Cascade

Re: Cascade

Michael Woodhouse — Wed, 06 Jun 2012 19:07:08 GMT

[quote user="Alet Engelbrecht"]My question is not really about the out of hours element (incidental), rather the giving of advice that clients run with and duplicate for every other problem, because 'the vet said so'... which is actually against the cascade, potentially harmful to the animal and even though no prosecutions yet, technically illegal.[/quote]

I frequently get people to administer aspirin or paracetamol to their animals OOH. I get them to read me the concentration of active from the packet.

The VMD broadly support that this is ok:

Medicines commonly found around the home - Sometimes a veterinary surgeon may judge there is a need to alleviate a pet's discomfort until a home visit can be made or the animal brought to the surgery. It would be unlikely that action would be taken if in such circumstances a home remedy, e.g. aspirin, were to be recommended.

Bottom of page 18 if you don't believe me

Linky

Re: Cascade

Hannah Wynne Richards — Wed, 06 Jun 2012 17:52:28 GMT

The best rota I was ever on was 1 in 3 Far more relaxing than 1 in 2 but not so busy (other than during the lambing season ) that I was run ragged and dreaded on call

Wynne

Re: Cascade

Hannah Wynne Richards — Wed, 06 Jun 2012 17:50:12 GMT

Alet It sounds as though you've had the same problem I've had OOH providers who then fail to provide There's no excuse

Wynne

Re: Cascade

Alet Engelbrecht — Wed, 06 Jun 2012 16:10:44 GMT

I am currently working a 1:8 rota and had 6 hours sleep my whole on-call weekend about a month ago. I still do not tell owners to give the dog with bite wounds a paracetamol/ibuprofen/aspirin (a case I was greeted with on Monday morning). I can perhaps still excuse the paracetamol (although without clinical assessment?) - at least there is a licenced veterinary equivalent for dogs and it is fairly safe (but again question ?cascade), but a colleague lost a cat to renal failure after a procedure after the owner administered ibuprofen. I have also had smirking GP clients telling how they gave the 'off-colour' cat some paracetamol for the fever - then the cat for some reason a lot more off colour...

My question is not really about the out of hours element (incidental), rather the giving of advice that clients run with and duplicate for every other problem, because 'the vet said so'... which is actually against the cascade, potentially harmful to the animal and even though no prosecutions yet, technically illegal.

Re: Cascade

Mark Hedberg — Wed, 06 Jun 2012 15:08:47 GMT

[quote user="Mark Holmes"]

[quote user="Mark Hedberg"]

Every 8th weekend? That's giving up a weekend every 2 months so your colleagues can have some time off too...I'd do that! ;)

[/quote]

Thats not the problem, there is no limit to how busy that three days can be. Client don't expect a different service if they are client number 50 or number 1. If you are up all friday night you can equally be up all saturday and sunday night as well. The pager can keep going off and off and off and off. In the time it takes to see a client you can have another three calls to take. There is no limit to what is required of you and there is no escape from Friday morning until Monday evening (or Tuesday morning when I on call Mondays as well)

[/quote]

I've done weekend on call, I know what it's like, promise! (Sole charge own OOH 3 years, 1 in 4 for 2 years.) Some weekends run you ragged. Some don't. You learned to hate that little black beeper! :D

Re: Cascade

Mark Holmes — Wed, 06 Jun 2012 14:57:22 GMT

[quote user="Mark Hedberg"]

Every 8th weekend? That's giving up a weekend every 2 months so your colleagues can have some time off too...I'd do that! ;)

[/quote]

Re: Cascade

Mark Hedberg — Wed, 06 Jun 2012 14:51:04 GMT

Every 8th weekend? That's giving up a weekend every 2 months so your colleagues can have some time off too...I'd do that! ;)

Re: Cascade

Mark Holmes — Wed, 06 Jun 2012 14:38:23 GMT

[quote user="Hannah Wynne Richards"]

Mark What is your OOH rota ? Would you be better off on call oftener, but quieter when your on?

Wynne

[/quote]

1:8 Which is a night every second week and a Friday-Monday every 8 weeks. Frankly doing it more frequently is not a pleasant thought. I bearly feel like I have recovered from one night on before the next arrives already and every 8th weekend comes around pretty blooming quickly.

Re: Cascade

Bob Russell — Wed, 06 Jun 2012 14:14:36 GMT

[quote user="Clive Ansell"]

[quote user="Bob Russell"]

Cascade is fairly irrelevant to the choice of i/v medication in this case as the drug prescribed by the operating vet is amoxycillin/clav. As there is no licenced i/v injection it has to be the human one. The choice of drug is not dictated by cascade.

[/quote]

I'm not so sure? surely in most cases where amox/clav is needed, a s/c injection and/or tablets of a licenced product is indicated. I believe synulox given s/c reaches effective serum levels in about an hour and wonder if the (over) use of the likes of Augmentin is indicated or even legal?

I have seen a young cat this morning that was seen and hospitalised over the bank holiday at a local OOH provider with an obvious and straightforward infected bite wound to its L antibrachium. It received i/v augmentin q8hrs for 48 hours. (the full body survey radiographs of all limbs, chest, abd, and pelvis, plus full set of bloods and blood gases were all normal too )

[/quote]

I am sure there must be some clinical justification for this lot but ours generally get a shot of synulox and a course of tablets to go home with! Would i/v Augmentin be clinically justified in the opinion of Mr Average competent vet? If so then cascade is irrelevant, as it should be.

Obviously some cats have fights and run into the road where they get hit by cars. Perhaps this was thought to be the case!

Did they g/a to thoroughly clean the wounds? Perhaps this might have been a better way to spend a clients money but I was not there!

Re: Cascade

Clive Ansell — Wed, 06 Jun 2012 13:59:04 GMT

[quote user="Bob Russell"]

[/quote]

Re: Cascade

Hannah Wynne Richards — Wed, 06 Jun 2012 13:54:43 GMT

Mark What is your OOH rota ? Would you be better off on call oftener, but quieter when your on?

Wynne

Re: Cascade

Bob Russell — Wed, 06 Jun 2012 12:55:45 GMT

I am happy to support the idea of cascade and accept it almost 100% for LA drugs. I am unhappy about the threat of criminal sanctions in SA practice but support the principle that licenced is better than unlicenced but without opening up that can of worms I do not support it when high veterinary drug costs push medication out of the reach of certain clients as long as the risk of using human generic drugs is explained fully to clients.

Cascade is not to be used as a way of stretching profits!

As there have been no prosecutions of vets (as far as I know) through cascade legislation and the comments and guidelines issued by the VMD have moderated (following the retirement of Prof. Dean?) I interpret cascade regulations using what I hope is common sense.

Re: Cascade

Mark Holmes — Wed, 06 Jun 2012 10:35:45 GMT

This ties in with the out of hours thread, When I am on call its not unusual to be pages 6-12 times in a night. Often the pager will go twice on the way home and its only 20 inutes away. I cannot see everything, it cannot be done. The vet last night was called 8 times and did not make her bed until 6.15. She worked yesterday and is working today. Clients in addition to expecting you to be safe also expect you to be chearful and chatty and sociable. Sometime I think we are expected to be superhuman.

Re: Cascade

Alet Engelbrecht — Wed, 06 Jun 2012 10:05:43 GMT

My question is not about the use of paracetamol in practice, but rather the advice that clients are given out of hours to give a human drug to an animal without any clinical exam or knowledge specific to the pet, because a vet is trying to avoid going out. I agree with Hannah, I don't think it is very good practice anyway, but apart from that - how does the cascade apply? It seems to be the bane of our lives in other respects, how can we justifiy pushing it aside OOH?

Re: Cascade

Mark Holmes — Wed, 06 Jun 2012 09:58:31 GMT

Paracetamol is very useful out of hours, it's also quite safe and effective in hours and a good adjunct to NSAIDS. I have suggested it myself in numerous occasions. I have added it into multimidal chronic analgesia for osteosarcoma and chronic arghritics and will continue to do so.

Re: Cascade

HMC — Wed, 06 Jun 2012 09:39:30 GMT

I don't think this is primarily a cascade issue but a good practice issue.

Re: Cascade

Alet Engelbrecht — Wed, 06 Jun 2012 09:26:23 GMT

Resurrecting an ancient thread...

After another client came in and said they spoke to a vet out of hours who told them just to give a paracetamol (if I'm lucky) or worse (ibuprofen) sometimes, to avoid seeing the patient out of hours - surely, now that we have veterinary paracetamols on the market, it is totally against the cascade? Ibuprofen has never been licenced, and with licenced nsaids, it should be illegal IMO.

I would like opinions from the forum, specifically if there are any justification to use these drugs (out of hours) that I am unaware of in my ignorance.

Re: Cascade

beldather — Mon, 27 Apr 2009 18:42:38 GMT

Thanks Phil,
You are of course 100% right on that one, I should have stated in regards to small animals.

Witholding periods/residues and the manner of herd medicine obviously make it a much more vital issue.

Regards

Blair

Re: Cascade

Phil Elkins — Mon, 27 Apr 2009 18:09:10 GMT

[quote user="beldather"]it is there to prevent the use of equivalent unlicenced 'cheap' generics in place of licenced 'more expensive' products.
[/quote]

This is not entirely true with reference to farm animal medicines. The cascade is there to ensure food safety and reliability.

Re: Cascade

beldather — Mon, 27 Apr 2009 16:57:26 GMT

As a newish vet to the UK, the cascade system caused me great pains when I arrived (australia is use what you need when you need it) as was constantly being told I was going against cascade. So i figured I'd better read it.
I've since decided its a very misunderstood system.

As far as I gathered from the wording, it is there to prevent the use of equivalent unlicenced 'cheap' generics in place of licenced 'more expensive' products.
The key is in the wording of using an 'equivalent' medication.
If in your medical decision you need to use amoxicllin intravenously, then use it. If there was a licenced IV amoxicillin product then it must be used over an unlicensed one.

Marbocyl is not the equivalent of amoxicillin and hence plays no role in the cascade system in this case.
I thoroughly recommending reading the wording of the cascade one night, so as to allow a more relaxed style of veterinary medicine.
It does appear to often be used as an excuse not to update to newer treatments that have yet to progess to licencing.

Regards

Blair

Re: Cascade

Tim Newton — Wed, 22 Apr 2009 15:50:49 GMT

I do not think the cascade compells you to change your treatment in this case. If you want iv amoxyclav as your drug of choice, yoiu have to go off lable and are not forced to use a different licenced drug that is a different drug family. However, you do have to go through the off label consent, etc

Re: Cascade

Phil Elkins — Wed, 22 Apr 2009 13:03:59 GMT

I would guess almost certainly Marbocyl according to the cascade. I suspect however, that even that use would be ff label depending on marbocyl's license claim regarding IV usage. Therefore, I think there is a potential loophole and justification in using other substances. Common sense predicts Augmentin use!