Clients who demand more topical ear meds without consult.

Re: Clients who demand more topical ear meds without consult.

Hannah Wynne Richards — Thu, 12 Feb 2015 14:51:07 GMT

I'm a dinovet, and I definitely don't just hand things out. I had that problem when I first bought this practice. My predecessor had a lax approach, but I'm much better off without the clients who "walked"

Wynne

Re: Clients who demand more topical ear meds without consult.

emma_j — Thu, 12 Feb 2015 12:06:37 GMT

+1 for no prescription medicines - topical or otherwise - without prior clinical assessment - and if it's a recurrence, then it needs a clinical exam to fully assess. If it's an ongoing condition, then there will already be a medication plan written in the clinical notes - if the plan isn't working, then it needs a clinical exam to fully reassess. Simples, really.

I also don't allow owners to guilt me into committing a crime, due to their refusal to take responsibility for their pet (ie, pay for the veterinary care it needs) and have explained to some before in those kind of terms, what they are asking me to do. I've not found this to be hugely confrontational - just stayed calm and explained what we can and can't do.

I do stock a full range of ear cleaners and happily hand those over the counter to these customers, based on what we suspect with instructions that for any prescription medications they would have to be seen.

I've just taken on a sole charge branch - and whilst my predecessor wouldn't exactly be 'dinovet' he was definitely at least 1 generation above me! I did have this conversation yesterday with an owner who was using canker powder and was asking for something stronger 'as usual' - she seemed reasonably impressed with the 'modern' way of thinking though, and has booked an appointment! Patience, smiling, and thorough explanations go a long way I think.

Re: Clients who demand more topical ear meds without consult.

Evelyn Barbour-Hill — Wed, 11 Feb 2015 18:33:35 GMT

[quote user="Yantha Smyth"] Do you think there would be justification to go off cascade and use a human Clotrimazole with the rationale of not over using antibiotic that is not required?[/quote]

Certainly.

[quote user="Glenn Hodgson"]About 1:1of my puppy vaccs have otodectes (central Scotland)[/quote]

Twenty years ago I saw ear mites regularly; apart from the pikey dogs it was nearly always puppies from a couple of breeders..... I used to recognise the puppy type as they came through the door. Those breeders have now either given up or b******d off or warned all their purchasers against coming to me, and ear mite infestation in a dog is a great rarity now.

[quote user="Thomas Johnson"]lateral wall resection[/quote]

is still a good thing to do in appropriate cases. It's got a bad name because so often it was done too late; also because it was done badly; also because people were told it would be curative in itself.

Vertical canal ablation is mostly useless.

Total ear canal ablation with lateral bulla osteotomy is effective in those cases where it is indicated, but the principle is completely different: it's like curing a broken leg by amputation.[quote user="Anthony Todd"]

[quote user="Thomas Johnson"]polyps in the vertical canal. [/quote]

Are they considered primary or secondary; I always thought they wee just the result of chronic infection or irritation, based on no evidence at all.

[/quote]

Sure, but once you've got 'em, it ain't gonna get better till you've removed 'em.

Re: Clients who demand more topical ear meds without consult.

Anthony Todd — Wed, 11 Feb 2015 18:21:46 GMT

[quote user="Thomas Johnson"] a lateral wall resection or vertical canal ablation in a dog,[/quote]

I would guess that most busy city practices did one aural resection / ablation month. Martin, what do you reckon??

Apart from the chronic middle ear infection it "cured" them except the verrucose allergic ones which continued to itch like before.

Re: Clients who demand more topical ear meds without consult.

Anthony Todd — Wed, 11 Feb 2015 18:16:54 GMT

[quote user="Thomas Johnson"]polyps in the vertical canal. [/quote]

Are they considered primary or secondary; I always thought they were just the result of chronic infection or irritation, based on no evidence at all.

Re: Clients who demand more topical ear meds without consult.

Anthony Todd — Wed, 11 Feb 2015 18:15:12 GMT

[quote user="Neil Wheadon"] 10 week old Beagle with whom I've just entertained the whole family looking at them through the auroscope[/quote]

I suspect it's where topical flea treatments [which kill mites as well??] aren't used????/

Good argument for Advocating their use [bloody 'ell that's the stuff I was thinking of but couldn't remember....]

Re: Clients who demand more topical ear meds without consult.

Neil Wheadon — Wed, 11 Feb 2015 17:10:44 GMT

[quote user="David Mills"]Not seen ear mites in dogs for years in this country, knowingly anyway[/quote]

Myself neither.......until I came to South Wales, zillions of them and just this minute seen a 10 week old Beagle with whom I've just entertained the whole family looking at them through the auroscope

Neil (from Somerset)

Re: Clients who demand more topical ear meds without consult.

Thomas Johnson — Wed, 11 Feb 2015 14:51:15 GMT

[quote user="Anthony Todd"]

[quote user="Anthony Dennison"]Psuedomonas can be sorted out with appropriate, albeit sometimes aggressive, topical treatment.[/quote]

So are resections ever done these days; or total canal ablations???? [er, with the middle ear still discharging....]

just interested

[/quote]

I did a lateral wall resection in a cat a couple of weeks ago, but that was because of polyps in the vertical canal. In the 11 years since I qualified I've never done a lateral wall resection or vertical canal ablation in a dog, I have referred 2 or 3 for a total ear canal ablation with bulla osteotomy. All the rest I've managed medically, as much as some owners would let me anyway...

Re: Clients who demand more topical ear meds without consult.

Anthony Todd — Wed, 11 Feb 2015 13:22:42 GMT

[quote user="Anthony Dennison"]Psuedomonas can be sorted out with appropriate, albeit sometimes aggressive, topical treatment.[/quote]

So are resections ever done these days; or total canal ablations???? [er, with the middle ear still discharging....]

just interested

Re: Clients who demand more topical ear meds without consult.

Yantha Smyth — Wed, 11 Feb 2015 13:16:28 GMT

I have always thought it would be useful to have a product with just anti-fungal +\- steroid for the malassezia otitides where you don't strictly need an antibiotic but don't have a choice because of the licensed triple combo products. Do people find that malacetic or chlorexyderm oto work for these, or more just help for maintenance and prevention? Do you think there would be justification to go off cascade and use a human Clotrimazole with the rationale of not over using antibiotic that is not required?

Re: Clients who demand more topical ear meds without consult.

Anthony Dennison — Wed, 11 Feb 2015 12:40:42 GMT

[quote user="Anthony Todd"]

I think the recommendation back in the day was a resection if Pseudomonas.

What's the current thinking and does anyone ever need to do resections these days??

[/quote]

Psuedomonas can be sorted out with appropriate, albeit sometimes aggressive, topical treatment.

Re: Clients who demand more topical ear meds without consult.

Anthony Todd — Wed, 11 Feb 2015 12:39:39 GMT

[quote user="Anthony Todd"]Does anyone do "aural resections" any more or are they all cured with tests and appropriate treatment?[/quote]

I think the recommendation back in the day was a resection if Pseudomonas.

What's the current thinking and does anyone ever need to do resections these days??

Re: Clients who demand more topical ear meds without consult.

Kate Richardson — Wed, 11 Feb 2015 12:17:45 GMT

[quote user="Will McMullan"]

I went through a phase of doing swabs and in-house cytology on every otitis externa case I saw, mainly because the others in the practice I worked at did, but became disillusioned with it as I didn't really see the point, and it just seemed to increase the bill. You guys who are doing it, what is your thinking behind it? Is it purely to identify if there are loads of rods and if there are use a topical fluoroquinolone? How does it affect your decision making? Also what sort of preparation do you do? I was just smearing swabs onto slides and diff-quick staining, is that correct?

Thanks

[/quote]

I don't do cytology on every ear and generally not at first presentation unless I suspect pseudomonas ( VERY sore, often ulcerated, purulent discharge rather than brown smelly 'yeasty' discharge) as this needs more aggressive treatment early on. Otherwise I advise swabbing for cytology in recurrent cases- I rarely do culture unless rods are seen, again to determine if pseudomonas or not. If its recurrent its either because its not been treated effectively ie not for long enough or there is an underlying factor, usually atopy. In these cases I try to prevent the infections by using an appropriate ear cleaner targeted at what bugs are there ie bacteria vs yeasts and targeting the underlying problem if necessary with pred/cyclosporine/steroid in ear cleaner etc

Just use diff quik

Re: Clients who demand more topical ear meds without consult.

Anthony Todd — Wed, 11 Feb 2015 12:02:14 GMT

[quote user="Martin Atkinson"]You are handing out antibiotics[/quote] etc

Better would be to say "why antibiotics?" It's an irritation, probably not an infection.

Why not hand out a bland cleaner [even without steroids, shock ,horror] probably will fix it, dog happy owner happy and "if it's not better in a week we'll have to see it".

Often it's a pure high-and-mighty decision and not based on any clinical need or principle.

Mind you, when an unknown "client" came in wanting 100Acp 25mg for her nervous dog which "the other vet" [not us] always did, I refused....

Re: Clients who demand more topical ear meds without consult.

Martin Atkinson — Wed, 11 Feb 2015 11:14:32 GMT

[quote user="David Mills"]

[quote user="Martin Atkinson"]Simple answer they never get a repeat unless seen. If it needs more it didn't work the first time so we need to find out why![/quote]

So, for instance, a swimming Lab gets an ear infection, treated, cleared. Goes swimming again 3 months later, same symptoms. You insist on seeing them?

[/quote]Simple answer again - yes. I can't understand why anyone has a problem with this. You are handing out antibiotics without seeing the patient on the assumption the owner is correct. Its a no-brainer - for what other condition would even consider doing this? You are breaking any number of rules/regulations and principles of good practice by agreeing. I really am surprised at your lackadaisical attitude on this David. The swimming Lab will have been given some ear cleaning drops to stick in the ears to disperse water anyway so the problem would only occur if the owner wasn't complying with instructions - even more reason to insist they are seen!!

Re: Clients who demand more topical ear meds without consult.

Will McMullan — Wed, 11 Feb 2015 11:00:38 GMT

Thanks

Re: Clients who demand more topical ear meds without consult.

Julian Earl — Wed, 11 Feb 2015 10:42:35 GMT

I think that the best option for keeping the client happy by supplying treatment is not to supply medicated drops but just one's favoured ear cleaner. As long as one points out that a ruptured ear-drum could still have serious consequences, it is doing something useful, and pacifying an owner. I indicate that any contaminated wound or surface is always cleaned before disinfected so it makes sense to the owners as a first option for treatment. Ear cleaners are over-the-counter products anyway so no issues of POM there I think. Combining this with a mini-lecture about resistance when this subject is well-publicised in media is usually convincing enough.

Re: Clients who demand more topical ear meds without consult.

Anthony Todd — Wed, 11 Feb 2015 10:03:06 GMT

[quote user="David Mills"]Anyone else want to join?[/quote]

Happy to help; big big advantage having vetsurgeon.org to collate data and make it legit.... and not a contemptible anecdote.

[Back in the day it was not too uncommon to treat a "purulent otitis" and find mites sometime later...]

Does anyone do "aural resections" any more or are they all cured with tests and appropriate treatment?

Re: Clients who demand more topical ear meds without consult.

Stigen — Wed, 11 Feb 2015 09:33:46 GMT

I think the ones that wants more eydrops are even worse...because you know that in most cases it`s just another conjunctivitis...and it takes like 2 minutes to diagnose. I had one yesterday that wanted some drops as it had had conjunctivits some 8 months earlier. I sad she had to be seen, and she did show up reluctantly. I checked the dog, looked at the eyes, used fluorescein etc...and sure enough just another conjunctivitis. I dragged out the consult a bit, making sure to spend more time on her....and gave her some different eyedrops than what she had previously...seemed to fly well with her.

THen later another guy comes in with his chihuaha in his arms...asking for eydrops as it had conjunctivits a year earlier. He did not want to pay for a consult...so I sold him some generic eyedrops to flush it....

Re: Clients who demand more topical ear meds without consult.

Braden Collins — Wed, 11 Feb 2015 04:38:09 GMT

To me, this is a "it depends" sort of answer.

We have a lot of grass seeds here, so during grass seed season everything with ear problems gets seen as we'll normally find 3-4 cases each day with seeds in ears.

We swab all ears that present with problems. To me, a yeast infection has a very different treatment plan than an ear with rods, so we need to know what we are dealing with.

We always ask for a free check at the end of the treamtent course. If clients don't do the follow up check, they don't get more meds without a consult.

For atopic dogs, if they have had the same problem mutiple times, the vet may authorise repeat dispensing of ear drops for up to 6 months between visits. No prescription medications are dispensed if we haven't seen the dog in the previous 6 months. We expect our vets to make a note on the history if repeats are permitted. If there's no notes, the clients get a recheck.

We also look at underlying causes and try to deal with them. For example, dogs that swim get TrizEDTA based ear cleaners for regular use. If a dog is getting repeat ear infections there is an underlying cause, and I think we have an obligation to try to deal with that rather than just chucking more meds at the ears.

Our vets decisions are final. If the vet who saw the case feels a recheck is indicated, the client doesn't get any more without that check. We've maybe lost one or two clients over the last couple of years because of this strict approach, but those aren't the sort of clients we'll miss.

Re: Clients who demand more topical ear meds without consult.

Glenn Hodgson — Tue, 10 Feb 2015 23:16:55 GMT

I take time to explain to client pros/cons of not checking pet (possibly cheaper,Vsf.b.s, haematoma brewing, stopping next flare happening etc etc) then,if needed, get more to the point, don't like it, lump it. Same for people wanting wanting antibiotcs to help their bitch have more or better puppies....... This is usually a longer discussion!

I always find a call from a vet to explain goes far better. clients find a NO hard to accept through a third party.

About 1:1of my puppy vaccs have otodectes (central Scotland)

Also use flouro ear meds about twice a year tops. Only ever following c&s. Grudgingly keep one bottle on the shelf for 3 vet practice.

Re: Clients who demand more topical ear meds without consult.

james herriot lied — Tue, 10 Feb 2015 22:37:28 GMT

[quote user="David Mills"]

Interesting concept, this. There is some quite serious support in human medicine for short-duration abx treatment - in some cases, including skin infections, treating for a short period of time and then letting the body do the rest has been shown to lower resistance development rates. Kinda counterintuitive, but we do seem wedded to treating beyond visual cure which in all likeliness just increases resistance development in the commensals responsible for the infection in the first place.

[/quote]

At the risk of not being swayed by novel but unproven theories in species we don't treat, I have a couple of questions:

1. Does creating a new super-breed of commensals do any harm? They sound quite able to out-compete the pathogens.

2. Doesn't the fact that dog ear infections are way more common than human ear infections, due largely to local inadequacy or misdirection of the immune system, rather defeat the object of 'letting the body do the rest'?

I direct everybody at Thornit in the post-infection phase. Marvellous stuff.

Re: Clients who demand more topical ear meds without consult.

Lindsey Edwards — Tue, 10 Feb 2015 21:40:57 GMT

I dispense cleaner if not painful, advise if unable or unwilling to clean ears, must be seen, likewise if removal or debris does not relieve symptoms. Always give info leaflet on maintenance care. Topicals not effective in face of gross contamination anyway and refuse point blank to dispense oral meds.

Re: Clients who demand more topical ear meds without consult.

Bibs — Tue, 10 Feb 2015 21:32:45 GMT

[quote user="Michael Woodhouse"]

[quote user="Elizabeth Billimore"]dog started on aurizon + marbofloxacin PO[/quote]

This is not a personal dig at you Elizabeth - but vets using fluoroquinolones as first line treatment for otitis annoys me far more than an owner asking for another bottle of Canaural.....

[/quote] Don't worry I've had nothing to do with this dog until today so I was just reading the notes from previous vets and I agree with you.

Re: Clients who demand more topical ear meds without consult.

Neil Wheadon — Tue, 10 Feb 2015 21:21:01 GMT

How cute are owners? If you refuse to give out an extra bottle and insist on a consult, what would you do? I'd half use the bottle I had, and save the rest for next time. In effect the dog is being undertreated and resistance is encouraged in both cases. Am I alone in thinking this? Neil