No-contact vet visits, telemedicine and veterinary ventilators sourced for human patients

Companion animal owners should ensure that their pet's tick prevention is up to date. Image(c) Anne Fawcett 2020

As the pandemic situation develops, it appears that veterinary hospitals around the world are considered essential services and remain open to provide animal care. That said, some may have reduced hours and the majority (those at which I work included) now instituting non-contact or low-contact veterinary visits.

These are where the veterinary team has no or minimal contact with the human (client) – we still have contact with the patient. But what it may mean is that the client leaves the animal, waits outside the premises while the animal is examined, and then is telephoned for the history.

No doubt there will be some teething issues, but these measures are designed to ensure that animals can be continue to be treated while minimising risks to clients and veterinary teams and complying with social distancing (or more accurately, physical distancing) recommendations.

We are likely to see a rise in the practice of telemedicine or remote consulting. In the USA, the FDA has announced that it regulations may be relaxed to facilitate telemedicine. You can read more here.

https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-helps-facilitate-veterinary-telemedicine-during-pandemic

Veterinarians are also being asked to make ventilators available for human patients. At this stage, an inventory is being conducted – the ventilators remain on site in veterinary hospitals but at least those who may need them know how many they can call upon, and where they are.

What does this mean for animals? It means that now, more than ever, owners need to ensure that their pets are on up to date tick prevention, and that they have enough prescription medication to manage conditions like chronic airway diseases. It means that owners of brachycephalic dogs need to be extremely careful that these dogs aren’t overexerted or overheated. You can read more about the measures here.

https://www.smh.com.au/national/nsw/veterinary-equipment-offered-to-save-human-lives-amid-virus-outbreak-20200323-p54cvk.html

What doctors can learn from vets, and what on earth is zoobiquity

Can doctors learn about managing self-harm in humans from vets who manage feather-plucking?

When I went through vet school our vet society proclaimed a t-shirt that shouted “real doctors treat more than one species.” Now the term “one health” has become such a buzz-word people are taking the claim seriously. Doctors and veterinarians have more in common than the use of the honorary term “doctor” (a REAL doctor actually has a PhD – but that’s another can of worms).

Cardiologist Barbara Natterson-Horowitz gave this fantastic talk on TedMED about medicine’s blind spot about the commonalities between animals and humans. You can watch the video by clicking this link or see below.

Dr Natterson-Horowitz dealt exclusively with human patients until she was contacted by a zoo to check out a chimp with a suspected stroke. One animal consult lead to another and she was checking out gorillas, lions, exotic birds.

She realised that she had had, until then, a hidden bias in her thinking: “……I feel that tug of human exceptionalism even as I recognise the scientifically isolating cost of seeing ourselves as a superior species apart.”

She began to ask herself “might I be taking better care of my patient if I saw them as a human-animal patient?”

For example, in 2000 doctors believed they “discovered” emotionally induced heart failure. It was reported in a gambler who lost his life savings in one hit, and a bride who was dumped at the altar. But this wasn’t new, nor was it uniquely human. Veterinarians had recognised fear induced heart failure for some time.

Doctors, she argues, could learn much from veterinary management of self-harm, post-partum depression and psychosis, separation anxiety and various cancers.

To take full advantage of these commonalities, UCLA embeds animal experts and evolutionary biologists in its medical rounds. Similarly, zoobiquity conferences facilitate collaboration disorders that human and animal patients have in common.

The Centre for Veterinary Education is running its first zoobiquity conference in Sydney.

I hadn’t heard the term zoobiquity til recently. The word, used by Natterson-Horowitz and colleague Kathryn Bowers in their book of the same name, refers to the link between human and animal health. (I'm still not quite clear on how or why zoobiquity is different to One Health but that will come I am sure).

As it happens, the Centre for Veterinary Education has just announced its first zoobiquity conference in February, around the important theme of nutrition:

Animals and humans get many of the same diseases yet human physicians and veterinarians rarely share their knowledge. Zoobiquity explores how the commonality of animals and humans can be used to diagnose, treat, and heal patients of all species. Drawing on the latest insights from both medical and veterinary science – as well as evolutionary biology and molecular genetics – Zoobiquity proposes an integrated, interdisciplinary approach to physiological, nutritional and behavioural health.

The Centre for Veterinary Education, the Sydney Medical School and the Charles Perkins Centre from the University of Sydney are thrilled to be hosting the first Australian Zoobiquity Conference in Sydney in 2015, the first such conference to be held outside North America. The theme is nutrition and disease in man and companion animals. Given that our companion animals share every aspect of our modern lifestyle, it is not surprising that, along with humans, our dogs and cats are suffering an obesity epidemic. What may not be obvious is our companion animals have encountered changes to their diet like our own – an increased intake of highly refined, calorie dense, nutritionally questionable foods.  

Our multidisciplinary program will go back to basics. What is the epidemiology of adiposity in Australia? What are the macronutrients we need for good nutritional health? What drives the desire for these macronutrients? How much salt do we need, how much water should we drink, and how much exercise should we get commensurate with our lifestyle? Dogs are obligate carnivores – should we forget the packaged food and return their diet in part to raw meaty bones? How does diet impact periodontal disease and how does periodontal disease impact health?

We have an outstanding line up of speakers who include zoologists, nutritional ecologists, microbiologists, molecular biologists, veterinary dentists, dietitians and human and veterinary physicians. We expect an invaluable cross-pollination of ideas as well as discussion and controversy. An unlikely debate may ensue with industry representatives from pet food companies.

What better theme to kick off with. With more animals and humans suffering from nutrition related diseases, including diabetes and obesity, than ever, its about time doctors and vets put their heads together. For further info, download the brochure here.

Atul Gawande on Being Mortal

Medical writer and surgeon Atul Gawande, author of Complications, Better and The Checklist Manifesto (yep, a book about checklists – which is an unexpectedly BRILLIANT read) just released Being Mortal.

This is not a book about veterinary science or veterinary practice but it is of interest to such an audience in the main because it deals with systematic problems with medicine – problems that will affect us all (if they don't/haven't already).

In this book he reflects on end-of-life care of human patients, including his own dad. 

BeingMortal takes aim at our fetish for medical intervention, right up to someone’s dying moments. It’s something as a vet I’ve come to appreciate. It is common, when I euthanase an animal, for the owner to tell me that they wish that a family member who recently died in hospital could have died at home, without all of the treatment that has become the norm for preserving human life – ventilators, antibiotics in the face of insurmountable infection, feeding tubes and so forth. Of course these technologies have a place, and have saved lives – but sometimes they simply prolong a life, which may not be a life the patient considers one worth living.

He is, as usual, very critical of his profession – in a constructive way. It takes guts to be critical of one’s profession, and I don’t imagine one publishes a book like this without copping inevitable flak. Gawande is also a physician with the maturity to admit and reflect on his mistakes. He recognises his own role in perpetuating the problem. Which makes for compelling reading.

Gawande astutely observes our fetish for intervention, and suggests that medical students may be set up for this early in their careers.

“You become a doctor for what you imagine to be the satisfaction of the work, and that turns out to be the satisfaction of competence. It is a deep satisfaction very much like the one that the carpenter experiences in restoring a fragile antique chest or that a science teacher experiences in bringing a fifth grader to that sudden, mind-shifting recognition of what atoms are. It comes partly from being helpful to others. But it also comes from being technically skilled and able to solve difficult, intricate problems. Your competence gives you a secure sense of identity. For a clinician, therefore, nothing is more threatening to who you think you are than a patient with a problem you cannot solve”.

Agreed. The problem of course is when attempts to do something – because we fear doing nothing- impact on the quality of life of patients.

Much of the discussion is around the care of the elderly, which – though improving in some areas – can be barbaric. Part of the issue is the obsession with safety which is prioritised over and above patient autonomy.

“Nursing homes have come a long way from the firetrap warehouses of neglect they used to be. But it seems we’ve succumbed to a belief that, once you lose your physical independence, a life of worth and freedom is simply not possible.”

He well and truly argues against that conclusion, discussing palliative care and hospice in a way that I’ve not been exposed to prior. And it’s a conversation that all health care professionals – and those who will use their services - should be involved in.

“The problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant. The problem is that they have had almost no view at all. Medicine’s focus is narrow. Medical professionals concentrate on repair of health, not sustenance of the soul. Yet- and this is the painful paradox – we have decided that they should be the ones who largely define how we live in our waning days. For more than half a century now, we have treated the trials of sickness, aging and mortality as medical concerns”.

The problem is that our population is aging. Now, more than ever, all of us need to consider the important question: when should we try to fix and when should we not? (One of the big revelations for me was the evidence in Gawande’s book that in opting to “not fix” there is still much we can do to improve quality of life).

Gawande argues that there is more to being old than simply being safe and living a bit longer, that the meaning in people’s lives is their ability to shape their own story, that we can ALL work to reshape our aged-care institutions – and even our culture – to improve the quality of everyone’s lives. I was in tears when I finished the book, but they were tears of hope. Gawande’s is a really positive message. This sort of reflection is what should lie at the heart of medicine.

“The battle of being mortal is the battle to maintain the integrity of one’s life – to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be. Sickness and old age make the struggle hard enough. The professionals and institutions we turn to should not make it worse. But we have at last entered an era in which an increasing number of them believe that their job is not to confine people’s choices, in the name of safety, but to expand them, in the name of living a worthwhile life.”

Animals aren’t a big feature of the book – although the ability to keep an animal in a home, hospice or aged care facility definitely improved the quality of life of many – but the content is relevant to anyone, vets, vet students or otherwise. In fact, it’s a book I’d recommend to any mortal. And it’s one I hope my doctor reads!

Reference

Gawande, A (2014) Being Mortal: Medicine and What Matters in the End. Metropolitan Books.

Caring for chronically ill pets

Caring for chronically ill pets can be a burden on carers too. Veterinarians can help alleviate some of the stress by remaining in contact and providing information.

The phrase “in sickness and in health” is built into wedding vows, but caring full time for an unwell spouse is (usually) the furthest thing from someone's mind when they marry. Similarly, when you adopt a pet, you don’t tend to think about additional care that might be associated with serious or chronic illness. It may feel like it’s “not what you signed up for”. As our pets age they need us more, not less, but being a carer can be stressful.

In human patients they talk about the “caregiver burden” – and to some degree, those caring for very ill companion animals may experience similar stress. As with any caring duties, this stress is reduced if the burden can be shared. But if you’re on your own caring for an animal, that can be tough. I know people who alter their work hours, change their routines, pop home at lunch time to medicate/check on a pet and so forth. Modifications to the home are not uncommon. Some owners of dogs with arthritis building ramps around the home, and some dogs suffering from visual deficits or dementia need toddler gates to prevent access to the stairs.

As a veterinarian I think it is important to be aware of the stressors faced by carers and providing support where possible.

There was an insightful study, published in 2013 (see reference below), documenting the impacts of caring for chronically ill dogs on the caregiver’s life.

In this study, twelve owners of dogs that required significant home care were interviewed.

Potential impacts on the life of an owner include:

• Change in daily routine
• Expenses associated with veterinary and nursing care
• Stress about their animal being in pain
• Fear that an animal may be hurt or die if unattended
• Anxiety about the animal’s death
• Changes in the behaviour of the animal
• Being woken in the night
• Increased cleaning requirements
• More time spent at home/reduced ability to travel
• Anticipatory mourning

The lesson here for veterinarians is that we need to inform owners as much as possible about the possible impacts on their lives, and provide support for people caring for unwell dogs. In particular, owners of unwell dogs appreciated:

• Detailed information
• Clear and thorough instructions for care
• Being able to contact someone to answer questions
• Advice on medication techniques
• Advice on what to expect and monitor
• Frank discussion about euthanasia

We also need to recognise that euthanasia is a blessing and a burden. Knowing that they can choose euthanasia may be a relief to some owners, restoring a sense of control even if they don’t take the option, while for others the burden of decision making is a stressor in itself.

Reference:

Christiansen SB, Kristensen AT, Sandoe P & Lassen J (2013) Looking after chronically ill dogs: impacts on the caregiver’s life. Anthrozoos 25(4):519-533.

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?

Barriers to diagnosis and treatment of infection in veterinary practice

On the whole, human patients don't tend to lick their own wounds...so they can avoid the Elizabethan collar. (For those wanting to know, it was easy to get on and very hard to get off!)

This week I’ve been industriously working on a presentation for infectious disease physicians and scientists at Concord Hospital about infections seen in veterinary general practice. It’s a great reminder of the many similarities between human and animal patients – as well as the differences.

When you look at the barriers to appropriate diagnosis and treatment of infection, there are some interesting comparisons. We have a great human medical system in Australia (under constant threat from politicians), but on the whole it means that many expenses are covered by Medicare.

There is no equivalent system for pets. Thus, unless the owner takes out private pet insurance, they bear the full costs for all diagnostic tests as well as treatment. There are also unique challenges in transporting animals to the vet – getting a cat into a carrier is not the easiest, transporting a vomiting or bleeding animal in a car can be a concern for many people, and carrying large or scared animals with injuries can be hard (though I am sure parents of human offspring struggle with similar challenges!). There is the issue of compliance – not all animals will take their medication readily, especially, it seems, feisty cats and territorial Chihuahuas (I can say this comfortably as Phil is – at last in spirit – a Chihuahua, and is tricky to medicate).

There is a temptation of some owners to attempt self-diagnosis (I’m a big fan of the internet but like any tool it can be used to help or harm) and often some (commonly doctors!) who use human medication on animals without consulting a vet. This can have disastrous results as animals metabolise drugs differently, so even over-the-counter drugs that are relatively safe for humans to take can be highly toxic and potentially fatal to pets.

Other challenges in appropriate diagnosis and treatment of infection in animals are the amount of diagnostic work up people consider reasonable. It costs the same amount of money to culture or biopsy tissue from a budgie or a large dog, but for some people the fact that they paid $5 for the budgie limits their willingness to work up the problem. Often the costs of Government-funded diagnostic tests are not even known by human patients.

In human medicine, because rechecks are often funded by the Government, patients are more likely to return to confirm clearance of infection – whereas this is less common in veterinary patients. And then we have the issue of the vast un-owned animal population – strays, semi-owned pets and wildlife.

Finally, there are some tests available in humans that we don’t yet have validated and available for animals.

Add to that the fact that our patients don’t tend to give verbal histories, spend much of their time un-observed, lick their own wounds, may require general anaesthesia just to get a diagnostic sample, may be asymptomatic carriers of zoonotic diseases, cannot consent to treatment, cannot pay their own vet bills and have no say about their own interests (i.e. a proxy – who cannot speak their language – makes all treatment decisions for them including those regarding euthanasia) – and you see how it can be sometimes tricky.

Nonetheless, overall veterinarians do a pretty good job at diagnosing and treating the majority of infections seen in practice. I am looking forward to hearing more about the challenges human doctors have around infection control and treatment.

For our conservation-minded readers, the Australian Museum is hosting a night talk by Dr Richard Major about efforts to conserve the White-fronted Chat, Epthianura albifrons. This tiny honeyeater was once all over Sydney, but now only found in two isolated patches of saltmarsh – completely surrounded by urban and industrial development. Among other things Dr Major and colleagues have been trialling cages to help protect their nests from predators. For bookings click here.

(On a non-directly animal-related topic, they’re also hosting a fascinating talk on the psychology of aging with Professor Henry Brodaty AO MBBS MD DSc FRACP FRANZCP – a psychogeriatrician whose qualifications and academic posts would take up this whole website. We see dementia-like signs in dogs and cats – although some of these are caused by systemic disease such as kidney failure. What is interesting in the aged-care field is the growing evidence that lifestyle and health activities can reduce the risk of age-related cognitive decline, Alzheimers etc, as well as improve mood, heart function, bones and strength. For more info, click here.

And Mick sent this link to photos of homeless people and their dogs. Don't forget to enter our Shark Girl  DVD giveaway.