Offering different levels of elective anaesthesia packages.

RE: Offering different levels of elective anaesthesia packages.

ell — Tue, 10 Apr 2018 17:49:06 GMT

Totally agree with you about the fees Clive. It is common for vets to ask why we charge so much ( £85) for IVFT. It is much more than just sticking a catheter in and attaching the drip. They are undervaluing their knowledge and the expertise of all the staff involved.

RE: Offering different levels of elective anaesthesia packages.

Evelyn Barbour-Hill — Tue, 27 Feb 2018 22:24:07 GMT

[quote user="Iain Richards"]Themalon - not heard of that one, and I've held down cats for ether induction![/quote]

It was moderately well known in the early seventies. In my first practice we used Themalon and local analgesic for the caesarean operation in dogs..

RE: Offering different levels of elective anaesthesia packages.

Anthony Todd — Tue, 27 Feb 2018 22:07:36 GMT

[quote user="Clive Ansell"]if an elderly animal dies under anaesthesia or soon afterwards.[/quote]

Yes, you'd think so, but nobody has had one, or istn't publishing it , which is my point....

RE: Offering different levels of elective anaesthesia packages.

Anthony Todd — Tue, 27 Feb 2018 22:05:42 GMT

[quote user="Iain Richards"]

Themalon - not heard of that one, and I've held down cats for ether induction!

[/quote]

https://en.wikipedia.org/wiki/Diethylthiambutene

Not that it will ever be use again, but it was all there was apart from chloroform, pentobarb or ether.

RE: Offering different levels of elective anaesthesia packages.

Iain Richards — Tue, 27 Feb 2018 20:06:25 GMT

Themalon - not heard of that one, and I've held down cats for ether induction!

RE: Offering different levels of elective anaesthesia packages.

Clive Ansell — Tue, 27 Feb 2018 18:38:59 GMT

[quote user="Anthony Todd"]what's changed?[/quote]

maybe defensive medicine and the fear, almost paranoia sometimes, about being sued? that "what if" situation if an elderly animal dies under anaesthesia or soon afterwards.

RE: Offering different levels of elective anaesthesia packages.

Anthony Todd — Tue, 27 Feb 2018 17:35:54 GMT

[quote user="GrooveJet"]a) I didn't say dental work was elective... but the timing of the anaesthetic is.[/quote]

Still waiting for one of these "compromised" animals to die under anaesthetic, even back in the day with intermittent thio and Themalon and only atropine and Acp when it came out.....

Why didn't we have blocked uraemic [I assume] cats die when unblocked etc. etc.??

No PABs, no fluids, and, in the early days, no extra O2, just air, yet no problems; what's changed?

The facts don't support the theory, not to say that modvets aren't wrong in theory, but in practice; not so sure.

RE: Offering different levels of elective anaesthesia packages.

Clive Ansell — Tue, 27 Feb 2018 17:22:53 GMT

[quote user="GrooveJet"]Wish I lived in the land of the self-righteous marvels that are posting on this thread... [/quote]

I think this has been a good thread, and a good discussion with some very sensible posts.

[quote user="GrooveJet"]must be lovely always knowing what's best for doggy[/quote]

We do as far as veterinary care is concerned. We are the veterinary professions with 5 or 6 years or training and X years of experience under our belts.

[quote user="GrooveJet"]In my world, owners sometimes just don't wanna play ball and we end up making compromises and doing what we can with the resources we have available.[/quote]

I think we all do that; I certainly do as much of my work is in practices in poorer areas. I advise and offer what I consider to be best clinical practice and work backwards from that if clients are unwilling or constrained financially. Nothing self-righteous about it.

RE: Offering different levels of elective anaesthesia packages.

Miriam Lodewyks — Tue, 27 Feb 2018 16:20:49 GMT

[quote user="Clive Ansell"]Is dental work in older patients elective? it is either required or not, and if so it is essential rather than elective? if not, don't do it. [/quote]

a) I didn't say dental work was elective... but the timing of the anaesthetic is.

b) I frequently run PAB and in a fair few cases it has led me to a complete change in treatment plans, ie. cancelling or postponing the GA, starting animals on renal support diets or ACE-inhibitors or a prolonged course of antibiosis beforehand...

c) Wish I lived in the land of the self-righteous marvels that are posting on this thread... must be lovely always knowing what's best for doggy and owner and always getting to do things your way. In my world, owners sometimes just don't wanna play ball and we end up making compromises and doing what we can with the resources we have available. I still think "economy" is better than "noconomy" though.

RE: Offering different levels of elective anaesthesia packages.

Clive Ansell — Fri, 23 Feb 2018 07:56:04 GMT

[quote user="Alistair Graham-Evans"]"I am not going to do a dental procedure to make your pet more comfortable and remove the appalling infection and pain from it's mouth because some blood parameters are elevated" - said no sensible person ever! "Would you like our special offer which includes maximum discomfort and pain resulting in a prolonged recovery and increased risk of renal complications and other poor perfusion problems so we can be cheaper than the opposition and it also saves us about $10 ? " said no-one ever![/quote]

No joke, and a few years ago now, I have worked in some low cost clinics where pain relief was offered as an add-on or an optional extra for routine neutering and dentals. One I remember offered a one off shot of Rimadyl for £6.50. But hey, they were pushing through dog castrates for £20 and bitch speys for £45.

Some of these practices were against using opiates too because of the cost, and it amazed me how many clients used to opt out of nsiad's, but most vets, myself included, would give analgesia as part of their anaesthetic protocol anyway. Nonsense.

RE: Offering different levels of elective anaesthesia packages.

Clive Ansell — Fri, 23 Feb 2018 07:42:22 GMT

[quote user="robloxley"]

So one vet says [quote user="Alistair Graham-Evans"]It does not need to be discounted or excessively expensive. If an I/V canula is in place ( and cheap ) it costs little to give fluids and adequate analgesia so all this can be inclusive in the price[/quote] and another

[quote user="Clive Ansell"]Again, if IVFT is required don't "factor it in for a tenner", charge properly for it as a profession procedure (minimum c£100)[/quote] and we wonder where "vets are raking it in" arises in clients' perceptions?

[/quote]

How and where does one draw the line between charging a sensible and realistic professional fee, and profiteering or ripping people off ? I genuinely don't know, but I do think as a profession we are guilty of selling ourselves cheap.

To me £100 or so for IVFT seems reasonable. Granted the consumables are £10 or less, but then one has to factor in the time taken and expertise involved, plus ongoing monitoring.

There are many different ways of cutting the cake; one could have a professional fee for anaesthesia which could include IVFT as required with just the cost of consumables being added on. Equally, there could be separate professional fees for anaesthesia and IVFT, which is what most practices I have worked in seem to do.

RE: Offering different levels of elective anaesthesia packages.

George Cooper — Thu, 22 Feb 2018 14:12:23 GMT

[quote user="bob lehner"]

[quote user="George Cooper"]I had a colleague who, at a practice meeting, pronounced that he wasn't getting anyone to book dental work in to be done, so we ran a spontaneous role-play to illustrate how wording used can make a difference.[/quote]

Excellent idea - if you have time would you give us a quick run through your dialogue.

Personally I've always found the old dog 'dental' (sorry EBH) conversation a tricky one - when the client is reluctant/impecunious/convinced their beloved smelly old crock will die under GA.

[/quote]

Bob - I'm gonna send a PM to you as I am just a bit nervous about the ensuing Mickey taking that will result en masse!!!!! Remember that my written words have to be colloquialised by the end user!

RE: Offering different levels of elective anaesthesia packages.

Anthony Todd — Thu, 22 Feb 2018 14:10:27 GMT

Sorry, must be me duplicating again.

RE: Offering different levels of elective anaesthesia packages.

Anthony Todd — Thu, 22 Feb 2018 14:06:54 GMT

[quote user="bob lehner"]when the client is reluctant/impecunious/convinced their beloved smelly old crock will die under GA. [/quote]

Is there any current data on anaesthetic death rates?

My experience is the "anaesthetic risk" patients ie old, blocked bladder, pyos, dentals [WTF is EBH, Bob?] ex. laps CHFs etc is that they sail through, and the problem/catastrophe ones are the too small kitten which dies on induction or the totally normal lab B/S again on induction....

Anyone had a really clinically dodgy dental die under GA?

RE: Offering different levels of elective anaesthesia packages.

bob lehner — Thu, 22 Feb 2018 13:53:19 GMT

Excellent idea - if you have time would you give us a quick run through your dialogue.

Personally I've always found the old dog 'dental' (sorry EBH) conversation a tricky one - when the client is reluctant/impecunious/convinced their beloved smelly old crock will die under GA.

RE: Offering different levels of elective anaesthesia packages.

George Cooper — Thu, 22 Feb 2018 12:07:03 GMT

This is a really confusing thread to dissemble!

One of the main problems in suggesting dental work is that the client doesn't necessarily recognise that there is a compelling reason for it to be performed. All they see/smell is the halitosis without realising the severe pathology that underpins that. So - when a GA and dental work is put forward, their "immediate" take is that the animal will die under the anaesthetic - because that is what happens, isn't it? I used to advise pre-op bloods purely as a way of "looking for normality" in those bloods to give the client peace of mind. No longer!

I also feel having read the thread, that if clients are actually refusing this procedure - i.e. the dental work - then somewhere along the line the whole work/benefit thing has not been explained to them in a way that they understand. As many have commented, if the animal needs whatever is being "advised" or even "strongly advised" then it should get it. Full stop. At whatever level is deemed appropriate for the animal's condition.

The client is palpably incapable of any form of informed decision in these cases. Full stop. (As is often the case with any type of "informed consent" IMO.)

If, however, they are genuinely strapped for cash and unable to raise the funds to proceed, then there are a couple of options - firstly euthanasia, for not to do anything is tantamount to severe neglect, sentencing that pet to pain, disease, and a reduced quality of life. Secondly - to seek to find an acceptable way forward by adjusting the work to be done, somehow. This is not "the client refusing the procedure, or declining the advice" assuming that a comprehensive explanation of the benefits has been done, but someone genuinely unable to find enough cash for what is becoming more costly work, year on year.

In these various scenarios I have found that using the most appropriate English, in a positive way, and an assertive way can hugely influence the outcome of such consultations.

[**anecdote alert** I had a colleague who, at a practice meeting, pronounced that he wasn't getting anyone to book dental work in to be done, so we ran a spontaneous role-play to illustrate how wording used can make a difference. Bless him - he "got it", and from then on had no difficulties booking work in]

A most useful and though-provoking thread. Thanks Groovy (?).

RE: Offering different levels of elective anaesthesia packages.

Rob Loxley — Thu, 22 Feb 2018 08:47:50 GMT

RE: Offering different levels of elective anaesthesia packages.

Alistair Graham-Evans — Wed, 21 Feb 2018 22:55:48 GMT

"I am not going to do a dental procedure to make your pet more comfortable and remove the appalling infection and pain from it's mouth because some blood parameters are elevated" - said no sensible person ever! "Would you like our special offer which includes maximum discomfort and pain resulting in a prolonged recovery and increased risk of renal complications and other poor perfusion problems so we can be cheaper than the opposition and it also saves us about $10 ? " said no-one ever!

I/V fluids are an integral part of a good anaesthetic to improve perfusion and maintain blood pressure. Blood tests are an addition to a clinical exam if indicated to assess an animal's health and investigate symptoms of disease. They are not part of an anaesthetic.

Anaesthesia should be of one standard - good. It does not need to be discounted or excessively expensive. If an I/V canula is in place ( and cheap ) it costs little to give fluids and adequate analgesia so all this can be inclusive in the price. Simple really.

RE: Offering different levels of elective anaesthesia packages.

Evelyn Barbour-Hill — Wed, 21 Feb 2018 22:39:26 GMT

[quote user="Chris Milligan"] Here in Canada failure to have a dental done after recommendation by a vet can see you in trouble with the local SPCA for animal cruelty, and failure to recommend a dental to a client for what would be considered trivial dental disease in the UK can get you in serious excrement with the regulatory body. [/quote]

Jeepers. Fortunately the UK is still more or less a free country.

What's a "dental"?

RE: Offering different levels of elective anaesthesia packages.

Chris Milligan — Wed, 21 Feb 2018 22:23:23 GMT

Interesting post, and raises the poison-tipped question of PABT's again.

Question - if your only criteria for doing PABT is whether or not to put a patient on fluids, and current practice standards recommendations are to have patients under anaesthesia on IVFT anyway, why take a PABT?

Of course if you're looking for other things that's a different question.

Patients generally die in anaesthesia because of airway complications, incompatability of drugs and pressure issues. The long term complications are why we do blood work generally (notable exceptions are TP, Glu, K and ALT) . I tend to find if you give owners a choice in something they perceive to be an "add-on" they almost always choose no unless you go full salesperson on them, which of course as a vet is not your job.

For me, for PABT should be included as an essential part of anaesthesia and long term outcome in patients who are considered at risk. Who's at risk is something you have to decide with careful consideration. I would say young, completely healthy patients undergoing elective procedures are not an at risk population. ASA grades and guidelines for anaesthetic risk are a good aid here and something generally poorly implemented outside of referral hospitals.

This brings us round to what we consider an elective procedure. Dental work in a patient with poor dental health is not elective in my opinion - it's necessary. Whether the owner chooses to do it or not is their choice of course. Here in Canada failure to have a dental done after recommendation by a vet can see you in trouble with the local SPCA for animal cruelty, and failure to recommend a dental to a client for what would be considered trivial dental disease in the UK can get you in serious excrement with the regulatory body.

RE: Offering different levels of elective anaesthesia packages.

Clive Ansell — Wed, 21 Feb 2018 18:33:54 GMT

Is dental work in older patients elective? it is either required or not, and if so it is essential rather than elective? if not, don't do it.

RE: Offering different levels of elective anaesthesia packages.

Clive Ansell — Wed, 21 Feb 2018 18:02:55 GMT

I am another one who doesn't like the idea of tiered anaesthetics, where clients are given a choice, or a range of choices along the lines of "economy" , "standard" or "premium". It implies that one tier is better or safer than another, and therefore by definition the other tiers must be less safe or less better (worse). Should we even consider offering an anaesthetic that is not so good, or less safe? It may be appropriate if selling airline seats, but should have no place within veterinary medicine.

Each case, dentistry or otherwise, should be assessed for anaesthesia on a personal case by case basis; the starting point being a full and thorough clinical examination and history taking. From that it can be decided whether pre op bloods and IVFT are required or not, and should be a non negotiable veterinary decision. I very rarely advise pre op bloods.

Of course there will always be clients, and practices, that want it done on the cheap. My position is to advise what I consider to be best clinical practice and work backwards from that, making sure good clinical notes are made.

The other point I have picked up from this thread; why is this profession hell bent on doing everything on the cheap? clients that have "mutts with halitosis" are in that position in many cases because dental hygiene has been neglected, often over years rather than months (I did dental work on a 14 year old Border Collie last week, where dentistry was advised as far back as 2012! - they shouldn't get a discount, they should be prosecuted) , then they moan about having to pay to have it dealt with. Again, if IVFT is required don't "factor it in for a tenner", charge properly for it as a profession procedure (minimum c£100)

RE: Offering different levels of elective anaesthesia packages.

Lindsey Edwards — Wed, 21 Feb 2018 17:13:57 GMT

[quote user="David Mills"]

[quote user="Anthony Todd"]

I don't suppose anyone has any evidence of post-op morbidity, let alone mortality?

I can't recall ever losing a dental, ever, and many of them would have been ancient with horrible mouths.

The improvement in their demeanor within 48 hours always impressed the owner.

[/quote]

Literally no relevance to the OPs question.

[/quote]

I think it is entirely relevent - it is unethical to guilt trp clients into a 'premo[quote user="David Mills"]

[quote user="Anthony Todd"]

I don't suppose anyone has any evidence of post-op morbidity, let alone mortality?

I can't recall ever losing a dental, ever, and many of them would have been ancient with horrible mouths.

The improvement in their demeanor within 48 hours always impressed the owner.

[/quote]

Literally no relevance to the OPs question.

[/quote]

I think it is entirely relevent - trying to guilt trip clients into 'premuim' packages which have no proven benefit to me is utterly unethical. Surely we should have some basis for reduced morbidity and mortaility using a 'better'/expensive/premium method before selling it to owners as such? If it is needed (in some cases it will be) it should be part of the treatment plan and non-negotiable and if not should not be sold as 'premium level'?

RE: Offering different levels of elective anaesthesia packages.

Miriam Lodewyks — Wed, 21 Feb 2018 09:06:23 GMT

Thank you Martin and Beats: I will ruminate on both of your thoughts... each is valid. Hence this post.

RE: Offering different levels of elective anaesthesia packages.

Beats — Wed, 21 Feb 2018 08:19:51 GMT

I'm fine with concept of different tiers of anesthesia pricing.

Obviously what differs is up to a vet's individual professional judgement and we are not all likely to agree. This is one reason to allow different pricing tiers.

If the other vets you work with don't agree on putting these patients on fluids, then adding £10 to a flat GA fee for everyone might not be a preferred option for everyone.

Where I work, not everyone is sold on having an iv cannula in place for induction. I like to. I charge an extra £1 for an iv cannula. But I just build that into my cost/estimate, not as an option on a consent form.

If you like BP, capnography, pulse ox, ECG and Bair-Hugger/Hot-dog applied to all your geriatric dental procedures, then I have no problem with you charging more than your colleague who remains unconvinced of the merits of gaseous anesthesia, let alone monitoring-toys.

Perhaps a less in-your-face approach than "premium" or "basic" would be to have different price tiers for different ASA categories?

General anesthesia = £xx

ASA grade 2/3 general anesthesia = £xx extra

Finally, my thoughts would be that I have no problem either with doing a cheaper anesthetic to allow the completion of procedrues where the cost matters, or a more expensive procedure maximising what I consider to be safest/best practice. Depending on the client base I serve I may want the option of doing both.

Ignoring what we accept to be a safer anesthetic, if I estimate the chance of death/serious-problem as 1:1000 or 1:10,000 with a £xx difference in price, there would be folks that would prefer the cheaper option, and those that would be happy to pay more. Assuming the safer anesthetic does actually cost more in some way, then having a different tier of pricing and making this optional makes sense to me.