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  • ‘Perfect Pals’ calendar competition

    ‘Perfect Pals’ calendar competition

    COMPETITION CLOSED FOR ENTRIES

     

    Many thanks to those who entered our 2022 calendar competition and sent photos of their “Perfect Pals”.

    The competition is now closed, and our judges are working their way through hundreds of wonderful pictures to create a shortlist of entries, which will be published in the October issue of VN Times, with readers voting online for their favourite image.

    VOTING STARTS SOON!

     

     

  • Making sense of effusions (part 1): is your patient septic?

    Making sense of effusions (part 1): is your patient septic?

    Interpreting effusion samples can be confusing, so try to think of effusions as if you were collecting a blood sample.

    Septic effusion
    Septic effusion.

    Many of the in-clinic diagnostic tests that apply to blood samples also apply to effusions, such as:

    • PCV/total protein
    • smears
    • glucose
    • lactate
    • potassium
    • creatinine
    • bilirubin

    It’s not enough to only check the protein concentration of the effusion then classify it as either a transudate, modified transudate or exudate and leave it at that – there is more information left to extract from that sample.

    Challenging diagnosis

    Determining if an effusion is septic can be a challenge. Here are the steps I take.

    analysis
    Abdominal and peripheral blood gas analysis.
    1. Perform a cytological examination of your effusion in the smear and look for inflammatory cells and the presence of bacteria. Look inside the cells as well as outside. If you don’t see bacteria it does not mean it isn’t a septic effusion, and only a couple bacteria are needed for me to call it septic.
    2. Glucose and lactate: You need to compare the glucose levels in the effusion with blood glucose levels. If the effusion glucose level is less than serum glucose, it is more likely you have a septic exudate. This makes sense in that bacteria would metabolise glucose in the effusion, leading to lower glucose levels. A by-product of metabolism is, of course, lactate. Therefore, you next need to check the lactate levels in the effusion and compare it to the serum lactate level. If lactate level in the effusion is more than the serum lactate level, then again you have more evidence you are dealing with a septic exudate.

    Try to measure glucose and lactate from both blood and effusion samples at the same time on the same machine. Keep in mind glucose and lactate values are less accurate for monitoring for the presence of bacteria in post-surgical patients.

  • Isoflurane and oxygen: the dangers of 2 and 2

    Isoflurane and oxygen: the dangers of 2 and 2

    It is a common practice to place all patients on 2% isoflurane and 2l/min oxygen flow rate, but blanket isoflurane saturations and oxygen flow rates can be dangerous.

    2 and 2
    Take time to consider your anaesthetic approach.

    Without a doubt, the majority of patients seem to do just fine at these levels; but every patient is different, and simply placing all patients on 2% isoflurane and 2l/min oxygen may be introducing an easily avoidable risk into anaesthesias.

    Isoflurane

    Isoflurane can cause severe effects such as hypotension and respiratory depression, so 2% isoflurane may be too high – especially for patients that are critically ill or have been premedicated with sedatives/anxiolytics.

    In these patients, the isoflurane can be safely titrated down while monitoring the patient’s reflexes and vitals. Consider administering IV pain relief instead of turning up the isoflurane levels if the patients are too “light” and responding to pain. Examples include a low dose pure-opioid.

    It is important to titrate its use like any other anaesthetic agent, maintaining an appropriate level of anaesthesia while minimising potential side effects.

    Oxygen

    It is common to use a standard 2l/min oxygen flow for all anaesthetics regardless of the type circuit, but this will not meet the oxygen requirements for larger patients. It is best practice to work out the appropriate flow rate amount using an oxygen consumption chart.

    I cannot stress enough the importance of taking the time to consider your anaesthetic approach in patients, especially compromised ones such as those with renal/hepatic disease or circulatory deficits.

    Titrating anaesthetic agent levels can increase the stability of your patient under anaesthesia and significantly reduce the life-threatening complications.

  • Online learning vs the university experience

    Online learning vs the university experience

    With education secretary Gavin Williamson recently coming forward to suggest that universities should reduce their fees if they choose not to return to face-to-face teaching, the question is being asked once again if online teaching can really hold its own against the real thing?

    Loneliness

    One of the main trials of the vet course has always been its difficulty. It’s hard, both academically and at times emotionally (and, when you’re called upon to tip a sheep, sometimes physically), there’s no getting away from that.

    Online learning doesn’t reduce the course’s difficulty, but it does have the potential to exacerbate it, especially for those with attention deficit disorders who benefit from a more tangible learning environment.

    The online platform is also unable to replicate that feeling of camaraderie you get from the live experience. If you can see your coursemates struggling on a particular topic you are also struggling with, then at least you’re reminded that you’re all in the same boat; but when you’re struggling to comprehend a lecture in your room by yourself – day in, day out – it can be easy to feel that maybe you’re the only one having trouble, and that you’re falling behind the rest of the herd.

    The little things

    All vet students and new grads will still remember the horrors of 9am lectures. Let’s be honest, nobody actively looked forward to them – especially, I’m sure, my fellow Bristol students, for whom struggling your way up one of the many formidable hills in gale force winds and torrential rain was a rite of passage.

    Saying that, you always end up missing what you don’t have, and while a classroom of shivering 20-somethings with 150 coats attempting to dry on the one single lecture hall radiator may not sound like the epitome of a good time, it’s just one of the little things that builds a person’s university experience.

    There will be highs and lows, good days and bad days that all make up the tapestry of academic life. While some may prefer to listen to recorded lectures in bed, I think being given the choice is inherently necessary.

    Isolation

    There are also an often-unheard body of students, for whom those lectures represented the only opportunity to interact with people and have space to learn. Sadly, not everyone at university has a living situation that supports their learning, whether it’s a disruptive home life, unreliable Wi-Fi, or any other number of things.

    I don’t think this is something that universities fully take into account, and I feel especially sorry for international students paying incredibly high fees while entirely unable to explore their new surroundings or get the experience they were advertised. For those who study far from their homes and families, online learning has the potential to be incredibly isolating. I know my own mental health has certainly suffered as a result, and I’m sure I’m not alone.

    Screens, screens, screens

    When I was little, my mother used to tell me that if I stared at a screen for too long my eyes would turn square, and although I’ve since dismissed it as a method to get me to tidy my room instead of watching Power Rangers, I now fear it may be true…

    I know that may sound a little “six of one, half a dozen of the other” seeing that in-person lectures use projectors and laptops as well, but I truly believe online learning massively ramps up your screen time. Even in 3-hour long lecture blocks, we would still be given short breaks between lecturers, you’d turn to talk to your friends and maybe focus more on the lecturer than the words on the slides.

    When your only way to learn is via your laptop, and your only way to recharge after those lectures is also your laptop (Netflix, Facebook, Twitter, Instagram, and so on), you could easily pull a nine-hour shift sharing predominantly at a screen. Excessive screentime has been linked to postural-injuries, back and neck pain, negative impacts on sleep and emotional states, eye strain and migraines.

    Imperfect fit

    Obviously, everyone’s experience of the past two years has been unique and, as such, I’ve found that my fellow students tend to have mixed opinions of online teaching platforms or “blended learning” (when the majority of your work is done online, but augmented with a smattering of in-person teaching, perhaps once a month).

    Some of my cohort really enjoy having all of our lectures at the touch of a button, while others have struggled with the lack of contact with their peers and mustering daily motivation.

    Personally, I can see both sides of the coin, but I think it needs to be accepted that while there are merits to both the new and old system, the two are simply not comparable – and like every teaching system, neither are a perfect fit for every student.

  • Pulse oximetry is great, but know its limitations

    Pulse oximetry is great, but know its limitations

    Pulse oximetry is a very useful diagnostic and monitoring tool that has become commonplace in veterinary clinics. It measures the percentage of haemoglobin saturated with oxygen, and is an indirect measure of arterial oxygen levels.

    pulse ox
    Dog with pulse oximetry.

    However, here are several important points to help you understand the limitations of pulse oximetry.

    Causes for false readings

    Falsely low readings:

    • motion artefact
    • peripheral vasoconstriction/low tissue perfusion from hypothermia or shock
    • pigmentation of mucous membranes
    • thick hair coat

    Falsely high readings:

    • haemoglobin abnormalities (carboxyhaemoglobin and methaemoglobin, for example)

    False sense of security

    Pulse oximetry can give us a false sense of security. We hold on to the adage “95% and above means everything is going along swimmingly”, but that couldn’t be further from the truth:

    Dog with pulse oximetry
    Pulse oximetry can give us a false sense of security.
    • It does not detect hypoventilation or apnoea: it can take several minutes for apnoea to result in hypoxaemia that is detected on pulse oximetry; therefore, it cannot be used as a sole measure of respiratory adequacy. This is best measured by capnography.
    • A common misconception is the oxygen saturation will drop with patients with anaemia. This is incorrect. The haemoglobin present in the decreased number of red blood cells will still be saturated to normal levels. However, this cannot be interpreted as the patient having adequate oxygen delivery to its tissues.
    • One last point: due to the oxyhaemoglobin dissociation curve, any drop below 94-95% is significant and warrants investigation. At 95% SpO2 the partial pressure of oxygen in the arterial blood is 80mmHg (normal), but at 90% SpO2 the partial pressure is 60mmHg (severe hypoxaemia) – for only a small percentage decrease, there is an exponential reduction in arterial oxygen content. This is even more important when patients are receiving oxygen therapy as the patient’s SpO2 should be 99-100% normally. So when a patient has an SpO2 of 95%, but is on high rates of oxygen, then significant respiratory compromise/disease must be present for an SpO2 of 95% or lower to occur.
  • The pen is mightier than the scalpel

    The pen is mightier than the scalpel

    For some, my past A-level choices of biology, chemistry and English literature may seem an odd mixture.

    At first glance, the arts and the sciences don’t seem go hand in hand, and are often viewed as polar opposites. I even remember being asked during one of my veterinary interviews if my decision to study English lit was an indication that I valued the arts above the sciences…

    As someone who had endured a considerable wealth of hours endeavouring to make it into vet school (and was, in fact, at an interview for vet school), it took me a couple of blinks before I could bring myself to answer that question.

    Words, words, words

    Since then, I am still yet to find another vet student or graduated vet who took English as their third A-level choice – perhaps because, until recently, most vet schools wouldn’t accept anything other than physics, maths or maybe economics at a push.

    With three years of the vet course down, and a master’s dissertation currently weighing on my shoulders, this truly baffles me, given that writing is such an inherent part of the scientific process.

    Whether it’s animal welfare, physiology, psychology or behaviour, almost everything we know and practice today can be attributed to some budding young scientist who did the research, wrote it up very eloquently, and had other scientists read over it diligently before they decided to write about it, too (otherwise known as a peer review).

    Similar principles

    Today, it does not matter how big of a breakthrough you make; if your grammar isn’t on point, nobody is going to publish it and your discovery may well fall on deaf ears. If you don’t know at least five different words for “furthermore” and can’t tell your colons from your semi-colons then are you even a scientist?

    I have personally always loved writing (couldn’t you tell?) and being able to combine my affinities for that with veterinary medicine sometimes feels a bit too good to be true.

    I also feel incredibly grateful for the skills my background in English have taught me. I may no longer be comparing the works of Mary Shelley and Thomas Hardy, but strangely, the same principles can be applied to literature reviews and grant proposals.

    Do what you love

    I would strongly encourage any wannabe vets not to shy away from exploring interests outside of the sciences, if that’s what you really enjoy.

    For me, an artier A-level was a really useful way to switch off the science part of my brain and recharge after a day of balancing equations – almost like my right and left brain taking turns at the wheel while the other had a little lie down.

    And who knows, if more medical schools required an A at English A-level, doctors might be know for better handwriting.

     

  • Hot dogs belong on a barbecue, not in the car

    Hot dogs belong on a barbecue, not in the car

    We’ve all heard horror stories of dogs left in hot cars by their owners; it’s an issue that comes around every year like the warnings of dangers of chocolate at Easter and mistletoe in December.

    Luckily, I’ve never seen a case brought into practice or even witnessed a dog shut into a car on a hot day – until this week.

    While shopping, I noticed a small Westie lying rather forlornly in the back of a parked car. The windows were cracked and it was a cloudy day, so the owners had obviously assumed popping into the shop for however long they’d intended would do their animal no harm. Not surprisingly, I was immediately concerned.

    Getting hotter

    Despite the clouds it was a hot day and muggy – and as it was only 11 in the morning, the temperature was only going to rise. No water had been left for the dog (either out of laziness or for fear that it would be knocked over), and although I could tell he was alert, he moved from seat to seat, clearly agitated and anxious.

    I’d hope the average passer-by would intercede, but being a veterinary student with all the worst-case scenarios scarred permanently into my brain, I didn’t feel right leaving it.

    The situation didn’t seem urgent enough to warrant bashing the windows in – especially as I had no idea if the owner was just around the corner. Instead, I checked with the shop the car park belonged to, and although it didn’t have a tannoy system they thanked me, took down the registration number of the car in question and promised to watch diligently until the owner returned.

    Legislation lacking

    Since then I have been brushing up the laws in the UK regarding leaving animals in cars, and although it is not illegal to leave a dog in a car (regardless of the temperature, or the windows being rolled up or down), the owner may be prosecuted if anything happens to the animal in that car.

    Given the number of dogs that die in hot cars, or shortly after being left in one every year, I think that this legislation needs to be reviewed. If you wouldn’t leave a child in a car unattended, why leave an animal that is arguably even more vulnerable?

    What to do?

    For anyone who finds themselves in the position I was – and there’s nobody around to help, the animal seems distressed or in danger, or you simply don’t know what to do – please know you are absolutely within your rights to call 999 and contact the emergency services. The best case scenario will be that the animal is absolutely fine and no intervention is needed – the worst case scenario is far, far worse.

    Try to check how long the car has been there by looking for parking tickets. If you’re unsure whether a dog is suffering within a hot car, look for signs of heatstroke/hyperthermia such as heavy panting or drooling, lethargy, collapse or vomiting.

    More advice can be found on the RSPCA or PDSA websites, and if in doubt, the RSPCA hotline (0300 1234 999) is available for advice.

  • Blood smears – make them a routine test

    Blood smears – make them a routine test

    Blood smear evaluation is an often overlooked, but very important, aspect of an in-house haematology.

    With the advancement in haematology analysers that can now detect reticulocytes and even band neutrophils, some practitioners are beginning to rely solely on the numerical data alone in evaluating the patient’s blood.

    Leukaemia
    Patient with elevated white blood cells caused by leukaemia (click to zoom).

    The art of blood smear interpretation is on the decline. However, it is an extremely valuable skill that must be practised and perfected and really should be part of every in-house haematology.

    Plus points

    What are the benefits of being good at blood smears?

    • Identifying a regenerative response, looking for reticulocytes (polychromatophils).
    • Looking for other possible causes of an anaemia – such as Heinz bodies, infectious microorganisms or spherocytes, which can indicate an immune-mediated haemolytic anaemia.
    • Confirming thrombocytopenias, as frequently platelet clumping can be reported as a thrombocytopenia.
    • Assessment of the nature of a leukocytosis. High leukocyte counts do not always mean infection. Neutrophilia can be caused by both elevated immature and mature neutrophils. Determining the nature of neutrophilia can provide crucial information in identifying the underlying cause and if the patient is coping or not. Apart from infection, other causes can include stress, corticosteroids and neoplastic leukaemias.
    • Normal leukocyte counts do not always mean the patient is okay. Patients can have severe left shifts, but normal leukocyte counts.

    Practice makes perfect

    Blood smear evaluation begins with becoming accomplished at producing great diagnostic smears. This takes practice; poorly performed smears can be non-diagnostic and frustrating to assess for both yourself and an external pathologist.

    A few tips on the technique:

    • Use a very small drop of blood. If you have picked up too much blood with the “spreader” slide, lift off and start the smear away from that drop of blood.
    • Angle the “spreader” slide about 30°. The bigger the angle, the shorter your smear.
    • Push the “spreader” slide forward.
    • The smear should end at about half to three-quarters of the way down the slide and must have a “feathered edge”.
  • Anaesthetic risks: when complacency sets in

    Anaesthetic risks: when complacency sets in

    Adverse events during anaesthesia in otherwise young and healthy patients is a rare occurrence. However, with low incidence of adverse events could come an increased risk of complacency on the part of the veterinary team.

    Take the following case as an example:

    Clicky
    Clicky the cat with Gerardo and his team.

    “Clicky” is a young and healthy cat that underwent a routine dental prophylaxis procedure. A few days after the procedure, she developed respiratory difficulties and presented to our emergency clinic.

    Possible problems

    She was diagnosed as having severe subcutaneous emphysema, most likely from a tracheal wall compromise that would have occurred as an adverse event from tracheal intubation.

    We need to handle cats very gently while they are intubated as their tracheas are nowhere near as robust as their canine counterparts.

    Overinflating the cuff is another cause of tracheal necrosis.

    Never be complacent

    What we think happened was the patient was repositioned during the dental procedure and the endotracheal tube was twisted in the process, causing either ischaemic compromise to a portion of the trachea or direct damage to the trachea.

    Thankfully, “Clicky” made a full recovery, but this case certainly highlights that we must never be complacent when it comes to handling our anesthesia cases.

    Low incidence does not mean no incidence, and individualised anaesthetic plans – along with in-depth training for the anaesthetist (who most often are veterinary technicians and nurses) – will help reduce the chances of adverse events occurring.

    Clicky's x-ray
    Clicky’s x-ray
  • Dr Google can be your friend

    Dr Google can be your friend

    doctor-google-2Technology has changed how we practice veterinary medicine. Gone are the days of the paternalistic relationship between vet and client, where the client will simply go along with whatever the vet deems necessary for the pet.

    Clients are becoming more knowledgeable and, as vets, we’re often faced with a situation where a client comes in armed with a “Dr Google” diagnosis.

    As practitioners, this can be challenging and confronting – maybe because our egos tell us it is an insult to our hard-earned years of training and experience. If this is the case, I think our perspective needs to change.

    Changing perspectives

    Working in an emergency clinic, we regularly talk to clients with questions about something they have read on the internet. I confess I used to feel threatened by this. However, I wasn’t comfortable feeling this way, so I decided to change my perspective on the matter.

    Dr Google
    Is it time to call a truce with Dr Google?

    Here are some ways to turn the old nemesis, Dr Google, into a friend – or, at the very least, call a truce:

    • Make it a point to acknowledge your clients for their initiative and interest in their pet’s health. You are not simply paying lip service, here – the reason these clients have searched for information about their pet’s health is because they care.
    • These clients are generally dedicated to their pet’s health and welfare; they are the ones who are often committed to doing what needs to be done, as long as they understand why and how – and that’s where you come in. Client education is a big part of our jobs.
    • They are pre-armed with knowledge, therefore saving time in the consult room, so you can spend less time describing what the adrenal glands do, for example, and more about why and how they can malfunction.
    • If what they have read is inaccurate, take the opportunity to gain rapport by giving them the correct information or directing them to reputable sites, such as VeterinaryPartner.com – this demonstrates to clients you are still the most reliable source for information about their pet’s health.

    Genuine concern

    Due to the ubiquity of information (and misinformation) about veterinary medicine available on the internet, there is an even stronger reason for us, as vets, to keep up with the latest advancements in veterinary medicine.

    Always try to remember, ultimately, the reason your clients have come to see you having already done some research on the internet is because they are genuinely concerned about their pet – so try to see this as something positive, rather than negative.

    By changing your perspective, you’ll soon find you no longer dread a consult with clients who have brought Dr Google along.