A reminder to stop and check pouches

Chloe the wombat. Image courtesy Taronga Zoo/Paul Fahy..

Meet Chloe. Tragically, her mum was killed by a car near Jenolan Caves in June. But a good Samaritan stopped, got out of their car, and checked the body. Inside mum’s pouch was a baby wombat.

Chloe gets a cuddle. Image courtesy Taronga Zoo/Paul Fahy..

Chloe, as she was named, was looked after by a carer and is now being hand-reared at Taronga Zoo. She requires feeds every five hours, and enjoys nibbling on shoes and exploring her environment. It is hoped that she will be independent enough to be released back into the wild in around 18 months.

Chloe has one of her many daily feeds. Image courtesy Taronga Zoo/Paul Fahy.

If you are heading off on a road trip this weekend, remember that many native animals carry pouch young. And if you are going to stop to check, do not stop suddenly – slow down, indicate, and park well out of the way.

Chloe can now walk - and even run. Image courtesy Taronga Zoo/Paul Fahy.

Oops. Stopped. Image courtesy Taronga Zoo/Paul Fahy.

Those nails are important for digging. Image courtesy Taronga Zoo/Paul Fahy.

In other news we’re off to the Dog Lover’s Show this weekend. If you haven’t yet bought a ticket, they are available at the door. And please don’t bring you’re on dog – there are some very good reasons to leave them at home for a little while.

Three things I learned about sutures

My desk on the day. Combine this with a good tutor and this is my idea of a productive day off.

Last week I attended a workshop on suturing. Suturing, you ask? Isn’t that something you should know already? Yep, and I’ve done it pretty much most days for the last ten years. All the more reason to tweak and refine – a process which really shouldn’t end (read more about developing surgical skills here).

Dr Ilana Mendels, founder of VetPrac, thinks the same way. So she organised a half-day suture workshop. It was attended by new and recent graduates – veterinarians one or less years out of university – but also a range of experienced vets, with ten, twenty or more years of practice.

Morning tea.

One thing many outsiders don’t realise is that while employers provide some expenses for veterinary continuing education, it’s often done on a vet’s day off, and at their own expense. I’m a big believer – where possible – in investing in one’s own education and training.

So our little group gathered under the tutelage of surgical specialist Andrew Marchevsky, from the Small Animal Specialist Hospital. His surgical caseload is incredible. He generally doesn’t find himself performing routine desexing procedures, but tends to take on things like spinal surgery, radical oncologic surgeries and skin reconstructions. And he’s not above obsessing about sutures. In fact, that’s what makes him a great surgeon.

During the workshop, we were provided with surgical instruments and an endless supply of different types of suture material.

What did I learn?

• Complications occur in the best hands. Even with the best surgeons, the best instruments and the best facilities, intestinal resection and anastomoses break down in at least 10 per cent of cases – and that’s a statistic from the human medical field. Second surgeries are not uncommon and – even where we think it is unlikely – we should inform owners that this is a possibility.
• In general, Australian veterinarians at least use suture that is too thick. According to Dr Marchevsky, we should be using finer suture – 3/0 in the gut, 4/0 for cats. He believes 2/0 is too thick for skin and ligatures in most cases.
• The aim of skin sutures should be for gentle apposition ONLY. There should be no tension and they should be slightly lose when placed.
• Suture materials are categorised by the length of time it takes for 50 per cent of the original strength to be lost. Bladder is the only tissue that returns to 100 per cent of its original strength following surgery (14 days, in fact). Skin takes around 365 days to get to 70 per cent of its original strength.
• Dr Marchevsky feeds animals following intestinal surgery sooner rather than later. It was once argued that animals should be fasted for at least 48 hours to prevent leakage of the surgery site. That ignores the fact that around 1L of gastric juices are produced every day and have to go somewhere. “They don’t leak because you feed them,” he said.
• When closing the linea alba, the less muscle you include in the sutures the better. The external fascia is the tension holding layer and this should be the focus.

Dr Marchevsky is a big fan of intradermal sutures and demonstrated his technique. He talked about the pros and cons of different suture patterns and did some troubleshooting.

For the nerds out there, I had also forgotten just how much physics and chemistry is involved in suture design and production. And it was also a nice opportunity to review the history of sutures. For example, absorbable sutures were introduced in the 1970s. These days sutures are sterilised with gamma radiation or ethylene oxide, depending on the material they’re made of.

Sutures are absorbed by hydrolysis, leading to gradual disappearance of the thread over a particular time.

We were taught to almost uniformly avoid braided sutures because they cause tissue drag and potentially a saw effect when they thread through tissue, but advances in coating such materials mean this is a reasonable choice in some cases. Capillarity of the suture is defined as the ease through which fluids can be wicked along the thread…its present to high in multifilaments due to “the loose intersticies of their fibres”, and monofilaments have no capillarity.

Braided suture is more flexible and has less memory than monofilaments, making it easier to use. (Memory is the capacity of the thread to return to its former shape. Thread memory has an impact on the way we USE suture, ie if it has more memory it likes to tie itself in knots spontaneously, which can frankly be a pain).

Knot security is determined by knot fixation which depends on: thread stiffness, coffecient of friction, elasticity and plasticity. According to the experts at B Braun, knots should have at least three loops with 3mm long ends. Cutting down those “ears” to make it neater isn’t helpful beyond the 3mm mark! What was interesting is that there remains a lack of consensus about knots. According to the B Braun literature, “it is commonly accepted that 4 knots are necessary for securing a braided suture and 6-8 knots are required in the case of a monofilament suture”.

Knot tensile strength is usually 30-50% less than the linear tensile strength of a suture – hence the need to get it right.

Thread gauge is standardised according to the European Pharmacopoeia decimal classification, although the packets us the United States Pharmacopoeia classification.

USP	EP (Decimal)	Thread gauge in mm
5-0	1	0.10-0.149
4-0	1.5	0.15-0.199
3-0	2	0.20-0.249
2-0	3	0.30-0.349
0	3.5	0.35-0.399
1	4	0.40-0.499

From “Suture Glossary” – B Braun

The diameter applies to both needle AND thread. Suture glide describes how well the suture passes through tissue, and, to throw some physics around “is a function of its coefficient of friction”. Monofilaments have better glide.

Definitely a course I would recommend!

Dog Lovers Show ticket winners and links

Becky (left) and Honey.

Why do we love dogs? Elizabeth, winner of our Dog Lovers Show competition, revealed why her family loves dogs.

Without these two Tibetan Spaniels my Grandma would have no one to talk to through the week. Every Thursday the four of us jump in the car and head down to the local dog park for some fun. Dogs give humans an excuse to bond, and share the love that we all need in simple ways! 

Jenna, who came second, said about dogs:

They are always there for you and are unconditional in their love and acceptance.

Words we can’t argue with. Ladies, we hope you enjoy the show on the weekend. If you missed out its not too late - you can still score tickets at http://dogloversshow.com.au/sydney.

The discussion about Tuesday’s Melbourne Cup continues, with the RSPCA calling for a whip-free race in 2015 (read their media release here).

The Guardian’s Oliver Milman wrote this thought-provoking piece about the complicity of Cup consumers.

It will be interesting to see whether this publicity leads to changes, and if so, what? 

Links

On the topic of dogs and love, we were interested to see this article about a Bernese Mountain Dog falling for a ferret.

Meanwhile from the interwebs, Ljudmila send this link about the Wildlife Photographer of the Year winners, and the winner is sensational (check here).

And these images of puppies photographed underwater are interesting.

Horses for courses? Two deaths after one race raise big questions

I don't have photos of racehorses...

Its impossible to ignore the discussion in the media about yesterday's Melbourne Cup.

As everyone recovers from the “race that stops a nation” (incidentally, possibly the most productive afternoon of the week for those who remained at work, without the distractions of emails or phone calls), the headlines speak of a darker side to the race: the cost that animals pay for our entertainment.

Its always good to discuss and review our attitudes toward animal welfare and ethics.

Two horses died – one immediately following the race and the other following a fracture.

The post-mortem findings were discussed this morning (see article here). Human athletes can die by similar means, but they have a say in the risks they take.

There are some related ethical issues. As I don't work with horses (often) I'm going to leave the discussion to two esteemed colleagues whose views I endorse. Professor Paul McGreevy and Dr Phil McManus, both from the Human Animal Research Network, have provided some interesting data and discussion about the use of the whip in horse racing both here and here.

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?

SAT Giveaway: the Sydney Dog Lover's Show

Oscar.

What are you up to next weekend? Do you LOVE dogs?

Thanks to the generous folks the Dog Lover's Show, SAT has a whopping TEN passes to the Dog Lover’sShow in Sydney (Friday 7 to Sunday 9 of November – i.e. this weekend).

It’s at the Royal Hall of Industries and the Hordern Pavilion with over 200 exhibitors and around 600 dogs (n.b. just don’t bring your own dog – see the notes here).

To win a pass to this event, all you have to do is email or tweet us about WHY YOU LOVE DOGS: in a sentence, in prose, poetry or pictures (a picture, after all, says a thousand words – though I am not sure my school teachers who have accepted a picture in lieu of an assignment).

Please include your NAME, email address, and a phone number. (Entry also confirms your permission for us to post your winning entry – but let me know if you won’t want your name posted). Individuals, couples and families are welcome to enter…to keep it fair I will award a max of four tickets to a group entry (but include all names, ages etc). 

You will need to be quick. The Dog Lover’s Show opens at 10am this Friday. All entries should be recieved before Wed close of business this week!