Giving advice over the phone about pain relief

Re: Giving advice over the phone about pain relief

Mark Holmes — Mon, 27 Jan 2014 09:55:26 GMT

[quote user="Christopher Saul"]

Drifting off topic slightly - not directly relevant to this situation (as I doubt paracetamol would do a lot for a major trauma patient, though may make the owner feel better and less likely to complain about you if you give her something to do), but just to pick up on the paracetamol theme:-

[quote user="Michael Woodhouse"]I use lot of paracetamol in dogs and find it surprisingly effective and safe. I've used it alongside convention NSAIDs as it has a different mode of action. I use it at the licensed Pardale dose rate (33.3mg/kg) which is 3X the BSAVA formulary dose[/quote]

we also use paracetamol a lot in-clinic, and find it safe too. My own opinion [this is pure anecdote, I admit] is that it's pretty useless as a single agent analgesic but seems to be synergistic with other analgesics and the patients we use it in seem more comfortable with it on-board alongside other analgesics. IV seems slightly more effective. We however stick to 10-15mg/Kg, as in our opinion 33mg/Kg is rather high.

[/quote] I use paracetamol a lot and find it very effective. Dose wise 33mg/kg is only licensed for 5 days. If intend to use it only for short term - post op for example I use that. Chronically I use it at 10-15 mg/kg as per Chris. Toxicity is cumulative I fear them becoming glutathione deficient at the higher dose for too long.

Re: Giving advice over the phone about pain relief

Aisling McGrath — Sun, 26 Jan 2014 21:39:45 GMT

[quote user="Evelyn Barbour-Hill"]What kind of profession is it where we have to wait for the grudging patronising weaselly ("it is unlikely that action would be taken") advice of the VMD on such a trivial matter, before using one's professional skill and knowledge, not to mention common sense, to do something right?[/quote]

I'd just like to say that I would always give my best advice as I would see fit (as in, in the best interests of the animal!), however I wanted to know if there was any rules/guidelines there to back me up; which it seems like there is, which is reassuring!

Re: Giving advice over the phone about pain relief

Michael Woodhouse — Sun, 26 Jan 2014 21:34:44 GMT

[quote user="Aisling McGrath"]If I decide to recommend, for example, an anti-histamine, for a dog that's just been stung by a bee, and we don't have any tablets in stock, so want them to just pick up Piriton at Boots, then, legally, I must write a prescription????[/quote]

I'd suggest they went to buy some Piriton from Boots for themselves, but tell them it would be ok to give the dog one if needed.

I do find antihistamines seem to help, a single bee sting I wouldn't take one, but if my face was swelling up and I'd been stung a dozen times then I would.

A true anaphylaxis is very very rare and we use injectable chlorphenamine and dex both IV in these cases. I've never had one so bad that I thought there was sufficient airway compromise that I have given adrenaline.

Incidentally the ambulance service is in the process of introducing IV paracetamol as a paramedic drug and the guys I have spoken to have been amazed how much analgesia such a simple agent can provide both alone and in conjunction with morphine.

Re: Giving advice over the phone about pain relief

Evelyn Barbour-Hill — Sun, 26 Jan 2014 19:36:58 GMT

[quote user="Michael Woodhouse"]

The VMD guidance seems to support such derisions.

[/quote]

The VMD indeed seems to invite many derisions.......

What kind of profession is it where we have to wait for the grudging patronising weaselly ("it is unlikely that action would be taken") advice of the VMD on such a trivial matter, before using one's professional skill and knowledge, not to mention common sense, to do something right?

Re: Giving advice over the phone about pain relief

John Flynn — Sun, 26 Jan 2014 19:02:21 GMT

I know it's the UK reg's your after and I'm sure someone knowledgeable will answer

...but as an aside in the meantime

I would suspect that for any hope of an antihistamine having much of an effect, you'd need to give it pretty quickly after said bee sting (or prefarably before it!). Would you personally take an antihistamine after being stung by a bee? [or indeed would you ring your doctor to ask what to do after a bee sting...?!] If there is any indication of an anaphylactic reaction, then I'd reach for the adrenaline personally, and unless you anticipate the dog is going to get more bee stings in the next number of hours, then I'm going to guess that a piriton tablet is not going to be worth going to boots to get...

Re: Giving advice over the phone about pain relief

Christopher Saul — Sun, 26 Jan 2014 18:56:08 GMT

Re: Giving advice over the phone about pain relief

Aisling McGrath — Sun, 26 Jan 2014 18:55:51 GMT

[quote user="Michael Woodhouse"]What's the issue?[/quote]

I wasn't aware of the VMD guidelines on this subject, hence the question on VetSurgeon.

However now my question is about a "non-emergency" situation.

If I decide to recommend, for example, an anti-histamine, for a dog that's just been stung by a bee, and we don't have any tablets in stock, so want them to just pick up Piriton at Boots, then, legally, I must write a prescription????

I know this is separate to my OP, however I feel it's a related issue...

Re: Giving advice over the phone about pain relief

Michael Woodhouse — Sun, 26 Jan 2014 18:46:16 GMT

I use lot of paracetamol in dogs and find it surprisingly effective and safe. I've used it alongside convention NSAIDs as it has a different mode of action. I use it at the licensed Pardale dose rate (33.3mg/kg) which is 3X the BSAVA formulary dose.

More than happy recommending owners give paracetamol in such situations before people move animals or if the only reason it needs seeing is the administration of analgesia. The VMD guidance seems to support such derisions.

What's the issue?

Re: Giving advice over the phone about pain relief

Aisling McGrath — Sun, 26 Jan 2014 18:39:13 GMT

That sums it up precisely! Thanks! That was exactly the sort of information I was looking for! [quote user="bob lehner"]

The VMD Guidance Notes no. 13 on 'The Cascade' (see vmd website) has a useful bit at the end on some practical issues, including:

'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. antihistamine, were to be

recommended. This means that in an emergency a vet could recommend that an animal owner could use a human medicine that the owner already has in his/her possession.

This does not mean a pet owner should be encouraged to go into a

pharmacy and ask for a human medicine for their pet.'

Seems to answer you question - human paracetamol is an over-the-counter product - so surely must class as a 'home remedy' .

(The only listed veterinary medical product as I recollect with paracetamol in it (Pardale V) is a NFA VPS product and doesn't need a prescription either).

[/quote]

Re: Giving advice over the phone about pain relief

John Flynn — Sun, 26 Jan 2014 17:50:30 GMT

Of course, leaving the dog unattended to go get a paracetamol might be counter-productive.

A bag of frozen peas wrapped in a tea-towel might be an alternative first aid measure otherwise?

Re: Giving advice over the phone about pain relief

John Flynn — Sun, 26 Jan 2014 17:47:14 GMT

[quote user="Toby Birch"]No conundrum at all. Bring it in.[/quote]

I'm not saying this is not the correct advice [pardon the double negative], but does no-one else wonder whether this leads to more closed fractures (particularly spiral tibial) becoming open in the process of transportation?

I appreciate that the outcome for such an open fracture may not be that different from what it was anyway, but I much prefer it when the skin is closed and I think that if the animal is resting and not struggling, then there might be less chance of the bone piercing the skin if I see it before the owner starts moving it in a car (particularly if they're on their own and therefore will be driving the car while the dog is bumping about unsupervised in the boot).?

Anyone else think this is a factor?

Re: Giving advice over the phone about pain relief

bob lehner — Sun, 26 Jan 2014 17:27:11 GMT

The VMD Guidance Notes no. 13 on 'The Cascade' (see vmd website) has a useful bit at the end on some practical issues, including:

'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. antihistamine, were to be

recommended. This means that in an emergency a vet could recommend that an animal owner could use a human medicine that the owner already has in his/her possession.

This does not mean a pet owner should be encouraged to go into a

pharmacy and ask for a human medicine for their pet.'

Seems to answer you question - human paracetamol is an over-the-counter product - so surely must class as a 'home remedy' .

(The only listed veterinary medical product as I recollect with paracetamol in it (Pardale V) is a NFA VPS product and doesn't need a prescription either).

Re: Giving advice over the phone about pain relief

Evelyn Barbour-Hill — Sun, 26 Jan 2014 17:20:27 GMT

I think you are all missing the point.

[quote user="Aisling McGrath"]

She has some paracetamol, can she give that?

Now, the use of human paracetamol for a dog is an extra label use of the drug. So requires a prescription? But this animal is in pain now. Can we advise the correct dose over the phone having never seen the animal and not truly assessed its current condition?

[/quote]

If you've given it a bit of thought and are as satisfied as you can be in the circumstances that it could help, or at least will do no harm, of course you can advise accordingly. So it's "off-label" and "outside the cascade" or whatever. So what? Stuff the cascade. You're a professional. Act like one and do what you consider best.

Re: Giving advice over the phone about pain relief

Toby Birch — Sun, 26 Jan 2014 15:29:31 GMT

No conundrum at all. Bring it in. Leaving it where it is should be able to be prosecuted under animal welfare laws. This theoretical animal is not impaled, entrapped and likely does not require any specialist lifting equipment that the owners or a passerby could not locate or improvise.

Re: Giving advice over the phone about pain relief

Linda Filshie — Sun, 26 Jan 2014 14:24:02 GMT

While paracetamol is useful analgesia for mild to moderate pain, surely it will do f-all for its presumably displaced # anyway? Best thing she can do for it is scoop it up in a heavy blanket (oo-er!) and bring it down so it can be seen ASAP once you're done with the caesarean.

Re: Giving advice over the phone about pain relief

Francisco Gomez — Sun, 26 Jan 2014 13:56:13 GMT

[quote user="Aisling McGrath"]

Any thoughts on this clinical conundrum would be appreciated.

[/quote]

Yes, find a job where you don't need to do OOH on your own. Plenty of clinics don't do their own OOHs and don't require sole charge.

" />

Obviously joking " /> but you know... we've been discussed this for last few months..

Re: Giving advice over the phone about pain relief

Neil Wheadon — Sun, 26 Jan 2014 13:36:19 GMT

You can't visit it as you have your hands in a caesarian

Therefore you explain for the welfare of the dog that she gets it into the surgery, as that's where it needs to be.

Here the nurse who is assisting your caesarian can triage and give it appropriate pain relief as after all if it's had an RTA, all you are doing is providing a taxi service for the dog and someones got to move it haven't they.

If this isn't good enough for her, then document it, finish the caesarian then visit.

Getting your practice to provide recording on the phones would be a good idea as you then have proof of the phone advise given.

Neil

Re: Giving advice over the phone about pain relief

John Flynn — Sun, 26 Jan 2014 13:23:35 GMT

I don't know ins and outs of UK regulations, but my thoughts as a vet:

Difficult situation.

Pros and cons to advising the dog to be kept calm where it is until you can get out to it versus trying to bring it to meet you at your clinic - some variables might swing me one way or the other, but might be impossible to know what best option is and I might regret not encouraging the other afterwards.

most paracetamol tablets are 500mg, so I'd be happy to advise giving half a 500mg paracetamol tablet in such a case, but would advise owner as single dose and check ingredients that not anything else in it and not to force it down the dog causing further distress as might not do that much good anyway and best pain management might be to keep nice and still. Can't see anything up to 30mg/kg as single dose orally doing any harm in a dog, but then how much good it'll do beyond making the owner feel is doing something is somewhat debatable I think. Of all analgesic drugs that owner might have, I'd have thought that paracetamol would be best choice in such circumstances.