Thursday, October 28, 2021

Veterinary bibliotherapy: The Chloroformist, by Christine Ball

 

The Chloroformist by Christine Ball, pictured here with a stinger anaesthetic machine.

Have you ever wondered what the experience of undergoing surgery would be like without anaesthesia? In The Chloroformist, written by anaesthetist and Woodford Library Museum history of anaesthesiology laureate Christine Ball, provides some vivid descriptions as she tells the compelling story of anaesthetic pioneer Joseph Clover.

As part of my PhD research, I’ve been researching advances in veterinary care and associated ethical challenges (you can read more about that here). 

One of the most important advances in healthcare – of humans and animals – is anaesthesia. It is difficult for most people to comprehend surgery without anaesthesia, particularly major surgery. Aside from causing patients fear, anxiety and distress, it increases the risk of infection (it is very challenging to maintain a sterile field if the patient is trying to escape) and injury (to the patient and/or operators). Lack of anaesthesia means that surgeons must operate much faster, with less time to attend to finer details, and increased risk of error.

Clover, a surgeon, developed an interest in anaesthesia, and become one of the most highly skilled and renowned experts in its delivery – particularly chloroform - during his lifetime.

According to historical records, the first major surgery in a human patient involving an anaesthetic occurred in 1846. Prior to the routine use of anaesthesia, surgery was brutal. For example, Ball documents the surgical treatment of men with bladder stones. 

Bladder stones I removed from a dog via cystotomy, performed under a full general anaesthetic.

Having removed these from animal patients – all under full general anaesthetic, and all treated with post-operative analgesics – it is hard to contemplate doing so on a conscious being. As I read this book, I could not help but reflect on the history of veterinary medicine, and be grateful that I work at a time when anaesthesia and analgesia are utilised routinely (and are of course still being refined).

Clover, a breathtakingly conscientious doctor and scientist, described by an equally breathtakingly conscientious Ball, kept detailed records of his anaesthetics. He was known for his gentle manner, reassuring patients (fear may have increased the risk of anaesthetic complications), as well as his commitment to careful patient monitoring. As someone who had trained as a surgeon, Clover was able to cultivate close working relationships with surgeons, improving outcomes for patients. When anaesthetic complications occurred, he would trouble-shoot these, and he invented and refined various devices for administering anaesthetics safely to patients.

The book will appeal to anyone interested in the history of medicine, anaesthesia, analgesia and surgery, and animal experimentation – an unregulated practice at the time.

The Chloroformist is meticulously researched and beautifully constructed.

The brief, final chapter is a surprising masterstroke. I found myself crying on the bus as I turned the last page. Someone please turn this into a television series!

Reading this book has left me with a desire to take a tour of the Geoffrey Kaye Museum of Anaesthetic History when it reopens. What an extraordinary resource.

The Chloroformist, by Christine Ball, is available from Melbourne University Press, RRP $34.99.  

Saturday, August 28, 2021

Mental wellbeing tips from Dr Natasha Wilks

 

Dr Natasha Wilks, a veterinarian and career coach, in surgery.

It seems everywhere you turn, everyone is burned out. The world wasn’t prepared for a global pandemic, nor its acute, chronic and acute-on-chronic impacts.

We know that the veterinary sector, like many others, has been hit with an increased case load in the face of a major workforce shortage. In some ways, it is a blessing. Tourism, hospitality, the arts and many other sectors have been decimated. Teachers, healthcare providers and those caring for others have had to deal with unprecedented and frequent change. We know, because many people in these sectors are our clients. Many of us are living in lockdown (I don’t think I’ve written a post without using the L word for some time now).

“While hugely rewarding, the veterinary profession also entails numerous challenges to mental health that necessitate the need for proactive management. Currently, the increase in workload is exceeding capacity all day, every day.  Vets are exhausted and overwhelmed.  It is like running an ultra-marathon.  There is currently a huge demand for vets and nursing staff, and with everyone in the practice being so busy, there can be breakdowns in team dynamics,” said Dr Wilks.

Dr Wilks is supporting the partnership between leading Animal Health company Zoetis and Beyond Blue, which is in its sixth year, with an on-demand webinar, Wellbeing for Vet Practices, with practical strategies for maintaining mental wellbeing in practice for vets and clinic staff. 



Zoetis is supporting mental health challenges in our sector by donating to Beyond Blue. Over the past five years, Zoetis has helped raise $500,000 by donating $5 from products sold during the campaign period (July to October 2021). They aim to raise another $100.000 by the end of 2021.

According to Lance Williams, Zoetis Senior Vice President and Cluster Lead, Australia and New Zealand, all funds raised will go towards the Beyond Blue Support Service.

 

“To date, Zoetis’ donations across veterinary and rural farming initiatives have allowed over 8,000 people, including vets, to get the help they need through the Beyond Blue Support Service and we are hoping to help more people this year,” he said.

 

This support is vital. You may be aware of reports of support services receiving record calls. According to Beyond Blue CEO Georgie Harman, the Beyond Blue Support Service continues to experience increased demand since the beginning of the COVID-19 pandemic.

 

What can we do about mental health? Dr Wilks offers five tips.

 

·       Start with you - Everyone is different, so it’s important to understand what is challenging you and why. Where possible, try to identify issues or instances that you find stressful and question what core values of yours they are at odds with.

·       Understand what works for you - There are definitely some basics that everyone should work on to help with their mental health, the key five - physical activity, healthy nutrition, sleep, taking breaks and holidays.

·       Change your perspective - As vets, we go through academia seeing mistakes as failures that affect our grades. In the real world, we need to live with the unexpected, so we have to be realistic and kind with ourselves to grow from adversity.

·       Find empowerment - Clinical Leaders and Practice Managers should provide a clear process for dealing with customers and guidance on when to escalate problems. Letting team members know that they have your support and what they can say in tough situations will give them the confidence to engage and disengage as needed. Part of dealing with difficult conversations is also understanding that customers are going through some of the same challenges we are.

·       Speak out and get help – Reach out to organisations that specialise in supporting mental health. Beyond Blue has developed a free six-week program, NewAccess for Small Business, that offers support by trained mental health coaches who have a background in small business. For more information, visit www.beyondblue.org.au/newaccess-SBO

In addition to the NewAccess program, the Beyond Blue Support Service offers free and immediate counselling, advice and referrals via phone, webchat or email. Beyond Blue’s online resources can help people take steps towards recovery and feel less alone. Beyond Blue’s online forums tap into a peer network that gives people connection and support from others who have been through similar experiences. The forums are safe and welcoming, monitored by a specially trained team.

For more information about depression and anxiety, visit www.beyondblue.org.au. To talk to a mental health professional for free, contact the 24/7 Beyond Blue Support Service on 1300 22 46 36.

Free web chat is also available from 3pm until midnight at beyondblue.org.au/getsupport and you can join the forums for free and download the safety planning BeyondNow app from the website.

For more information for veterinary professionals on how to support Zoetis to raise funds to encourage mental health through its partnership with Beyond Blue, visit zoetis.com.au

Tuesday, August 24, 2021

Veterinary bibliotherapy: All My Patients Are Under the Bed

 

"All My Patients Are Under the Bed" by Dr Louis J. Camuti, Marilyn Frankel and Haskel Frankel.

I’ve been delving into veterinary history for a couple of projects, and stumbled upon the veterinary biography of one Dr Louis J Camuti, written with support from his clients and friends Marilyn and Haskel Frankel. The book, AllMy Patients Are Under the Bed: Memoirs of a Cat Doctor provides a fascinating insight into veterinary practice in the 20th century.

Dr Camuti was born in 1893, and worked until his death – likely due to a fatal arrythmia when driving – in 1981. He was aged 87 and had been in practice for over 60 years.

The book is intended for a non-veterinary audience, focused mostly on anecdotes about quirky cat owners and their cats. But it contains some fascinating insights into veterinary practice in a different era.

Dr Camuti graduated from New York University in 1920. He lived through the great influenza pandemic in 1918, contracting the virus in 1919 when he was a second lieutenant in the New York Cavalry. When the flu struck his camp, over 100 men died. He made it home – with a fever – and married, but as a precaution didn’t kiss his new wife.

When the horses were struck by shipping fever, Dr Camuti was given the job of destroying all of the sick horses - one that caused significant distress.

"I told myself over and over again that the animal was sick and could not be saved. Wasn't I really sparing it pain? yes, but it was something I had to remind myself of everyday. I knew that bringing the peace of death to an animal was as much a part of being a veterinarian as helping a dog to give birth to its puppies, but still I suffered. I guess I was still a kid, and like all kids who think of becoming
doctors, the first thought is of life. It is only later on that you have to face death as part of the job" (p51).

We now know that killing animals can be a source of moral stress for veterinarians. And moral stress can indicate there are systemic animal welfare issues that need to be addressed. In Carmuti's case there was no alternative to killing the horses, he was a subordinate given the order. But he did endeavour to change the method of killing to ensure it was as humane as possible in the circumstances. Perhaps these traumatic early experiences drove him to focus on companion animals.

He later discussed a request for euthanasia of a seemingly healthy St Bernard. This didn't occur because Dr Camuti, who purchased a bottle of chloroform from the pharmacy on the way to the housecall, accidentally anaesthetised himself when he opened it in a poorly ventilated bathroom. Both the vet and the dog survived.

Early in his career, Dr Camuti established a few practices, but his penchant for feline patients became known and he performed house calls in New York City. In the latter two decades of his life he set up an exclusively house call practice. He would begin his evening rounds from about 4pm, sometimes until well after midnight, often getting to bed at 4am. His wife Alex would book appointments – before people had mobile phones or email. She also rode alongside him and waited in the car, ready to move it if the parking inspectors or police turnedup. He would attend up to 30 housecalls a week.

Many of Dr Camuti’s clients did not have cars or cat carriers. Getting to the vet was impossible. And Dr Camuti felt that his patients were more relaxed in their homes – though he did spend a lot of time trying to find his patients in their homes (that aspect of house calls remains unchanged).

He would ask clients to have his favourite hand-soap ready (Cashmere Bouquet), and boil syringes (they were glass then) on the stove tops of his clients. He practiced when there were no analgesics registered for use in companion animals, when Nembutal (pentobarbital) was used as a sedative, and when blood tests weren’t routinely performed. If a patient needed surgery, a spey for example, he would often perform this in the owner’s home, on the kitchen table or similar. Veterinary practice is very different now.

After he survived a cardiac arrest, Dr Camuti couldn’t climb the stairs to reach patients in apartments above the first floor. So he took to examining many cats in the hallways of huge apartment buildings in which they lived (I would have been terrified of a patient escaping). On the day he died, he was still seeing patients.

The book makes much of the “quirky” relationships people had with pets. It was written before anthrozoology was established as a field of scholarship, well before James Serpell’s book In the Company of Animals put the human-animal bond on the academic map.

When I read about practice, at a time when there was no pain relief for veterinary patients, when there was little awareness about animal welfare, when humane euthanasia could not be guaranteed, it reminds me how far our profession has come.

That is not a criticism of Dr Camuti. He was the first feline-only veterinarian in the USA. Despite limitations in practice, Dr Camuti was deeply concerned about animal welfare, expressing his views about declawing: 

"People who have cats declawed usually do so for one of two reasons: to prevent being scratched by an aggressive cat or to preserve their furniture. Such people are obviously thinking only of themselves, not of the pets they are supposed to love. For their own selfish reasons they put their cats through a surgical procedure which is severe, both physically and emotionally. Very often a cat is declawed without any attempt on the part of the owner to train the animal first to use a scratching post. The cat never had a chance. In fact, I've known of cases where a prospective owner demands a cat to be declawed before he'll adopt it. I certainly would never give a cat to such a person because the request itself is an indication that the household is not suitable to a cat". p91. 

And he goes on. This passage reminds me of important positionstatements on declawing in cats, published more recently by the American Association of Feline Practitioners and the International Society for Feline Medicine.

He was also against ear cropping and tail docking in dogs, and raised concerns about the neglect of long-haired cats, the impact of inbreeding, failure of many people to recognise (and control) their cat's reproductive potential, and the hoarding of animals. He treated a range of exotic pets, back at a time when people could acquire a primate on a whim without any sort of license, permit or clue as to how to meet the animal's welfare needs.

Veterinary biographies like these are such important historic records, often for the minor, seemingly routine details they capture about past veterinarian’s daily routines and habits. This biography is worth a read. Especially if you do appreciate cats. 

On another note, if you are tempted to write your own veterinary (or non-veterinary) biography, the Vet Cookbook is hosting a writing workshop on narrative non-fiction with award winning author Brendan James Murray. Check it out here 


Wednesday, August 18, 2021

Writing non-fiction: a workshop for veterinary team members

The Vet Cookbook, spotted on a bookshelf in the UK!

If you’re experiencing low morale, you’re not alone. This blog is coming to you from Sydney, Australia, officially in week 8 (or 9, I am losing count) of hard (and getting incrementally harder) lock-down, but essentially week 12 because of a voluntarily lock-down preceding the official one (somehow it just didn't feel right interacting closely with people socially while COVID was re-emerging in Sydney).

The hard lock-downs necessitated by the circulation of the COVID-19 Delta strain seem to be taking their toll on everyone I know, in profound and sometimes heartbreaking ways.

One of my personal coping mechanisms is reading, usually whilst acting as a human hot water bottle for a certain cat in my life. There’s nothing like a gripping story – whether fiction or fact-based – to take your mind to another place. And reading is COVID safe!

Which brings me to the big news: the Vet Cookbook Committee has secured a brilliant author/teacher to run our second ever writing workshop for veterinary team members.

The first online workshop was taught by award-winning author Tracy Sorensen, who, among other things, is currently writing a cancer biography from the perspective of her abdominal organs. If you missed the workshop on creative writing but want to learn more, I recommend Tracy’s novel The LuckyGalah. A beautiful, richly evocative novel, both uplifting and surprising. I am waiting desperately for it to be made into a movie or series.

Our second online workshop, this time on narrative non-fiction, will be taught by author and school teacher Brendan James Murray. Brendan has twice received National Literary Awards from the Fellowship of Australian Writers for his short stories, and his first book, The Drowned Man, was joint winner of the Ned Kelly Award for Best True Crime in 2017. His second book, the critically acclaimed Venom, was featured on the ABC's Conversations program as part of the 'Best of 2018' series (it is, along with the Lucky Galah, on my personal list of best Australian books of all time). His third book, The School was released by Picador Australia in 2021 and proved a gripping read.

This workshop is on narrative non-fiction.

Brendan James Murray, author of The Drowned Man, Venom and The School.

So, if you feel like you have a story – or a book – inside you, consider enrolling. And if you don't feel much like a writer but you enjoy a good read, the books by both of these authors are outstanding.

As I am sure I have mentioned, when we compiled the Vet Cookbook, it became clear that many members of our profession are terrified of being negatively judged (even about a recipe). This workshop is a safe space where veterinary team members are free to express themselves. 

There are 23 places left in the two-part workshop, to be held from September. The not-for-profit workshop is subsidised by funds raised by the Vet Cookbook to promote the well-being of veterinary team members.

For more information and to enroll, check this page. Enrollment is open to all veterinary team members, regardless of their writing ability.

Friday, July 30, 2021

Updates on palliative end of life care and companion animals, companion animal euthanasia and Companion Animal Rescue Awards

 


One silver lining of the global pandemic has been the widespread availability of accessible continuing professional development. If you’re in hard lockdown, as we are here at SAT HQ, it’s a good time to update or upskill. 

And you don’t need to organise someone to dog, cat, bird or other-species sit while you travel to a conference. While I’ve been learning, Hero has been fast asleep on my desk, dreaming away while I listen (most recently to the ANZCVS online Science Week series).

Another silver lining of the pandemic is that people who cohabit with senior animals who find themselves in hard lockdown are able to ensure their comfort 24. However, animals who are very old or at the approaching the end of their lifespan may suffer declines in quality of life, due to various conditions and afflictions. Some of these can be managed to improve quality of life.

In just over a week on Saturday August 7 I will be taking part in the Australian Veterinary Palliative Care Virtual Education Event, a four-hour conference which will cover a range of topics including:

  • Symptom burden and prognosis: lessons learned from the human healthcare model (Jackie Campbell)
  • Is a natural death better for companion animals (than a veterinary assisted death) (myself)
  • Night walking in geriatric dogs (Heather Chee)
  • Lumbosacral disease in dogs: a physiotherapists approach (Brooke Williams)
  • Management of chronic nausea and vomiting (Gemma Birnie)
  • Preparing clients for loss: conversations and resources every practice should have (Rosie Overfield)

For more information or to register, visit www.avpcac.com/conference or email admin@avpcac.com

As always, discussions of end of life care can be upsetting, and do raise deep philosophical questions. I’ve just written this reflection on ethically indicated euthanasia in companion animal practice. You can access it here: https://www.mdpi.com/2306-7381/8/8/141  

Finally, if you have not already entered the Pet Insurance Australia Companion Animal Rescue Awards, now is the time to do so as entries close on July 31.

Categories include Volunteer of the Year, Foster Carer Story and People’s Rescue Story. To find out how to enter, visit: https://rescueawards.com.au/

I have supported these awards every year since they began as a volunteer judge because they acknowledge and promote the incredible, innovative, compassionate and very hard work of those committed to finding companion animals suitable, safe homes.

If you are going to enter, don’t leave it to the last minute – the entries do take a bit of time, and the judging is rigorous.

Stay safe.


Monday, July 19, 2021

Veterinary Bibliotherapy: Burnout – A Guide to Identifying Burnout and Pathways to Recovery

“...you might suppose that burnout rates would be highest in those whose work simply because they have to, be less evident in those whose work furnishes them with a career, and lowest of all in those who are passionate about their work. We, however, argue that the inverse applies, as burnout rates appear lowest in those who work simply as a job, higher in those who view their work as a career, and highest in those whose work is at the level of a 'calling'.”

(Gordon Parker, Gabriela Tavella and Kerrie Eyers, Burnout: A guide to identifying burnout and pathways to recovery.

Burnout is a hot topic right now, particularly in the veterinary profession due a proliferation of recent studies documenting high levels of burnout among veterinary team members.

When I first heard the term, I can't pinpoint the date but I'm guessing two decades ago, burnout seemed very much framed around the individual. Maybe people who went too hard and, like a candle, simply burned to the wick. When I began my career, people said “don’t work too hard or you’ll burn out”, as if there were a threshold level of work beyond which burnout became a certainty.

In contrast, people were also saying things like “do what you love and you’ll never work a day in your life”, “immersion is the key to success”, and “you need to get as much experience as you can”. People talked about work-life balance, but they behaved according to the mantra that good veterinary team members worked hard.

Since then, there seems to be much debate about the biggest problems in our profession: is our main scourge compassion fatigue? Empathy fatigue? Moral distress? Secondary trauma? Burnout? Which of these are responsible for career attrition or rates of suicide in our profession?

It is against this background that I read Burnout: A Guide to Identifying Burnout and Pathways to Recovery by Gordon Parker, Gabriela Tavella and Kerrie Eyers (Allen &Unwin). This book manages to discuss, in an engaging way, the evolution of the understanding of burnout, what it is, and what it isn't, and what we need to do about it.

Burnout isn't a medical diagnosis (at least not yet). According to the World Health Organisation InternationalClassification of Diseases (ICD-11, 2018), burnout is a syndrome comprising

  • feelings of energy depletion/exhaustion
  • increased feelings of detachment from one's work, or feelings of cynicism or negativity
  • decreased professional efficiency. 

According to the authors of Burnout, compassion fatigue may be a component of burnout, “being part of a broader 'inability to feel' or lack of joie de vievre”.

The authors explain that there is no single magic bullet, no single brain or endocrine pathology to target, no proven pharmacological cure, and no one-size- fits-all plan to treat burnout. They do stress that any strategy requires addressing both the worker and work conditions. The individual and the system they work within. And by work they also mean the work of carers.

Most scientific papers I've read on burnout to date utilise the Maslach Burnout Inventory (MBI) to measure burnout. The authors of this book developed the Sydney Burnout Measure (SBM), and used it to perform a number of large studies on burnout which they argue revealed different features of burnout. One example is the presence of cognitive impairment, which may manifest as difficulty concentrating or poor memory. They also found an association between perfectionism and burnout. Relatable?

The authors talk about occupations at high risk, including doctors, nurses, lawyers, managers, police and veterinarians.

According to Professor Parker, factors increasing the burnout risk for veterinarians include long hours, high university debt, low remuneration, difficult interactions with clients, animal death and euthanasia. High levels of perfectionism have been reported among veterinary professionals.

“Prevention strategies would require addressing salient drivers and handling perfectionism,” he said.

While burnout isn't a medical diagnosis, the authors warn that employers should take appropriate precautions and limit liability.

The book outlines the key components of addressing burnout:

  • addressing work issues
  • adopting strategies to manage stress
  • address the trait of perfectionism

It contains a number of in-depth case studies, as well as mentions of well-known figures who have been alleged to have burnt out over time. I didn't know, for example, that Florence Nightingale and William Osler likely suffered from severe burnout at times in their illustrious careers.

The book's appendix contains the Sydney Burnout Measure, a checklist of workplace triggers and a perfectionism scale.

Overall this is a very readable book. It is based on science, and written by the scientists who undertook the studies it is based on, yet it is accessible and even – I dare say – enjoyable to read. 

Tuesday, July 13, 2021

How can pet owners get the most out of low and no-contact veterinary visits

 

Socially distant dog (c) Anne Quain
Social distancing in veterinary settings is critical to ensure ongoing veterinary care.

New South Wales, the state from which this blog comes to you, is in hard lockdown. That means hardship for many people, but it also means the return of low and no-contact veterinary visits.

Low and no-contact veterinary visits are designed to maximise social distancing between all humans involved to minimise the risk of COVID-19 transmission.

You can still take your companion animal to the vet.

But the experience may be different to the vet visits you are used to.

At the advent of the COVID-19 pandemic I undertook research on ethically challengingsituations encountered by veterinary teams. One of the major issues that emerged was being able to attend to animals (our core work) while also keeping ourselves and our families safe. Low and no-contact consultations, and confusion associated these, was one cause of stress.

So, how can companion animal owners access necessary care for their animals while also ensuring the safety of veterinary team members?

1.     Let the vet team know you are coming.

Book ahead for an appointment or, if a genuine emergency, phone and let the team know that you are coming.

Different clinics may have different protocols, for example some may require you to wait with your animal while others may allow you to drop off animals.

2.     Prepare in advance.

Veterinarians usually take a history when they see a companion animal. This isn’t just chit-chat – it includes vital information which directs assessment of the patient and further investigations.

Broadly, a history can be divided into two parts:

General history.

This includes general information about a companion animal including what they are normally fed (meals, snacks AND treats); their normal activity levels and exercise routines; and lifestyle factors, for example whether they are indoors or outdoors, have contact with other animals or have a history of travel. This also includes medication (including complementary and alternative medicines) and supplements taken. Where possible it helps to provide the name of the medication, the dose and how often it is given (e.g. ½ of a 50mg tablet morning and night). Finally, if your pet has any allergies (for example to medication) or intolerances (for example to food) it helps to know this in advance.

Specific history.

This relates to the reason for coming in. What is the problem or problems? When did it begin? What are the symptoms you have noticed and how have they progressed? Were there any changes in the lead up to the onset of symptoms? (For example, I saw a dog with a three-day history of vomiting. The day before that, she was fed a leg of lamb).

Our research revealed that communication between veterinary team members and clients is more challenging during the time of COVID. For example, some veterinary team members reported that it was hard to hear or be heard clearly while wearing masks; others struggled in non-contact consultations because neither they nor the client could point to an area on the animal’s body.

If you have multiple concerns that you want addressed, write it down. This helps reduce miscommunication.

If symptoms are intermittent, infrequent or episodic (like coughing or limping that comes and goes) it can be useful to take a video to share with your veterinary team. If there is a concern relating to a site on the patient’s body (for example, a wound or a lump) it can be helpful to take photos – both from a distance and also close up.

3.     Be proactive.

If your pet is typically very fearful or shows signs of reactivity (e.g. barking, growling, lunging, licking lips or muzzle) or aggression in a veterinary setting, let the team know so they can work with you to plan the best strategy.

4.     Follow the Government advice.

If you are sick, awaiting the results of a COVID test or isolating, have someone else bring your animal to the vet, or contact your veterinary team for advice.

Just like anywhere else, if you do enter a veterinary facility, wear a mask, sanitise your hands and check in using the QR code provided.

It is important that your mask stays on even when you are talking. Often people want to remove their mask when they are speaking to ensure they speak clearly – but you need to avoid doing so.

Wherever possible, only ONE person should accompany the animal to the vet.

5.     Please be patient.

Right now, veterinary clinics may be very busy. This is due to a number of factors including: staff shortages; increased staff absenteeism (for example, due to COVID testing and isolation); a large number of animal adoptions during the pandemic and the need to minimise foot traffic in veterinary hospitals.

While you wait, please practice social distancing, i.e. don’t gather with other waiting clients.

You may need to wait outside of the building – please ensure all pets are contained (cats in carriers, dogs on leads); and bring a book.

Make sure your phone is charged and switched on.