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How to anaesthetise a reindeer

I’ve written before about omnicompetency, but the word is mostly used in the sense of vets being able to work in mixed practice and tackle the veterinary care of horses, dogs, cats and farm animals in the same day – certainly, the first thing to come to mind would not be a reindeer.

However, on my recent equine placement, the staff were met with quite the challenge when a reindeer was referred in.

“Reindeer aren’t something you’d expect to see every day in practice,” says Jordan.

With a history of acute coughing/regurgitation, the reindeer in question had a suspected food impaction in the cranial oesophagus. Conscious radiographs and an ultrasound scan (he was a very well-behaved reindeer) confirmed suspicions of foodstuff, but it didn’t seem to be in the oesophagus.

Collaborative anaesthesia

The equine team – with help from one of the farm vets and some phone calls to other colleagues and practices that had dealt with reindeer before – came up with an anaesthetic protocol and proceeded to surgery.

The reindeer was induced with ketamine and xylazine before a gastroscope was used to try to visualise the larynx and trachea.

There appeared to be a diverticulum or outpouching from the oesophagus at the level of the larynx, which is where the food impaction had settled.

This discovery triggered a discussion as to whether our findings could be normal in some reindeer – similar to the Zenker’s diverticulum in people – since its appearance suggested a congenital, rather than acquired, defect.

A gastroscope was used to aid placement of an endotracheal tube and the reindeer was, subsequently, maintained under anaesthesia with isoflurane. He was positioned carefully in consideration of the rumen and ventilated throughout the procedure, which was to incise into the pouch using a lateral approach and remove the impacted food material.

Back to his reindeer games

He recovered well from the anaesthesia and was happily bounding around a paddock before long, eating some specially imported moss provided by his owner.

Reindeer aren’t something you’d expect to see every day in practice, but it was a great example of how veterinary knowledge can be adapted and applied to new situations, with the added benefit of working together with others with varying levels of experience to come up with a solution.

June 30, 2016
Standing surgery

On my latest EMS placement at an equine hospital, I’ve seen a number of surgeries – some done under general anaesthesia (GA) and others under standing sedation.

After getting over the fact a horse can stand half asleep while having its face drilled into and not really seem to care, I started wondering about the pros and cons of both approaches.

“Sinus surgery to remove a bony mass – that is me in the pink scrubs holding the head,” says Jordan.

Generally, standing sedation is accompanied by less haemorrhage and, therefore, increased visibility – in sinus surgery, for example. It also eliminates many risks associated with general anaesthesia. However, asepsis may be harder to maintain (for example, if the horse moves and the surgical site comes into contact with something that isn’t sterile, such as the stocks).

Lower costs

For the client, procedures conducted under standing sedation would be much cheaper than the costs incurred from general anaesthesia.

During general anaesthesia, atelectasis contributes to the risks from an intraoperative point of view, as well as myositis and cardiac concerns (of which the risk can be considerably reduced by the use of acepromazine in the premedication protocol).

A risk of injury also exists during recovery and knockdown, such as worsening incomplete fractures or other self-inflicted wounds, which can, to some degree, be prevented by carefully assisted knockdown and paying careful attention during recovery with the use of ropes.

Achieving optimal sedation for standing surgery can, in some cases, be difficult. For example, the horse must be adequately sedated, but not so much it is swaying; this can be an issue for intricate surgeries, but may be more of a problem for diagnostic imaging (such as MRI or bone scintigraphy).

In these cases, I have seen morphine used – opposed to the usual sedative culprits, such as detomidine, butorphanol and xylazine – and it seems to achieve sedation without so much swaying.

Choosing correct method

The choice of standing sedation versus GA depends on the type of surgery required, but a number of procedures can be done using either method.

Last week, I saw tie-back surgeries (prosthetic laryngoplasties to correct laryngeal hemiplegia) done both ways, which made for an interesting comparison. The standing tie-back was considerably quicker, taking into account the time for knockdown and recovery, as well as surgical time.

Both tie-backs were followed by a laser hobday procedure (ventriculoectomy), meaning both procedures were conducted under the same sedation in the standing horse, whereas the tie-back performed after GA had to be followed later the same day, after the horse had recovered sufficiently to undergo standing sedation for the laser.

The second tie-back was a repeat of a previously failed procedure, hence GA was chosen to allow removal of the first prosthesis.

The standing technique is still being tweaked, but, despite reports of postoperative infection in more cases than ideal, the easier access to the laryngeal cartilages while standing – and the avoidance of further risks associated with GA – contribute to continued work to perfect this method.

Some surgeries, however, can still only be done properly via GA. Colic surgery, for example, requires significant abdominal access and, often, examination of the gastrointestinal tract. It is also highly recommended septic joint surgery and lavage is conducted under GA to ensure optimal sterility on closure of the joint.

Conclusion

Having now seen both types of surgery in the horse, it’s astonishing how quick standing surgery can be, and how much goes into the preparation and recovery for GA – even for the shortest of procedures. In one surgery, division of the aryepiglottic fold, causing epiglottic entrapment, took a matter of minutes – if you didn’t count the couple of hours total taken for premedication, knockdown and recovery from GA.

The choice very much depends on the procedure, and is assessed for each case. I do, however, think the advantages to standing surgery are significant and look forward to seeing more standing techniques developed in the future.

June 13, 2016
The beginning of the end of vet school

Exams passed, Jordan can walk the halls of Glasgow’s small animal hospital without feeling like an imposter.

As regular readers of this blog may have noticed, I was a little apprehensive about starting my final year at veterinary school…

Having already been in the small animal hospital for two days, we finally received our results – confirming I and many of my fellow classmates had passed our exams and could now wear our final year jackets without guilt and walk around the hospital without feeling like imposters.

However, despite now knowing we had qualified to be in the hospital, it still felt like we had been thrown in the deep end.

In at the deep end

My first rotation was emergency and critical care, with the first part being internal medicine. The first couple of days were spent frantically researching the background of patients coming in for appointments, bumbling through clinical exams and brushing up on my rusty practical skills.

It was my first time taking consults alone and, after missing out key questions the first few times, I eventually got into the swing of things and made fewer mistakes.

Image: seregraff / Fotolia.

Despite feeling like I didn’t know anything to begin with, I at least managed to scrape together a few sensible ideas when clinicians tried to worm differentials out of us. It has been a steep learning curve, changing the way of thinking entirely to apply things to a real patient in front of you, which usually has not read the textbook.

OOH my goodness

Just as I was beginning to feel comfortable with medicine, we swapped to out of hours – which, against my presumptions, turned out to be a really enjoyable week.

I adjusted to nights far easier than I expected and was powering through until one particularly long night when a bulldog came in with a suspected gastric dilatation volvulus (GDV).

This was the first genuine emergency we’d been involved in and stress levels were running high. Having rapidly set up fluid boluses, taken radiographs to confirm our suspicions, checked lactate levels and run in-house bloods, we went through to theatre. After a very long night of surgery and having warned the owner of an extremely grave prognosis, we were delighted to see said bulldog looking bright and happy the following evening, eating and pulling us down the corridors to the runs outside.

Not all GDVs end with such a happy ending, as we had learned earlier in the week – a dog that underwent the surgery at its own vets came to us for overnight care in ICU and, after a rocky night of a supraventricular tachycardia that we struggled to keep under control, crashed the following morning, was resuscitated successfully once, but could not be saved when it crashed again minutes later.

Hearts, not brains

Coming from nights straight back into days, however, was much harder and I felt like a zombie for the first day of my cardiology week.

On the subsequent days, when my brain was working again, I was able to make a bit more sense of echocardiography and gain a better understanding of some conditions and the tray menu options available.

I also learned a bit more about the genetics of Bengal cats and found trying to heart scan a cat that’s only two generations away from a leopard cat can be quite challenging (and may involve chasing said cat around the ultrasound room for some time, following an artful escape act).

This year isn’t going to be a picnic, but, although I already feel exhausted, if last month is anything to go by, it will be an enjoyable one.

May 17, 2016
Behind the scenes at Fitzpatrick Referrals

Two years ago, I received an email to confirm an EMS placement at a certain well-known veterinary practice in the south of England.

Fitzpatrick Referrals: arguably one of the most recognisable practice premises in the UK. Image taken from the VBJ Practice Profile.

In my head, the placement remained far off until – three days after one set of exams ended and four weeks before another set – it seemed to sneak up on me far quicker than expected.

Brain slightly frazzled from exams, but orthopaedics (hopefully) fresh in my mind, I found myself pulling into the car park of Fitzpatrick Referrals.

Making sense of things

Being such a large and busy hospital, the first few days were a bit manic, with lots of new faces and protocols to get used to. To be honest, just finding my way back to the staff room was quite a challenge.

As my first time in a referral hospital, there were notable differences from first opinion practice, and the sheer number of surgeries the vets would get through in one day was impressive.

I was able to see a lot of surgery, which helped make sense of the numerous abbreviations our orthopaedic lectures presented, for both the conditions and procedures – an FCP corrected by PUO or the options of TPLO or TTA for CrCLR meant very little until I was able to see the procedures and understand a little more why they helped correct the particular conditions.

(If you’re still wondering: FCP = fractured coronoid process; PUO = proximal ulnar osteotomy; TPLO = tibial plateau levelling osteotomy; TTA = tibial tuberosity advancement; CrCLR = cranial cruciate ligament rupture).

Standard versus innovative

Noel Fitzpatrick: veterinary visionary? You be the judge.

The above are among many other “standard” referral procedures carried out at other referral orthopaedic hospitals throughout the country. There are, of course (as seen on television), other surgeries Noel carries out. Whether these are considered groundbreaking, experimental or too much is open to interpretation, but they are certainly unique to the “Supervet”.

Noel himself is clearly very passionate and believes wholeheartedly his innovations provide the best options in the world for his patients.

Many other vets would disagree. Many believe he goes too far; that the prolonged recovery and rehabilitation time for heroic procedures are not justified in patients that live in the moment and cannot perceive the future advantages temporary discomfort may bring.

Having been “behind the scenes”, I’m still not sure where I stand on these heroic procedures, but am certain the ethics must be considered on an individual case basis, as is done at Fitzpatrick’s – for example, limb-sparing surgery was decided against in a case of osteosarcoma in which survey chest radiographs showed metastasis.

Camera shy

Undoubtedly, Noel is an extremely clever bloke who has dedicated his life to providing animals with the best orthopaedic technology possible, but his methods will always remain controversial.

The placement was certainly a worthwhile and very different experience. The stationary cameras around the practice were easy to ignore, but observing a surgery that was being filmed, with the surgeon re-explaining the procedure for the third time at a different angle, not so much.

A very definite highlight was scrubbing into a TPLO and being handed the bone drill, to my utter terror and delight at the same time. I’m not sure the novelty of putting a screw into a dog’s leg will ever wear off.

May 16, 2016
An irrational fear of the final year

Having averaged four hours’ sleep a night for a couple of weeks, I came out of fourth year exams alive… just.

Poster image created online with the Keep Calm-o-Matic.

Sleeping pattern ruined, and a number of family and friends to see in quick succession (seeing as the next time I’ll be “home home” will be in five months or so), the four-day “summer holiday” we were given was anything but restful.

Midway through a week of induction lectures and “how to cope with real life” talks, the prospect of final year rotations beginning in five days’ time is becoming very real.

However, I think the induction week has had the opposite of the desired effect and, subsequently, I am anticipating my first week in the hospital with utter terror.

Panic mode

In theory, we should have the knowledge base to cope with whatever they throw at us in final year. However, in my panic-stricken state, I can only imagine drawing a blank at the first case I’m given and already feel sick at the thought of looking like the idiot I’m almost certain I am.

I feel under-prepared and tired from the last few weeks, not to mention the fact I don’t know if I’ve passed the exams and deserve to be in the hospital in the first place.

Several family members have asked me if it feels like my time at vet school has gone quickly, to which I can only answer “yes and no” – on one hand, it feels like I’ve always been at vet school; on the other, final year has sprung suddenly out of nowhere.

Time flies

Sound familiar?

More relaxed times seem a long way off, such as soaking up the German sun at a yearling auction, or paddling waist-deep through a swamp to care for a puma. Even scrubbing into orthopaedic surgery a month ago seems much more distant. Time flies when you’re having fun… or are kept stupendously busy by the various aspects of vet school.

While this transition feels tough, I’m sure tougher ones are ahead (such as this time next year, when we’re all about to enter the real world of work), but I’ll worry about those closer to the time.

I can only hope students in the year above (those finishing final year), who claim they felt the same way when starting rotations, were speaking the truth and, somehow, as unlikely as it seems right now, we’ll come out the other side as qualified, competent vets.

The question now is whether to spend the next few days – between the remaining induction lectures – catching up on sleep or frantically trying to relearn everything I’m supposed to already know…

May 4, 2016
Omnicompetence – maybe not so foolish?

The first of April brought with it the usual abundance of amusing online articles, tweets and blogs, only claiming credibility until midday – and the veterinary community was no exception.

Sun Life’s “courtesy pet” joke didn’t have vet student Jordan fooled for a minute.

Some April Fools were obvious hoaxes – such as Sun Life’s courtesy pet scheme, offering owners a replacement pet in place of their beloved while away at the vets – while others were a little harder to interpret, such as BEVA’s announcement of a privately funded equine vet degree – or maybe that’s because I was still half asleep and it was the first one I’d seen before realising the date.

Food for thought

Although it was cleared up at midday that BEVA president Mark Bowen was not due to become dean of the first UK equine-only vet school and that the nine traditional degrees would remain the only ones available, it did provoke some thought about whether it would be such a bad idea after all.

While plans for a traditional five-year omnicompetence approach, followed by a further three years of equine-only study, seemed a little far-fetched (fourth year has nearly finished me off – I certainly don’t think I’d hack eight years at vet school), many veterinary schools around the world use a condensed version of this model.

For example, Utrecht University in the Netherlands follows the format of a three-year bachelor’s degree for all species, followed by a three-year master’s degree aimed solely at one species/area (with the exception of 20 weeks). The University of Leige in Belgium compromises in that the fifth year is spent rotating through clinics for all species and half of the final (sixth) year is spent in one area in particular, with a choice of small animal, farm or equine.

Omnicompetence or specialisation?

The question of omnicompetence or specialisation is highly debatable and seems to go around in circles in the UK. Earlier career specialisation would be favoured by some who know, undoubtedly, they never want to see a cat, dog or rabbit again after vet school – likewise for those who shudder at the thought of an emergency caesarean and an angry farmer.

Early specialisation as an equine vet could mean you’ll never find yourself taking a blood sample from a lion. Image courtesy Shamwari Conservation Experience.

But what about those like me, who, after a considerable amount of vet school already under his or her belt and a variety of EMS placements (good and bad), when posed with the question “what sort of practice do you want to go into?” still can’t come up with anything more eloquent than: “Umm… mixed?”

The advantage of omnicompetence is that, in theory, graduates should leave vet school equipped with the knowledge and skills to address most cases in general practice in any field/species, deal with emergencies and know who or where to refer a patient to if the case is beyond his or her abilities.

Early specialisation could change this to the extent an equine or farm graduate asked “can you just look at my dog” may end up looking a bit silly.

Everything changes

Circumstances also change and accidents do happen. A vet may end up sustaining an injury while working with horses or livestock that could prevent him or her from doing so in the future, so a species-specific degree could force him or her to leave clinical practice altogether.

Similarly to the “new vet schools” debate, it is feared introducing species-specific degrees may reduce job availability for graduates who have taken the traditional educational pathway, making the equine sector, in particular, even more “elitist”. Ultimately, this could potentially drive the profession away from the concept of mixed practice altogether.

Master of one?

More like our medical counterparts, we could lose our “Jack of all trades” status and end up being highly specialised instead, which does, of course, have its advantages, but leaves those of us who want a bit of variety and flexibility in the dark.

For me, omnicompetence is definitely the right starting point for a veterinary degree, but I know others have very different opinions. I did, however, enjoy the brief social media debate before a communal sigh of relief.

My personal favourite April Fool this year, however, was the University of Glasgow’s announcement the university tower would be reopening as a public helter-skelter (see video below) – and I’m still disappointed it isn’t true.

April 20, 2016
Sheep worrying at lambing
Easter brings not only the endorphin rush associated with an abundance of chocolate eggs (perhaps more so for those of us who gave up goodies for Lent), but also the picturesque seasonal backdrop of spring lambs merrily bouncing about.

An abundance of public footpaths allow the wanderer to happily stroll through the British countryside. Image: antbphotos / Fotolia.

If only the reality was so idyllic…

Unfortunately, the lambing season brings with it a growing number of reports of sheep worrying and, even more concerning, reported dog attacks on young lambs.

Right of way

We are lucky to live in a community where many public footpaths allow the wanderer to happily stroll through the British countryside. However, most of these footpaths cross private land, the owners of which have very little choice in their presence and, at best, can apply for them to be moved, but not closed off completely.

The consequence of this is that, short of double fencing or restricting which parts of land are usable, farmers may be forced to keep livestock in fields that aren’t just accessible by the public, but actually form public rights of way.

There are many downsides for the landowner, but most prominently at this time of year is the susceptibility of young lambs to uncontrolled dogs.

It’s a distressing reality there are owners out there who would allow their animals to attack livestock, or lack the good sense to recognise they cannot exercise enough control over their animal to prevent something like that happening.

Keeping it legal

The results of a particularly nasty dog attack on one of my family’s sheep.

The Countryside and Right of Way Act states the public may only exercise their right to access open land if they keep dogs on a fixed lead of two metres or less near livestock.

Under the Dogs (Protection of Livestock) Act 1953, the owner of a dog worrying livestock is guilty of an offence. More recently, livestock are also covered by the Dangerous Dogs Act (1991), under which, if the dog attacks another animal, the owner can be given an unlimited fine, or sent to prison for six months. The owner may also be banned from owning dogs in the future and could be ordered to have the dog destroyed.

While there are laws supposedly protecting livestock, the reality is very difficult to police, unless the farmer catches the guilty dog or has CCTV. A farmer is also within his/her rights to shoot a dog that attacks livestock on their land.

Attacks, while the most instantaneous causes of devastation, are not the only problem. Sheep worrying earlier in gestation can also cause abortion, ultimately at a loss to the farmer.

Encouraging responsibility

Raising awareness within the veterinary and farming community would be preaching to the choir, but is there more we can do, as a profession, to encourage dog owners to take responsibility? Be that keeping their dogs on a lead, obedience training or simply avoiding sheep fields at particular times of year – perhaps it is up to small animal clinicians to lead the way on this one.

Posters in practices reminding owners of the repercussions of their actions could be enough, or even an off-hand remark to an owner about being careful walking through the fields at this time of year.

References
March 30, 2016
RCVS VN council election manifesto: Wendy Nevins RVN

WENDY NEVINS RVN

Operations manager, The Webinar Vet

T: 07809 702074

E: wendy@wendynevins.com

Wendy began her VN career in 1991 as a trainee at a small animal practice in Surrey. On qualifying, she moved to Yorkshire and started work in mixed practice, and after becoming head nurse, left to relocate to Germany with her forces husband.

Back in the UK in 2000, Wendy moved to Devon and spent two years at a two-branch, small animal practice as a nurse, VN assessor and eventually, practice manager.

Moving to the north-west in 2002, she worked as a nurse in a small animal practice before becoming the Veterinary Nursing Approved Centre coordinator at Myerscough College. After four years there, she returned to practice part-time, where she started working for Anthony Chadwick at his Skin Vet practice. During this time, Anthony launched The Webinar Vet, and, once established, sold up. Wendy stayed behind as operations manager and is often known as “Webinar Wendy”.

In her role, Wendy organises CPD for vets, nurses and SQPs. She also deals with dermatology referral clients and spends at least one day a month working in practice.

Why is she standing?

Wendy says she is “extremely proud” to be a veterinary nurse and wants to take an “active part” in ensuring the profession moves forward.

“I feel I have gained valuable experience throughout my different career roles, which will benefit the role requirements of an elected member and our cause as a whole,” she said. “I have a very good understanding of the varying levels of our profession and I am in a privileged position of having contact with members daily, ranging from students to the most experienced VNs.”

On education, Wendy says she feels “passionately”, and has a “wide exposure”, thanks to her time at Myerscough and The Webinar Vet.

“I believe I will also add value… establishing and reviewing schemes for post-qualification and CPD for VNs. This also includes recommending to the council amendments to the rules relating to the registration, conduct and discipline of veterinary nurses, if required. I am widely accessible to nurses due to my current role, so I can offer effective communication between VNs and the council. On future challenges and issues? You tell me. I aim to be an effective voice for the nurse in practice – an effective voice for you.”

Hustings highlights

Wendy tackled lack of VN engagement in the RCVS in her passionate video, citing poor voting turnout figures and calling the electorate to action. “I want to help increase engagement, hopefully by… carrying on communicating with nurses via social media and within my role at The Webinar Vet,” she said. “Voting in an election is important.

Can you get other VNs to vote? Do you know nurses who don’t vote? If everyone who votes gets one more VN voting, we can increase that [2015 turnout] 11 per cent to 20 per cent.

“It would be great if you voted for me to represent you on VN council, but more importantly though – please, please vote.”

March 24, 2016
RCVS VN council election manifesto: Helen Tottey RVN

HELEN TOTTEY RVN

Trainer at Onswitch; project manager at Mojo Consultancy

T: 07885 408811

E: helentottey@blueyonder.co.uk

Helen has had a varied career. Qualifying in 1996, she started in general nursing before concentrating on consulting. In 2004, she left practice to work for Petplan, but quickly realised she missed practice life.

Returning in 2007, Helen opened her own practice, employing the vet, finding the premises and having them fitted out. In 2013, she sold it, recognising its growth required more than a sole VN.

Helen now works for Onswitch as one of the trainers on its Bertha Bus, and is a project manager at Mojo undertaking various veterinary projects including working alongside International Cat Care.

Why is she standing?

Helen says she will “fight for VNs to have their voice heard” if she is elected.

“I am proud to call myself an RVN and be part of a dedicated, caring and hardworking profession,” she said. “I am passionate about getting our profession heard.”

This passion is evident when you see how Helen has been promoting the VN title petition. She has written to her MP, generated an article in her local newspaper and even contacted the Chris Evans breakfast show on BBC Radio 2 on the eve of BVNA Congress for the past two years – “VNs would have heard their profession mentioned in the ‘representing the nation’ section,” she said.

Helen believes her daily contact with vet professionals of all kinds is a strength. “Working as a trainer and PR, I meet many VNs, student VNs, vets and receptionists, which keeps me in touch with the issues in our profession,” she said.

Attempting to protect the title is “only the beginning of a great VN future”, says Helen, which should open up more opportunities for VNs and lead to the profession “gaining the recognition we deserve”.

Hustings highlights

Helen thinks Defra’s promise to review Schedule 3, and the possibility of having a tiered system where VNs undertake post-registration qualifications, could be a good thing for career engagement.

“As we qualify, our skills develop from our day one skills and our interests grow, with some VNs preferring more clinical roles in practice and surgery, and others preferring more client contact. Until you’ve experienced that, you don’t know where you want your career to take you,” she said. “By including post-registration qualifications, maybe this would help career development, VNs feeling they had a career and that it was worth staying in the veterinary profession.

“I know this is a main area for why people leave the profession, so I think it is good we work on career development,” she said.

March 24, 2016
RCVS VN council election manifesto: Matthew Rendle RVN

MATTHEW RENDLE RVN

Senior clinical VN, London Zoo

T: 07947 812630

E: matthew.rendle@zsl.org

Matthew’s VN career kicked off in 1989 at The Park Veterinary Centre in Watford, a busy mixed and exotics 13-vet practice. It was here he completed his training and here in 1994 where he became senior theatre nurse.

Leaving in 2003, Matthew headed to the Zoological Society of London (ZSL) to pursue his interest in zoo and wildlife nursing, where he remains.

Matthew is a regular lecturer to veterinary nursing and veterinary surgeon undergraduates at the RVC, and lectures on herpetology throughout Europe and America.

Why is he standing?

Matthew says he has “dedicated his life” to being a VN for 25 years, and has observed “many changes” that have taken place during this time.

“Our role and the general understanding of it has improved significantly within my time in the profession and it continues to,” he said. “I am passionate about veterinary nursing and consider myself very lucky to work at ZSL. With my experience and background, I am in a fortunate position to help educate and support the next generation of VNs.”

Matthew said it would be a “great honour” to be elected to council, as will be having the opportunity to represent UK VNs and “contribute to the advancement of our profession”.

“I would relish the opportunity to promote the vital role of the RVN,” he said.

Hustings highlights

In Matthew’s video, he said he feels there needs to be a “greater understanding” of the roles of a modern VN and, while these roles are “misunderstood” by the public, VNs are “too keen to blame this on everybody else”.

“I think a lot of it is our own fault,” he said. “We need to raise our profile and demonstrate professionalism wherever possible, and during my time on council I would really like to push forward on that.”

As a male VN, he would also like to work on diversity within the profession. “I’ve been a VN for more than 25 years now,” he said. “I’ve always really enjoyed it, and haven’t felt at any point that being male has held me back in any way, but again I think this comes down to public perception of what VNs are.”

March 24, 2016