Home visits

Re: Home visits

Utlendigur — Fri, 27 Mar 2009 15:00:27 GMT

Going back to the original topic...17yrs in practice in an ok area have still caused more than a few nasty moments. The midnight visit to an RTA dog - the address turned out to be a squat in a derelict building with about 12 drunk young lads (just scooped the dog up and got out asap), being virtually imprisoned by a drunk depressed client who wouldn't let me leave for about 2hrs, the collapsed dog whose owner was so drunk I could barely understand him and who couldn't even tell me the address where the dog was - he suggested I pick him up in my car on a street corner - stupidly I agreed, asked my boss to accompany me but he simply told me to phone him when I got back, dealing with drunken abusive clients alone, having to carry a pts 40kg (I weigh 55kg!) dog 100m up a steep Welsh hillside singlehanded. I could go on. Added to that is the fact that we have no suitable lone working policy other that "you could phone the nurse if you were worried" - so nobody knows that I have even gone on a call, let alone checks I've returned - I even tried writing a risk assessment and policy but my boss has ignored it. Vets seem to be in a grey area between healthcare professionals and private companies. NHS workers get back up from police and are expected to wait for that to arrive if worried. Plumbers and the like can refuse visits with no comeback. Personally I would like to see a default position of not visiting unless the vet is happy to go - rather than only being able to refuse if you can prove concerns over "life and limb". Also I would like employers to be forced to show they have workable written staff safety policies that are actually in use. We are a tier 2 PSS practice which uses Citation - and yet our H&S manual simply omitted lone working - and RCVS never queried it, or the lack of a risk assessment (which is a legal obligation)

Re: Home visits

Karen Eggleton — Tue, 24 Mar 2009 19:06:59 GMT

JAK Marketing 80p narrow tourniquet (none of that rubber or velcro rubbish) - my best buy ever! (possibly because it was cheap) and I was ALWAYS an artery forceps & elastic band girl. I'll cry the day I lose it...

Re: Home visits

Alex Avery — Tue, 24 Mar 2009 17:43:23 GMT

I second the elastic band and artery forceps...for dogs, in cats I generally give around 10ml IP (and overdose of an overdose!) having forwarned the owner that this can take a little while to work and may need a second intracardiac injection. I dont find the cat objects to the injection at all and only about 5% need 2nd injection and then its probably because I am aware of the time pressures. I have always done it this way as dont like the idea of restraining old (arthritic) cats with poor veins, plus I am often unable to call on an extra pair of hands. As for dogs, I dom/torb them and (touch wood) have never had any vomit. I wait until they are a bit sleep but not flat out and dont find their veins are too collapsed at all for raising with said elastic band.

its interesting to hear what others do and I may reconsider my approach. as for horses mat, warn the owners and cross fingers!!!

Re: Home visits

Hanna Bennett — Tue, 24 Mar 2009 17:12:01 GMT

i hate those tourniquets! can never get them to release! swear by an elastic band and pair of artery forceps...

Re: Home visits

Mark Frost — Tue, 24 Mar 2009 15:03:10 GMT

I'll certainly give it a go.. just to add that I haven't (yet) had one actually vomit and only very occasional gagging - I don't really have a problem from that point of view its more the pain aspect that would stimulate me to change!

Re: Home visits

ms1083 — Tue, 24 Mar 2009 13:31:24 GMT

I was waiting for someone to ask that. I have not yet had ket/midazolam lumbar muscle IM injection get much response at all to. In theory ketamine stings on injection - does the midazolam stop that? I always warn the owner though. Its such a tiny volume, and injected though orange needle quickly seems to cause very little/no reaction. Even if it did sting its so quick and I still feel that is better than gagging/vomiting with dom so it wouldn't change what I do. Do try it Mark, I bet you would be converted!

Re: Home visits

Mark Frost — Tue, 24 Mar 2009 13:20:40 GMT

I'd also highly recommend the handy tournique for IV catheter placement...

Re: Home visits

Mark Frost — Tue, 24 Mar 2009 13:10:45 GMT

Hi Matt, hope you are well!!

Very much agree with the ketamine/midazolam combo for old ill cat investigations, but for euthanasia do you have any problems with pain on injection? Mostly there is no reaction to dom/torb in the cats I use it in and wouldn't want that to change!

Re: Home visits

Karen Eggleton — Tue, 24 Mar 2009 00:15:27 GMT

I'd second Matthew's midazolam/ketamine combo plus a brilliant JAK tourniquet for IV cephalic. Still searching for my perfect dog pre-euthanasia sedative & have been scouring the American forums. There they nearly always seem to sedate pre euthanasia, mostly with Telazol which I don't think we can get. The alternative seems to be Big M.A.K., which (I think) is midazolam, ACP, ketamine. I tried midazolam/ketamine in a large dog recently and didn't get on-too much volume, too much sting, too much dysphoria.I always used to use dom/torb but found it variable & have read lots of horror stories about all the things that can then go wrong after its use, like collapsed veins & slow euthanasia if you have to resort to IP.

The American welfare societies have plenty of info on the use of intracardiac injections which it would appear some centres do on mass withoout prior medication.The general concensus is that it is inhumane unless the animal is heavily unconscious. I was always quite happy to use it if necessary until recently-sedated a cat with diazepam & ketamine then did intracardiac stick but it stretched horribly and although it died immediately, I was convinced I caused it pain . I always check with a toe pinch first but am not so happy to use this method anymore. Quite like intrahepatic but I find it either works great or is useless.

If anyone has a handy solution for pre-euthanasia sedation in a dog that does not cause pain on injection, vomiting, dysphoria, doesn't knacker the veins & is foolproof, I'd love to know. I do housecall euthanasias on my own & I age approximately 5 years each time!

Re: Home visits

ms1083 — Mon, 23 Mar 2009 22:36:35 GMT

For the average cat I use ketamine (about 0.25ml of 100mg/ml solution) mixed with 0.25ml midazolam of (5mg/ml solution) in the same syringe givem in the lumbar muscles.This causes anaesthesia in about 1-2mins and does not cause vomiting, its very smooth and also as a bonus it raises blood pressure so veins are easier, although if alone I tend to go for the kidney (never from conscious though). Always do this on visits and quite often in the consulting room too. Most owners who don't want to stay for the pentobarb stay whilst the sedation works.

Never tried it on a dog, tend not to need to sedate but if I do I use acp/dom&torb and always put in catheter when on visits - its all easy then.

Also use this combo for old,ill,critical cats for sedation for xrays etc at 5-7mg/kg ketamine and 0.25mg/kg midazolam. Only problem is that midazolam does not last as long as ketamine so they do sometimes have a bit of a ketamine wake up. Diazepam lasts longer but not well absorbed from muscles so give it iv with ketamine instead of midazolam and at same dose, 0.25mg/kg.

Re: Home visits

Mark Frost — Mon, 23 Mar 2009 22:22:07 GMT

Unfortunately I do not believe we can ever know for sure what degree of pain/stress occurs in these situations regardless of method, however in my experience (with cats in need of euthanasia) restraint and IV injection/catheterisation is more stressful (in some situations) than the method I sometimes employ. Seeing animals under general anaesthesia react to an ear flush, or dental exploration and not responding in any way to the procedure is enough for me. I am always careful that the depth of sedation is profound before injecting and have frequently had horror stories of IV euthanasias from clients during. Its not for every case, but I genuinely believe that when it is used it is the best option for the animal concerned. I would be happy if an anaesthesia expert could back up either argument as if I'm wrong I'd love to find a viable alternative!

Re: Home visits

Gillian Mostyn — Mon, 23 Mar 2009 20:21:35 GMT

[quote user="Mark Frost"]With most cats I use dom/torb (at approx 0.05ml/kg each - often higher as I don't tend to calculate), and then inject pentobarb intracardiac once the cat is fully asleep[/quote]

I know we all have our own methods, but how do you know this isn't painful? Both dom and torb are sedatives, not intended to induce anaesthesia. I am certainly not an expert in anaesthesia, but I would have thought that even if the animal doesn't react, it will most probably be able to feel an intracardiac injection? Or is the depth of sedation that profound? I am not being sentimental - inevitably PTS carries some degree of stress for cats - but I would have thought intracardiac injections could be avoided except in anaesthetised animals?

Re: Home visits

Hanna Bennett — Mon, 23 Mar 2009 16:51:46 GMT

'fraid not - i use acp/domitor which does cause vomiting, however i find if you explain this to owners beforehand they are quite accepting.

having said that i put a catheter in every euthanasia i do, so only sedate the really fractious cats, whose owners are usually so grateful not to watch their pet go screaming that they accept the side issue of vomiting quite well.

Re: Home visits

Mark Frost — Mon, 23 Mar 2009 16:46:21 GMT

With most cats I use dom/torb (at approx 0.05ml/kg each - often higher as I don't tend to calculate), and then inject pentobarb intracardiac once the cat is fully asleep. Obviously, this is fully explained to the owners first and I very rarely have any kind of reaction at all - from a vomiting/distress point of view. Rarely, they take very deep gasps following the pentobarb but this is explained to the owners before hand and the cat is fully sedated and unaware (they never respond to the injection itself). I've found that this is much less stressful for both cat and owner and I generally don't need anyone else present and don't need to worry about getting a vein in a fragile, old, struggling and stressed cat.

Judging each case separately, I do still go IV first occasionally but rarely. I use the same technique for some small dogs if they are difficult to handle - particularly in home visit and emergency situations - but I don't find it reliable enough for larger dogs unless given IV and you may as well given pentobarb to start!

Re: Home visits

Mialee Blair — Mon, 23 Mar 2009 15:58:35 GMT

if this isnt taking it off topic-do you have a good solution for sedating cats in this situation-I have yet to find anything that doesnt induce vomiting and that causes great distress.

Re: Home visits

Evelyn Barbour-Hill — Mon, 23 Mar 2009 13:24:57 GMT

No offence taken! It's just a personal feeling, no big deal. At the surgery with skilled assistance I can just slip a little pentobarbitone into a cephalic vein and off they quietly go; or if need be, slip it into a kidney. Out at the house the danger of distressing difficulties and struggles is just too great.

I was once accused (about 1974) of all sorts of incompetence and cruelty. I got to the house, the owner said "there's the cat" and went back to drinking tea and blethering with her gossips. The cat struggled, I had to put pentobarb intraperitoneal and wait for it to fall asleep and then put some intracardiac. I kept it restrained on my knee while waiting, and it meowed a bit. The boss got a furious letter from the owner saying I had manhandled the cat, it was shrieking in agony, blah blah blah.

Re: Home visits

Hanna Bennett — Mon, 23 Mar 2009 07:57:21 GMT

Not meaning to cause offence, but why never cats? From personal experience with my own pets i would never wish to take them to the surgery to be euthanased, especially cats as the journey distresses them so much, and i see no reason why clients should be any different in this respect. Difficult cats can be sedated the same as dogs, surely? The issue i was questioning was the distance more than anything else.

Re: Home visits

Evelyn Barbour-Hill — Mon, 23 Mar 2009 01:17:51 GMT

[quote user="Hanna Bennett"]We had a call at eight pm a couple of nights ago to euthanase a cat that had been hospitalised for two days and we had advised euthanasia. The owner refused and asked to take it home. He lives at least forty minutes drive away, and the vet on call had to refuse as it was too far if another call came in, which the owner was unhappy about. Where do we stand on this?[/quote]

You are fine. I can't imagine anyone disagreeing with this. You are not professionally obliged to pander to the client's every whim (although you may do so for commercial reasons if you wish). And personally I never euthanase cats at home.

Re: Home visits

Liz w — Sun, 22 Mar 2009 22:40:57 GMT

Most vets probably don't want to catagorise themselves as either offering home visits or not offering home visits - but if you normally do, but don't want to go to a rough area on your own late at night, then what do you tell the clients? and are you going to have to publisize that you do home visits to postcodes xyz but not abc?

Re: Home visits

Hanna Bennett — Sun, 22 Mar 2009 12:00:34 GMT

Feel i should explain a bit more about our Pet Taxi service - we have the choice between one which is run by a rather butch woman who can lift bigger dogs than me - and is a van kitted out for transporting large dogs etc in a kennel not a normal taxi, or the local animal ambulance service who have two staff most of the time, one driving and the other with the animal, who are capable of transporting critically ill animals.

We do visits for euthanasia but only for this reason, if the client wants the dog treated we do not take drugs out on visits with us - some parts of town are renowned for their high levels of drug abuse - so the only alternative would be to transport the dog back to the surgery anyway. We will send nurses out to collect dogs (usually two of them and usually at least one of them male) that the owner cannot move, but as previously stated we charge more than the above pet taxi services so these are preferable for most clients. As for euthanasia visits, we try and fit them in round our schedule, and always explain to clients that we are obliged to see appointments that are booked prior to them phoning, so the timing is not always as they would wish. As long as this is explained sympathetically most people understand.

Having said that we frequently get requests for euthanasia visits from clients of our neighbouring practice, and are told they have been refused by them. If we can fit it into our (usually very busy) schedule then we will oblige. How are they allowed to refuse these when they are obviously registered clients?

And i would love to have a nurse available at all times out of hours as someone else has stated - have been occasions where i have been most grateful to the cleaners for being on the premises as i have faced angry clients - one of whom i was doing a favour for as he turned up to collect his dog's insulin after the surgery shut, and given i was in the pub next door for a staff members birthday i agreed to nip back and dispense it without charge, but he took umbrage at 'my tone of voice' when i explained that there should have been a charge and recommended that he be more careful in future - decided to kick the chairs around the waiting room while shouting at the top of his voice. Thankfully he is no longer a client but it does make you more wary!

Generally it is the OOH visits that present the problem not those in normal surgery hours, which i suppose alot of people bypass now by using an emergency service provider. We had a call at eight pm a couple of nights ago to euthanase a cat that had been hospitalised for two days and we had advised euthanasia. The owner refused and asked to take it home. He lives at least forty minutes drive away, and the vet on call had to refuse as it was too far if another call came in, which the owner was unhappy about. Where do we stand on this?

Re: Home visits

Gillian Mostyn — Sun, 22 Mar 2009 08:09:41 GMT

[quote user="Virginia Campbell"]I probably would have gone out to the case Gillian Mostyn described but I don't think I should have to if I don't want to, and if I do I think it's reasonable to request that they get their family/neighbours out of bed too to come and help lift.[/quote]

Absolutely. I am a 5'4" 33 year old - there is no way I would ever go on a visit anyway without a nurse during the day, and I always check there will be help available at night. As I said, our health should be MORE important that the animal's and we could still be suffering with injuries long after that dog and its owners are distant memories....

Another anecdote - got called to a daytime visit for a collapsed red setter. When I suggested they come to the surgery, in a pet taxi, was told they couldn't lift it. I went out, euthanased the dog, the nurse and I then rolled it onto our stretcher at which point the two men present (!!!) said 'ooooooo - that's too heavy for you to lift' and they carried it to my car. ????????????????????? I just stood there amazed.........

Re: Home visits

Virginia Campbell — Sat, 21 Mar 2009 22:01:05 GMT

[quote user="Mialee Blair"]I do feel that owners have a responsibilty to plan for the possibility of an animal needing veterinary attention, of course there is always the housebound elderly client with a big dog [/quote]

Housebound elderly clients should be as capable of forward planning as anyone else, especially if they choose to own a large dog. We aren't expected to wreck our backs hauling big collapsed dogs onto tables without help at work during the day- in fact it's positively frowned upon- so why should we have to do it in the middle of the night hoisting them into a car? It only takes one overweight golden retriever and an awkward lift to give you a chronically knackered back. I probably would have gone out to the case Gillian Mostyn described but I don't think I should have to if I don't want to, and if I do I think it's reasonable to request that they get their family/neighbours out of bed too to come and help lift.

If a client sounds drunk I think it's reasonable to require them to find somebody sober to transport the animal to the clinic and communicate with the vet.

If a client is abusive on the phone - whether they are distressed or not- I think it's perfectly acceptable to slam the phone down, document the conversation, and refuse to have any further communication with the client or to see the animal at the clinic or elsewhere.

Re: Home visits

Evelyn Barbour-Hill — Sat, 21 Mar 2009 21:00:18 GMT

Just to lighten things with a barely-relevant anecdote:

Some years ago when I felt commercially obliged to do visits, I once went at night to a terrace house in a pretty rough part. The owner was a young bachelor with two GSDs. I can't remember what the problem was, something only moderately serious. Inside this house all was utter luxury, carpets, leather, gilt, no expense spared. The owner paid in cash without a murmur.

A few years later the young man was arrested, being probably the biggest wholesale drug dealer in North Wales.

I like to think that on that visit at least both I and my car could not have had better protection.

Re: Home visits

Karen Eggleton — Sat, 21 Mar 2009 20:44:22 GMT

I run a small animal housecall service, providing 24/7 cover, am (youngish) female & work solo. I had concerns when I started up my practice that I did not want to have requests from non registered clients (in other words, people I did not know) requesting a home visit in the middle of the night. I approached the RCVS about having a separate emergency number for OOH that is only available to my clients. I did not want to be in the position of having to say no to someone requesting an emergency home visit ( for my own conscience & from the point of view of RCVS rules) and although I am aware that I can refer people back to their vets if already registered elsewhere, I suspected I would have people not being completely truthful with me about where their pet may have been seen previously. If they claim not to be registered anywhere, then they become my responsibility.Plus, certain local practices will avoid home visits at any cost and I was not willing to be their substitute.

Initially, I was informed that to have a separate OOH number for my clients was acceptable. On speaking to a second Professional Conduct member, I was told that it was not and that I must have my OOH number freely available to anyone who may call.

Well, I'm sorry but my personal safety comes above a client's demands. I have one client who I find a little disconcerting so, forewarned, I always now go on daytime visits to him accompanied by my partner.OOH, I may not be able to plan ahead for back up. I am not willing to put myself in this position OOH but the impression the RCVS leaves me with is that this is of no concern to them.

Re: Home visits

Mialee Blair — Sat, 21 Mar 2009 20:21:31 GMT

Just to look at it from another point of view, why should we have any obligation to do visits at all either OOH or routinely?

Have you tried getting a home visit from a dentist?

Have you tried getting a home visit from a GP, during the day is difficult at night you either wait literally hours or are told to go to casualty.

As a practice we do do visits during working hours though always tell clients who ask about euthanasia visits etc that if they phone in the middle of evening surgery its not going to be possible. What I object to is being legally obliged to or such a big issue being made of it.

I do feel that owners have a responsibilty to plan for the possibility of an animal needing veterinary attention, of course there is always the housebound elderly client with a big dog but the vast majority of visits seem to involve parking in the drive behind 2 cars!

Oue local ambulatory practice offers a 24hr service for euthanasia only, any other emergencies are directed to another OOH provider who does not routinely do visits so dont know how that would tie in to the proposals?