ISSUE 7 • May 2013 THE CONNECTION SPECIALIST Veterinary Specialists www.vetspecs.co.nz Meet Will! Our first exoprosthetic limb patient By Brent Higgins and Elena Saltis Will is a ten year old working Collie who got his foot caught in a farm gate in September 2012. He presented to Vetspecs with an open and comminuted metatarsal II fracture and tarsometatarsal luxation of the left pelvic limb. At presentation, we were concerned that he had a vascular injury as the toes were cold and discoloured. Ischaemic injuries to the distal pelvic limb can occur when vessels, such as the perforating metatarsal artery, are traumatised. Tissue viability can be difficult to predict when there is a significant amount of traumatic swelling and so, after discussion with the owners, we proceeded with stabilisation. After epidural analgesia, a type II tarsometatarsal external skeletal fixator (ESF) was applied with a type 1a ESF applied to metatarsal II, creating a rigid mechanical construct. Open wound management and laser therapy were utilised until it was clear that permanent ischaemic injury was continuing to ensue. This was a really disappointing result for the whole team who had completely fallen in love with Will. After discussion with the owner, Will was taken on by one of the nursing team at Vetspecs and planning for exoprosthetic artificial limb replacement was initiated. Whilst proximal limb amputation was an option, this has marked biomechanical disadvantages to the quadriped and involves removal of healthy components of a limb. We now have the technology Brent and Elena fitting the prosthetic device. Elena working with Will through his proprioception and stability exercises. The Vetspecs Team with Will and his prosthetic hind limb donated by Orthopets in Colorado.
Transcript
ISSUE 7 • May 2013
THE CONNECTIONSPECIALISTVeterinary Specialists
www.vetspecs.co.nz
Meet Will! Our first exoprosthetic limb patientBy Brent Higgins and Elena Saltis
Will is a ten year old working Collie who got his foot caught in a farm gate in September 2012. He presented to Vetspecs with an open and comminuted metatarsal II fracture and tarsometatarsal luxation of the left pelvic limb. At presentation, we were concerned that he had a vascular injury as the toes were cold and discoloured. Ischaemic injuries to the distal pelvic limb can occur when vessels, such as the perforating metatarsal artery, are traumatised. Tissue viability can be difficult to predict when there is a significant amount of traumatic swelling and so, after discussion with the owners, we proceeded with stabilisation. After epidural analgesia, a type II tarsometatarsal external skeletal fixator (ESF) was applied
with a type 1a ESF applied to metatarsal II, creating a rigid mechanical construct. Open wound management and laser therapy were utilised until it was clear that permanent ischaemic injury was continuing to ensue. This was a really disappointing result for the whole team who had completely fallen in love with Will. After discussion with the owner, Will was taken on by one of the nursing team at Vetspecs and planning for exoprosthetic artificial limb replacement was initiated. Whilst proximal limb amputation was an option, this has marked biomechanical disadvantages to the quadriped and involves removal of healthy components of a limb. We now have the technology
Brent and Elena fitting the prosthetic device.Elena working with Will through his proprioception and stability exercises.
The Vetspecs Team with Will and his prosthetic hind limb donated by Orthopets in Colorado.
2 ISSUE 7 • May 2013www.vetspecs.co.nz
to allow these patients to continue to use four limbs despite the loss of a foot or even feet! The foot was amputated at the most distal possible location, which in this case was at the level of the tarsometatarsal joint. The amputation was performed in such a way that ‘stump toleration’ to a subsequent exoprosthetic was optimised; this meant ensuring the suture line was on the surface with the least load-bearing responsibility. Physiotherapy to the stump included laser and deep tissue mobilisation. For the remaining proximal limb, the contralateral limb and the spine, physiotherapy included stretching and flexibility exercises and range of movement (ROM) manipulations.
Elena Saltis, Physiotherapist and Canine Rehabilitationist, and Dr Brent Higgins, Registered Specialist in Small Animal Surgery, have undergone overseas training in canine orthotic and prosthetic treatments. As a result, Vetspecs is now offering and performing exoprosthetic limb replacement for amputee patients. They are the only practitioners in New Zealand that are trained and skilled in prosthetic limbs using the world leader in this technology, US company Orthopets. Elena and Brent underwent their training in Australia and, since then, Elena has travelled to the Orthopet facility in Colorado to undergo further instruction. Elena constructed Will’s individualised fibreglass impression mould and documented all the necessary
measurements, along with videos and pictures of Will. This was sent to the factory in the USA for construction of a temporary custom-made prosthetic. After three months of use, Will’s initial prosthetic will be sent back to the USA for analysis and the permanent prosthetic limb will be made.
Current physiotherapy with Will has included: caveletti poles, balance discs, peanut ball, manual limb placement while walking, pelvic limb strengthening, stretching/flexibility, gait training, weight shifting, as well as manual therapy and laser. Will is currently loving his new limb and is running around the farm and playing with other dogs. His biomechanics have been terrific during this adaptation phase. He has not shown any discomfort with his limb and is back to working - his true love. Please check out Will’s music video showing his excellent limb function on the Vetspecs Facebook page and or at vetspecs.co.nz and drbrenthiggins.com.
For more information on the wonderful team at OrthoPets please see their website www.orthopets.com or email them at [email protected]
Will's stump.
Upcoming CPD Event's with Vetspecs
Vetspecs offers the following services:
May: Canterbury Cutting Edge Vets, Monday 27th
June: Journal Club, Friday 7th
July: Canterbury Cutting Edge Vets, Monday 22nd
August: Vetspecs Roadshow Christchurch, Thursday August 8th Greymouth, Friday August 9th Invercargill, Thursday August 22nd Queenstown, Friday August 23rd
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5ISSUE 7 • May 2013 www.vetspecs.co.nz
Ban the Surgical Scrub!By Brent Higgins and Kate Cambie
There is a revolution occurring in the aseptic preparation of our patients and the surgical team. For years we have been inadvertently increasing the bacterial load on our and our patient’s skin due to practices which cause micro-trauma to the epidermis. However, the current scourge of (nosocomial) hospital-acquired infections in human hospitals and the resultant morbidity and mortality that has ensued, has highlighted the need for more care to be given to our hands and the surgical preparation of our patients. The World Health Organisation currently recommends non-abrasive scrubbing practices. This article describes the theory behind this change in aseptic philosophy and how to bring those changes to your practice. In the 1800s an Austrian surgeon, Ignaz Semmelweis, noted an incredible reduction in mortality rate from puerperal fever after obstetrical procedures when his staff washed their hands with chlorinated lime based disinfectant. He proposed that puerperal fever was carried on the hands of hospital staff. This suggestion was treated with derision from his peers. How dare he suggest that the very people who were helping these mothers were the very ones who were causing their deaths. It was only after Louis Pasteur confirmed the germ theory and Joseph Lister started practicing aseptic techniques that this philosophy became accepted.
Unfortunately, this recognition was too late for Semmelweis who died at the young age of 47 after being committed to an asylum.
Yet, here in 2013, hospital staff in the veterinary and human setting still do not consistently wash their hands between patients and hospital-acquired infections flourish. Hands are the major source of patient contamination and preventing transfer of bacteria to patients is really easy. It simply involves washing our hands immediately before and after patient contact and immediately before and after a sterile procedure (like IV or urine catheter placement and contact with body fluid). The process is made easier by the use of alcohol-based gels distributed around important locations in the clinic. It involves a cultural change where all practice staff understand the importance of this policy. When hand washing policies are adhered to, nosocomial infection rates plummet and there are huge numbers of studies to support this in human literature. These gels can also be used for aseptic preparation of the surgeon. Although scrubbing with iodine or chlorhexidine does temporarily reduce the bacterial load on the hands, the bacterial load bounces back to a higher load than in unscrubbed hands because scrubbing creates microlacerations in the epithelium. Thus surgeons tend to carry higher than normal bacterial loads on their skin. The
current recommendation is that surgeons only wash their hands (with an antiseptic such as chlorhexidine) at the start of the day or if they have organic matter on their hands, and that they do not scrub using a brush at any time. We currently use Avagard gel from SVS, a alcohol and chlorhexidine based gel. There are plenty of studies showing that these gels enhance the efficacy of reducing bacterial load, enhance time efficiency and decrease costs compared to standard scrubbing practices.
In terms of patient preparation, it would seem intuitive that similar principles apply. Most human surgeons have made the change to a one-step alcohol based paint for their patients and there are two veterinary studies that have found
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7ISSUE 7 • May 2013 www.vetspecs.co.nz
STAFF PROFILE Libby Leader, Cert VNWhere did you complete your nursing studies?I graduated from CPIT in 2008 with a Certificate in Veterinary Nursing. My first job was in the cattery of a general veterinary practice. A few years later, I had worked my way up to be the clinic’s Surgical Co-Ordindator. My keen interest in surgery made the opportunity to become a surgcial nurse at Vetspecs an exciting step forward in my career.
What do you like about your job at Vetspecs?Being the latest edition to the nursing team, I am still learning so much on a daily basis. I am quickly making the adjustment from the routine of general practice to the somewhat unpredictable pace of a referral centre.
I am really enjoying the high standard of nursing that is required with every case that I am involved with.
Tell us a bit about your life outside the clinicI love movies and music. My latest project is learning and performing some Michael Jackson dance moves from his epic "Thriller" album as my girlfriend wants us to do it at her upcoming wedding reception! I have two members in my fur baby collection. They are two naughty kittens called Malkovich and Devlin. They are constantly getting up to mischief together.
Where was the last place you went on holiday?In September last year, my boyfriend
and I set sail on a cruise bound for the Pacific. The ship left Brisbane and sailed for a week stopping to visit two New Caledonian Islands and Vanuatu. We enjoyed swimming, sun bathing and a few cocktails! The first day on the ship was pretty hairy as we encounted some rough seas. Luckily my anti-nausea tablets worked a treat! The weather soon settled down and we had a wonderful holiday.
no difference in the infection rate and bacterial colony count with the same one-step paint system. Vetspecs is currently performing a comparative study of standard patient scrubbing versus this paint method in orthopaedic surgeries. The veterinary literature is incomplete on the use of this paint method for patient preparation so evidence to recommend a change to this type of patient preparation is still lacking. However, we have been using the one-step paint method for six months now and, anecdotally, have not seen an increase in infection rate. In fact, we are seeing fewer post-operative skin irritations. Hopefully our study will confirm our current feelings that ‘patient paint’ aids our patient preparation efficiency and lowers associated morbidity. Three ml and 35ml alcohol and chlorhexidine-based wands are available for purchase from SVS. We still use aqueous scrubs for feet and on areas that are visibly soiled. For demonstration videos on these new aseptic techniques please go to drbrenthiggins.com
Step One: Removing any loose hair from the clipped area.
Step Three: Using a ChloraPrep 3mL Chlorhexidine paint applicator to prepare an epidural site.
Step Two: Preparing the skin with an alcohol swab to remove dirt and grease.
Step Four: Using a SoluPrep 35mL Chlorhexidine paint applicator to prepare the surgical site.
Further reading:• Presurgicalhandasepsis:Concepts
and current habits of veterinary surgeons, Verwilghen and others, Veterinary Surgery, 40 (2011) 515-521
• Evaluationofaone-stepsurgical preparation technique in dogs, Rochat and others, JAVMA 203 (1993) 3, 392-395
ACROSS
4. New Zealand company celebrating its 25th year supplying the veterinary community. 5. A complication of using abrasive scrubbing practices on skin. 8. A common skin disinfectant. 9. What month is Vetspecs on tour this year? 10. Acronym used for technologies used to immobilise fracture fragments externally. 13. The new weight management diet from Hills (9, 4). 15. The invasion of patient tissues by disease-causing organisms. 18. The name of one of Libby’s naughty kittens. 19. The biggest source of hospital acquired infections. 20. Which month did Will present at Vetspecs? 21. What did Will catch his foot in? 23. NZ’s newest total hip replacement procedure.
DOWN
1. The technique used to prevent contamination during surgery. 2. He confirmed the germ theory (5, 7). 3. Where in the world is Orthopets? 6. Hospital-aquired.
Montreal Street
Moorhouse Ave
Hazeldean RoadAntigua Street
Disraeli Street
Crossword
Left to right: Helen Milner (Owner & Director), Brent Higgins, Aparna Tikekar, Becky Clarke, Lauren Keenan, Sonya Watts, Katie Cambie, Libby Leader, and Philippa Burns.
Vetspecs team
1
2 3 4
5 6
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8 9 10
11 12
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16 17 18
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23
7. The Austrian surgeon who instigated hand washing (5, 10). 11. A piece of exercise equipment used in Will’s physiotherapy treatments (6, 4). 12. 3M hand preparation product. 14. The most superficial layer of skin. 16. The American company that donated Will’s new leg. 17. A new technique used on patient skin to prepare the surgical site. 22. Acronym for the governing body who recommends non-abrasive scrubbing practices.
Go on, get
your entries in!
Fax, email or post your completed crossword to Vetspecs by 31st of May 2013. All correct entries go into the draw to win a $100 hamper, kindly supplied by SVS. Remember to include your name, clinic name and contact number so you can be notified. Winner will be drawn on Friday the 7th June 2013 and put on our facebook page.
