Arrythmias

This past week in surgery we had a patient that had an arrhythmia under anesthetic.  Although it is not our job as RVTs to diagnose the arrhythmia, it is important that we are aware of what an abnormal ECG looks like in order to be able to notify the DVM.

Remembering back to Anatomy and Physiology, this what one single heartbeat looks like on an ECG:

From: https://commons.wikimedia.org/wiki/File:SinusRhythmLabels.svg

A p-wave is followed by a q-r-s complex and a t-wave.  The size of the waves and the distance between them may vary from patient to patient, but they should not vary from one beat to the next in any patient.


If that is a normal complex, then, a normal ECG looks like this:

From https://commons.wikimedia.org/wiki/File:Normal_Sinus_Rhythm_Unlabeled.jpg

Note that the rhythm is regular: the distance between each of the p-waves is the same.  On an abnormal ECG, the rhythm will be irregular: the beats will not all be the same distance from one another.  Now you must determine if the the rhythm is regularly irregular or irregularly irregular.  Huh?  Let's look at that a bit more closely.

Regularly irregular means that there is a pattern to the irregularity.  For instance, two beats are the same distance apart, but then the third one is spaced further.  Then that pattern repeats: short, short, long, short, short, long.  

Sinus arrhythmia (the heartbeat speeds up during inspiration) is a form of a regularly irregular heartbeat.  Despite the fact that this is an arrhythmia, remember that it can be normal in dogs (but not cats!)

Irregularly irregular is when there is no pattern to the irregularity.  This may show as differences in distance between waves, missing waves or 'extra' waves.  Premature Ventricular Contractions (PVCs) are an example of an irregularly irregular rhythm.  (Note that the UPenn website in the two previous links is an excellent resource for small animal cardiology.)

Since in practice we don't always have patients attached to an ECG for routine procedures, how will you know if they have an arrhythmia?  When you auscultate the heart, it is important to not only count the rate, but note if the rate is regular.  If it is irregular, determine if the irregularity is regular or irregular.  While auscultating, watch the patient breathe.  Does the rate change with inspiration?  Palpate the pulse while auscultating; is there a pulse for each heartbeat?  With practice, you will be able to hear irregularities while listening to the Doppler as well.  If you are hearing dropped/missing beats, the irregularity of rhythm is not associated with respiration, or you are not feeling a pulse with each heart beat, get that patient hooked up to an ECG!

So, what types of arrhythmia are you most likely to see?  This article outlines the five most common arrythmias seen in dogs and cats.  Out of those five, from my experience, sinus arrhythmia, premature beats and atrioventricular (AV) block are those that are most commonly seen in general practice.  You will note in the article that the captions of the AV block and premature beats state that the arrhythmia was auscultated: your ears are often the best tool for recognizing a problem!  It is so important that we take the time to listen, not just count a quick heart beat, especially prior to an anesthetic.  It takes less than 5 minutes to get a patient hooked up to an ECG and get a reading and it is definitely worth the time.  Even if it is normal, the more you see, the easier it is to recognize an abnormal tracing.

Integrity

Integrity: according to the Cambridge Dictionary, it is the quality of being honest and having strong moral principles.  It is one of the values that I hold highest in my life, so much so that I will tell a cashier that they have given me too much change.  Charles Marshall said: "Integrity is doing the right thing when you don’t have to—when no one else is looking or will ever know—when there will be no congratulations or recognition for having done so."  He goes on to talk about having integrity even if it means losing a job, money, a friend, or, I would add, a grade.  I think that integrity is important in any profession, but especially in one where life and death are involved.

Building a reputation of honesty and integrity can take years, but can be wiped out with one bad choice or decision.  Making that bad choice early on in a relationship, and you may never recover.  Veterinary medicine is a small world and word gets passed around.

So, what difference does it make if I am honest, even if no one is watching?  For me, I couldn't live with the feeling of being dishonest.  But if you think that some things are no big deal, think about this: you can't be dishonest in one place and honest everywhere else.  A lie inevitably needs another to cover it up.  And getting away with one lie makes it a lot easier to be dishonest in other, possibly more consequential ways.

I have had instances where a student cheats on an exam, and I am sure on some level they are saying to themselves "What difference does it make?  It's just an exam, not real life; who will know?"  Well, first of all, you will know.  But secondly, if you cheat on an exam, how can you be trusted to not 'cheat' elsewhere.  If your DVM asks you to give a treatment, but you don't know how to do it, will you say so, and risk feeling humbled?  Or will you go ahead, not really knowing what to do, risking the patient's health or life?  If you are asked to perform a task that you know as an RVT you are not permitted to do, will you risk losing your job by saying no?  Or will you go against legislation, bylaws and codes of ethics and perform the task?  If your boss asks you to log a drug that you know was not used for a patient, will you do so?  What if you give the wrong drug or the wrong dose, but no one saw.  Will you admit it so that steps can be taken to mitigate the damage?  Or will you just hope like heck that the patient is okay, or that someone else gets blamed?  These are all situations that can (and have) come up for RVTs.  Integrity says that you do what is right, no matter what the cost.  Will you do it? As this article says "Success will come and go, but integrity is forever". 

Client Education

Client education is one of the most important parts of an RVTs job and yet many of us don't spend the time to do it well.  We want to work with the animals, not the people!  But always remember that any pet that you are working with has a human attached.  We do a great job taking care of the pet while they are in hospital, but we also have a responsibility to ensure that we educate the associated family members on how to continue that care at home.

After any surgery or hospital stay, there will be aftercare involved.  Whether there is a wound to care for, medications to give, or exercise restrictions, it is essential that the client be taught how to properly perform these tasks.  Book an RVT appointment to ensure that you have time to go over everything without rushing.  This can be done at the time of morning drop off, or when you call to give an update.  Take the client into an exam room, without the pet present, so that there are no distractions.  Do not try to give homecare instructions in the reception area!


Where possible the RVT who worked with the patient should be the one to go over homecare.  Introduce yourself by name, as the RVT who took care of Fluffy.  I always try to make a personal comment about the pet such as "she has been a very good patient" or "I love the little spots on her nose".  This can help establish a connection with the client and builds trust: Fluffy is not just another dog to you.

Be sure to go over every aspect of the patient's care with the client and have written instructions that they can take home.  Use plain English: just because you understand medical terminology, doesn't mean that the client does.  Speak slowly and clearly and be aware if there are any communication barriers.  For instance, is English a second language?  Does the client have hearing challenges?  Knowing of these in advance will allow you to take steps to ensure that the communication is received.

Go over each of the medications that you are sending home.  What is the reason for each one?  Do they need to finish all the medication or do they give only if needed?  Describe any side effects that they may see with each medication.  Under what circumstances should they discontinue use and call the office?  How many tablets should be given each dose and how often should they be given?  Be specific with instructions: remember that clients do not know what BID means and some may not understand that "twice a day" means every 12 hours.

If the pet has an incision or wound, describe how the client should care for it.  Does it need to be cleaned daily?  If an Elizabethan collar is to be worn, explain why it is important, as well as if it can be removed at any time.  Offer alternatives to the collar if possible as some pets won't tolerate them.  Describe signs of infection: "you may notice some swelling and minor discharge initially, but if it increases, is accompanied by heat, or it concerns you in any way, call our office".  When should the pet be rechecked?  When are the sutures to be removed?  Are there exercise restrictions?  "No running or jumping until the sutures are removed.  Five minute, leashed walks only for the first 3 days.  Increase to 10 minute walks on day 4 and 5; 20 minutes thereafter until the sutures are removed."

Dietary needs should be outlined for the client.  Explain that the pet may not want to eat right away after an anesthetic.  If they are fed, they should be given only one-half of a normal meal to reduce the chance of vomiting.  Is there a specific food that should be fed after the pet's hospitalization?  How much and how often should they be fed?  When should the client start re-introducing the pet's regular food and how gradually should they do so?  Again, be very specific with instructions: feed every 8 hours for the first two days and give 1/4 of the regular food with 3/4 of the prescription food.  On days 3 and 4 feed every 12 hours and give 1/2 of regular with 1/2 of prescription, etc.

Keep in mind that having a pet hospitalized is a stressful time for clients; they may be feeling overwhelmed and not able to take in everything that you are saying.  Having written instructions, as mentioned, is essential.  Be sure to ask if they have any questions, but recognize that they may not think of them until they get home.  Let them know the office hours and tell them to call if they have any concerns.  Tell them they can ask for you directly.

Providing clear homecare instructions gives your patients the best chance at a full and quick recovery.  It also ensures that your client knows that you care about their pet, almost as much as they do.  There is no greater feeling than having a patient come back in for a recheck after a hospital stay with a happy wag or a purr, knowing that you helped make that happen!

This is a great article on post-op care.
This article offers practical tips for communication and client education.
This AVMA webpage is a great source of client education articles and dvm360.com has many client handouts and patient care form resources.
Also from dvm360.com, the top 10 favorite veterinary handouts of 2016. (Not specifically homecare instructions)

Euthanasia

Euthanasia: it is a difficult topic for many new RVTs.  We get into this business to save animals.  I was very idealistic when I first graduated and thought that every patient should be saved no matter what.  Over the years, experience with clients, patients and even my own pets has given me perspective and insight.  I now think that humane euthanasia is a wonderful gift that we can give to our patients when we can’t control their pain or disease process to the point that they can no longer do the things they enjoy.

Any time a pet is diagnosed with a chronic disease, a decision must be made by the caregiver on whether to treat the disease or not.  As RVTs, although we would like to, we cannot make that decision for the client.  And often, we don’t like or agree with the decision that they do make.  It is important to remember that being an advocate for our patients does not include making judgements on how their caregivers choose to care for them.  Remember that we do not know what else the client has going on in their life and those details will influence their decision.

By Uwe Gille (Own work) [GFDL or CC BY-SA 3.0], via Wikimedia Commons

I believe that clients should be given as much information as possible to make their decision.  This article includes a list of questions that clients commonly ask when their pet is diagnosed with a chronic disease (of course, this conversation is likely to be between the DVM and the client, but sometimes clients find RVTs easier to ask questions of.  Be certain that you don’t discuss prognosis; this is the DVMs responsibility).  As you can see from the list, there are many things that clients must think about, including the time commitment they will have to make for treatments.  Care of a pet should never be a burden on a client; this can lead to resentment of the pet and that is not fair to them.  If a client is not willing to commit to treatment required, then it may be best to simply keep the pet comfortable for as long as possible.

Another article on the topic also discusses the many things that clients must think about when making the decision on how to treat their pet with a chronic disease.  These decisions go much deeper than finances, including the client’s current own mental and emotional health, if they are currently caring for other family members, and whether the pet will even tolerate treatments.  If it is going to be a battle to give the medications needed, it can be detrimental to the loving bond between pet and owner.  Surely not the best way to spend the dusk of a pet’s life.  

By Sgt. 1st Class Walter Van Ochten [Public domain], via Wikimedia Commons

This article demonstrates that the choice of treating a pet is very individual; not only the person, but the pet.  The decision one makes for Fluffy may be very different than the decision the same person makes for a different pet at a different time.  Some pets are stoic and do well when having to be in hospital for a time.  Others are terrified to even leave an exam room without their owner.  Perhaps finances have changed, the client is in a different place emotionally or they now have an aging parent to care for.  Remember that for every pet that you are caring for “in the back” there is a person connected for them “up front”.  We must absolutely be a voice for our patients but we must never forget that their family has to make the decision based on what is best for them and their pet at the time.

I think as RVTs, our most important role in decisions of euthanasia is to be real when speaking to clients.  That doesn’t mean necessarily telling them what we think is the right thing to do.  It means supporting the DVM in giving the client the information they need.   And then supporting the client in whatever decision that they make.  They know their pet best and they will make the most loving decision they are capable of at the time.   

Radiographic Positioning

I found this article on Radiographic Positioning and it highlights some interesting regulatory differences between the US and Canada.  For instance, the article states that the US Nuclear Regulatory Commission has whole-body dose limits of 5 rem per year for occupational personnel, however Health Canada limits radiation doses to personnel to a much lower 20 mSv (In Canada, the Sievert (Sv) has replaced the REM (rem) as the unit of dose equivalent.  One rem equals 10 mSv).

Permissible Dose Equivalent Limits of X-Radiation to Operators and Other Occupationally Exposed Personnel
Annual permissible dose equivalent limits
Applicable body organ or tissue	Radiation workers	Other workers and members of the public
Whole body	20 mSv	1 mSv
Lens of the eye	150 mSv	15 mSv
Skin	500 mSv	50 mSv
Hands	500 mSv	50 mSv
All other organs	500 mSv	50 mSv

Table from Health Canada Safety Code

As mentioned in the article and as discussed in class we should always use the principle of ALARA when taking radiographs.  Increasing our distance from the primary beam, decreasing our exposure time, using positioning aids and using a properly developed technique chart can all help decrease the amount of radiation we are exposed to.  Clearly, wearing personal protective equipment will also reduce our exposure and I was surprised that according to the article, PPE is only suggested in the US!  The lead equivalent in the US (0.25mm minimum in most states) is also less than that required here (0.5mm minimum at 150kVp).  PPE should be handled and stored correctly, and I recommend checking the wear of your PPE every 6 months, rather than yearly.  You should check it sooner if the integrity is in question (for instance if someone left a gown folded rather than hung up).  Any piece should be replaced if more than 10% of the protective surface is damaged.

More information on radiation safety can be found in the WorkSafeBC Guidelines Part 7 Division 3

The positioning tutorial in the article is very good, although some of the photos are not ideal.  There are a few places where the positions deviate from what we discuss in lab, which I will review here.

The lateral views of the scapula that they discuss are somewhat different from how we demonstrate them.  Their second view is the superimposed view we perform but they do not consider the view where the scapula is dorsally displaced, which is the only exposure that allows an unobstructed view of the entire bone structure.  Assuming that the position does not cause the patient pain, it is the first choice of lateral views.  Note that in the image of the caudocranial view of the scapula, the caudal portion is cut off, even though the text correctly states to include the entire bone.

In its conclusion, the statement is made that first and foremost we should do what is best for the patient.  I think that you should first ensure that you and the rest of the staff are protected, then do what is right for your patient.  Of course, the two often go hand in hand.  A perfect example was this week: a struggling, stressed patient made it impossible to get good images.  To continue would have further stressed the patient and put you at more exposure to radiation.  As RVTs, we must advocate for our patient and ourselves.  We discussed the risks with the DVM and made a plan to defer the radiographs until we could sedate the patient.  This decreased the patient (and our) stress, allows for better images and avoids retakes.

Registered Veterinary Technologists

I am a Registered Veterinary Technologist (RVT).  Many of you have likely not heard this title, much less know what one does.  Maybe you may have heard the terms vet tech or simply tech, when you have had your dog or cat into the veterinary clinic for vaccines or a check up.  I think it's important that we call ourselves by our full title.  Registered Veterinary Technologist.  It lets the public know that I have a credential, a protected occupational title.  I went to school for two years (there are now some Bachelor programs in the US).  I had to pass the Veterinary Technician National Examination in order to be registered with my provincial and national associations.  I have bylaws and a code of ethics.  I induce and monitor anesthesia, I collect and run lab samples such as blood and urine, I take x-rays and ensure that staff are safe when doing so, I place intravenous catheters, I perform dental cleanings, I provide nursing care, I am a gentle touch when my patient is scared, I am the voice for those who can't speak for themselves.  I am a Registered Veterinary Technologists.  It is not just what I do, it is who I am.

I am not the only person who has said these things.  In fact, if you ask any RVT, they are likely to give you the same, or a similar, answer. We are passionate about what we do.  But it is a sad fact that the lifespan of an RVT is about 5 years.  It is at that point in their career when the lack of pay, the lack of utilization and the lack of respect start to take their toll.  Now let's be honest, no one gets into the field thinking they are going to get rich. But when you can't simply make ends meet on what you are paid, it is time to start re-evaluating.  Part of the issue of low pay is that in many states and provinces, there is no requirement for credentialing.  A veterinarian can hire anyone off the street, pay them minimum wage, and train them to perform the tasks that RVTs went to school to learn.  Of course, these OTJs ("On-the-job trained) don't have the knowledge behind what they are doing, as one DVM states in this article.  And therein lies the problem.  Knowing how to do something, but not why you are doing it, or how to troubleshoot if something goes wrong, is dangerous in my opinion.  And that brings us back to the lack of respect and utilization.

If a veterinarian can hire anyone to do my job, who is going to respect my credential?  If you don't need it to do the job, what does it even mean to have it?  Look, we went to school for two years to learn how to care for our patients.  So when we aren't permitted to use our skills, or someone else can do a task in place of us, it eats away at us.  Sometimes it is an issue of control (the vet can't give up placing their own catheters or inducing anesthesia themselves), but often one of economics.  And yet, as this article states, a 2010 study demonstrated that for each "credentialed technician" per DVM, the veterinarian's gross income increased by over $93 000!  Surely that is enough to pay a fair wage.

So, what can pet owners do?  Ask if your veterinary clinic or hospital has Registered Veterinary Technologists on staff.  If they don't, find out who is doing all the technical tasks.  If a high school student was administering medication to your child in a hospital would you be okay with it?  If not, is it okay for your furry family member?

Here are a few related links and blog posts that you might find interesting.

Four reasons why RVTs leave the field
What keeps RVTs in the field
Vet Tech Problems Twitter Account
Reasons why Vet Nurses are Essential

A Dog's Purpose?

This morning on the way to the Y to swim, I heard of a controversy about a new movie coming out called "A Dog's Purpose".  I had seen the trailers for the movie and had already told my partner we had to go see it.  She is the movie buff, not me, and it is rare for me to say that, so I was looking forward to it.  The premise is that a boy has a dog, grows up with the dog, the dog dies.  The dog is then reincarnated over and over until he is eventually reunited with his owner, now an old man.  To me, this dog was the man's "forever dog": that one dog that gets in your heart and never leaves.  I had such a dog; he was my angel and saved my life on more than one occasion.  I went through a severe depression and quite possibly would have suicided, but for Oreo.  Who would have taken care of him?  Oh yes, he saved me.  So when I saw the trailers, I knew that I would have to go see it.

The controversy?  A video of the filming of a scene in which the dog is to be in a fast-moving river.  Apparently the dog is terrified to go into the water; the trainer is wrestling with him to get in.  When they eventually get the dog into the water (by throwing him?  I don't know), they have to cut the scene because the dog becomes submerged.  They are on a set and can stop the rapids to get the dog to safety, but he shouldn't have been put in danger in the first place.  I won't watch the video; I can't.  I was going to put a link to the news story in this post, but when I googled it, I saw a still image and couldn't go any further.  And I don't want to.  It would make me angry and sick at the same time.  I would feel the dog's terror, not just be a witness to it.  Just hearing about it reminded me of when I was a young child, around 12, and I saw video of a seal hunt.  I remember seeing the club being brought down on that defenseless creature and I actually screamed "No!" at the TV.  I think it is the breaking of trust that hits me hardest.  Not that the seal trusted humans the way a dog would, but it likely had no reason to (or understanding that it should) fear humans.  And dogs DO trust us.  If a human performer said "I don't feel safe; I am too tired to safely do this scene" we would trust that the performer knew his limits and we would listen.  Dog's senses are way more in tune than ours; this poor dog was saying "something is not right" and the person he trusted didn't listen. 

I am sure that the fact that I am emotional and tend to 'put myself in their shoes' is what makes me a good Vet Tech.  If a patient is 'misbehaving' when we are trying to complete a procedure, I try to see what it is that they are reacting to.  We can't explain what we need to do in words so every single step is a surprise to them if they have never had it done before.  Are we making them feel more vulnerable than we have to?  Are we crowding or cornering them when we don't need to?  Do we need to just slow down and break the procedure into smaller parts so they can adapt/adjust to this new experience?  How can we get done what we need to do without breaking their trust?

So what is a dog's purpose?  Is it to do what we tell them to do, blind trust, no questions asked, go against their instincts even if everything inside them is screaming "NO!"?  So that we can make a movie?  There are calls to boycott this movie now.  I am not sure I can go see it.  What else happened on that set to the canine actors?  By going to see the movie am I endorsing that treatment?  There is supposed to be a Humane Society or SPCA representative on the set to ensure the animals are treated properly.  Where were they?  I don't know what the answer is.  I think more will be revealed and hopefully some learning will come out of it.  Time will tell.

I have a new little dog now.  She is not Oreo reincarnated.  Far from it.  But when I come through the door and she runs to the couch to greet me, squeaking with joy, wriggling her whole body, nothing that happened that day matters.  Her only purpose in that moment is to say to me "I adore you.  I trust you.  You are my everything."  I better do everything in my power to earn it.