caesarians

Re: caesarians

Alet Engelbrecht — Mon, 18 Jun 2012 12:26:46 GMT

[quote user="Alexa Bardell"]

Been there, tried that. Get told that fine to have new ideas and some are valid but until a problem arrises with the current way of doing things why should we change. Having said that as long as I don't have a lot of problems/failures with the way I do things then we seem to have reached an agreement.

Was really a question about whether I should try flank caesarians as have always done midline.

[/quote]

Firstly, as a qualified vet you are responsible for your own actions. We often hear that the best protocol is the one you are most familiar with. Apart from that - if one should change, it should be clinically justifiable. Your approach is certainly the most commonly used worldwide (please correct me if I'm wrong) and clinically justifiable. I would not try flank c-sections just for the sake of it, UNLESS there were a clinical reason to do so.

[quote user="Julian Earl"]I think you'll find it's the boss who usually has to clear the shit up when there is a problem in a practice. I've never known a disgruntled client ring up and want to speak to the assistant when things go wrong. [/quote]

This gets me really riled up. As an assistant or a locum, I have NEVER minded speaking to a disgruntled client. Where another vet or staff member was involved, I have always tried to back them up. Remember, back up does not mean COVER up. I would expect my boss to do the same and in the one practice that my boss did not back me up (on two occasions approximately a month apart), the relationship of trust between boss and employee broke down severely and I left shortly after. With all the different vet schools and foreign graduates in the UK, one has to be flexible enough to allow for some clinical differences.

Re: caesarians

Hannah Wynne Richards — Mon, 18 Jun 2012 10:30:15 GMT

I've always done mid-line because that's how I was taught at uni When I was a pre-veterinary pupil doing work experience at my local practice, some of the older veterinary surgeons did flank-presumably because that's how they were taught-but I would say by now it's 50 years out of date

Wynne

Re: caesarians

Lorna McHardy — Sun, 17 Jun 2012 19:43:39 GMT

[quote user="Alexa Bardell"]

Most of the time have clinical freedom but then they are the boss so have to be a bit careful.

[/quote]

I suppose much depends on how strongly you feel about the clinical decision in question. I've never been asked to do a flank spay in a bitch, but I did work in a practice where the protocol was to not give analgesia to cat castrates. If you've got a strong case and good reasons, and aren't just refusing to follow protocol because it's not what you're used to, stand your ground.

Re: caesarians

Vet2Vet — Sun, 17 Jun 2012 17:24:45 GMT

Sorry guess I should clarify that as small animal surgery text .

Re: caesarians

Vet2Vet — Sun, 17 Jun 2012 17:23:55 GMT

Personally , I have not seen a flank caesarian described in a surgery textbook ( I use Fossum ) . Maybe , if there are dated references to the technique it would be easier to consider and discuss ?

Re: caesarians

Anthony Todd — Sun, 17 Jun 2012 14:11:36 GMT

[quote user="Alexa Bardell"]Been there, tried that. Get told that fine to have new ideas and some are valid but until a problem arrises with the current way of doing things why should we change.[/quote]

I suspect the key may be an interchange of "me", "we" or "he". I'm sure someone could do caesars via a transverse abdominal incision as they do in humans and the results might be fine but saying "this is the way we do it" is actually " this is the way I do it" [or was taught it, which is the usual reason] isn't a valid argument for an unpopular, or less popular technique.

I wonder if your boss ever says "mmmm, you may be right"? Does he ever change anything? Does he still use ether?

Re: caesarians

Mark Holmes — Sun, 17 Jun 2012 13:17:17 GMT

[quote user="Julian Earl"]

[quote user="Mark Holmes"]My issue is the "in this practice we do X" attitude. Midline is not only a recognised technique but more common. You are 8 years graduated and a professional responsible for your own actions. If things go wrong you have to clear up the shit. Do what you are comfortable with its your op.

[/quote]

I think you'll find it's the boss who usually has to clear the shit up when there is a problem in a practice. I've never known a disgruntled client ring up and want to speak to the assistant when things go wrong.

[/quote] No but it's still the assistant who is held responsible. It's one thing to be responsible for an action you were happy with and another completely to be responsible for an action you were not comfortable with.

Re: caesarians

a.bardell — Sun, 17 Jun 2012 12:42:17 GMT

Was really a question about whether I should try flank caesarians as have always done midline.

Re: caesarians

Julian Earl — Sun, 17 Jun 2012 12:40:48 GMT

[/quote]

Re: caesarians

Anthony Todd — Sun, 17 Jun 2012 11:58:42 GMT

[quote user="Alexa Bardell"]so far have managed to just shrug of this and other "discussions" but occ start doubting myself so nice to have others input.[/quote]

Why not "discuss" with your boss. I get very frustrated when I try to have a "discussion", on a purely clinical or therapeutic level, and "whatever" is the assistant's only response.

You never know, your boss may be hoping for enlightenment and some sort of peer-to-peer interchange.

Re: caesarians

plantagenet — Sun, 17 Jun 2012 11:29:43 GMT

As a boss, I would find it hard to impose a clinical decision on someone as long qualified as you, after all it's your can to carry if things go wrong. I would do midline myself.

I did insist on not catgut in the midline but that's as far as I've gone and get a bit cross if stuff is ordered in rather than using what's on the shelf. Otherwise I employ experienced (locums) and trust them to do their own thing.

With a new grad it might be different, but I guess they would like some guidance.

Re: caesarians

a.bardell — Sun, 17 Jun 2012 10:24:19 GMT

thanks for all your comments, mirror my thoughts exactly. This is a mixed practice and think this is the reason for flank approach by the bossess.

so far have managed to just shrug of this and other "discussions" but occ start doubting myself so nice to have others input.

part of the problem I think is that when I started here I was already 6 yrs qualified and they were always used to new grads they could mould to their likeing. Most of the time have clinical freedom but then they are the boss so have to be a bit careful.

Re: caesarians

Mark Holmes — Sat, 16 Jun 2012 18:58:07 GMT

My issue is the "in this practice we do X" attitude. Midline is not only a recognised technique but more common. You are 8 years graduated and a professional responsible for your own actions. If things go wrong you have to clear up the shit. Do what you are comfortable with its your op.

Re: caesarians

Alet Engelbrecht — Sat, 16 Jun 2012 18:07:15 GMT

I have never done a flank bitch spay or flank c-section. I had to learn how to do a flank cat spay when I came to the UK and although I quite like them, I do not see an advantage over the midline approach. All recent studies that I am aware of favour a midline approach.

I have never seen a problem with puppies/kittens interfering with the midline incision, but if that is the (theoretical) concern, why not use intradermal sutures? Way faster and clients always impressed by the neatness!

My mum is a vet (mixed practice in South Africa) and they used to use flank exposure for pretty much all reproductive surgery (?large animal influence as another thread suggested), but everyone changed to midline approaches when I was still in primary school, which always led me to believe it was an 'old' approach. I've always been under the impression that the linea alba has much better suture holding capacity than the muscle layer, especially if it is stretched with a big litter. Old is not necessarily bad, but no reason for any boss to force a 'traditional' approach on another vet that may be more familiar with another (more current) approach. If anything, I would suggest that your boss is using an outdated approach, but arguably with good results and therefore can probably continue to do as he pleases. However, to expect you to change for the sake of it without clinical justification, I would take offense to.

Re: caesarians

Charlotte Marshall — Sat, 16 Jun 2012 17:16:31 GMT

I have done flank caesars in the past, when I first started my old boss liked them. He felt the pups were less likely to interfere with the incision and it is true that the subcutaneous blood vessels are usually not as large. I do wonder if it was a hangover from the large animal work we were doing as well though. There did seem to be more stitching up to do and I don't think access is as good. We did see quite a lot of seroma formation. We got a few breeders who specifically requested them midline and gradually we swopped and did them all midline.

I have not done one flank now for years and I prefer doing them midline. I think clients prefer midline as well as they are concerned about scarring showing especially in short coated animals.

Re: caesarians

Ian Mostyn — Sat, 16 Jun 2012 17:15:23 GMT

I have done caesars both flank and mid-line and in a lot of ways I preferred the flank approach. I didn't find it any more difficult and the wounds healed very well. The theory was that the wound was away from the pups and less likely to get infected. I tried to blunt disect through the muscle where possible to reduce bleeding and damage and did a 3 layer closure. I do mid-line these days more through convention than anything else but I would have no problem with an assistant that wanted to do a flank approach. We do cats flank so why not dogs? And yes, I have done plenty of flank cat caesars as well.

Ian

Re: caesarians

Clive Ansell — Sat, 16 Jun 2012 16:18:16 GMT

I prefer a midline approach; I think it is more straightforward and allows for better access, as well as being far easier for allowing quick increased access in the event of an emergency such as a dropped bleeding ovarian pedicle. Also I don't like the idea of going through 3 layers of muscle. I close with simple continuous PDS in the linea alba and s/c vicryl in skin, never had any problems.

That said, I have never done a bitch c-section through the flank, but I have done some flank bitch speys - a good mentor when I was student got me doing both to compare - I found them more difficult.

What are the reasons for your boss prefering a flank approach?

Re: caesarians

Mark Rowland — Sat, 16 Jun 2012 13:52:58 GMT

Ha Ha, Seconded

Re: caesarians

Utlendigur — Sat, 16 Jun 2012 13:45:40 GMT

[quote user="Alexa Bardell"]Just wandered what other people's opinions are?[/quote]

On the surgical approach or the practice?

Surgical approach...I've always done midline because of the better exposure, and I just feel that such a big incision through muscle is more likely to be painful and at risk of seroma formation.

The practice. I think there are several ways of looking at it. If it is quite a minor thing, a throw-away comment, and it's not getting to you, you could just ignore it or laugh it off. If you are getting a dressing down each time or having to defend every caesar you do, especially if your boss is undermining and criticising you over other things, you might be better doing something before it starts to rankle. You could tackle it head on and politely say that it is becoming an issue and could you please sort it out once and for all ie are you being told to do a flank approach or are you allowed to continue doing midlines (in which case would he/she please stop hassling over the issue!). If it is part of a wider problem with being undermined and having your professional decisions questioned, it may become the straw that breaks the camel's back, and leaving may be better in the longterm. Only you can know how much it bothers you versus how much reason there is to stay.

Re: caesarians

Mark Rowland — Sat, 16 Jun 2012 13:39:53 GMT

So once that "discussion" has been had, do you repeat it every time the procedure has been carried out or deem it reasonable behaviour to do so?

I dont think the OP would have brought it up if they weren't being made to feel at least uncomfortable.

Or perhaps I misread the thread...

Re: caesarians

Malcolm Ness — Sat, 16 Jun 2012 13:29:12 GMT

[quote user="Mark Rowland"]pressurise[/quote][quote user="Mark Rowland"] argument[/quote]

These words didn't appear in the OP. You (and others) might have inferred that kind of atmosphere but I didn't and I guess that is the root of our difference.

In our practice we have set clinical protocols that we expect all to follow. All protocols are open to change following presentation of an (evidence based) reason to change, discussion with all vets and an agreement to change.

Re: caesarians

Mark Rowland — Sat, 16 Jun 2012 13:13:23 GMT

No, because as the op has suggested, the argument has been done at the practice again and again. Do you pressurise your employees to do things your way if they have their own way of doing things that are recognised and perfectly acceptable? I dont. If they can justify things to me I am happy to give them clinical freedom. If the discussion has been done once, its not something I would bring up again, except perhaps in jest.

Re: caesarians

Malcolm Ness — Sat, 16 Jun 2012 13:07:20 GMT

[quote user="Mark Rowland"]Seconded.[/quote]

??? leave a job because someone has a different opinion yet is liberal enough to let you do your own thing for 8 years.

I favour (and teach) mid-line caesarians and while I could muse on the theoretical justification for that approach, I am not certain that I could muster a good evidence based argument to support my belief.

Re: caesarians

Mark Rowland — Sat, 16 Jun 2012 13:01:59 GMT

Seconded.

Re: caesarians

Mark Holmes — Sat, 16 Jun 2012 12:50:56 GMT

My opinion is get a new job! 8 years working for somebody with that attitude is long enough.