staging.vettimes.com

Tag: Emergency and Critical Care

  • Don’t rush: a systematic approach to x-rays

    Don’t rush: a systematic approach to x-rays

    One of my responsibilities in our emergency hospital is the training and mentoring of vets new to the field of emergency and critical care.

    First look
    FIRST LOOK: The patient was bitten by another dog and presented with multiple puncture wounds and difficulty breathing. Radiographs were taken to assess for thoracic injuries (click to zoom).

    A common area I have found where clinicians request more training is radiographic interpretation.

    When I review radiographs and find pathology that was missed, it Is more often due to a lack of systematic approach to reviewing the radiograph than the clinician’s lack of experience or knowledge.

    There is, of course, no one set way you should go about interpreting a radiograph – but whatever the method, the entire radiograph should be assessed, not just the area of interest.

    Radiograph tips

    1. Try not to struggle with your patient. If possible, appropriately sedate your patient (or anaesthetise if safe to do so). This reduces stress for everyone involved and improves your chance of getting a good radiograph. For musculoskeletal radiographs, you often need to manipulate painful joints and limbs to get diagnostic images.
    2. Take appropriate views. For example, I aim to get three plane projections for thorax and abdominal radiographs – i.e. left and right laterals and VD (or DV). Three views are critical for the assessment of both lung fields, and also to help interpret abdominal gas patterns more effectively.
    3. Collimate, rotate, crop, label and adjust the image appropriately. Displaying radiographs in a standardised format is important for proper assessment. Reviewing anatomy in the same way each time helps develop an understanding of what is normal, and makes identifying abnormalities easier.
    4. This is my top rule: At first, IGNORE the area you are interested in. This means, if you are interested in looking at the GI tract in a vomiting dog, try not to focus – albeit initially – on the stomach and intestines on your radiograph.
    5. Start at the periphery. This means things like the spine, subcutaneous tissue, etc – you would be surprised how often lesions are missed in these areas.
    6. reveal
      SECOND LOOK: This fracture was missed on initial review of the radiographs (click to reveal).

      Now take a look at the cavity space (the pleural and abdominal space, for example). You should not be able to see the pleural space, and you should see no evidence of air or fluid in the abdominal space. When it comes to musculoskeletal radiographs, don’t forget to consider joint cavities and soft tissue structures such as ligaments and tendons.

    7. Lastly, make sure you assess every organ (again leaving your organ of interest until last). Things often overlooked include the prostate, kidneys and mediastinal region. At the end of this, I always ask myself, have I missed an organ?

    Tunnel vision

    Another thing I like to do sometimes is take a step back and assess the radiograph again. I find this gives a better global view of the projection, as opposed to staring at it closely.

    This is because when we focus on our area of interest, we start developing the habit of tunnel vision, introducing the potential for missing lesions.

  • Ionised hypocalcaemia, pt 4: controversies and prognostic indications

    Ionised hypocalcaemia, pt 4: controversies and prognostic indications

    Ionised hypocalcaemia (iHCa) is a well-known electrolyte abnormality in critical human patients, which is also beginning to be recognised in our critical feline and canine patients.

    The exact mechanism for the development of iHCa is still unknown – making prevention difficult, if at all possible. Controversy also exists as to whether treating iHCa is of any benefit, especially in non-clinical cases.

    Despite these issues, serum concentration is proving to be an accurate prognostic indicator for the morbidity and mortality rates of some of the more critical patients.

    Research

    Over the past 30 years, significant resources have been put into trying to demystify the pathophysiological causes of iHCa in critically ill people; however, the exact mechanisms are still to be determined.

    Some proposed mechanisms include:

    • abnormal parathyroid hormone secretion or function
    • abnormal vitamin D synthesis or function
    • hypomagnesaemia
    • calcium chelation
    • alkalaemia
    • calcium sequestration in tissue or cells
    • an increase in calcitonin precursors (procalcitonin)

    In a canine study where endotoxaemia was induced, it was found hypovitaminosis D was associated with iHCa (Holowaychuk et al, 2012).

    Veterinary studies

    The true incidence of iHCa in critically ill canine and feline patients is yet to come to a consensus, due to the limited veterinary studies.

    In one retrospective study, 90% of 55 cats with septic peritonitis was reported to have iHCa (Kellett-Gregory et al, 2010), while only 24% of septic dogs (n=58) was reported to have iHCa (Luschini et al, 2010).

    Regardless of the true incidence, the commonness of this change questions whether a need exists to treat iHCa, especially cases in the mild or non-clinical categories.

    No consensus

    At this stage, no consensus exists to either support or prohibit the treatment of hypocalcaemia in critically ill patients.

    Well-designed prospective studies are scarce in human literature and non-existent in the veterinary field; no evidence-based guidelines are available for treatment.

    Based on logic, arguments for the administration of calcium to critically ill patients include:

    • iHCa during hospitalisation is a negative predictor for morbidity and mortality of patients.
    • Hypocalcaemia can cause decreased myocardial contractility.
    • In hypotensive patients dependent on vasopressors or inotropic agents, the supplementation of calcium may be beneficial.

    Arguments against calcium supplementation include:

    • Calcium accumulation within cells predisposes to hypoxia and ischaemia-reperfusion injury.
    • Increased mortality in experimental models of sepsis when calcium is supplemented, on top of the lack of evidence to support this act.

    Prognostic use

    Serum calcium concentrations – or, rather, the trend of it in hospital – appears to be of valuable prognostic indicators.

    Kellett-Gregory et al (2010) found although no direct associations existed between the presence or severity of iHCa at the time of patient admission, a positive correlation existed between the lowest iCa post-hospitalisation, and the length of hospitalisation and duration of intensive care stay.

    Of the cats that had iHCa, those that failed to return to a normal ionised calcium (iCa) during hospitalisation had a significantly lower rate of survival to discharge. Interestingly, iHCa was not associated with the status of hypotension, coagulopathy or arrhythmias, so cannot be used to predict the occurrence of these.

    These findings were echoed by Luschini et al (2010), where low mean ionised calcium and lowest documented ionised calcium concentrations were found to be associated with a poor outcome. The severity and duration of iHCa appears to be important in determining prognosis in these patients.

    Conclusion

    Controversy exists regarding whether treatment of mild iHCa in critically ill patients is recommended; however, one thing we now know is serum iCa concentration is a reliable predictor of mortality and morbidity in canine and feline patients.

    References

  • Life after vet school – graduation: where do I go from here?

    Life after vet school – graduation: where do I go from here?

    Nothing hits you quite as hard as reality, as you walk out of your final fifth year veterinary exam.

    Up until this very moment, your life has followed a structured timetable, carefully planned by the veterinary school. Now, with it all finished, who is there to lead you from here onwards? This is probably the most daunting question every final year vet student faces. University lecturers can only help you get so far, then you’re on your own.

    Forging your own path

    For those of us who are lucky enough to know exactly what they want in life, the path is quite clear. As the saying goes, “where there is a will, there is a way” – and it doesn’t get more true than that, for the rest the path is unclear, and there is uncertainty and doubt.

    In this post I share my thoughts about the three main options that for new graduates: general practice, rotation internships and emergency internships.

    General practice

    • Great at putting the last five or six years of learning into perspective, it will solidify what you have learned.
    • After one to two years you will have something to fall back on if you decide to try something else later.
    • You will have primary case control this will allow you to develop and fine tune your communication, medical and surgical skills.
    • The more remote the general practice, the likelihood you will be required to perform more advanced or complex diagnostic, medical and surgical procedures increases; therefore, the learning curve will be steeper.

    Generally, this is a good place to start, especially if you are uncertain as to what direction you want to head in. I started here. My only caveat is that you select a practice you feel best suits you and offers the best environment for learning.

    Rotating internships at specialist hospitals/referral centres

    Gerardo Poli during his graduation.
    Gerardo Poli during his graduation.

    Some new graduates go straight into rotating internships because of the opportunity to see a variety of cases and also because they wish to proceed down the pathway to specialisation.

    • Generally limited primary case responsibility as you will be following and assisting a specialist or registrar.
    • Offers the best exposure and foot in the door for a career as a specialist.
    • Exposure to a wide variety of complicated cases.
    • Opportunity to be involved in and possibly perform complex diagnostic, medical and surgical procedures.
    • Build connections and network within the specialist or referral community.
    • Most only last one year before a new pool of interns come through.

    If you have experienced general practice and you know it is not for you then a rotating internship at a specialist referral hospital will allow you to get a taste of what is available.

    Emergency internships

    I do not generally recommend emergency internships to new graduates, despite the fact I have developed training programs to assist in the transition into emergency and critical care. There are large emergency practices part of a specialist referral centres and small centres running within a general practice hospital, but not all emergency hospitals offer internships.

    Before deciding, here is what you need to know:

    • It has t best opportunity for a softer entry into an emergency career.
    • Generally prior experience is recommended as it can be a very steep learning curve.
    • The abnormal hours can be isolating socially and adjusting sleeping patterns can be difficult.
    • Most emergency internships are designed to retain interns not rotate them through, such as they “train to keep”.
    • You will get primary case control and exposure to more critically ill patients.
    • Depending on the type of practice and the arrangement you may get to perform more complex diagnostic, medical and surgical procedures as opposed to referring them to the associated specialist service.

    If you are looking at a career in emergency I would recommend a larger hospital where multiple vets are on at the same time and you have the support you need.

    Regardless of where you find yourself, the most important thing to realise is you have to start somewhere. Decide and take action. If you find yourself doing something you don’t like then you have learned what you don’t want to do. That is a valuable learning experience in itself. There are many ways to a destination, and no experience, whether it is good or bad, it is never wasted. Even in the darkest of days, remember, with every closed door, if you are looking another will open. Best of luck with all your future endeavours.

  • The beginning of the end of vet school

    The beginning of the end of vet school

    Hospital
    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.

    cat scratch quote
    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.

  • RCVS VN council election manifesto: Racheal Marshall RVN

    RCVS VN council election manifesto: Racheal Marshall RVN

    RACHEAL MARSHALL RVN

    Rachael Marshall RVN.

    Head of clinical nursing, Vets Now

    T: 07860 924759

    E: racheal.marshall@vets-now.com

    Racheal qualified as a VN in 2003 and worked in a busy mixed practice for three years, progressing to a senior nurse position.

    After that, she worked as a lecturer in veterinary nursing and animal management at York’s Askham Bryan College. She returned to clinical work in 2008, joining emergency and critical care specialists Vets Now, where she has been ever since.

    At Vets Now, she started as an RVN in one of the clinics before becoming a senior nurse. She then became a district manager before taking up her current position in 2014. As head of clinical nursing, Racheal is responsible for driving and ensuring consistent nursing standards across the company.

    Why is she standing?

    Despite veterinary nursing coming a “long way” in the 12 years since Racheal qualified, the emergency and critical care specialist believes there are still “battles to be fought” to ensure the RVN is “fully recognised and appreciated”.

    “I wish to use this opportunity to work for greater understanding and clarity of the VN role to allow our wide range of skills and experience to be recognised and valued,” she said. “[I also want to] help empower nurses with career progression so they can reach their full potential working alongside vets.”

    Racheal believes her working background has given her a lot of experience in practice and leadership, giving her good understanding of the inner workings of business, which helps her “understand the challenges we face and be able to consider these from all angles”.

    “Veterinary nurses are a valued and essential part of the veterinary team, and to enable our profession to continue to grow and evolve, we need to ensure we speak out and continue to be heard,” she said.

    “I would consider it an honour and a privilege to be your voice on VN council and will work to ensure the voices of all RVNs
    are heard – whatever career stage you are at or pathway you have taken.”

    Hustings highlights

    Racheal discussed issues of retention of VNs within practice in her video.

    “This year almost 500 nurses have been removed from the register, and this is at a time when employers are struggling to recruit RVNs,” she said. “My aim would be every veterinary practice only employed RVNs, but if we haven’t got the number of nurses out there, this isn’t going to be possible.”

    She said she also feels veterinary nurses have the right to undertake additional skills post-qualifying as “we’ve all worked hard to achieve our qualifications and should be able to use all of the skills and knowledge we have to be able to work to our full potential”.

  • RCVS council election manifesto: Amanda Boag

    RCVS council election manifesto: Amanda Boag

    AMANDA BOAG

    Amanda Boag.MA, VetMB, DipECVECC, DipACVECC, DipACVIM, FHEA, MRCVS

    Mid Jawcraig Farm, Falkirk FK1 3AL.

    T 01324 851381

    M 07790 030068

    E amanda.boag@vets-now.com

    PROPOSERS: Daniel Brockman, Julian Wells

    After postgraduate clinical training in the UK and the US, I spent my early career working in academia as a lecturer in emergency and critical care (ECC) at the RVC.

    Since 2008, I have been clinical director of Vets Now where, along with time on the clinic floor, I am responsible for the clinical and professional standards across 53 sites, as well as being fully involved with the structure and running of a veterinary business.

    I am founding president of the European College of ECC and am proud to have played an important role in the development of ECC as a career path and specialism in the UK. I have lectured widely throughout the UK and internationally, and hope any of you I have met have found me to be both practical and pragmatic about the realities of clinical veterinary practice.

    I am involved with a number of veterinary organisations, including being a trustee of the British College of Veterinary Specialists, providing clinical support for Pet Blood Bank and chairing the recently formed Major Employers Group.

    I have been an elected member of RCVS council since 2012 and have served on several committees, including the education committee and the operational board, having been treasurer since 2014.

    Manifesto

    The veterinary profession is one I am very proud to be a part of. In the 18 years I have been qualified, there have been many changes to our profession – some driven by us, others where we reflect changes in society. As an RCVS council member, I will continue to work hard to ensure our profession increasingly shapes its future and projects a confident role in the society it serves.

    Since I was elected four years ago, the RCVS has undergone many changes. If re-elected, over the next four years, I will work to ensure the positive developments in governance and communication continue. The RCVS must also continue to build strong and constructive relationships with other veterinary organisations.

    I was privileged to have been involved with the Vet Futures report and believe it articulates clearly the challenges, but also the opportunities, facing us over the coming years. We must now translate that into practical actions and be open to workable, innovative, solutions in areas such as omnicompetence, protection of work-life balance, telemedicine and regulation of professionals in an increasingly commercial world. As a college that regulates, the RCVS is a unique organisation and it is essential it plays its part, working alongside the other major veterinary organisations, in ensuring our profession remains vibrant and independent into the future.

    With my diverse background in both the academic and commercial worlds, the perspective that comes with working closely with hundreds of different first-opinion practices, and my experience across several organisations, including the RCVS, I believe I am well placed to continue to play an important and active role on RCVS council. Moreover I care deeply about our profession and will continue to bring a modern and common sense approach to protecting its future.