professional standards

Re: professional standards

grumpyoldman — Sat, 01 Mar 2014 22:14:00 GMT

[quote user="Gillian Mostyn"]This idea of the dropping of standards - does anyone have any hard evidence[/quote]

Medicine and anaesthesia are on average much much better , as are all the diagnostics and toys .

Surgery at the top is also vastly improved , Surgery in the middle has deteriorated , by this the uninsured client that wants to fix a problem for 1000-1500 has to shop around for skills far more than 20-30 years ago , This has also lead to a tendency to try and manage surgical problems medically , examples perineal hernias , obstipated cats getting multiple enemas instead of STCR , fractured pelvis cases needing sacro illiac screws being left to hobble about , None sojgrens dry eyes not getting a PDT . Even chronic unresolved none responsive anal sacs trawling about between 3 or 5 practices before someone will remove them without problems . Labradors with elbow dysplasia being managed on metacam and getting bagged at 3 instead of having thieir ulna cut at 6 months .

So lots of things are better at the top ,but some things are not in the middle ,and most people are in the middle.

Re: professional standards

grumpyoldman — Sat, 01 Mar 2014 18:44:00 GMT

[quote user="Hannah Wynne Richards"]

to lack the old-fashioned loyalty which used to exist between fellow professionals.

[/quote]

I do not think there ever was much of that really , but there probably is none at all now . It was always a bit dog -eat dog ,but much more subtle , people did wait for clients to come through the door and did not try and drag them through with free dog food and other freebies .

That is the main difference really marketing selling and pushing , but a drop in competence , I now see perineal hernias as a fourth and fifth opinions because there are no senior partners left who can do an internal obturator transplant for less than a £1000 or do it at all really , everyone tries to ship them off to a guru or leaves them on lactulose forever . Not really what I would call increased competence or progress !!!.

Re: professional standards

grumpyoldman — Sat, 01 Mar 2014 18:32:08 GMT

[quote user="Kishor Mahind"]This is for grumpyoldman also to read following from other discussion going on the forum.[/quote]

GIVING YOUR BUSINESS AWAY TO THOSE WHO KNOW THE COST OF EVERYTHING AND THE TRUE VALUE OF NOTHING IS NOT PROGRESS ITS STUPIDITY !!! and George Bernard Shaw was a glib artisan with no scientific background or input.

Re: professional standards

Evelyn Barbour-Hill — Sat, 01 Mar 2014 17:24:48 GMT

[quote user="Gillian Mostyn"] the 'local GP' has gone (thank goodness)[/quote]

I disagree.

Re: professional standards

Michael Woodhouse — Sat, 01 Mar 2014 15:39:06 GMT

[quote user="Robin Grimmer"]

And "we have no proper nurses".

Come on, this is 2014.

[/quote]

We are mainly large animal. We've had 2 small animal ops this week (admittedly that is quiet for us, but busy with outside work).

I've done more farm surgery.

What would I do with a proper nurse the rest of the time? (although she would have been handy for the bitch caeser at midnight on Thursday)

Re: professional standards

Anthony Todd — Sat, 01 Mar 2014 15:37:54 GMT

[quote user="Robin Grimmer"]I had a blocked cat in this morning. Been ill for 2 days, owner didn't notice any straining etc. Just a very sick cat. I did bloods,[/quote]

Sorry, I'd just take a wild guess that the levels would be off the clock and unblock the cat while you were waiting for the results. How would the results make any difference to the treatment anyway?

Have you ever seen a cat blocked for 2 days with normal [K++] and BUN?

Unblocked cats always get better.... well mine did anyway.

And another poster, on the recurrent blocked cats thread, actually said he took bloods to cover his rear if things didn't go well.

Scabies yes, poor example, I agree but you know what I was getting at.

Look at some skin cases and note how relief was delayed for the sake of a diagnosis.

Re: professional standards

Hannah Wynne Richards — Sat, 01 Mar 2014 15:11:05 GMT

Robin You're absolutely right. Be prepared to do things properly, by modern standards - but also remember that animals are ill 24/7 therefore all practices need TO MAKE ARRANGEMENTS for 24/7 cover, and also be prepared to visit (and stop making specious excuses to avoid visiting ) when necessary. Best of the new, and best of the old.

Wynne

Re: professional standards

Robin Grimmer — Sat, 01 Mar 2014 14:31:53 GMT

[quote user="Anthony Todd"]

And the bottom-protecting bloods before unblocking the cat for the same reason.

[/quote]

I had a blocked cat in this morning. Been ill for 2 days, owner didn't notice any straining etc. Just a very sick cat. I did bloods, I wasn't 'bottom protecting' . I wanted to what it's renal levels and potassium were before treatment, so I could give the owners a better idea of prognosis, how long he might need to stay in on a drip etc and then have something to compare to after treatment.

And there's nothing wrong with giving a case of scabies a short course of steroid at the beginning while your treatment is working - Demodex a different matter of course.

Re: professional standards

John Flynn — Sat, 01 Mar 2014 11:59:23 GMT

[quote user="bob lehner"]Which is really what the currently trendy term 'Clinical Governance' is all about[/quote]

And as with so many trendy terms, it sounds a little wishy-washy to me.

What is this supposed to mean?

I looked up the reputable source of wikipedia to find a term relevant to large NHS health structures, not isolated veterinary practitoners.

If it means nothing, then say nothing; if it is suppposed to mean something specific, then spell it out?

Did anyone see the bbc comedy twenty-twelve? loved it! "I really think that is what sustainability/legacy is all about"

[quote user="bob lehner"](and by the way it is in the Code of Professional Conduct that all VSs must make CG part of their life [/quote]

as ever, glad i'm not part of uk regulation but i'll remember it for my next clinical appraisal as i strategise risk management on morbidity audits, prefarably in triplicate

Re: professional standards

bob lehner — Sat, 01 Mar 2014 11:45:49 GMT

[quote user="Marie Kubiak"]Seeing practice 15yrs ago I remember one place where the Xray machine was in dog kennels with no protection provided for in-patients during use, others where use of gloves/gown/mask was unheard of during any surgery, chemo/referral/ultrasound weren't considered options... One of my jobs as a student was to pick through the sharps bin and remove all syringes from attached needles to save space - health and safety has also definitely improved since this time![/quote]

Quite agree - there were some terrible issues in the past - I'm still awaiting the onset of some ghastly cancer from all the rads I soaked up in my early days in practice - however I'm afraid you might still find practices where some of this goes on, even now, to a greater or lesser degree..

Thanks in no small part to PSS vets and nurses seeking employment these days can at least have a realistic expectation that their employers have properly addressed the major hazards of the veterinary environment.

Re: professional standards

Anthony Todd — Sat, 01 Mar 2014 11:43:13 GMT

[quote user="Hannah Wynne Richards"] !!!!!!!!!!!!!!!!!!!!!!!!!!!!![/quote]

[think of all the ink being wasted, let alone the mBs]

Anyway, to return, and await the inevitable red star.

"proper nurses" My head nurse started as a school girl, anaesthetised all the GAs for 40 plus years and never lost one, mind you it was the Stephens. [don't start].

Some of the most dangerous nurses we ever had were RVNs who wouldn't see the wood for the trees.

We operated always without gloves and masks doing far more ops daily with certainly no more comebacks than recently and using dissolveable sutures in the skin of cat says etc. etc.

Now it's always the fault of the material, never technique.

My point is this.

While "standards" have improved often "standards" are equated with modern medical methods and not successful end results.

I am reminded of the classic RMM cartoon 40odd years ago "I want the dog to get better, doc, so skip the lab tests".

And the bottom-protecting bloods before unblocking the cat for the same reason.

The muscle biopsy of the temporal atrophy where no one can suggest any treatment other than pred.

The endless Xrays and scans for an obvious FB when really an ex-lap in 30 mins would give far more info and sort the problem or not.

The trend now not to treat without, at least, some tests in all cases, and often with an elizabethan collar on a dog to prevent damaging the skin prior to the biopsy...

The trend now is diagnosis at all cost [and boy, the cost] rather than cure quick, or at least relieve symptoms while a diagnosis is pursued, only if the diagnosis will change anything....

Of course drugs, diagnosis and treatment have improved enormously and tests in some cases are essential, but sometimes I feel that our primary purpose of all that is to make the animal better and that has slid down the list of priorities.

And I know someone will tell me to scrape for scabies before hitting it with steroids; even I did skin scrapes and never gave scabies steroids....

Re: professional standards

bob lehner — Sat, 01 Mar 2014 11:33:42 GMT

[quote user="Kishor Mahind"]

[quote user="Hannah Wynne Richards"]

Best of the old, and best of the new - or at least that's what I'm trying to achieve.

Wynne

[/quote]

Very well said, this is exactly what everyone should be striving for - old brings experience, new brings fresh ideas and innovations.

[/quote]

Which is really what the currently trendy term 'Clinical Governance' is all about (and by the way it is in the Code of Professional Conduct that all VSs must make CG part of their life - not a lot of people know that I suspect).

Re: professional standards

Hannah Wynne Richards — Sat, 01 Mar 2014 10:53:26 GMT

Gillian. That's me sunk. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Wynne

Re: professional standards

Gillian Mostyn — Sat, 01 Mar 2014 10:41:57 GMT

[quote user="Bob Russell"]£10 boosters and a vet that cannot speak English is another matter![/quote]

But equally a £50 booster from a 10th general Anglo Saxon doesn't guarantee a quality service.....

Re: professional standards

Bob Russell — Sat, 01 Mar 2014 10:18:42 GMT

[quote user="James Laidlaw"]Having a "standard" aneasthetic regime in itself isn't the best idea. Each patient is an individual and it's aneasthetic should be tailored to that patient.

[/quote]

Nothing wrong with a standard anaesthetic regime. If it works for the vast majority of patients it is standard. What counts is being willing and able to adjust/modify when the patient is not standard!

We use ACP/buprenorphine/propofol/iso for 90%+ of cases. It is therefore standard. i/v triple mix for cat castrates, reduced dose ACP for boxers/collies. Having a standard protocol means more experience and in my view safety.

I believe general standards of care are way above that in the past. CPD is so much more available than it was in the past.

£10 boosters and a vet that cannot speak English is another matter!

Re: professional standards

Marie Kubiak — Sat, 01 Mar 2014 09:18:53 GMT

I have to say I think clinical veterinary practice has come on significantly, even in recent years. Seeing practice 15yrs ago I remember one place where the Xray machine was in dog kennels with no protection provided for in-patients during use, others where use of gloves/gown/mask was unheard of during any surgery, chemo/referral/ultrasound weren't considered options... One of my jobs as a student was to pick through the sharps bin and remove all syringes from attached needles to save space - health and safety has also definitely improved since this time!

I cannot say that there has been any concurrent change in the dedication of vets or patient/client empathy, however I think vets are getting more demanding with their own standards of living and with good justification. It isn't easy to balance a family and social life with 24/7 commitments and just because previous vet generations have survived it doesn't make it right. Wanting time off call and to be confident standing up to the increasingly demanding (and litigious) client base are not things that make us bad people. This has been debated ad infinitum on other threads so I won't get back into it but equating the attempt to regain a work-life balance in line with other professions doesn't automatically make veterinary or animal welfare standards drop.

Marie

Re: professional standards

Gillian Mostyn — Sat, 01 Mar 2014 09:03:47 GMT

Well going back to professional standards, I have always found that, as a profession, veterinary surgeons and nurses to be a really nice bunch of people who genuinely care about their patients and their colleagues and always try to give a high standard of care. I have found that all the Vets that I have had contact with, working in the many and varied practices around me, are great people willing to help each other out at any time. I don't like this 'corporate bashing'. I am not a fan at all of the JVP business model - I do think that it is taking the income and control away from the person doing all the work and undermining the profession's image - but the people working in these practices are, on the whole, still working hard under sometimes difficult conditions, just trying to make a living like the rest of us.

This idea of the dropping of standards - does anyone have any hard evidence? As far as I can see it, there has always been a range of available services, from the vet doing 'kitchen table operations' to the state of the art practice. If anything, there are fewer of the former now. Yes, veterinary practice is changing, but that is the same for every profession. In the same way that the 'local GP' has gone (thank goodness) and we now have modern medical practices with easy access to different opinions, services and specialisms.

I would compare the sentence 'vets of today aren't like they were in our day' to the comment 'the youth of today....'. You can't argue with a rose tinted view of the past!

Re: professional standards

Robin Grimmer — Sat, 01 Mar 2014 08:00:27 GMT

I don't see how you can say this:

[quote user="Michael Woodhouse"]

We have a large board in the waiting room with our logo and the slogan "a modern practice with traditional values". I stand by that 100%.

[/quote]

And "we have no proper nurses".

Come on, this is 2014.

Re: professional standards

Mark Holmes — Sat, 01 Mar 2014 03:40:37 GMT

[quote user="Michael Woodhouse"]

[quote user="Mark Holmes"]Butorphanol is not adequate analgesia, at least use buprenorphine, better still comfortan.[/quote]

I think buprenorphine is a lousy sedative and takes too long to work. We have no proper nurses so like them flat with the pre-med. The alpha 2 provides good analgesia with the partial opioid. I did use some Confortan but found noticeable respiratory depression. For more painful ops I will give it as closing up so it's in place for recovery. Obviously they get NSAID pre-op. They are not in pain.

Have you ever given a colicing horse IV butorphanol? Try that and then tell me its not a decent analgesia...........

[quote user="James Laidlaw"]Each patient is an individual and it's aneasthetic should be tailored to that patient.[/quote]

I consider each patient as an individual, but I'm not sure the last time I did anything different (alter dose rates depending on co-morbidity). The last bottles of Alfaxan went out of date.

[/quote] Visceral pain is not somatic pain, dogs are not small horses. Tramadol works great in humans and is poor in dogs. Use comfortan at 0.3 mg/kg even Dechra admits the licensed range is too high. Speak to anaesthetists they wouldn't consider butorphanol. Give buprenorphine sooner. Butorphanol effectively antagonises comfortan so giving it later makes it much less effective.

Re: professional standards

Michael Woodhouse — Sat, 01 Mar 2014 00:50:23 GMT

[quote user="Mark Holmes"]Butorphanol is not adequate analgesia, at least use buprenorphine, better still comfortan.[/quote]

Have you ever given a colicing horse IV butorphanol? Try that and then tell me its not a decent analgesia...........

[quote user="James Laidlaw"]Each patient is an individual and it's aneasthetic should be tailored to that patient.[/quote]

I consider each patient as an individual, but I'm not sure the last time I did anything different (alter dose rates depending on co-morbidity). The last bottles of Alfaxan went out of date.

Re: professional standards

Mark Holmes — Sat, 01 Mar 2014 00:21:39 GMT

[quote user="James Laidlaw"]Having a "standard" aneasthetic regime in itself isn't the best idea. Each patient is an individual and it's aneasthetic should be tailored to that patient.

[/quote] Yes and no. A "standard" may not be ideal for every patient but there is an argument to support familiarity with a drug combination and that familiarity may in a general practice setting be safer than the marginal benefits you get from a tailored "perfect" drug combination. I tried to list the various combos I use and realised it would be a long post. It's quite a menu but often based on handling and analgesia as priority concerns.

Re: professional standards

James Laidlaw — Sat, 01 Mar 2014 00:09:49 GMT

Having a "standard" aneasthetic regime in itself isn't the best idea. Each patient is an individual and it's aneasthetic should be tailored to that patient.

Re: professional standards

Mark Holmes — Sat, 01 Mar 2014 00:02:55 GMT

[quote user="Michael Woodhouse"]

[quote user="Hannah Wynne Richards"]What is your standard anaesthetic regime?[/quote]

Medetomidine/butorphanol pre med, propofol induction and iso maintenance. I tried Alfaxan but don't like it. Sevo is only licensed for dogs. We do anaesthetise some farm animals and iso has a meat withdrawal in the horse and can therefore be used under the cascade in food producing animals.

That's not really the point though. As long as you have a safe effective way of carrying out a procedure and are prepared to look around and improve your practice then deciding not to run with every new trend is not a problem, in my eyes.

We have a large board in the waiting room with our logo and the slogan "a modern practice with traditional values". I stand by that 100%.

[/quote] Butorphanol is not adequate analgesia, at least use buprenorphine, better still comfortan. I cannot think of any good reason for using butorphanol. It gives no better sedation, it's no cheaper is a poor analgesic. Why?

Re: professional standards

Michael Woodhouse — Fri, 28 Feb 2014 23:46:33 GMT

[quote user="Hannah Wynne Richards"]What is your standard anaesthetic regime?[/quote]

We have a large board in the waiting room with our logo and the slogan "a modern practice with traditional values". I stand by that 100%.

Re: professional standards

Kishor Mahind — Fri, 28 Feb 2014 22:38:28 GMT

[quote user="Hannah Wynne Richards"]

Best of the old, and best of the new - or at least that's what I'm trying to achieve.

Wynne

[/quote]

Very well said, this is exactly what everyone should be striving for - old brings experience, new brings fresh ideas and innovations.