pantoprazole IV q24h (to decrease acidic stomach secretions). It was noted that Axel was oozing from attempted venipuncture/catheter sites, which was concerning for coagulopathy. A third 20g IV saphenous catheter was placed and 3 units of fresh frozen plasma (FFP) transfusion (equivalent to 12ml/kg) IV was started with

frequent monitoring for transfusion reaction. FFP is a blood component therapy product that contains clotting factors and plasma proteins. FFP does not contain any platelets, so is primarily used to treat coagulopathies resulting in clinically significant bleeding. Axel was breathing more comfortably once intubated and his tachycardia improved slightly to 140-150bpm. His pulse oximeter was reading at 97-99%. All gastrointestinal losses were quantified and bolused back with plain IV crystalloids and urine output was quantified q4h. Four hours after starting and titrating pressor therapy (up to 1.2mcg/kg/min), a Doppler BP of 108mmHg systolic was measured. Approximately six hours post presentation, a 5Fr x 13cm triple lumen catheter was placed in the left lateral saphenous vein and collect blood for clotting times. Placing a central (jugular) line in a patient with a coagulopathy is

contraindicated, so instead a peripherally inserted central catheter (PICC) line was used. Axel’s citrated-prothrombin time (PT) and citrated-activated partial thromboplastin time (aPTT) were both prolonged at 36 seconds (11-17 seconds) and 171 seconds (72-102 seconds), respectively, indicating a disruption in Axel’s clotting cascade. Prothrombin time evaluates coagulation status by testing the extrinsic portion of the clotting cascade, including factors I, II, V, VII and X. Activated partial thromboplastin time evaluates coagulation status by testing the intrinsic portion of the clotting cascade, including factors VIII, IX, XI and XII. Axel remained intubated with flow-by oxygen overnight.

By morning, Axel’s heart rate had normalized (100-130bpm) but he was having occasional ventricular premature contractions (VPCs). An IV lidocaine CRI at 30mcg/kg/min was started. Lidocaine is a class I antiarrhythmic that is used primarily for ventricular arrhythmias. His blood pressure had also stabilized (110-140mmHg systolic), therefore the norepinephrine was discontinued. IV midazolam CRI was added at 0.1mg/kg/hr for more appropriate sedation and the intravenous fentanyl CRI was decreased to 5mcg/kg/hr. Axel continued to have normal respirations with normal respiratory effort. His SpO2

ranged between 96-98%, so it was decided to attempt extubation. Upon oral exam, it was noted that Axel had moderate laryngeal edema and erythema and a diminished gag reflex. He was extubated then re-intubated with a sterile #8.5 endotracheal tube and continued on flow-by oxygen at 10L/min. He was given an additional 3 units (12ml/kg) FFP transfusion with frequent monitoring for continued prolonged clotting times; citrated-PT = 37 seconds (11-17 seconds) and citrated-aPTT = 167 seconds (72-102 seconds). Blood glucose was hovering in the low 100’s; the dextrose additive was weaned down to 2.5% per liter. Axel continued to have significant GI losses (hematochezia) that continued to be quantified q4h and replaced with plain

FFP is a blood component therapy product that contains clotting factors and plasma proteins. FFP does not contain any platelets, so is primarily used to treat coagulopathies resulting in clinically significant bleeding.


Case STUDY

IV crystalloid boluses. His urine output remained appropriate (4-10ml/kg/hr) and urinary catheter care was performed q8h. It was noted that Axel had developed some bruising and mild peripheral edema, so passive range of motion (PROM) exercises and extremity massage was added as part of his recumbent care.

Later that evening, Axel was observed resting and breathing comfortably. His ECG was showing a bradycardia (78bpm) with normal rhythm. The first Doppler BP that evening was 170mmHg systolic. The DVM was alerted with concern Axel was experiencing Cushing’s reflex, which is a neurological response to increased intracranial pressure (ICP). When the brain experiences increases in ICP, there is a protective catecholamine release, which causes systemic vasoconstriction (hypertension) and a reflex bradycardia. 4ml/kg of 7.2% hypertonic saline (HTS) IV was given, followed by 1g/kg mannitol IV. HTS and mannitol have an osmotic effect that decreases ICP by removing potential fluid around the brain. Following administration of HTS and mannitol, Axel’s HR and BP normalized and remained normal throughout the rest of the evening. Placing a feeding tube to start enteral nutrition was discussed, but was put on hold as nasal manipulation is contraindicated in cases of potential increased ICP. Axel’s coagulopathy was improved but clotting times were still prolonged, with citrated-PT = 21 seconds (11-17 seconds) and citrated-aPTT = 137 seconds (72-102 seconds). Another 2 unit FFP transfusion (10ml/kg) was started with frequent monitoring. Axel’s attitude/mentation remained obtunded, although he was difficult to assess due to his multiple sedation/analgesic CRIs.

Continued Care On his third day of hospitalization, another attempt was made at extubation. However, Axel’s laryngeal edema was more severe (50% worse than the previous day). Additionally, an 8Fr nasogastric (NG) tube had been placed and during confirmation

placement radiographs, it was noted that he had a marked alveolar/interstitial lung pattern. It was discussed at length with Axel’s owners that given the marked/worsening laryngeal edema, marked pulmonary changes, and evidence of traumatic brain injury, a temporary tracheostomy was advised. The goal of placing a tracheostomy tube (Figure 2) was to allow for better neurological assessment and improved mobilization.

The following night, Axel was prepared for his tracheostomy procedure. Prior to the procedure, Axel’s fentanyl and midazolam CRIs had been discontinued. Axel was then induced with 1.5mg/kg alfaxalone IV. Alfaxalone is a neuroactive steroid that affects the central nervous system and therefore can be used for general anesthesia. He was connected to a rebreathing circuit and maintained on isoflurane and 100% O2. The surgeon placed a sterile 7 Fr tracheostomy tube (with inner cannula) and Axel’s ET tube was removed. Inhalant gas was discontinued and a 0.75mg/kg bolus alfaxalone was given IV to allow for continued tracheostomy tube securement. Axel did well under anesthesia and his recovery was uneventful. He was placed in right lateral recumbency so that his tracheostomy tube (T-tube) would remain unobstructed. Humidified (so as not to dry out airway secretions) flow-by oxygen continued at 10L/min. His fentanyl and midazolam CRIs remained discontinued postoperatively so that we could give Axel a chance to recover and better assess his neurological status. His VPCs had subsided so his lidocaine CRI was also discontinued. Every 1-2 hours, T-tube care was performed, which entailed sterile suction of T-tube, sterile removal/cleaning of inner cannula, and cleansing around the insertion site. For each instance of T-tube care, Axel was pre-oxygenated and oxygenated post procedure. Since there was concern about aspiration pneumonia (vomited during transport, findings on oral exam and placement radiographs), saline nebulization q6h was added to Axel’s orders.

Figure 2 (top): An example of a tracheostomy tube placement.; Figure 3 (bottom): Axel making small improvements each day of hospitalization.

The goal of placing a tracheostomy tube was to allow for better neurological assessment and improved mobilization.


Case STUDY

Due to Axel’s continued hemorrhagic GI losses and slightly worsened prolongation of citrated-PT = 25 seconds (11-17 seconds) and citrated-aPTT = 143 seconds (72-102 seconds), an additional 3 units FFP transfusion (equating to 15ml/kg) IV was given with frequent monitoring. An enteral nutrition (Clinicare) CRI was started at 1/3 resting energy requirement (RER; calculated using [body weight in kg x 30] + 70). A single dose of 1mg/kg furosemide IV was given to help with interstitial edema and third-spacing. For the remainder of the shift, Axel was quiet but slowly becoming more responsive.

Over the following three days, Axel showed progressive improvement (Figure 3). On day four of hospitalization, he was sitting up on his own and was able to stand for short amounts of time. His GI losses became significantly reduced, so he no longer needed replacement fluids and he began eating a bland GI diet. On day five, his urinary catheter was removed, he began drinking so IV crystalloids began to be weaned (including discontinuation of dextrose additive). Antibiotic coverage was deescalated in order to start transitioning to oral meds and Axel was becoming more interactive with the nursing staff. His peripheral edema was improving as he became more active and his clotting times improved, with citrated-PT = 13 seconds (11-17 seconds) and citrated-aPTT = 115 seconds (72-102 seconds). On day six, his multi-lumen catheter and tracheostomy tube were removed. He also had a complete transition to oral meds (20mg/kg amoxicillin-clavulanic acid q12h, 1mg/kg omeprazole q24h), his IV fluids were discontinued, and he was extremely interactive. Over this period of hospitalization, Axel’s vital signs remained

normal and he showed no evidence of neurological deficits.

Discussion Heatstroke is the most severe manifestation of heat-induced illness; it occurs when the normal bodily mechanisms for dissipating heat are unable to function. An animal’s body temperature is regulated by balancing heat gain and heat loss. When an animal experiences heatstroke, the heat loss mechanism is overwhelmed, causing a rise in core body temperature. Heatstroke results in direct, thermal injury to epithelial cells, which can affect all major organ systems. Damage to these systems comes from a sequence of events, starting with generalized vasodilation (distributive shock), which causes decreased perfusion to vital organs. Decreased perfusion leads to tissue ischemia (lack of blood/oxygen supply), which can be fatal. In these cases, gradual cooling is essential since heat dissipation involves peripheral vasodilation; if an animal is cooled too rapidly, vasoconstriction occurs, causing blood supply to be restricted and further diminishing vital organ perfusion and oxygenation. Every major organ system can be affected, leading to multiple organ dysfunction syndrome (MODS). MODS arises from a physiologic insult; it is the development of potentially irreversible physiologic derangement involving multiple organ systems. Axel experienced circulatory collapse, coagulopathy, myocardial insult, hepatic insult, and GI insult. It was very concerning that his coagulopathy would progress to disseminated intravascular coagulation (DIC). DIC is a pathological process in which there is widespread activation of clotting factors that deposit fibrin and form clots in blood vessels; this leads to microvascular thrombi and

compromise of tissue blood flow. Heatstroke requires dedicated and extensive nursing care and multiple therapeutic interventions to assess and treat all organ systems affected.

A contributing factor to Axel’s heatstroke was his brachycephalic predisposition. Brachycephalic syndrome is a collection of physical abnormalities in brachycephalic breeds that lead to upper airway dysfunction. The most common abnormalities are stenotic nares, an elongated soft palate, a hypoplastic trachea and everted laryngeal saccules. Stenotic nares are malformed nostrils that are narrow and can collapse during inhalation, making it difficult to breathe through the nose. An elongated soft palate causes the tip to protrude into the airway, interfering with movement of air into the lungs. A hypoplastic trachea has a narrower than normal tracheal diameter. Everted laryngeal saccules are when the saccules located in the larynx turn outwards, causing them to move in front of the trachea, partially obstructing airflow. One or a combination of these anatomical abnormalities makes breathing difficult because of increased airway resistance and increased effort to inhale, and can cause upper airway inflammation, swelling and edema.

Final Outcome Axel was discharged after being hospitalized for seven days in the ICU. He was breathing normally, his tracheostomy stoma site was beginning to heal and his coagulopathy had resolved. Axel’s owners planned to follow up with a surgical specialist in the following weeks to have brachycephalic surgery done. J

When an animal experiences heatstroke, the heat loss mechanism is overwhelmed, causing a rise in core body temperature. Heatstroke results in direct, thermal injury to epithelial cells, which can affect all major organ systems.


Case STUDY

A few years ago, the NAVTA leaders met for a strategic planning session.

The first order of business was to evaluate the current NAVTA Mission Statement, determine its relevancy, and go from there. It was immediately apparent that the leaders were unable to recite the mission statement, leading to a lively discussion. At the time, the NAVTA mission statement was several sentences long, and full of language that was irrelevant and unmemorable. Without a concise, tangible mission, organizations flounder.

After a revision, NAVTA’s Mission Statement reads: Advancing veterinary nursing and veterinary technology. The leaders now have a six-word mission statement as their guiding principle.

What is your mission guiding you through your days as a veterinary technician and through your career? You may answer, “Nothing” or “I have goals and dreams, but no solid mission.” If that’s the case, here is a terrific exercise!

Consider designing your own personal Values, Vision and Mission statements. You may be thinking, “That feels awfully cold and corporate.” Yes, it may feel that way, but many team members have completed this short worksheet and found great relief, support and guidance in declaring their values, vision and mission. As you work through the process, remember you are a valuable asset to the

veterinary team. Each member brings a kaleidoscope of color, experience, and expertise to the table. Together you make up a unique team, offering extraordinary care to pets and pet parents.

As you begin this creative exercise, allow your thoughts and suggestions to flow, without boundaries. Allow for real creative brainstorming to occur; when you express yourself authentically, you can create a dynamic veterinary career that serves you and the community in a purposeful way.

Be BOLD, Be BRIGHT, Be COURAGEOUS in writing your thoughts.

ValuesFirst, begin with identifying your own personal values. This is where the soul searching begins. Don’t think about what your manager or peers want you to say, declare what YOU VALUE, in your heart of hearts! Values are defined as beliefs that we hold dear to us, allowing us to find direction and drawing us to others with similar values. When we know what we cherish and identify aptitudes and atti-tudes, we draw more of that energy to us.

• As an example, my Values are: relationships, creativity, problem solving, sustainability, trustworthiness, and courage

Consider what you believe about being a team member and serving pets and pet owners. For example, you may believe in providing TLC to every pet that walks in the door.

Rebecca Rose, CVT

What's Your Mission? Defining Personal Values, Vision, & Mission as a Veterinary Technician

Pho

to b

y iS

tock

pho

to.c

om

/ h

erra

ez


NAVTA SPOTLIGHT

Answer These Values Questions:In regard to serving pets I believe:1.

2.

3.

In regard to my work day, I believe:1.

2.

3.

In regard to serving pet parents (clients), I believe:1.

2.

3.

Write your Values. What is the common theme in your answers?

WELL DONE! Stating your values can be perceived as a difficult task. You may have never put much thought to your personal beliefs, let alone attempted to write them down.

VisionNow, without boundaries of any kind, think about the future. Where do you want to be, personally and professionally in the future? Don’t write down what your significant other thinks you should be doing or what your supervisor thinks your path is; declare what you envision for yourself.

A Vision Statement is on the lofty side of the BIG IDEA, free of boundaries (ALL BOUNDARIES) and judgments (ALL JUDGMENTS).

• As an example, my Vision is: be a physically fit, spiritually hip granny with time and resources for friends, family and grandchildren. I passionately lead by example while assisting others to find their “groove” and fulfill their personal goals and aspirations.

The cool thing about your vision is you do not have to know how it will come to fruition. That’s not your job! Your job in the vision is to keep your mind focused on the outcome. You will be surprised what will inspire when you define your vision and begin to co-create with the resources and support around you.

Creating something without boundaries means to let go of all restraints. Stop thinking: “My boyfriend won’t let me do that,” or “I don’t have enough money,” or “There is no time in my day to make this happen.” Erase those thoughts from your mind. Write free-flowing and without boundaries.

In addition, don’t judge what comes to your mind. If, all of a sudden, out of the blue, you think, “I want to work for an Industry Partner as a Regional Manager” GO WITH IT! Don’t question where it came from or why it popped into your head, or how you are going to achieve it. That’s not your job at this moment. Your job is to embrace all the ideas that flow through you in this exercise. Ready, Set, GO!

Clear your head and answer the following questions about your future.

Without boundaries, in regard to serving pets within the field of veterinary medicine, how do I see myself in the future?

Without boundaries, in regard to my work day, what do I envision myself doing in two years?

Without boundaries, in regard to serving pet parents, how do I see myself offering extraordinary care in two years?

Write your Vision:

MissionLast, but not least, design your mission. What do you do on a daily basis that brings you the greatest joy? Remember, the shorter, the better. A six-sentence mission statement may not serve you well. A six-word mission statement (even though more difficult to craft), will be far more powerful! A Mission is defined as “what I do on a daily basis that brings me joy, abundance, resources, financial sustainability, and connection to the people who I most align with.” • As an example, my Mission is: to

build masterful, passionate veterinary teams and coach individuals to offer services that are best for the pet, pet owner, veterinary team and hospital.


NAVTA SPOTLIGHT

Finally, design the Mission for your career.On a daily basis, how do you offer the best care possible to the pets you serve?

On a daily basis, what is the best part of your day?

On a daily basis, what brings you greatest joy while working within veterinary medicine?

On a daily basis, how do you offer the best care possible to pet parents bringing in their beloved pets?

What else?

Write your mission:

Congratulations! You successfully completed your values, vision and mission statements! Combined, these statements can guide you through difficult and exhilarating circumstances.

If this was difficult or uncomfortable, you are not alone. These types of conversations make a lot of people uncomfortable. If that is the case, put the NAVTA Journal down, let the concept soak in, and revisit this again in a few days. Maybe, at that time, your subconscious will have had time to formulate the answers you were unable to articulate earlier.

Putting to use your personal Values, Vision and MissionYou may be at a crossroads in your career. These statements may clearly define where you want to go in bringing greater joy and fulfillment into your days. You may be seeking new responsibilities to continue growing personally and professionally in your career and this may light the pathway to achieving that goal. You may see your situation no longer aligns with your values and that is okay (a bit frightening, but okay!).

Use your defined values, vision and mission as your guiding light, your guiding principle. J

REBECCA ROSE, CVTRebecca Rose, CVT cares about and understands veterinary teams. She is the founder and president of CATALYST Veterinary Practice Consultants. She has over 30 years of involvement in the veterinary industry, including experience as team coach, a practice manager at two AAHA-accredited animal hospitals, and as an award-winning veterinary technician. Rebecca is a Past President of NAVTA (2015-2017). You will find Rebecca facilitating workshops for veterinary teams at local, national and international conferences and retreats. It brings her great joy to support veterinary teams in reaching their highest potential. Feel free to email her at [email protected].

CATALYST CHRONICLES

You are invited to sign up for the weekly CATALYST Chronicles delivering informative eNewsletters focused on veterinary team development, retention and teams living well. http://catalystvetpc.com/Chronicles-join

Join Veterinary Teams Living Well, a closed Facebook page for veterinary professionals offering tools for a purposeful, sustainable career in veterinary medicine.

Pho

to b

y iS

tock

pho

to.c

om

/ s

hiro

noso

v


NAVTA SPOTLIGHT

Pho

to ad

apted

from

iStock.co

m / kem

albas

Nicole Blumenkranz, BS, RVT

As an RVT working in an ever-changing field, lifelong learning has always been important. This personal goal

led to earning a Bachelor’s degree in Veterinary Technology, which required a capstone research project. The project was both exciting and overwhelming at the same time, as the goal was to find a topic which was meaningful and inspiring. However, this was quite the challenge and during this time, work was another big factor in the development process. Working in a leadership role on an internal medicine team within a busy multi-specialty animal hospital left a feeling of an inadequate work-life balance, as it was mostly work. This became more noticeable as a natural shift occurred to create space for academia. That is when the project took shape. It occurred to me that others in this field could also be struggling with issues of work-life balance. This experience led to a journey of further exploring the topic of work-life balance (WLB) and how it affects those in the veterinary profession.

Work-life balanceWork-life balance can be described as when an individual “can enjoy the combination they desire among activities in their job, family, community and self-development,”1 which

This program was reviewed and approved by the AAVSB RACE program for 1 hour of continuing education in jurisdictions which recognize AAVSB RACE approval. Please contact the AAVSB RACE program if you have any comments/concerns regarding this program’s validity or relevancy to the veterinary profession.

LEARNING OBJECTIVE:Upon reading this article, participants will be able to discuss the four facets of work-life balance, understand the importance of self-care, and gain knowledge of recent work-life balance research in the veterinary profession.

Work-life

in the Veterinary Industry

B A L A N C E



are the four facets of work-life balance. The topic of work-life balance affects people from all different cultures, genders, ages and career paths.2 As each individual is unique, it is important to note there is not a one size fits all approach in regard to work-life balance. One person’s balance could be another person’s imbalance because each individual is different.3 It is also essential to understand work-life balance does not entail an equal division of each individual aspect which, again, consists of job, family, community and self-development.3 This can be pictured as a pie chart, rather than a scale, where each of the four aspects are not always equally divided at 25% but they can only total 100%. In some seasons of life, family takes up much of the available energy and time, so it may require giving less time to, one, two or all three of the other aspects in order to create balance. In other seasons building a career may be more of the primary focus. The pie chart continually fluctuates as life changes and priorities are redirected.

“Work-life balance (WLB) has become a major public issue, which could be related to lack of job security, abnormal work hours, technology and work intensification.”4 The lack of a healthy WLB can cause a person to have emotional stress, anxiety and depression. It has been found that “problems at work are more strongly associated with health complaints than are any other life stressor, more so than even financial problems or family problems.”5 Chronic stress has been linked to several health issues such as “cardiovascular disease, sexual health problems, weakened immune system, migraines and headaches, stiff muscles, acne and weight gain.”5 It has also been associated with “mental fatigue, forgetfulness, irritability, difficulty concentrating and lowered self-esteem.”5 Ultimately, this can lead to burnout

syndrome and addictive behaviors. In the end, it not only affects the individual person, but their family and their careers also become victims of this imbalance.5

History The term work-life balance was first used to describe Americans in 1986 as it became more common for employees to spend increased time at work, or on out-of office work-related responsibilities.6 Research identified that for Americans, work-life balance is important to both men and women.2 However, this was not the case in other countries, where work-life balance was more gender specific.

Research comparing work-life balance from eastern and western perspectives, identified that different countries have different focuses for achieving work-life balance. Chandra, a researcher from the International Management Institute, found that in order for Americans to achieve work-life balance, their greatest need was flexible working practices.2 The ability to offer this benefit can be dependent on the type of work and internal structure of the organization, as it may be more practical for some than it is for others.

Self-DevelopmentThe American nursing community emphasized the need for self-care in order to have work-life balance.7 Not only is self-care helpful to the individual on a personal level, it can also impact the workplace culture and employees.7 When looking at balancing personal and professional responsibilities, one needs to take self-care into consideration. Self-care is not self-indulgence; rather it is choosing behaviors that balance the effects of emotional and physical stressors.7 According to Richards, there are six pathways of self-care, which include physical, mental, emotional, and

spiritual, relationships and choice.7 An unhealthy work-life balance can decrease the amount of time, energy or eagerness for one’s own self-care. For those in the care industry, the first element to any caring model is self-care.7 Therefore the role of self-care should be equally essential to the veterinary industry, as it is in the caring profession. Richards states that each team member must be healthy to create a healthy team; further supporting that employers should take an interest in promoting healthy employees by means of work-life balance.7

Work-life Balance ProgramsSome employers have taken initiatives to create work-life balance programs for their employees. Such programs include: child-care, eldercare, employee assistance, as well as fitness and recreation.8 Child-care programs can range from onsite childcare, to offering a discount for childcare services, or seasonal childcare programs (during winter or summer breaks), to name a few.9 In regards to eldercare, a company or organization can offer eldercare assessment,

The lack of a healthy work-life balance can cause a person to have emotional stress, anxiety and depression.

Pho

to b

y iS

tock

pho

to.c

om

/ n

zpho

tonz



case management, and accessibility to local eldercare networks which offer seminars or support groups.9 If employee assistance programs are available this provides the employee, or their immediate family members, short term and confidential counseling services for a variety of issues which might be affecting their work, even if it is not directly related to the workplace.9 Having a healthy lifestyle, which includes eating well and exercising, can reduce stress and burnout, as well as help people to be better problem solvers.10 Employers should be vested in their employees’ health because it affects their productivity and effectiveness.10 Another benefit of increased health can be a decreased need for health care services, which helps drive down health benefit costs for the employer.10 This creates a mutually beneficial exchange between the employer and employee.

Simply having work-life balance policies in place has been shown to increase job satisfaction for all employees, even those who do not take advantage of such programs.11 However, if the employees are unaware of these possible benefits then they cannot build positive feelings toward the workplace or employer. This further enforces the value of communication between employees and the employers in regards to work-life balance policies.

Workplace CultureAlthough it is beneficial to establish work-life balance policies in the workplace, the main determinant of job satisfaction is actually the work-life balance culture. The work-life balance culture is explained as whether or not the values of the organization support their employees to have a balance of their life at work and their life away from work.12 If there is not a supportive climate then it is less likely for employees to have a positive effect from the work-life balance policy.12 This concern was also addressed in a study regarding the two-step process of workplace responsibility for work-life balance. The first step is the commitment from the workplace and the

second is keeping this commitment in order for employees to reap the benefits of work-life balance policies.13 In this research, they also found that work responsibilities geared around teams lack the ability to have the flexibility required to maintain these work-life balance protocols.

Rennar states the change in workplace culture starts at the top of the employee hierarchy and all employees must hold that responsibility.14 Rennar is an advocate for education, acceptance, communication and accountability in regards to effective work-life balance protocols.14 A successful manner to provide work-life balance programs is to include them with career development initiatives. This is beneficial because then both the employee and upper management understand the employee’s goals, which can allow management to help with necessary support.

Differences were found regarding managers and work-life balance issues between small and large enterprises. In larger businesses, the managers were more aware of the need to apply work-life balance practices than in smaller businesses.12 Another finding from this research established the lack of work-life balance practices in the smaller companies was due to lower levels of management training and less qualified managers in these companies.

Non-Work AspectsThe idea that one’s time consists strictly of work or time for leisure is not practical, as there are many other personal responsibilities that must be fulfilled outside of work. These responsibilities can be grouped into unpaid work categories such as caring tasks associated with family (caring for children and the sick or elderly). The aging Baby Boomer population in the United States is reaching new records and it is estimated that the number of seniors, those over the age of 65, will nearly triple by the year 2030.15 With this generation there has been an increase in divorce, low fertility rates, as well as a rising life expectancy compared

to previous generations.16 Typically, seniors wanting to stay in their home rather than a nursing home have relied on family members for assistance. “Women—who have traditionally served as parent care providers—are more likely to be employed than in previous generations, limiting their availability, and increasing their time constraints.”16 Another factor to consider with those generations coming after the Baby Boomers is the trend to have children later in life. This can potentially create the need for them to care for their children as well as their aging parents or their in-laws at the same time. If this becomes necessary, it can cause strain for those family members offering caregiving services.

Beyond the roles of caring for family members, individuals maintain other personal relationships. These may include the relationships one has with siblings, friends, sporting groups, church groups and community that may put additional demands on employees.17 Other responsibilities include non-caring tasks such as domestic work (household chores and home maintenance) and consumer work (shopping). Additional unpaid work consists of non-job-related training or studying, searching for a job, and work-related travel.18 One can pay for goods or services such as grocery delivery, maid service, or lawn care, as a way of outsourcing some responsibilities. Although not all tasks can be outsourced, the ability to outsource certain roles of unpaid work can contribute to having a work-life balance by creating more time for the individual to pursue other activities.18 Nonetheless, the idea of unpaid work must be considered a critical part in the work-life balance spectrum.

Generational AspectsAnother avenue that has been explored is whether or not there are generational differences regarding work-life balance. Research shows that the amount of time spent at work has increased over the past two decades.6 It was assumed that increased technology would create more productive



Work Life Balance by the NumbersWe received over 600 responses to this Work-life Balance Assessment. Here are our results:

RESPONDENTS84%

Veterinary Technicians

A low work-life balance score is concerning and action needs to take place quickly, while a moderate score indicates improvement is needed.

The Work-life Balance Assessment was created by and used with permission from Lisa Martin (https://lisamartininternational.com). It was administered via the Facebook page of the National Association of Veterinary Technicians in America (NAVTA). 604 responses were received during a two-week period.

Age Group with highest percentage of participants in each work-life balance category

of respondents think the issue of work-life balance is important

95% 80%

95% of men had high and moderate work-life balance scores compared to

80% of women.

37% of participants were considering a career change.

Of those considering a career change,

95%

11.4% Veterinary Assistants

4.5% Other 93%

do not have a high work-life balance

423 scored moderate 110 scored

low

73%Moderate

19%Low

8%

19% scored low,which increases chance of burnout

of participants

More than 92%

High

51 +

HIGH

18-40

M

ODERATE

41-50

LOW

did not have a high work-life balance.



employees and allow for more time for non-work endeavors.6 However, our consumerist culture has caused an increase in time spent at work, and a less supportive culture allowing employees to prioritize and consider other aspects of their life.6 Baby Boomers, born between 1945-1964, are predominantly known for their hard work ethic and their loyalty to their employer but for also prioritizing work even at the cost of self or family.19 Those in Generation X were born during the years of 1965-1979. This generation are known to be less committed to one employer during their career and they value the ability to work to live rather than live to work.19 Smith argues the Millennial employees, people born between the years of 1980-1995, have an increased need for work-life balance than previous generations because Millennials place a higher value on relationships and lifestyle than work.6 It was also found that Millennials believe that a healthy work-life balance leads to better job performance and better ethical decision making as an individual.6 Time will tell how the future generations, such as Generation Z, enter the workforce and create new standards for themselves regarding work-life balance. In the end, these generational differences are important for employers to understand in order to recruit and retain employees from each generation.

Project Data AnalysisBased upon the Capstone project, the analysis of the data supported the value of such a study, which focused on work-life balance for veterinary technicians. With permission from Lisa Martin (https://lisamartininternational.com) to use her Work-life Balance Assessment and with the help of the National Association of Veterinary Technicians in America (NAVTA), who provided authorization to share the electronic survey via the NAVTA Facebook page, over 600 responses were received during a two-week period. Of the 604 responses, 508 (84%) participants were veterinary technicians, 69 (11.4%)

participants were veterinary assistants and 27 (4.5%) were listed as other. The results showed that 93.0 % of participants found the issue of work-life balance important and the other 7% were neutral. The data also identified that more than 92% of participants did not have a high work-life balance. Of the participants in this group, 423 participants (73.3%) scored moderate, and 110 participants (19.1 %) scored low on the Lisa Martin Work-life Balance Self-Assessment. According to Lisa Martin, a low work-life balance score is concerning and action needs to take place quickly, while a moderate score indicates improvement is needed and a high score is considered excellent. Although, the highest percentage of participants scored a ‘moderate’ work-life balance based upon the Lisa Martin Self-Assessment, 19% of participants scored a ‘low’ work-life balance, which puts them at risk for burnout.

On average more men, 18 (94.7%), had high and moderate work-life balance scores compared to women, 448 (80.3%). However, both male and female participants found the topic of work-life balance important. This is consistent that in America work-life balance is not gender specific, as it is in other countries.2 When comparing the importance of work-life balance to parent and non-parent groups, both groups found it important, which is also consistent with a study by Haar in 2013.17

When looking at generational differences in the data, the age group who had the highest percentage of participants in each category of high, moderate and low was analyzed. The analysis determined that the age group with a high work-life balance

were those 51 or older, the age group of 18-40 had a moderate work-life balance, and age group of 41-50 had a low work-life balance.

The participants’ perceived work-life balance rating of high, moderate or low was compared to their Lisa Martin self-assessment score of high, moderate or low. Interestingly, 70% of all participants scored the same on their comparison. This data supports the perspective that the majority of the participants were able to accurately define their work-life balance without an assessment. A significant finding was that 36.9% of participants were considering a career change. Of those participants who were considering a career change, 95% did not have a high work-life balance. This supports the contention that there is a correlation between not having a high work-life balance and the incidence of turnover. It also indicates the significance of prioritizing work-life balance for both employees and employers.

The data indicated that 95% of participants are aware of the work-life balance topic. More than 90% of participants recognized that work-life balance is important, which supports the need for balance within the veterinary profession. The data also revealed that more than 90% of participants did not have a high work-life balance. When combining this finding with the increased awareness level of the 95%, this raises concern that awareness alone does not guarantee a high work-life balance. All and all, this indicates that there is a high awareness level of this topic; however, counterintuitively veterinary professionals have a low success rate to achieve it.

As previously discussed, the topic of work-life balance is one that affects men and women of different age groups, parents and non-parents, and in a variety of working roles.17 However, the results of this study indicate that the topic of work-life balance is relevant to the veterinary community, more specifically veterinary technicians and assistants, in the United

There is high awareness of the topic of work-life balance; however, counterintuitively, veterinary professionals have a low success rate achieving it.



States. The low number of participants who have a high work-life balance is concerning for future veterinary technicians as more college graduates are entering the field. If this current trend continues, this could cause a decline in the number of people considering to enter the profession. This is also concerning for employers of veterinary technicians and assistants because having a work-life balance helps retain talent and decrease the amount of turnover.11

The data indicated that approximately 40% of participants acknowledged they were considering a career change, an identified side effect of low work-life balance. An employee shortage could result in a decreased ability to sustain a profitable business and maintain excellent customer service as well as patient care. Existing staff must work harder and longer often resulting in increased errors. This increased workload causes added stress resulting in lower morale and job satisfaction. It can

affect employees mentally and physically and lead to an increased need for time off.20 This gives further merit that work-life balance should be a priority for both employees and employers considering retention and turnover rate issues. The most recent American Animal Hospital

Association Compensation and Benefits report identified that the national average turnover rate for veterinary technicians is 22%, which is higher than the national average of 18.1%.21,22

ReflectionsWhat if there was a shift within in the profession where individuals and the workplace made work-life balance a priority and encouraged everyone to better care for themselves, their team members, their patients, and their clients? Awareness is only the beginning, but action must take place in order to create change. Each individual must initiate change and take responsibility for their own actions. The important factor is this change can start right now. J

REFERENCES1. Tanaka S, Maruyama Y, Ooshima S, Ito H.

Working condition of nurses in Japan: awareness of work-life balance among nursing personnel at a university hospital. Journal of Clinical Nursing. 2011; 20(1/2):12-22. doi:10.1111/j.1365-2702.2010.03354

2. Chandra V. Work–life balance: eastern and western perspectives. International Journal of Human Resource Management. 2012; 23(5):1040-1056. doi:10.1080/09585192.2012.651339

3. Nappo-Dattoma L. Striving for a healthy work-life balance in a 24/7 world. Access. 2015; 29(4):12+

4. Agosti MT, Andersson I, Ejlertsson G, Janlöv A. Shift work to balance everyday life - a salutogenic nursing perspective in home help service in Sweden. BMC Nursing. 2015; 14(1): 55-77. doi:10.1186/s12912-014-0054-6

5. Gallagher S. The symptoms and impact of lack of work-life balance. Self-growth. http://www.

selfgrowth.com/articles/the_symptoms_and_impact_of_lack_of_work_life_balance. Accessed November 10, 2017

6. Smith KT. Work-Life Balance Perspectives of Marketing Professionals in Generation Y. Services Marketing Quarterly. 2010; 31(4): 434-447. doi:10.1080/15332969.2010.510724

7. Richards K. Self-care is a lifelong journey. Nursing Economics. 2013; 31(4): 198+

8. Wang, J, Verma A. Explaining organizational responsiveness to work-life balance issues: The role of business strategy and high-performance work systems. Human Resource Management.2012; 51(3): 407-432. doi:10.1002/hrm.21474

9. Canadian Centre for Occupational Health & Safety Page. http://www.ccohs.ca/oshanswers/psychosocial/worklife_balance.html. Updated February 12, 2018. Accessed February 12, 2018

10. Barringer P, Orbuch D. Stress, wellness, and compliance: practical strategies for reducing stress, improving personal health, and engaging your employees: useful tips for keeping a “healthy” balance at work as well as in life. Journal of Health Care Compliance. 2013; 15(1): 23+

11. Sánchez-Vidal ME, Cegarra-Leiva D, Cegarra-Navarro JG. Gaps between managers’ and employees’ perceptions of work–life balance. International Journal of Human Resource Management. 2012; 23(3): 645-661. doi:10.1080/09585192.2011.561219

12. Cegarra-Leiva D, Sánchez-Vidal ME, Cegarra-Navarro JG. Work-life balance and the retention of managers in Spanish SMEs. International Journal of Human Resource Management. 2012; 23(1): 91-108. doi:10.1080/09585192.2011.610955

13. Heywood JS, Siebert WS, Xiangdong W. Work-life balance: promises made and promises kept. International Journal of Human Resource Management. 2010; 21(11), 1976-1995. doi:10.1080/09585192.2010.505098

14. Rennar H. In search of true work/life balance: in order to consistently attain work/life balance, we mt change our work ethic and corporate

NICOLE BLUMENKRANZ, BAS, RVT-GNicole Blumenkranz, BAS, RVT-g, received her BAS in Veterinary Technology in 2017, she will finish her Masters in Organizational Leadership in December 2018, and is currently completing her certificate in advanced executive coaching. Nicole received her RVT license in 2012 and has worked in general practice and specialty medicine for 12 years. She currently teaches in an AVMA accredited veterinary technology program in California. She is passionate about the veterinary industry and promoting healthy workplaces, healthy teams, and healthy individuals, as well as the next generation of veterinary technicians.

Work-life balance should be a priority for both employees and employers considering retention and turnover rate issues.



culture through education, acceptance, communication and accountability. Financial Executive, 23(3), 57+

15. The Center for Health Design Page. https://www.healthdesign.org/sites/default/files/news/How%20Boomers%20Will%20Change%20Health%20Care.pdf. Updated May 2007. Accessed February 9, 2018

16. Scommegna P. Population Reference Bureau Page. http://www.prb.org/Publications/Reports/2016/todays-research-aging-caregiving.aspx. Updated February 2016. Accessed February 9, 2018

17. Haar JM. Testing a new measure of work–life balance: a study of parent and non-parent employees from New Zealand. International Journal of Human Resource Management. 2013; 24(17): 3305-3324. doi:10.1080/09585192.2013.775175

18. Collins G. Cleaning and the work-life balance. International Journal of Human Resource Management. 2007; 18(3): 416-429. doi:10.1080/09585190601167557

19. Rook D. JP Griffin Group Page. https://www.griffinbenefits.com/employeebenefitsblog/the_changing_definition_of_work_life_balance. Updated August 29, 2017. Accessed February 9, 2018

20. Nestor-Harper M. Understaffing issues in the workplace. Houston Chronicle. http://smallbusiness.chron.com/understaffing-issues-workplace-46884.html Accessed November 10, 2017

21. Larkin M. Technician shortage may be a problem of turnover instead. JAVMA News. https://www.avma.org/News/JAVMANews/Pages/161015r.aspx

22. Hall KC. 2016 Total turnover rates by state. Compensation data. Accessed November 10, 2017

Let’s Review...1. The first element to any caring profession is

a. Education

b. Self care

c. Training

d. Experience

2. What is the correct number of aspects that encompass work-life balance?

a. Two

b. Five

c. Seven

d. Four

3. What is the greatest need for Americans to achieve work-life balance?

a. Flexible working practices

b. Increased vacation time

c. 30-hour work week

d. More employee benefits

4. Which generation has an increased need for work-life balance?

a. Baby boomers

b. Millennials

c. Generation X

d. Generation Z

5. What is the national average of turnover rates for veterinary technicians?

a. 10%

b. 15%

c. 18%

d. 22%

CO

NTI

NUING EDUCATIO

N

Q

U IZ O NLIN

E




Mirtazapine is an antidepressant commonly used for people; and it

turns out, also possesses appetite-stimulating properties—which is considered a side effect in humans. Mirtazapine was approved by the Food and Drug Administration (FDA) earlier this year to stimulate appetite in anorectic cats.

Mirataz® (mirtazapine transdermal ointment) is the first transdermal product to receive FDA approval for use in cats. And of course, that is a huge deal.

Often times, pilling cats is akin to non-compliance for many clients.

As cats are living longer lives, there are more geriatric cats than ever. Often geriatric cats seem to slowly lose their appetite, no longer want to eat at all, or become what’s typically termed as “finicky” about their diet.

Of course, finicky cats are not typically being “finicky” just because they’re cats, but because they’re waving a red flag that something may be wrong.

In senior cats, other considerations should be made when addressing loss of

appetite. Perhaps the cat has renal disease, or osteoarthritis pain. Maybe there’s another underlying medical condition—the possibilities are endless when inappetance is a symptom, and further diagnostics are required. Perhaps, the cat isn’t eating because of a new therapeutic diet (which means the cat may not have been feeling well in the first place). Or maybe the decline in interest in food is occurring in response to medications the cat may be taking. Gone are the days of dismissing a decline in appetite as just a “finicky” cat.

An often overlooked consideration for diminished appetite is pain. If you’re in pain, even a delicious meal like Christmas dinner may not be appealing. It’s the same for cats.

Osteoarthritis should be always be considered when a cat stops eating. Osteoarthritis is a common radiographic finding in older cats, with a prevalence of up to 90 percent in appendicular joints.1 When addressing loss of appetite, some veterinary professionals don’t look for signs of pain, including asking simple lifestyle questions such as, “Has the cat stopped using stairs? Has the cat stopped jumping up on beds?

Is the cat showing an increase or decrease in grooming?” These can all be clues and possible pain indicators.

Of course, a far greater issue is clients who don’t see the veterinarian because their cat seems well. Even cats in pain may effectively mask agony. At that point, the cat may have even lost weight from not eating, and an appetite stimulant that works quickly may be imperative as well as providing pain relief.

The non-profit Winn Feline Foundation funded the initial Mirtazapine studies led by researcher Jessica M Quimby, DVM, PhD, DACVIM.2,3 There’s no question that a transdermal application in cats adverse to pills makes perfect sense. And appetite stimulation is so very important, especially in fragile geriatric patients. So, it may come as no surprise, that some suppliers want to continue compounding it themselves. There is clearly a market. However, the FDA isn’t thrilled with that prospect. In fact, they’ve offered an uncharacteristic warning from a September 21 alert—which may have slid under the radar (Box 1).

FDA approved drugs have been

Loss of Appetite in Senior CatsSymptoms, Causes, and Treatments

Finicky cats are not typically being “finicky” just because they’re cats, but because they’re waving a red flag that something may be wrong.

Pho

to b

y iS

tock

pho

to.c

om

/ M

irraP

hoto

gra

phy


Head to Tailwith Steve Dale

ABOUT STEVE DALESteve Dale, CABC (certified animal behavior consultant) is co-editor of Decoding Your Dog (authored by members of the American College of Veterinary Behaviorists) and is a contributor to many veterinary books including The Cat: Clinical Medicine and Management (edited Dr. Susan Little and Treatment and Care of the Geriatric Veterinary Patient (edited Dr. Mary Gardner and Dr. Dani McVety). He’s a columnist for Veterinary Practice News and Pet Vet Magazine, and a contributing editor at CATSTER. He is host of two national radio shows, and is heard on WGN radio, Chicago. He serves on the Board of Directors of the Winn Feline Foundation and Human Animal Bond Association. And he speaks at conferences around the world. Among his many honors the AVMA Humane Award and he’s in the Dog Writer’s Association Hall of Fame. His blog is www.stevedale.tv.

demonstrated to be safe and effective for their intended use and manufactured in a consistent manner. This is a huge deal compared to even presumably trusted compounders who may not be so consistent, and who don’t answer directly to the FDA.

Here are the take-home messages:• Encourage twice annual veterinary

visits for all cats, but to the best of your ability, insist on it for older cats. It’s impossible to catch changes in cats you’re not seeing.

• Ask about lifestyle changes. Sometimes the client assumption is old age, when the cat may be in pain. A cat in chronic pain will likely exhibit a loss in appetite.

• Ask about nutrition, not only what the cat is eating, but how much the cat is eating. And, of course, note any difference in the patient’s weight. Again, you can’t weigh a cat you’re not seeing (a challenge I’ll address in a future column).

And remember, cats don’t become “finicky” overnight without a reason. J

REFERENCES1. Topics in Companion Animal Medicine, Sharon

C. Kerwin, DVM, MS, DACVS; Volume 25, Issue 4, November 2010

2. Mirtazapine toxicity in cats: retrospective study of 84 cases 2006-2011; Journal Feline Medicine & Surgery; 2016 Nov;18(11):868-874. doi: 10.1177/1098612X15599026. Epub 2016 Jul 10

3. Drug exposure and clinical effect of transdermal mirtazapine in healthy young cats: a pilot study; Journal Feline Medicine & Surgery; 2017 Oct;19(10):998-1006. doi: 10.1177/1098612X16667168. Epub 2016 Sep 1

BOX 1. FDA Statement on Compounded Formulations of Transdermal Mertazapine

The U.S. Food and Drug Administration reminded veterinarians of the differences between Mirataz (mirtazapine transdermal ointment), an animal drug that the FDA approved in May 2018 with demonstrated safety and effectiveness to manage undesired weight loss in cats, compared to the use of compounded formulations of transdermal mirtazapine, which some veterinarians started prescribing before there was an FDA-approved product available. FDA approval of this drug means that veterinarians have an approved mirtazapine product with known safety, efficacy, and quality to provide to their patients rather than relying on the only previously available products that are compounded from bulk drug substances that are unapproved animal drugs.

Unlike FDA-approved Mirataz, compounded formulations of transdermal mirtazapine have not been reviewed by the FDA for safety or effectiveness and may vary in quality and potency. With many compounded transdermal drugs, the rate and degree of absorption are unknown and may vary to deliver too little or too much of the active ingredient, making treatment outcomes unpredictable.

Manufactured for Kindred Biosciences Inc., Mirataz is a prescription animal drug that is intended to be applied topically on the inner surface of the cat’s ear once daily for 14 days. Mirataz must be prescribed by a licensed veterinarian because a trained professional is needed to correctly diagnose the cause of weight loss in cats and determine whether the drug is an appropriate treatment.

Pho

to b

y iStockp

hoto

.com

/ Atid

e


Head to Tailwith Steve Dale

Reducing heartworm transmission, clarifying testing

recommendations and avoiding shortcuts in heartworm treatment

are priorities of the 2018 canine heartworm guidelines recently

released by the American Heartworm Society (AHS). The guidelines,

which focus on heartworm prevention, testing and treatment,

as well as heartworm biology and epidemiology, are used by

thousands of veterinary practices to guide their clinical protocols

and day-to-day decisions about heartworm management.

Revisions to the AHS guidelines are published as needed, based

on assessment of heartworm research that impacts principles

of heartworm management. The 2018 guidelines have just been

released and reflect the following updates to the Society’s

recommendations.

Heartworm Prevention: Weigh the Relative RiskGiven the highly preventable nature of heartworms, prevention

practices are the cornerstone of any practice’s heartworm

management program, says Chris Rehm, DVM, President of the

American Heartworm Society. “Unfortunately, the latest AHS survey

found that incidence has been trending up rather than down, with

the number of infected dogs per clinic rising by 21 percent

in the U.S. and its territories between 2013 and 2016.”

Environmental and climatic changes, as well as the

relocation of microfilaremic dogs and the expansion of

microfilaremic wild canid territories are considered to be

contributing factors to both incidence numbers and the

spread of heartworms to areas once considered non-

endemic. Effective prevention also requires diligence in

compliance on the part of pet owners.

“For these reasons, we continue to stress the importance

of year-round administration of macrocyclic lactone (ML)

preventives, along with practical steps to reduce mosquito

exposure, such as eliminating standing water on the

property and

keeping pets

indoors during

peak mosquito

times,” says Rehm.

“Year-round

prevention is the single most important step owners can take to

reduce the risk of heartworms to their pets.”

In an update to their prevention recommendations, the AHS

Guidelines state that veterinarians should also consider the use of

EPA-approved mosquito repellents/ectoparasiticides to control the

mosquito vector and reduce heartworm transmission if the risk of

heartworm transmission is high.

“The use of repellents is not a blanket recommendation, nor

should repellents ever be used in place of ML preventives,” stresses

Rehm. “In regions with relatively low heartworm incidence numbers

and few mosquitoes, use of heartworm preventives alone can be

sufficient to safeguard patients. Where mosquito proliferation

and heartworm incidence numbers are high, however, additional

measures may be warranted on either a year-round or seasonal

2018 Canine Heartworm GuidelinesRevised Guidelines Stress Risk Analysis in

Prevention, Testing and Treatment Decisions

Year-round prevention is the single most important step owners can take to reduce the risk of heartworms to their pets.

Pho

to b

y iS

tock

pho

to.c

om

/ V

aler

iyLe

bed

ev


NAVTA NEWSHEARTWORM GUIDELINES

basis. Individual veterinarians are in the best position to assess the risk for their

practices as well as for individual patients.”

Heartworm Testing: Putting Heat Treatment in PerspectiveStudies have been conducted over the past decade to better understand

the potential for heat treatment of serum samples to unmask blocked antigen,

raising questions about optimal heartworm testing methods. While noting that

further study of this effect is warranted to better understand the mechanisms

in play, the AHS Guidelines affirm that the high sensitivity of antigen and

microfilaria tests make heat treatment unnecessary for routine heartworm

screening.

“This doesn’t mean there isn’t a time and place for this practice in heartworm

diagnosis,” Rehm notes. The AHS Guidelines recommend veterinarians consider

heat treating serum when either the presence of circulating microfilariae is

detected or the veterinarian suspects active clinical disease in the absence of a

positive antigen test.

Heartworm Treatment: Stick with the AHS Protocol“One of the most frequent questions we hear—especially from pet owners—is

about the need from adulticide treatment for infected dogs. It’s understandable

when you consider the expense of treatment and the need for multiple

veterinary visits,” says Rehm. “We also get questions from veterinarians

about the AHS protocol itself, which includes pretreatment with an ML and

doxycycline, followed by a month-long waiting period, then three doses of

melarsomine on days 60, 90 and 91.

“Heartworm disease is a complex disease, and there are no shortcuts to

appropriate treatment,” the AHS leader emphasizes, noting that the AHS

protocol was designed to kill adult worm infections with minimal complications

while stopping the progression of disease. “Skipping any one of these steps

can affect both the safety and efficacy of heartworm treatment.”

Rehm adds that non-arsenical treatment protocols, including the “moxy-

doxy” combination of moxidectin and doxycycline, have been studied in

both Europe and the U.S. to better understand how to manage heartworm-

positive dogs that aren’t candidates for melarsomine treatment. “Because

some dogs are simply not candidates for adulticide treatment, there is a place

for alternatives such as these,” he explains. “However, it’s also important for

veterinarians to understand that these non-arsenical protocols have serious

disadvantages, the most important of which is the length of time required to

kill adult worms, during which time heartworm pathology and damage can

progress. This also greatly increases the length of time the pet needs strict

exercise restriction, which is problematic.”

In a 2017 AHS survey of approximately 5,000 veterinarians, three-quarters of

practitioners stated they follow the AHS heartworm guidelines. “As the primary

heartworm resource for veterinary practitioners and the public, it’s our job to

continually assess new information on heartworm management and adjust our

guidelines accordingly,” Rehm concludes. “Our hope is that the 2018 updates

will clarify what veterinarians can do day-to-day to reduce the threat of this

significant disease.”

ABOUT THE AHSFounded during the Heartworm Symposium of 1974, the American Heartworm Society (AHS) aims to further scientific progress in the study of heartworm disease, inform the membership of new developments and encourage and help promote effective produces for the prevention, diagnosis and treatment of heartworm disease. Information and resources on heartworm disease can be found at heartwormsociety.org, while an online treatment app can be found at heartwormtoolkit.com.

LEARN MORE ONLINE

To access the complete set of AHS canine and feline heartworm guidelines, visit heartwormsociety.org.


NAVTA NEWSHEARTWORM GUIDELINES

I am a licensed veterinary technician. That’s how I introduce myself these days and I

say it with pride. It’s a badge of honor I am proud to wear. It is who I am at my core as it impacts every aspect of my life; mentally, physically, emotionally and professionally. Not only does it fulfill my desire to help animals, it provides me with a plethora of opportunities to learn new things that challenge me every day.

I didn’t initially intend to pursue a Veterinary Technician degree. I began college as a Biology major at Virginia Commonwealth University with my sights set on vet school. I had been hired at my dream job—a local emergency and specialty center in Richmond, Virginia. I was 18, I felt invincible, and the education was invaluable. Within a year, I began to realize this was not such a dream after all. I spent my days working long shifts and trying to decide between sleep or studying. I was working 70 hours a week as a “part-time” employee but the rush was addicting. I

couldn’t pull myself away from work, or the unique cases I’d never seen before. But, like with all highs, I eventually crashed.

The turn-over rate was incredibly high in this hospital and I couldn’t rely on help being there when needed. My ability to provide high-level patient care dwindled. It became nearly impossible to swap shifts or schedule time off even when sick. On several occasions I went to management for assistance. I expressed my concerns for patient care due to lack of staffing and needed a manageable schedule for school, but it fell on deaf ears. My mental, physical, and emotional health was of little consequence. I had no one I could turn to who would understand my dilemma. I suffered in silence and my own self-care fell behind work and school. After two years working in this environment, burnout, depression, and anxiety slowly clawed its way into my life.

I inevitably failed to complete my undergraduate career. I withdrew from all

my classes and accepted a full-time position with the hospital. I decided I would spend my energy doing what I really loved: caring for critical patients. In my mind, spending more time in the hospital would reduce my level of stress and improve patient care. It was a terrible idea, but one I convinced myself would work. Just six weeks later I lost my job. I was blindsided and my confidence in the profession crumbled away as I walked out of the doors to that hospital, sobbing, broken and confused.

I kept moving forward despite my exhaustion and doubts, and immediately enrolled in the St. Petersburg Veterinary Technology distance education program. I was offered an assistant position in a start-up veterinary clinic. However, when the new clinic opened I felt like a deer in headlights. I realized all the criticism and doubts that had been put in my mind gnawed away at me. If I failed to hit a vein for a blood draw, or took too long at the microscope, I perceived it as another criticism of my skills. My stress returned and I was crying often. I wasn’t doing what I loved. After two months, I decided I needed to return to an ICU; I would rather be stressed by the chaos of treating critically ill and injured patients. So I made another change.

In August of 2014, I was hired by

Natalie Pedraja, LVT

Compassionis a Two-Way Street

I was working 70 hours a week as a “part-time” employee but the rush was addicting. I couldn’t pull myself away from work, or the unique cases I’d never seen before. But, like with all highs, I eventually crashed.

Pho

to b

y iS

tock

pho

to.c

om

/ k

iefe

rpix


MemberPERSPECTIVE

Veterinary Referral and Critical Care in Manakin-Sabot, Virginia. I felt a bit like Dorothy in the strange land of Oz; I was surrounded by farmland, cows, and a well-staffed ICU. I suddenly had this influx of support available and people willing to help when needed. What a concept! It took me a few months to relinquish my insecurities. With the help of school and my mentor, Susan (a Veterinary Technician Specialist in Emergency and Critical Care), the next two and a half years flew by. I learned to love my work again.

I graduated from my technician program and passed my VTNE. I had unlimited support from my coworkers, as well as my manager, Suzanne. Aptly nicknamed “Susie Sunshine,” she was around to cheer me on and help me in any way I needed. I had never experienced such positivity and understanding from management before, which became crucial to my survival. But within a week of being licensed, I was jarred by the realization that everything I’d just accomplished could be taken away if I made a single error. The wrath of my depression and anxiety was suddenly unleashed in full force. I felt stupid and inexperienced. By the end of each shift, I had cried in the bathroom multiple times. I began driving home at night playing out the fantasy of a truck hitting me head-on. For almost three months I lived with the hope that I wouldn’t wake up the next morning. The ritual was always the same: I’d get in my car, have my first breakdown, leave the hospital, start sobbing uncontrollably halfway home, argue with myself about why I was like this, why I was so broken, greet my dogs who licked the drying tears from my cheeks, use the rest of my energy to take care of them, collapse into bed, sob some more, then fall asleep. Lather, rinse, repeat.

Rather than address my feelings of despair, I thought another job change would help. I contacted my large animal mentor, Dr. Bom Harris, and we made plans to meet up and chat. When she saw me, she very bluntly informed me that I looked unwell. I tried to crack a joke and instead wound

up fighting back tears. I opened up to her about my depression, anxiety, and burnout. She didn’t smile and tell me to keep my chin up. Instead, she laid everything out that I needed to hear: I couldn’t keep going like this, I was burning myself out, I looked sick and exhausted, and I needed to get a handle on this now or else I wouldn’t last. I talked through my options before settling on the one thing that terrified me the most, but made the most sense: I needed to take a break. But I feared losing my job along with the rest of my sanity. She assured me that if the hospital valued me as much as it seemed, my needs would be respected. “Take a break, take a break. It’ll be better in the long run.” I repeated this to myself over and over and over again until it was an affirmation of the self-care I was about to initiate.

I went to Suzanne and asked if management would consider a hiatus followed by part-time re-entry and she helped make it happen. All of the feelings of guilt and anxiety over this meeting left me feeling lighter already; there was a light at the end of the tunnel. I needed a break and the ball was rolling. I would also train for a more manageable role upon my return in the surgery department.

The next step was addressing my mental health. I contacted a licensed clinical social worker. I wasn’t ready to start taking medication, but I needed someone to talk to outside of work. I found someone who would truly listen and help me explore my insecurities. She taught me to employ coping mechanisms, such as repeating positive affirmations and acknowledging successes. When I left a shift feeling depleted, I tried to focus on my accomplishments, no matter how small. As a new surgery technician, this is what I started doing; I was new to the world of anesthesia, but I took pride in everything I did. After two months of working part-time—I was ready to fully return with a more stable mind and a renewed faith in myself.

This October, with the very unfortunate death of yet another valued technician, I made a point to reflect upon my struggles

with mental health and burnout in the first year of practice as an LVT. I reflected on my achievements: I placed a central line without assistance and with confidence in myself; I ran my first complex neurosurgery—an atlanto-axial stabilization—which went so smoothly, I couldn’t have been happier! I learned to say “no” to the people who contacted me around the clock for advice about their sick pet.

I came to realize that there is a life and world outside of veterinary medicine, and I can be happy existing in it. I want my colleagues to know this: you are not alone in your struggles and your happiness is not out of reach. Most importantly, know that to truly have compassion for your patients you must first have compassion for yourself. It’s always a two-way street. J

ACKNOWLEDGEMENTSI want to thank Suzanne Owens for being my cheerleader through tech school; Susan Clark for teaching me 90% of the technical skills I have now; Bom Harris for helping me take care of myself; Erica Ditzler for being an amazing friend and ER doctor and believing in me when I didn’t believe in myself; Bridget Boken for getting me into the surgery department and becoming my newest mentor; Olga Van Beek for being a patient and understanding doctor and hospital owner; and the many other technicians, assistants, and doctors who helped get me to where I am now; and my parents, Lisa and Glynn Dumelow, for always having faith in me, even when I couldn’t find faith in myself.

Without you all I’d still be lost.


MemberPERSPECTIVE

Spring ushers in a new crop of veterinary conferences as well as chances to

claim much needed CE’s to maintain one’s credentials. While using the cell phone is an integral part of getting information about the conference through associated apps, it can also be a distraction from learning and engaging in veterinary medical updates. Consider a conference an intense short course (which you have just spent a large sum of money to attend) and limit the socializing both in-person and virtually until after 5:00 pm.

According to Business Insider, the average person (aged 25-34) sends and receives approximately 2,240 texts via their phone each month; that’s approximately 75 texts on their mobile devices per day.1 Likewise, CNN reports that people spend on average

of 10 hours per day on their phones performing a variety of tasks.2 Phones have become “virtual baby sitters,” instantly at reach when one becomes bored, curious, lonely, etc. Unfortunately, this behavior has spilled over to providing entertainment when one is patiently waiting for a speaker to conclude their presentation. While users may feel they are being patient and respectful by sitting quietly, it is extremely hard for speakers to stay focused and engaged about a topic they are passionately presenting when the audience’s faces are directed downward, illuminated by the screen glow.

Although veterinary technicians pride themselves on being multi-taskers, the human brain is incapable of getting all of the value out of a presentation while

thumbing through texts and emails. Envision the most recent conference presentation you attended. The room is dark and at the perfect temperature, and the speaker has begun to speak. The presentation is well done, the slides are engaging, and you slowly ease out our phone. The moment you choose to unplug is the moment you miss out on what the conference experience has to offer.

To make the most of the conference experience, consider the following: • Get a good night sleep before

attending the conference and have breakfast. This is especially important prior to day one as this is often the most exciting day when you will most likely want to see and do everything.

• Think about why you are here and plan your conference days accordingly. To best plan, pick up registration materials as early as possible; many conferences have early-bird or

Conference Time…

Get Unplugged!Oreta Samples, D.H.Sc

It is extremely hard for speakers to stay focused and engaged about a topic they are passionately presenting when the audience’s faces are directed downward, illuminated by the screen glow.



pre-conference activities which will allow you to skip long lines and pick up your packet early. Make sure you bring your I.D. with you and any documents needed to retrieve your packet.

• When you have time, review the entire packet, possibly at dinner or in the evening back at the hotel. Pick the speaker sessions that you are interested in and make a schedule. Include the title, location, speaker name and time so you can stay on schedule. This prevents last-minute decisions and allows plenty of time to explore the exhibitor area. If you know you are not comfortable sitting for long stretches, plan breaks to catch up with friends, have a snack, check email and make calls. Conventions, even with planning, tend to morph into marathons - so pace yourself.

• Unplug. When entering a presentation, don’t just silence your device, turn it off. You are less tempted to check your email if your phone is off. Instead, pull out the notepad and pen provided in your packet and jot down notes you wish to remember from the presentation. Also, remember to attend sessions and pick up information on topics that you have interest in. It’s okay to tag along with your “bestie” to something you’re not personally interested in on occasion, but don’t make a habit of it or you will be tempted to pull out the phone.

Professional conferences are not cheap. Attendees take time away from work, invest money and, at times, go to great lengths to be there. Consider all that can be gained from this experience: change of scenery, 20-40 hours of recognized expert presenters covering current topics of veterinary medical importance, the chance to touch or feel the latest medical technology available and, of course, great fellowship and networking opportunities. There is no

other time of the year when you can focus 100% on these things. To get the most out of the experience, consider letting your Facebook or other social media contacts know you are unplugging for a while and limit personal calls to break times or the evenings. Above all, unplug and enjoy. You will be glad you did. J

REFERENCES1. Chart of the Day. Retrieved from Business

Insider: http://www.businessinsider.com/chart-of-the-day-number-of-texts-sent-2013-3; Accessed April 2018

2. CNN US edition. Retrieved from CNN: https://www.cnn.com/2016/06/30/health/americans-screen-time-nielsen/index.html. Accessed April 2018

ORETA SAMPLES, D.H.ScDr. Samples is a 1994 graduate of Fort Valley State University, holding both a BS and AAS in Veterinary Technology, a Master’s Degree in the field of Public Health and in a Doctorate in Health Sciences from Nova Southeastern University in Fort Lauderdale, FL in 2008. As an Associate Professor, she currently serves as Program Coordinator for the MPH Program at Fort Valley State University, her alma mater where she has worked in a variety of roles for the past 22 years including adjunct instructor, laboratory technician and Registered Veterinary technology instructor. She is a co-editor of McCurnin’s Textbook for Veterinary Technicians, 10th Edition; of which she authored three chapters in the 9th edition. She has also published several articles related to veterinary clinical pathology, parasitology as well as numerous book reviews through VSPN.org. She is a past-founding committee member of the Academy of Veterinary Clinical Pathology Technicians (AVCPT) and currently serves on the Editorial Board of NAVTA and Executive Board of AVTE, GEHA and GPHA.

Pho

to b

y iStockp

hoto

.com

/ Anto

nio_D

iazVETERINARY NURSING IN ACTION | December/January 2019 | 41


As a NAVTA member you'll receive: • The NAVTA Journal and NAVTA e-newsletter

• 20% membership discount if you are a specialist or member of your state association

• 10% discount on VetMedTeam.com courses

• 10% off Puppy Start Right for Instructors Course, hosted by the Karen Pryor Academy

• 5% discount on Disability Insurance through VetInsure

• 20% discount and free, 30 day trial on Vetlexicon, the worlds largest online clinical reference source, provided by Vetstream

• 20% off FearFree Certification

• 20% discount from PetPlan Pet Insurance

• Discounts with Pet Health Insurance Plans

• 25% off and Free Shipping on Elsevier Publications

• Complimentary membership with VetCheck—the amazingly simply veterinary communications software!

• 20% discount on annual subscription to VetCompanion®

• Access to NAVTA Social Link—allowing networking and engagement with other members!

• Access the NAVTA Career Center—allowing you to post resumes and look for jobs across the nation!

• Watch for more EXCITING opportunities and benefits to come in 2019!

Joining NAVTA is truly an investment in YOU.Visit www.navta.net to become a member or to renew your membership today.

Do you want to connect with people who believe in you,

support you, and elevate you in your life and your career?

If you’re ready to feel empowered, join or renew your membership with the National Association of Veterinary Technicians in America (NAVTA). We welcome everyone in the industry, including credentialed veterinary technicians, veterinary assistants, veterinarians, educators and students.

NAVTA gives you the voice that elevates your role in the veterinary community, sparking conversations around the world that keep our members on the cutting edge of research and education in the industry.

MEMBER RENEWAL

Pho

to b

y iStockp

hoto

.com

/ Am

y New

ton-M

cCo

nnel

Introduction

There are thousands of different species of birds. While anesthesia among them

is similar, there are special considerations for some species. This paper will focus on raptors. The classification of raptors includes the two orders Falconiformes (hawk-like birds) and Strigiformes (owls). The taxonomy of Falconiformes is a debated subject but the order usually includes five families: (1) Cathartidae (New World vultures), (2) Accipitridae (hawks, eagles, Old World vultures, etc.) (3) Falconidae (falcons, kestrels, caracas, etc.), (4) Pandionidae (ospreys) and (5) Sagittariidae (secretary birds). Although there are many types of raptors they all have a few distinct characteristics: a hooked beak with sharp edges, fleshy ceres (soft skin) at the base of the beak, sharp and curved talons, keen vision, and are carnivorous.

Notable differences in avian anatomy and physiology To effectively understand the main differences between anesthesia in birds and mammals, it is important to understand the anatomical and physiological differences in the cardiovascular and respiratory systems.

Cardiovascular SystemBirds have a highly developed heart that can withstand the strenuous activity of

flying, diving, and swimming. It is considered more efficient than their mammalian counter parts due to higher stroke volumes, higher resting mean arterial pressures, lower heart rates, and higher cardiac outputs1 Another difference in the avian cardiovascular system is the presence of the renal portal system. There is much debate over the significance of the renal portal system in avian medicine. The theory is that the blood from the caudal half of the avian body passes through the kidneys, causing some drugs to get immediately excreted, and in some cases, causing nephrotoxicity2. Due to the conflicting views and need for more research, it is the authors view that administration of drugs in the caudal end of the body including the hind limbs should be avoided whenever possible.

Respiratory System Upper Respiratory TractThe upper airway of raptors is fairly similar to mammals. The glottis is at the base of the tongue and is not surrounded by an epiglottis or vocal folds. Additionally, raptors have complete trachea rings. Because of this anatomical adaption, endotracheal (ET) tubes that have cuffs should not be used. A cuff (inflated or not) in the trachea of a raptor can cause mucosal necrosis2. Therefore, only non-cuffed ET tubes or cole tubes should be used (Figure 1).

This program was reviewed and approved by the AAVSB RACE program for 1 hour of continuing education in jurisdictions which recognize AAVSB RACE approval. Please contact the AAVSB RACE program if you have any comments/concerns regarding this program’s validity or relevancy to the veterinary profession.

LEARNING OBJECTIVE:After reading this article readers should be able to understand some of the major considerations of raptor anesthetic procedures and protocols, analgesia, anatomy and physiology, and physical restraint.

RAPTOR ANESTHESIAJenna Larios, LVT and Monica Madera, DVM

Figure 1: Non-cuffed endotracheal tube (left) and cole tube (right) used in avian medicine.



Lower Respiratory TractBirds do not have a diaphragm separating the thoracic and abdominal cavity. During inhalation the keel (an extension of the sternum) moves forward and the ribs outward. Birds have two lungs that are relatively small; this is where gas exchange takes place. In addition to lungs, raptors have nine air sacs throughout their coelomic cavity that are not directly involved with gas exchange. Air sacs largely increase respiratory capacity, aid in thermoregulation by acting as a cooling mechanism, and make the airflow unidirectional. Since the flow of air is unidirectional it takes two respiratory cycles to move inhaled air completely through the respiratory system. During the first inspiration, the majority of the air travels to the caudal air sacs with a small amount passing through the lungs. During the first expiration, air from the caudal air sacs then flows to the lungs. With the second inspiration, air in the lungs passes to the cranial air sacs, and with the second expiration, air in the cranial air sacs is exhaled. In addition to air sacs, birds have four pneumatic bones (humerus and femur) that communicate with the respiratory system. Accordingly, intraosseous catheters should never be placed into the humerus or femur. Open fractures of pneumatic bones may cause inhaled anesthetic to escape, therefore requiring slightly higher vaporizer and oxygen flow meter setting.3

Physical Restraint When handling raptors the major hazards to the clinician and the handler include the talons, beak, and wing slapping (especially from large raptors like eagles). Raptors will bite, but their talons are the first to be avoided. Proper restraint requires good control of the legs and the head. The main goal of restraint is to make sure the handler, clinician, and patient are safe. This needs to be done while positioning for the medical procedure properly, protecting any of the feathers from breaking, and minimizing stress of the patient. Good communication is needed between the clinician and the handler at all times to prevent injuries. Protective gear should include eye protection like goggles and gloves that are at the appropriate length and thickness for the species being handled (Figure 2). To reduce stress, covering the head of the patient with a raptor hood or a towel to block out visual stimuli is recommended (Figure 3).

Pre-Anesthetic Preparation When considering a patient for an anesthetic procedure the clinician should consider running pre-anesthetic blood work. A complete blood count (CBC) and chemistry panel is ideal. It is important to have a normal CBC that has been run in the last seven to 14 days. Chemistries in wild animals are interpreted a bit differently than in companion animals.

Figure 2: Handler is wearing goggles and long thick gloves while holding a juvenile Bald Eagle that restrained with one hand around the neck and the other holding both feet.



Wild animals do not often have changes in chemistry values associated with old age, but can show changes when a patient is nutritionally stressed. Prior to the procedure the bird should be housed in a quiet and warm area away from any domestic animals with minimal auditory or visual stimulation to decrease stress. Ideally, raptors should be fasted about 12 hours prior to induction of anesthesia as they are at higher risk of regurgitation than other avian species. Although, regurgitation is less likely in owls. Fasting may not be possible in a smaller species that cannot go long without eating due to their high metabolic rate.

AnalgesiaThere are μ, κ, and δ opioid receptors in both mammals and birds in similar proportions.3 It has been shown that the κ receptors are particularly critical to analgesia in birds.4,5 This guides the decision to use opioids such as butorphanol, which is a μ antagonist and κ agonist, for analgesic protocols.5 Tramadol has been used for analgesic protocols as well, and while it has low affinity for μ receptors, it also acts

to inhibit uptake of other neurotransmitters acting as α2 agonists in terms of pain control.5 Aside from opioids, the other form of pain control most commonly used in birds is non-steroidal anti-inflammatories (NSAIDS), such as meloxicam.5 Meloxicam acts specifically on COX-2 receptors to inhibit production of inflammatory substances. Similar to mammals, this medication is used for inflammatory pain control but does not necessarily have the

same renal and gastrointestinal effects in birds seen in mammals, making it a good choice for long term pain control.5

Pre-Anesthetic AgentsPre-anesthetic agents are used to make handling easier, enhance analgesia, decrease anxiety, and reduce inhalant gas anesthetic requirements. For quick and non-invasive procedures, many professionals do not use pre-anesthetics. When a pre-anesthetic is used, butorphanol is the best choice. For orthopedic surgery, midazolam can be used to aid in muscle relaxation. When using midazolam it is important to consider that without its reversal agent, recovery can be prolonged. It is not recommended to use NSAIDs like meloxicam prior to anesthesia due to the chances of renal toxicity during hypotensive periods, but is a great choice as a post-op medication.2 Atropine is not recommended as a pre-anesthetic as it thickens respiratory secretions that can obstruct the ET tube. However, if the patient is bradycardic during anesthesia, atropine is indicated.

InductionWith advances in inhalant anesthesia, the use of parenteral anesthesia has greatly decreased in avian medicine. Injectable agents can be used for restraint of short diagnostic procedures and minor surgeries.1 With the high risk of apnea associated with parenteral anesthetics, intubation and ventilation is still recommended. Inhalation anesthesia is, in general, the safest and most convenient method in avian patients. Isoflurane gives a rapid and smooth induction and recovery. Sevoflurane provides a slightly quicker induction and recovery because of its lower blood solubility.6 There have been numerous reports of isoflurane increasing the likelihood of cardiac arrhythmias, specifically in Bald Eagles.7 Second-degree heart block was the most common side effect observed, and it was not observed to be followed by cardiac arrest.7 Other studies in the same species showed that isoflurane also induced hypertension, tachycardia, and more arrhythmias when compared with sevoflurane.7 Recommended induction rates in raptors are 4% isoflurane and 6-7% sevoflurane.8 Once the patient’s

Figure 3: An example of a raptor hood used to decrease stress by blocking visual stimuli.

Pho

to b

y iStockp

hoto

.com

/ Glo

balP



eyes are closed and leg muscle tone is greatly decreased, the percentage of gas can start to be turned down. It is important to keep hold of the patient’s legs in the event that the initial reduction of gas anesthetic causes them to wake up. Since birds have high respiratory efficiency, changes in anesthetic gas should be made in small increments. In the author’s experience, most patients can be maintained on about 2% isoflurane and 3% sevoflurane, although larger raptors, such as eagles, may need to be maintained on higher anesthetic flows.

Anesthesia techniques and supportive care

Intubation and InhalationIntubation is recommended for any procedure that has the potential to last longer than 30 minutes, if the patient is at high anesthetic risk due to health status, or is particularly susceptible to regurgitation. Raptors that are more prone to regurgitation include those that have eaten recently or a species that are known for regurgitating, such

as vultures. Crop palpation and/or radiographs can be confirmation of a patient not eating. If using an ET tube it should be placed directly after induction occurs. ET tubes are relatively easy to place in raptors since their glottis can be visualized at the base of the tongue and is unobstructed by an epiglottis (Figure 4). Raptor tracheas narrow about halfway down, so ET tubes should not be advanced more than a quarter of the length of the trachea. Once placed, ET tubes are secured to the lower beak by a piece of tape or can be sutured

in through the commissures of the mouth and secured

to the tube by a finger trap suture pattern. The size of the ET tube depends on the size of the patient. In general it can range from sizes <2mm in screech owls to 5.0-5.5 mm in Bald Eagles. Size <2mm ET tubes needed for small raptors are not commonly carried in most vet clinics, but they can be made from small feeding tubes or urinary cannulas. When using these small ET tubes, clogging of the tube is very common and using positive pressure ventilation helps keep the tube clear.2

After the ET tube is placed, the patient should be hooked up to the appropriate breathing circuit. In raptors, non-rebreathing systems are recommended. Birds over 5 kgs. such as eagles can be maintained on rebreathing systems that are designed for felines and pediatric human patients.6 The flow rate is recommended to be 1L/min/kg, although most precision vaporizers are not calibrated to work at flow rates low enough for many small birds.6 In the authors experience flow rates of 1-1.5 L/min in small to medium sized raptors and 2 L/min in large raptors are sufficient.

Fluid therapy/Vascular Support For long anesthetic procedures or critical patients it is highly recommended that an indwelling intravenous or intraosseous catheter be placed after induction to provide a slow drip of crystalloid fluids and quick access for emergency drugs. A rate of 10ml/kg/hr is recommended.8 For short anesthetic procedures subcutaneous fluids can be given instead.

MonitoringHeart rate, respiratory rate, nictitating membrane response, muscle relaxation, temperature, and pedal withdrawal are routinely used for monitoring avian patients during anesthetic procedures. If the equipment is available, using capnography for routine monitoring of ventilation and to avoid alkalemia and/or acidemia is recommended. The anesthetist should listen to the patient before and immediately after induction establish baseline of vitals to be aware in the trends of that particular patient. Since changes in avian patient vitals happen rapidly, it is important that a well-trained technician can recognize changes and effectively correct them based on the underlying causes. In many birds, the window of time for successful resuscitation is about 30 seconds due to their high metabolic rate, so it is critical that any complications be addressed immediately.6 The anesthetist should be aware and keep the clinician aware throughout the procedure. Atropine and epinephrine should be drawn up before the start of anesthesia to reduce reaction time should an emergency situation occur.

ReflexesReflexes in avian patients are the same as in mammals using palpebral, corneal, and pedal withdrawal. For quick and non-painful procedures a light plane of anesthesia is acceptable where the patient will lose voluntary movement +/- palpebral. In a surgical anesthetic plane, the patient should lose palpebral and pedal withdrawal, while corneal reflex is still present but may

Figure 4: Glottis seen at the base of the tongue.



be slower. If the corneal reflex is no longer present the patient’s anesthetic depth is too deep and needs to be adjusted.

TemperatureBirds have higher body temperatures than mammals, and maintaining body temperature is highly important in anesthetized raptors as they tend to lose heat quickly. Temperature loss is very prevalent in small species of raptors as a result of impaired thermoregulation due to their small body mass relative to surface area.8 A significant drop in body temperate about 15-25 minutes after induction is expected. Other causes of a decrease in body temperature includes: removing feathers, scrubbing the surgical site, the use of alcohol on ECG probes, fluids being used to flush any wounds, and high oxygen flow rates. Hypothermia may be corrected or prevented through use of warm fluids for vascular support and flushing of the surgical site, a table top heating source, and warm rice packs. Hyperthermia can be corrected or prevented by placing icepacks wrapped in a towel alongside the body of the patient. Monitoring body temperature using an esophageal stethoscope placed at the level of the heart provides the most accurate core temperature. An electric thermometer can also be placed in the cloaca but will likely not give the true core body temperature.

Respiratory Rate and Ventilation Respiratory variables are considered the most important part of monitoring anesthesia, since cardiac changes usually follow changes in the respiratory system. Respiratory rate should be 12-20 cycles per minute with breaths that are deep and even, however the respiratory rate is highly dependent on the size of the bird, with larger patients having a slow respiratory rate and smaller patients having a higher respiratory rate.8 Judgment of adequate respiratory rate and depth of breaths should be assessed visually.

It is common for birds to hypoventilate under anesthesia and it is good practice

to provide supportive ventilation at about six breaths per minute as a precautionary measure. Manual ventilation should consist of two breaths to complete the respiratory cycle due to the previously discussed anatomical differences of the avian respiratory system. Mechanical ventilators can be used in avian patients but it’s important to use a ventilator that is equipped to handle low pressures and low tidal volumes.

Apnea is not uncommon in avian patients in a surgical plane of anesthesia. Possible causes of apnea in raptors include poor ventilation, endotracheal tube placement, hypothermia, and respiratory depression caused by anesthetic agents. In response, the vaporizer settings should be lowered, and manual ventilation should be performed until voluntary breathing returns.

Heart RateThere are a few different ways for heart rate to be monitored during an anesthetic procedure. A stethoscope is a reliable method of cardiac auscultation especially during quick and non-sterile procedures; however they may be cumbersome during sterile procedures due to the presence of drapes and patient positioning. Another option for auscultation is an esophageal stethoscope that can be taped to the lower beak next to the ET tube. In addition to a stethoscope, alternative monitoring equipment such as a Doppler or an ECG machine should be used. ECG leads, either alligator electrodes or subcutaneous needle electrodes can be placed on birds in the same places that they are placed on mammals. Leads should never be attached to the bird’s patagium. In birds it’s important to note that the QRS complex is inverted. This has to do with a small

difference in electrical conductivity in the avian heart and is considered normal.

A Doppler is probably the most common method of monitoring cardiac function during prolonged anesthetic procedures in raptors. An advantage of using a Doppler is the amount of information provided: heart rate, rhythm, changes in blood flow and force of the signal, etc.

The heart rate in raptors varies greatly amongst species based on their size. Small raptors will often have rates over >200Bpm and can sometimes be too fast to count. Mid-size raptors (300-600g) have an average heart rate of 180-250Bpm, whereas large raptors have heart rates about 80-

USING A DOPPLER TO MONITOR RAPTOR CARDIAC FUNCTION

If using a Doppler, the transducer can be placed in a few locations:

> The superficial radial artery on the ventral side of the elbow joint near the basilic vein

> The deep radial artery on the ventral carpal joint

> The roof of the mouth (very useful in larger raptors)

> The cranial tibial artery on the cranial surface of the hock joint

Pho

to b

y iStockp

hoto

.com

/ yong

kietVETERINARY NURSING IN ACTION | December/January 2019 | 47


150Bpm. The chart included in this article can be used as a guideline for the different parameter among different avian species (Figure 5). Being able to maintain a steady rhythm within the heart rate reference range for the given species is more important than the absolute number.8 A decreased heart rate should first be corrected by reducing the anesthetic gas concentration. If the heart rate continues to stay low, addressing any possible hypotension should be considered. The use of atropine may be indicated. If bradycardia has not responded to these adjustments, the procedure should be terminated, gas anesthetic should cease, and recovery pursued. If at any point cardiac arrest occurs, initiate CPR.

RecoveryRecovery is a critical phase following anesthesia. Once the procedure is over the vaporizer should be turned off, the endotracheal tube disconnected, the system purged of anesthetic gas and then reconnected to the patient so it can be maintained on oxygen throughout the rest of the recovery period. Recovery can take anywhere from 10-30 minutes depending on the anesthetic drugs used and length of the anesthetic procedure. A brief excitatory phase may be observed as the anesthetic plane lightens that may be accompanied

by regurgitation or hyper-salivation.8 Once the bird begins to voluntarily move its head it can be extubated. After extubation the bird should be monitored occasionally for signs of hyper-salivation or regurgitation. If either occurs the mouth can be swabbed out with cotton tipped applicators. After the bird is able to hold its head up it can be placed inside a crate in a warm, dark, and quiet area. If the patient is not standing on its own, it can be placed on top of towels in the shape of a donut. After long anesthetic procedures birds will usually sleep for a while when left alone.

ConclusionOverall, the approach to avian/raptor anesthesia differs from that of mammals though the principles remain the same. The major differences are in regard to the avian cardiovascular system and respiratory system. As with any anesthetic episode, it is important that a well-trained technician be responsible for these patients to ensure a smooth induction, appropriate monitoring with subsequent responses, and a successful recovery. J

REFERENCES1. Abou-Madi N. Anesthesia and Analgesia: Avian

Anesthesia. Veterinary Clinics of North America: Exotic Animal Practice. 2001;4(1):35-44.

2. Scott D. Raptor Medicine, Surgery, and Rehabilitation. 2nd ed. Boston, MA: Cabi Publishing; 2016.

3. Hawkins M. Physiology of Avian Pain and Physiology. 2005. Veterinary Information Networ, Inc.-VIN. https://www.vin.com/members/cms/project/defaultadv1.aspx?id=3851955&pid=11187&. Accessed May 10, 2018.

4. Machin KL. Avian Pain: Physiology and Evaluation. Compendium. February 2005:98-98.

5. Johnston MS. What’s New in Avian Anesthesia and Analgesia. 2005. Veterinary Information Network, Inc. - VIN. https://www.vin.com/members/cms/project/defaultadv.1.aspx?id=4832927&pid=11330&. Accessed May 5, 2018.

6. Speer BL, Heard D. Current Therapy in Avian Medicine and Surgery. St. Louis, Missiouri: Elsevier; 2016.

7. Joyner PH, Jones MP, Ward D, Gompf RE, Zagaya N, Sleeman JM. Induction and recovery characteristics and cardiopulmonary effects of sevoflurane and isoflurane in bald eagles. American Journal of Veterinary Research. 2008;69(1):13-22. doi:10.2460/ajvr.69.1.13

8. Redig PT, Willette M, Ponder J. Raptors. In: Zoo Animal and Wildlife Immobilization and Anesthesia. 2nd ed. Ames, IA: John Wiley and Son, Inc; 2014:459-471.

Figure 5: A guideline of vitals in different avian species including raptors.

Pho

to b

y iS

tock

pho

to.c

om

/ p

aulo

oo



JENNA LARIOS, LVTJenna Larios is an Illinois native and has

been a veterinary technician for four years.

She graduated from Joliet Junior College’s

Veterinary Medical Technology program

in with an Associated in Applied Science

degree and became a CVT. She worked

in a general practice for three years and

as an emergency veterinary technician for

a year and a half. She wanted to expand

her clinic skills outside of small animal and

moved to Virginia to complete a one-year

technician internship at the Wildlife Center

of Virginia. This is where she learned a lot

about conservation medicine along with

clinical and anesthetic skills in large mammals,

birds, and reptiles. Surgery has always been

her passion and recently began a permanent

position as a surgery LVT at Virginia

Veterinary Surgical Associates and plans to

pursue a VTS in Anesthesia and Analgesia.

MONICA MADERA, DVMDr. Monica Madera graduated with a B.S.

in Biology from Virginia Tech in 2012 and

obtained her DVM from Virginia Tech in

2016. Following graduation, she completed

a small animal rotating internship and an

internship in wildlife medicine and surgery

with the Wildlife Center of Virginia. She

began working at North Country Animal

Health Center in the summer of 2018 where

she works with the pets and people of

Watertown, NY as well as the native wildlife

and Thompson Park Zoo and Conservancy.

Her professional interests include wildlife

medicine and ophthalmology. Outside of work

she enjoys swimming, hiking, and cycling.

Let’s Review...1. What bones are pneumatic and should never have an

intraosseous catheter placed in them?

a. Femur and tibotarsus

b. Ulna and radius

c. Humerus and tibiotarsus

d. Humerus and Femur

2. How many ventilations are required to complete a breathing cycle in birds?

a. 4

b. 2

c. 1

d. 3

3. What is a major difference in a bird ECG compared to mammals?

a. Lack of a T wave

b. Inversion of QRS complex

c. Inversion of P wave

d. Small QRS complex

4. What ET tubes should be used in avian species?

a. Cuffed ET tubes

b. Non-cuffed ET tubes

c. B and D

d. Cole tubes

5. What is the most common form of induction in raptors?

a. Propofol

b. Isoflurane or Sevoflurane via face mask

c. Ketamine and Valium combination

d. Both B and C

CO

NTI

NUING EDUCATIO

N

Q

U IZ O NLIN

E




Hosted by Jade Velasquez, LVT, Founder, Veterinary Support Network

Veterinary Support Staff Unleashed

We all have times when the holidays can seem overwhelming. Just know we all struggle with this together. If you need help, reach out. Try to dive into what brings you peace and joy this season. Enjoy the good times and remember that all of you give your patients and clients the gifts of your time, caring, passion and skill. The gift of giving is one of the best gifts in the world, and YOU do it every day. That is truly honorable.

Don’t forget to take care of yourselves!

The holidays are rapidly approaching. This can be an extremely joyous time, yet some pressures seem to increase at work. We struggle with dark long days, tight finances, working the holidays, feeling stretched to the

limit, or the dreaded “euthanasia season.” All these things can feel overwhelming and can contribute to feeling down during the fall/winter months.

This month, I decided to ask VSSU members: How do you combat the holiday blues?

My husband and I like to stay in our pjs all day, order Chinese food, watch movies and bake cookies. It’s fun to take a break from everything and have a fun lazy day with your favorite person.”

—Wendy M.

I love fun clinic activities. Decorating as a team, potlucks (especially if you are open during holidays - I love when everyone brings treats and you have delicious spreads to eat all day!). We have done clinic stockings, and everyone would get little trinkets to put in them, as well as gifts from management. Holiday parties are fun, especially if you do cool stuff like escape rooms or bowling, including an activity as well as the party. Dressing up in holiday themed scrubs is great too. Just being cheerful.”

—Liz C.

I love spending time with my family! My mom, my sister and brother always do a craft day once a year around Christmas time. One year we made fabric elves, another year we made homemade snow globes. I just had a baby boy 6.5 months ago and can’t wait to continue this tradition with him this year!"

—Brittany H.

Making donations, baking, eating, getting/making presents for my friends. Pet sitting during the holidays keeps me super busy, so I enjoy time with all of the fuzzies and scaleys! Can’t be sad with so much animal love!”

—Sabrina H.

Pho

to b

y iS

tock

pho

to.c

om

/ a

do

gsl

ifep

hoto


Professional PULSE

Proud partner of

ViroxLearning.com

Get Certified in Infection Prevention Today!

An animal’s sensitivity to harsh chemicals is 10,000x greater than ours. That’s

why Rescue™ has been formulated to be odor-free as well as gentle on users,

equipment and the planet – but powerful enough to kill Parvovirus in as little

as 1 minute. It’s the best alternative to the legacy disinfectants that can cause

nose blindness which can add to the fear, anxiety, and stress of a veterinary visit.

...to use Rescue™ Disinfectants.

300 MILLION REASONS

7651_Virox_RescueNoseAd-01F-AAHA.indd 1 9/11/18 2:00 PM

JOURNAL1931 N. Meacham Road Schaumburg, IL 60173

Date post:	15-Jun-2020
Category:	Documents
Upload:	others
View:	2 times
Download:	0 times

Are you taking care of you? - cdn.ymaws.com€¦ · Are you taking care of you? The only chews with...

Documents