Pre injection blood tests.

Re: Pre injection blood tests.

Hannah Wynne Richards — Sat, 28 Jan 2012 09:25:42 GMT

I'm with Martin Dagmar and Julian

Wynne

Re: Pre injection blood tests.

Dagmar Steele — Sat, 28 Jan 2012 08:57:28 GMT

[quote user="Julian Earl"]

I'm with Martin and Dagmar here. I have rarely, if ever, seen a bite wound that needs more than analgesia, antibiosis, and maybe lancing/flushing if abscessating. However, I would not be so quick to dismiss animals as not requiring treatment simply because it will wait, waiting being suggested as acceptable because the condition is not life-threatening presumably. What we swear to protect is welfare and our attendance should not purely be determined by whether an animal's life is in danger, it should be determined by whether there is suffering that can be alleviated sooner by attending.

The classic example is the dog with anal gland pain, whether impaction or sacculitis/abscessation. These dogs are not going to die but there can be no doubt that they can be in excrutiating pain and should be seen. Other examples exist of course, but in the past I have listened to vets scoffing about owners ringing in the night about a dog with AG disease. If there could be pain even in the absence of an endangered life, then the animal should be seen. After all, pain is painful.

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I see you've already been given five stars for this, it wasn't me but I fully agree with you! And what we should never forget is: it is the owner who has to watch their beloved pet suffer, and in this case minutes can easily turn into hours... and they do not have the knowledge we have, for them a certain amount of blood looks life-threatening, a dog that cannot walk because of an anal gland abscess looks in danger and so on. So it is understandable they want it to been seen to now. We should at least give them the option, even if we tell them there is no real danger the pet will die. I did refuse to sell flee control products in the middle of the night though :-)

Re: Pre injection blood tests.

Lorna McHardy — Fri, 27 Jan 2012 21:13:26 GMT

[quote user="Clive Ansell"]

Also, cross referencing to another thread, this is the only OOH clinic I know that has a workable structured protocol in place to deal with OOH home visits.

[/quote]

Tell me more!

The rest of your description sounds very similar to the one I work for.

Re: Pre injection blood tests.

Julian Earl — Fri, 27 Jan 2012 20:48:58 GMT

[quote user="Martin Atkinson"]

[quote user="Dagmar Steele"]

Martin,

most of the time I find myself agreeing with you and the OP seemed way over the top to me. But following the cat bite discussion I have to disagree. I think that most owners of a cat with a very bite wound would want to see a vet rather sooner than later and understandably so. And even if I make the diagnosis on the telephone I might be wrong about it, so I would actually see it and treat with antibiotics and pain meds. I would not advise x-rays or any kind of surgery, bloodworks and so on in OOH unless something suspicious comes up, but yes, I would see and treat the cat. Refusing to do so would be considered malpractice where I live and work. A vet refusing to see a dog with a broken claw, bleeding a bit, has been sentenced to a hefty fine a couple of years ago.

[/quote]

OK, I confess to being dogmatic/bloody minded and playing devil's advocate to some extent to defend my position. If it was Sunday morning I would probably see the cat as it may be a lot worse by Monday. If it was 11.30pm Sunday night I would advise them to wait until the morning, if they insisted I would see it but would suggest that it would be cheaper for them to wait, in most cases they would see the sense in that, but I would object strongly to an OOH provider who insisted it was essential to be seen straight away. The most it would get is an injection of antibiotic and analgesia, even if I thought an X-ray was worthwhile it would wait until the morning. All the other observations I made I'm sticking with.

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Re: Pre injection blood tests.

Stephen Courtney — Fri, 27 Jan 2012 19:23:40 GMT

[quote user="Martin Atkinson"]

[quote user="Stephen Courtney"]

[/quote]

How about telling the truth - your dog does not need any treatment, it will probably get better by itself. Yes if we want OOH clinics to be there to enable us to have more time off and a better quality of life they have to make a profit and this will involve charging clients more but this does not condone excessive, unnecessary, even incorrect treatment. Just be honest with the consultation fee, maybe advise that there will be a charge even for telephone advice. I'm afraid the day I treat a pet to appease the owner rather than for the benefit of the patient is the day I should retire.

[/quote]

I do tell the truth, and i don't dish out antibiotics like sweeties either. I've been doing my job long enough to be able to cope with intimidation and arsiness from clients. I dish out loads of ID and probiotics and things like diarsanyl to keep people busy and out of my hair.

Problems come with those animals where you have checked them over, late at night and find little, except a nagging feeling that , just maybe...are you missing something, could it be pancreatitis, a volvulus ( had one weird chronic diarrhoea that came to see me on a Saturday afternoon, that turned out to be a colonic torsion) or something else. It is so easy to miss something, and one of the advantages to an OOH consult is that usually you can take as long as you need. Bearing in mind that the client has seen fit to bring the animal in, i might well run a biochem and a PCV to rule out any possible hidden issues.

Re: Pre injection blood tests.

Malcolm Ness — Fri, 27 Jan 2012 18:27:02 GMT

[quote user="Martin Atkinson"]

To counter Malcolm's previous post:

recommending unnecessary procedures = unethical practice

[/quote]

For the avoidance of doubt, I am against defensive practice if that is what is meant by doing lots and lots of diagnostics without appropriate reference to the patient's condition or the potential diagnostic yield of the test.

Re: Pre injection blood tests.

Bob Russell — Fri, 27 Jan 2012 13:05:56 GMT

My only concession to defensive medicine is to make sure owners realise I cannot work wonders without information. Some of this information can only be obtained by performing further tests that can be expensive and sometimes unrewarding.

On occasions this discussion will be brief and in order of likely value eg: blood tests first then perhaps X-rays then ultrasound even MRI. These are not recommendations but indicate that there are limits to my crystal ball!

There is nothing wrong with discussing options but this is not the same as pressurising an owner!

Re: Pre injection blood tests.

Kate Richardson — Fri, 27 Jan 2012 12:24:25 GMT

[quote] Can't see why you would give synulox in a dog with diarrhoea that is not pyrexic and not passing significant quantities of blood. Does anyone else consider this misuse of antibiotics? And why cerenia in a dog that is BAR and not vomiting?

I would have thought a few tins of i/d and a tube of prokolin would do the trick in a case like this, and advise rx the next day if not improved, if starts to vomit, goes off food or shows any other symptoms.

[/quote]

Whilst I agree the treatment was inappropriate/excessive, this isn't a fault of OOH providers only...

Re: Pre injection blood tests.

Hannah Wynne Richards — Fri, 27 Jan 2012 09:05:29 GMT

I'm with Martin If they whinge say "You're paying for the priviledge of being allowed to speak toa highly qualified professional person "

Wynne

Re: Pre injection blood tests.

Hannah Wynne Richards — Fri, 27 Jan 2012 09:02:33 GMT

Not doing home visits was another of my complaints I have less freedom,but more peace of mind doing most of my own OOH

Wynne

Re: Pre injection blood tests.

Martin Atkinson — Fri, 27 Jan 2012 09:02:31 GMT

[quote user="Stephen Courtney"]

[/quote]

Re: Pre injection blood tests.

Clive Ansell — Fri, 27 Jan 2012 07:26:39 GMT

[quote user="alex gough"]

But OOH providers have bigger bad debts, lower case numbers and no routine cases to fund themselves. Would vet practices prefer to pay them a much larger monthly retainer to keep them solvent and then have the work kept in house? Or risk having dedicated OOH providers pack it in completely, and everyone go back to doing their own on call - I cant see that being popular!

[/quote]

Good question, who should pay for providing a 24/7/365 service?

I think user practices shouldn't pay a fee at all to OOH clinics; the fees should be paid by the end user of the service, the client. Then OOH providers should stand on their own two feet, and will either survive or they won't.

At the moment monthly fees paid by practices are paid by the clients ultimately, those who do not use the OOH service are in affect subsidising those who do. In addition, clients who are not responsible enough to be registered with a veterinary practice who turn up at OOH clinics are being subsidised by responsible and registered clients, not really fair.

Maybe if user practices do pay fees, the clients should be charged an itemised levy on their bill, for example £3 of the £30 consult fee is to pay for OOH provision?

One of the small independent OOH clinics I know is owned by a local small group of practices. It is run to break even and not make a profit, all the profits are made by the day practices. User practices within the group don't pay a fee as all owned by the same group, any external practices do. There are two sets of fees; clients of user practices pay about 15% less than non registered clients. Seems to work well. Also, cross referencing to another thread, this is the only OOH clinic I know that has a workable structured protocol in place to deal with OOH home visits.

Re: Pre injection blood tests.

Stephen Courtney — Thu, 26 Jan 2012 22:02:00 GMT

Fiona, you are right, I didn't notice the synulox thingy till after I'd replied. shouldn't have had antibiotics at all, that is true.Or the cerenia, which I did comment on.

Part of the problem when you are charging OOH rates to a client who was worried enough to harrass you for something that could/ should have waited till morning - is that you then need to be seen to be doing....something! Sometimes these things are given to treat the owner rather than the dog, and i agree that is wrong. I try to limit antibiotic use generally, and almost never use potentiated amoxy for diarrhoeas. i like metronidazole for pyrexic, blood diarrhoeas, dogs with tensmus and colitis signs, and recurring or persistent cases where I want to rule out giardia - in young dogs this is most of them, so I tend to use it sooner than later. I feel chronic giardiasis is a common cause of later food intolerance. When doing the OOH shifts, I don't do extended GI work ups or things like the PCR based diarrhoea panels - those are for daytime vets who are there to follow up results and monitor progress. but i would give treatment like a weeks panacur or metronidazole, or both, if I think it should be done.

Re: Pre injection blood tests.

Fiona French — Thu, 26 Jan 2012 20:18:15 GMT

[quote user="Clive Ansell"]

[quote user="Stephen Courtney"]

[quote user="Clive Ansell"]

I have another one this morning; 8 month cocker spaniel seen last night at OOH clinic. BAR, diarrhoea, no blood, no vomiting, not pyrexic. Basic bloods were run and injections of Cerenia, Zantac, Vetergesic and Synulox were given. Referred back to own vet today for further workup, rads etc.

[/quote]

Are you implying this was excessive?

[/quote]

Only slightly.

It was an 8 month old otherwise healthy dog, BAR, t'n, no sign of pain or discomfort, no evidence of any other disease other than possible dietary diarrhoea. I would have offered telephone advice but offered to see if the clients wished. I would not have given any of the injectables, dietary advice only. If the dog didn't improve, got worse, or started showing any other signs then I would investigate further.

[/quote]

Can't see why you would give synulox in a dog with diarrhoea that is not pyrexic and not passing significant quantities of blood. Does anyone else consider this misuse of antibiotics? And why cerenia in a dog that is BAR and not vomiting?

Re: Pre injection blood tests.

Robin Grimmer — Thu, 26 Jan 2012 19:51:26 GMT

[quote user="Neil Wheadon"]

My long term worry about OOH providers is where are future staff coming from? There are over 50 Vets Now Clinics and at least that many private clinics. That requires about 250 vets. These need to be surgically experienced and be able to deal with clients at stressful times,

[/quote]

I agree. Many VN clinics seems to struggle to find staff to cover all the shifts. I get the locum agency emails which have all the VN shifts and sometimes they have loads of weekend shifts to fill and it's already Thursday! I wonder how on earth they cope? I suppose the poor blighters that work there full-time have to cover all the extra shifts.

Re: Pre injection blood tests.

Martin Atkinson — Thu, 26 Jan 2012 17:37:52 GMT

[quote user="Dagmar Steele"]

[quote user="Malcolm Ness"]

[quote user="phipps"]There is another truism in emergency practice - it is far easier to defend doing too much than it is to defend doing too little[/quote]

Defensive practice = Good Practice.

Discuss

[/quote]

not necessarily, but it is definitely not bad practice, which might be the case if you do too little. It's a sign of the times that vets have to think of what they could be accused of as well as what would be the best treatment. The one thing that goes out of the window is how to save the client as much money as possible. Is that necessarily a bad thing? Should it be our job to bother about clients finances? I for once decide in each case, I might treat less aggressive if the owner is an elderly nice lady on a very small pension, but be more demanding if the owner is very concerned with bucketloads of anxious questions. Of course I always offer what I think is the best treatment available, but I also offer the second or third best option if there is no money available. I have read papers on cat bites telling me I have to open up each single wound and do a resistance test on each one... well, I might do it if the abscess persists after antibiotics and painkillers....

[/quote] Take 5 stars in return for this. To counter Malcolm's previous post:

recommending unnecessary procedures = unethical practice

discuss.

Damn that just what we've been doing for the past 5 pages.

Re: Pre injection blood tests.

Dagmar Steele — Thu, 26 Jan 2012 17:31:24 GMT

[quote user="Malcolm Ness"]

[quote user="phipps"]There is another truism in emergency practice - it is far easier to defend doing too much than it is to defend doing too little[/quote]

Defensive practice = Good Practice.

Discuss

[/quote]

Re: Pre injection blood tests.

Malcolm Ness — Thu, 26 Jan 2012 17:16:35 GMT

[quote user="phipps"]There is another truism in emergency practice - it is far easier to defend doing too much than it is to defend doing too little[/quote]

Defensive practice = Good Practice.

Discuss

Re: Pre injection blood tests.

Dagmar Steele — Thu, 26 Jan 2012 17:03:10 GMT

never bothered with these stars but will happily oblige :-)

Re: Pre injection blood tests.

Martin Atkinson — Thu, 26 Jan 2012 16:49:32 GMT

[quote user="Dagmar Steele"]

:-)

I now agree with you again, Martin :-)

[/quote]

Thank you, can I have 5 stars then please.

Re: Pre injection blood tests.

Hannah Wynne Richards — Thu, 26 Jan 2012 16:40:13 GMT

iI'm with Dagmar The case presented here involved what seemed like an attempt to over treat-but not seeing when the veterinary surgeon and nurse are already not only on duty but actually in work is inexcusable-my clients weren't refusing to pay OOH rates-they weren't given the chance to do so until it was too late

Wynne

Re: Pre injection blood tests.

Dagmar Steele — Thu, 26 Jan 2012 16:36:12 GMT

:-)

I now agree with you again, Martin :-)

Re: Pre injection blood tests.

Martin Atkinson — Thu, 26 Jan 2012 16:29:33 GMT

[quote user="Dagmar Steele"]

Martin,

[/quote]

Re: Pre injection blood tests.

Dagmar Steele — Thu, 26 Jan 2012 16:17:04 GMT

Martin,

Re: Pre injection blood tests.

Martin Atkinson — Thu, 26 Jan 2012 16:07:59 GMT

[quote user="phipps"]

[quote user="Martin Atkinson"]In the case of a cat bite it is debatable whether this could be called an emergency at all and the client may well have been better advised in all honesty to take the cat to their own vet in the morning.[/quote]

You and I know that, but for the client, who has never seen a cat bite abscess, doesn't and is very worried and wants their cat seen to now. Would you tell the client to wait until the morning if you were doing your own out of hours? And it is clinically justified to provide immediate analgesia to a cat that has a painful wound, isn't it? How can you tell over the telephone that it is only a cat bite wound?

Yes I would advise the client this which is why I would expect the OOH clinic to do the same, the symptoms were: 4/10 lame - that is not very lame is it?

[quote user="Martin Atkinson"] I don't expect the OOH provider to offer a convenience service to people who find it easier to come in out of hours and are simply prepared to pay a premium for the privilege.[/quote]

Why not, if it makes the clients life a little easier? (excluding vaccinations, worming, flea control, dentals and neuterings etc of course)

Because they are my clients, it is not up to a 3rd party to decide to see them as a convenience, that is one step away from client poaching!

[quote user="Martin Atkinson"] In cases where emergency treatment is genuinely needed I expect the OOH vet to provide exactly that, enough to keep the animal alive and well until it can be sent back to me.[/quote]

Hmm, but thats not necessarily (usually) what the client wants is it?

Ditto my previous statement.

[quote user="Martin Atkinson"] I have not referred this patient to the OOH vet for a second opinion so I don't expect him/her to take over the case.[/quote]

Quite so, we see only first opinion cases, usually, but we have responsibility for that case and it's management until it is passed back to you.

There is a difference between 'management' and supercession.

[quote user="Martin Atkinson"]Perhaps some OOH providers should realise that they are only receiving work because a vet chooses to use their services, not that we are so eternally grateful for them to be there that we couldn't live without them. [/quote]

Any sensible OOH service provider recognises this and I know that vets now, for example, works very hard to make sure all of their employees take this approach.

Good.

[/quote]