Tuesday, November 4, 2014

Human vs animal patients

A baby flatback turtle has an injecton.

This week I’ve been faced with the prospect of giving injections – to a human patient. At a conservative estimate I’ve given at least 45,000 injections to animal patients in my career, but never to a Homo sapien.

However, my friend Emma – having undergone a major operation last week – requires daily injections of enoxaparin sodium (Clexane) as prophylaxis against clotting during her recovery phase.

I’ve given the same medication to cats that have suffered from clots, usually feline aortic thromboembolism. These injections sting and cats usually let me know by vocalising, flinching or sometimes attempting to bite.

The difference with Emma is that she can tell me it hurts. She can tell me what she is anticipating, what works – and even rate my performance and convey that information to me (dogs may rate my performance too, I just don’t have direct evidence).

I was fortunate enough to receive a demonstration of the injection technique by Emma’s friend Dr Vaishali. As a human doctor she’s very used to talking to her patients, and their families, and asking them whether they’d like to stand up, sit down, hold someone’s hand, what rate of injection they prefer and so on. She also knows the best injection sites on a human being.

A re-enactment of one of the injections with Dr Vaishali supervising and non-human
nurse Sofi providing reassurance.

A topical local anaesthetic patch is applied to the injection site an hour before, although this just numbs the surface. As our patient was able to tell us, it’s the injection of the drug, rather than the needle penetrating the skin, that hurts.

The patient heard, understood and participated in all discussions about exactly how the injection would be performed. I was reassured that she understood I had no intention of hurting her – in fact, this patient knew the drug, knew what it was for and knew some pain was inevitable.

Just as I was about to inject, a remarkable thing happened. The patient reassured me. I can’t recall the exact words, but something along the lines of not to take it personally if she reacted in pain. I was confident she wouldn’t bite, but very wary that the wrong technique might cause unnecessary pain.

I slowly pinched the skin on her thigh, ensuring I had a nice bit of subcutaneous tissue (and not muscle) to inject into, then injected – at a moderate rate. I withdrew the needle then looked at the patient.

She provided me with detailed feedback – yep, it hurt, but no more than necessary. I’d done okay. Emma’s friend Dr Nicole, asked why I was looking so gobsmacked.

“I’m not used to getting verbal feedback from the patient”, I explained.

Strangely enough, we never received a lecture on injections or injection technique at uni. It was a skill we were supposed to pick up by watching. Is that simply because our patients won’t tell us, or someone else, if we did it a bit roughly or too fast?

According to an online resource from Central Manchester University (you can read it here)

Giving an injection safely is considered to be a routine nursing activity. However it requires knowledge of anatomy and physiology, pharmacology, psychology, communication skills and practical expertise.
According to this guide, injectors should:

  • Explain the reason for injection (not something veterinary patients can comprehend)
  • Describe the procedure/obtain informed consent (we can consent our clients (owners) but not patients
  • Check for any allergies/history of anaphylaxis - the owner's report is the best we can get
  • And then confirm the drug, dose and patient identity before positioning the patient. That we can do. 

There are a lot of helpful guides to injecting human patients but fewer resources about injecting companion animals.

Being able to talk to a patient is a somewhat mind-blowing experience for someone who must rely entirely on non-verbal cues. It is an experience that allows me, in an indirect way, to empathise more with my animal patients. If they could talk, what would they say?