Vets Now utterly overcharging.

Re: Vets Now utterly overcharging.

Michael Woodhouse — Sat, 10 Jul 2010 23:25:21 GMT

[quote user="Hannah Wynne Richards"]

Micheal

If the majority of the anaesthetists you met at college were residents, then they were probably varying things for their case books !!!!!!!!!!!!!!!!!!

It might be an idea to ask someone who already has an anaesthetic diploma if you could spend a day or two observing them ( it might count as CPD time )

Wynne

[/quote]

Oh it would count as CPD, but I could find better use of my CPD time! Anaesthetics not really an issue, thanks. Unless I wanted to start pratting about with CRIs and NMJBs then I would seek further training.

Different species not comparable in terms of anaesthetic risk - still around 1 in 1-200 horses die and most of their anaesthetics are done by an anaesthetist, or at least by a second vet (a very rare luxury in vet medicine).

Re: Vets Now utterly overcharging.

Anthony Todd — Sat, 10 Jul 2010 23:16:43 GMT

[quote user="Evelyn Barbour-Hill"]Er, should that be Hydra[/quote]

#Move to pedant's corner

Re: Vets Now utterly overcharging.

Clive Ansell — Sat, 10 Jul 2010 21:33:10 GMT

[quote user="Louise Buckley"]

[quote user="Evelyn Barbour-Hill"]

[quote user="Clive Ansell"]Many OOH staff are of course on commission based pay.[/quote]

Interesting

[/quote]

NOT Vets Now staff!

[/quote]

I was not referring to Vets-Now specifically. As well as working for Vets-Now as a locum where I was paid a flat rate with no commission, I have worked in 3 other independent OOH clinics where commission is paid to permanent staff.

On the subject though, this is taken from a Vets-Now vacancy advert.

Your Package
You will be well rewarded as we offer a competitive salary, and access to our excellent flexible benefits package, which can be tailored to meet your individual needs and lifestyle. You’ll also be eligible for our Clinic Bonus Scheme, which for an on target performance can add at least 2.5% of your salary. In addition, we provide a regional allowance in selected locations.

What does "eligible for our Clinic Bonus Scheme, which for an on target performance can add at least 2.5% of your salary" mean exactly?

Re: Vets Now utterly overcharging.

Evelyn Barbour-Hill — Sat, 10 Jul 2010 19:10:08 GMT

[quote user="Anthony Todd"]Boy, this thread's got more heads than medusa. [don't start one on mythology FCS!][/quote]

Er, should that be Hydra? I think Medusa had just the one head but lots of snakes. Perseus chopped it off and later found it jolly useful when rescuing Andromeda.

Oops I've started one on mythology!

Re: Vets Now utterly overcharging.

Hannah Wynne Richards — Sat, 10 Jul 2010 14:32:08 GMT

Micheal

If the majority of the anaesthetists you met at college were residents, then they were probably varying things for their case books !!!!!!!!!!!!!!!!!!

It might be an idea to ask someone who already has an anaesthetic diploma if you could spend a day or two observing them ( it might count as CPD time )

Wynne

Re: Vets Now utterly overcharging.

Hannah Wynne Richards — Sat, 10 Jul 2010 14:27:10 GMT

Sorry Evelyn My apologies I should read things more carefully in future. It's your "Me too " comment which I placed in the wrong category, and assumed you meant you didn't have the equipment !!!!!!!!!!!

All I can do is apologise

Wynne

Re: Vets Now utterly overcharging.

Anthony Todd — Sat, 10 Jul 2010 06:58:35 GMT

[quote user="phipps"]On these figures it would seem that the veterinary profession has some catching up to do[/quote]

Be careful with comparisons. Very few human patients die in the theatre but are placed on life support and put in ICU, and die later from "complications".

If a certain well-known pop singer who died in the US after, apparently, being given i/v propofol at home, had been in hospital at the time, the outcome may have been the same but I'll bet it wouldn't have been an an"anaesthetic death".

Boy, this thread's got more heads than medusa. [don't start one on mythology FCS!]

Re: Vets Now utterly overcharging.

Glen McIntosh — Sat, 10 Jul 2010 01:34:16 GMT

[quote user="Michael Woodhouse"]My main experience of vet anaesthetists was at college. Varying the opioid due to day of week and prevailing wind rather than a particular benefit of drug X over drug Y. [/quote]

Perhaps they were doing this as a learning excercise for the students, to give you exposure to all of the different drugs that you might experience in practice, rather than for their own amusement or stimulation?

[quote user="Michael Woodhouse"]

The majority of the anaesthetic is very dull and if you use a standard pre-med and same induction and maintenance etc you wouldn't get bored? They vary things for their own stimulation, something that I try not to as since anaesthesia only requires a small part of my time, same recipe produces good results. I alter drugs when appropriate, but that's actually not very often (casers, blocked cats, really bad heart are the few examples that pop into my head ATM).

[/quote]

If I am honest I probably have a similar veiw and approach. And it is a truism that the safest anaesthetic is the one you have most experience with. But I was given pause after a recent CPD event where we were given statistics from some recent studies. I cannot remember the exact figures but for veterinary (cats and dogs) patients the rate of death peri-ga for all GA's (healthy and sick patients) was something like 1 in 1000 GA's. In human patients similar studies showed mortality rates were something like 1 in 10000. (Or maybe it was 1 in 10000 and 1 in 100000 respectively, I can't remember exactly.) But whatever the exact figures they showed that veterinary patients were around 10 times more likely to die during or after GA than human patients. Most human GA's are performed by specialist anaethetists.

On these figures it would seem that the veterinary profession has some catching up to do if we want to match our medical cousins. Of course there may be a whole lot of reasons for this difference apart from the presence of a specialist anaesthesiologist during human GA's, but it did make me ponder that maybe specialist anaethetists have some use after all and that vets as a whole (and their patients), including me, could benefit from regular CPD training in anaesthesia.

Re: Vets Now utterly overcharging.

james hunt — Fri, 09 Jul 2010 23:33:24 GMT

[quote user="Michael Woodhouse"]

My main experience of vet anaesthetists was at college. Varying the opioid due to day of week and prevailing wind rather than a particular benefit of drug X over drug Y.

[/quote]

This was the only reason that you were given by the anaesthetist for the choice of drug? To some extent yes i agree, opioids do pretty much the same thing, some just work faster/persist longer than others.

[quote user="Michael Woodhouse"]

[quote user="james hunt"]I'd hazzard a guess that in most cases they'll be trying to produce appropriate levels of analgesia/anaesthesia with minimal cardiovascular and respiratory depression, and minimise risks of drug side effects/toxicity? [/quote]

Aren't we all every time we induce anaesthesia?

[/quote]

Yes quite, and i'm pretty confident a specialist anaesthetist is going to be able to achieve this far more consistently than I am able to.

Re: Vets Now utterly overcharging.

Louise Buckley — Fri, 09 Jul 2010 23:21:57 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Clive Ansell"]Many OOH staff are of course on commission based pay.[/quote]

Interesting

[/quote]

NOT Vets Now staff!

Re: Vets Now utterly overcharging.

Michael Woodhouse — Fri, 09 Jul 2010 23:20:11 GMT

[quote user="james hunt"]Have you asked your 'Anaesthetists' what they are trying to achieve by employing these drugs, which you feel the patient doesn't need or benefit from?[/quote]

My main experience of vet anaesthetists was at college. Varying the opioid due to day of week and prevailing wind rather than a particular benefit of drug X over drug Y. Animals that were stable under anaesthesia we [as students] were instructed to turn down until something started to come around during surgery. That happened most days. If the animal is stable - leave well alone.

Aren't we all every time we induce anaesthesia?

Re: Vets Now utterly overcharging.

james hunt — Fri, 09 Jul 2010 22:45:43 GMT

Thanks, Evelyn, you're right. Michael- apologies if that sounded offensive, but suggesting that 'Anaesthetists', or even anaesthetists decide to use different drugs in different cases for the sake of it is rather a generalisation.

Have you asked your 'Anaesthetists' what they are trying to achieve by employing these drugs, which you feel the patient doesn't need or benefit from?

I'd hazzard a guess that in most cases they'll be trying to produce appropriate levels of analgesia/anaesthesia with minimal cardiovascular and respiratory depression, and minimise risks of drug side effects/toxicity?

Re: Vets Now utterly overcharging.

Evelyn Barbour-Hill — Fri, 09 Jul 2010 19:09:34 GMT

[quote user="james hunt"]Oh, and Michael Woodhouse, just because your patients survive their anaesthetics doesn't mean that they couldn't have been performed more adeptly by someone who knew what they were doing[/quote]

That is the sort of comment that any of us in one context or another might feel like making, but having typed it would see that gratuitous offence reflects more on the giver than the recipient and would delete it without sending.

Re: Vets Now utterly overcharging.

Evelyn Barbour-Hill — Fri, 09 Jul 2010 19:01:52 GMT

[quote user="Hannah Wynne Richards"] and Evelyn. If you haven't got the equipment,[/quote]

Why am I included by name here?

By the way, some of you are now forgetting the point of the original post: should the OOH provider have done all that stuff (it wasn't just a bit of biochemistry and intravenous fluid) if it could have waited till normal hours at the main practice, and if they did do it for any reason are they entitled to charge special night rates for every bit of it?

Re: Vets Now utterly overcharging.

james hunt — Fri, 09 Jul 2010 16:23:44 GMT

[quote user="Anthony Todd"]

So, actually, in the clinical situation and for therapeutic purposes, you can tell if a cat is hyperkalaemic from the heartrate then?

[/quote]

I'd like to second Wynne's insightful post that heart rate in these animals will be affected by more factors than the electrolyte balance, which may result in a severely hyperkalaemic cat having a heart rate in the physiological range...so you consider it's not THAT sick,

...but you only listened to it's heart for 15? 30 ? seconds, and you didn't pop an ecg on so you didn't see the peaked T waves, and the acidosis which has accompanied the hyperkalaemia is causing some nasty myocardial depression..so that by the time you cautiously give a bit of propofol the blood pressure is in it's boots and kitty doesn't wake up (seen it)

On the other hand you could take a moribund, hypothermic, hyperkalaemic cat, perform a short investigation (yeah, probably 15 minutes to get the electrolyte results, interpret an ECG and do some not very difficult calculations to start glucose/insulin treatment) and send it home 48 hours later.

Oh, and Michael Woodhouse, just because your patients survive their anaesthetics doesn't mean that they couldn't have been performed more adeptly by someone who knew what they were doing

Re: Vets Now utterly overcharging.

Hannah Wynne Richards — Fri, 09 Jul 2010 16:07:05 GMT

Charlotte, Micheal, and Evelyn. If you haven't got the equipment, you haven't got it, so you have to cope as well as possible without-and the reason so many practices could be better equiped is that veterinary fees are too low.

Not having the equipment is one thing, not offering best treatment to owners who would be prepared to pay , when the equipment is there is another altogether

I would have been tempted to say to Hannah's client "How much do you think the poor taxpayer would have been charged if you at gone to the hospital with a blocked bladder in the middle of the night ?" Hopefully I would have been able to restrain myself, before the owner put in a complaint that I was rude !!!!!!!!!!!!!!!!

Wynne

Re: Vets Now utterly overcharging.

Nixthevet — Fri, 09 Jul 2010 12:25:51 GMT

Just quick reminder to those like Anthony who are trying to learn more about treatment of blocked cats that the Calcium Gluconate does absolutely nothing to treat the Hyperkalaemia- instead it protects the heart fromt he cardiotoxic effects of the Potassium- so must be followed by some effective treatment for the hyperkalaemia to have any benefit. Also only lasts for a short period. The Calcium Gluconate is basically used to stop the cat dying whilst you start some effective treatment.

Re: Vets Now utterly overcharging.

Michelle Tapp — Fri, 09 Jul 2010 10:37:03 GMT

[quote user="Anthony Todd"]Cytology is a non-emergency better done by experts.[/quote]

Most machines in house will produce electrolyte results within 5 minutes.

[quote user="Anthony Todd"]Cytology is a non-emergency better done by experts.[/quote]

A lot of insurance companies require that the urine microscopy is performed within two hours or they won't pay for the prescription diet and again it is a relatively quick test and the crystals easy to recognise.

My personal prtocol is very much tailored to the individual cat. The cat that was eating an hour before and is jumping around the consulting room (usually the one that the owner has seen a previous obstruction or a very alert owner) I would usually cs Urea/Crea/elecs - if these are normal - which they quite often are in these cats, I quite often don't use iv fluids (from a cost point of view - the fluids are more expensive to the owner than the tests!). The more depressed cat that is stretched out on the consulting room table I would usually do preanaesthetic profile and elecs. I think its a good idea to have baseline Urea/Crea as I have seen a few cats that remained azotemic for 5days post unblocking and remained on fluids longer than you would normally expect.[quote user="Anthony Todd"]No one has commented on the regime with Ca and insulin; dose, measurements, problems [/quote]

Most papers now recommend that all cats with hyperkalemia receive Calcium Gluconate 10% 0.5-1ml/ke iv to conteract the cardiotoxic effects of hyperkalemia. I think even without the ability to measure electrolytes it may well be a good idea to administer this in all depressed blocked cats as a precaution. I can't say that I have found bradycardia and arrythmia as a significant presenting sign in these cats - the last one I had had no obvious arrythmia, HR 140bpm (might be considered bradycardia but the cat was v quiet so clinically hard to say) and K+ was 8.7.

With the moderately hyperkalemic cats I would sometimes use Glucose iv or in the fluids to stimulate endogenous insulin production to reduce the K+. I do use neutral insulin in severe cases and this obviously needs careful Glucose monitoring and administration but does work well and quickly.

All of this is always with thorough discussion and communication with the client throughout. I think clients are likely to feel in hindsight that they've been forced into things possibly because in the case of the blocked cat there is no choice but to have a procedure that wherever it is done is going to cost them money and some owners are unfortunately not prepared for that!

Re: Vets Now utterly overcharging.

Anthony Todd — Fri, 09 Jul 2010 08:17:31 GMT

Now I'm learning! It looks like Hartman's is the fluid of choice and electrolytes done but surely after the cat is unblocked [and when it is starting to get better, says he cynically].

Sounds like it's a pretty good bet that bradycardias and arrythmias have high [K+] so these should have the full monty shebang but start when you get the electrolytes back.

No one has commented on the regime with Ca and insulin; dose, measurements, problems etc. which would help me.

I can imagine it taking 30mins to get electrolytes; time better spent getting the cat unblocked and on Hartmans analgesia etc. Take your sample as you put in the cannula and do it later.

No good sending electrolytes off at 2.0am......

Good to tell the owner re prognosis and the sort of information they'll be happy paying for.

In house electrolytes, with the latest kit are reliable enough aren't they?? Cytology is a non-emergency better done by experts.

Re: Vets Now utterly overcharging.

Tim Cheyne — Fri, 09 Jul 2010 07:59:15 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Clive Ansell"]With haematology, I prefer to use an external lab with a haematologist or pathologist examining a film and reporting on cell morphology rather than a machine that just counts cells.[/quote]

Me too. And I reckon most biochemistry is more reliable and meaningful from an outside lab too.

[/quote]

I agree with Clive about the cell morphology, the interpretation of which is very specialised and requires a knowledge of differences between the various species but I do not see why 'outside' biochemistry should be 'more meaningful' than in-house provided that there is reliable equipment and good laboratory discipline. That perhaps is the crux of the matter; regular cleaning and calibration, use of controls, and repeating of 'dodgy' samples is too onerous and time consuming for the in-house lab handling only one or two samples daily. On the other hand, the speed with which in-house results are obtained can be very important.

We should not forget too that only very rarely can an outside lab confirm a diagnosis on the biochemistry result(s) of a single sample; these are a guide and the final interpretation is the responsibility of the clinician in the light of signs, symptoms and history.

Tim.

Re: Vets Now utterly overcharging.

Evelyn Barbour-Hill — Fri, 09 Jul 2010 00:22:00 GMT

Me too. And I reckon most biochemistry is more reliable and meaningful from an outside lab too.

Re: Vets Now utterly overcharging.

Michael Woodhouse — Thu, 08 Jul 2010 22:55:18 GMT

[quote user="Charlotte Marshall"]surely I am not working in the only practice in the country without access to in house electrolyte measurement.[/quote]

Same here - Vettest that I sort of believe but no electrolytes.

Re: Vets Now utterly overcharging.

Anthony Todd — Thu, 08 Jul 2010 22:51:39 GMT

[quote user="Clive Ansell"]The 6% figure seems very high to me[/quote]

Yeah, me too, never had an unblocked cat die [that I can recall]. The abstract asked as many questions as it answered.

Re: Vets Now utterly overcharging.

Clive Ansell — Thu, 08 Jul 2010 21:55:16 GMT

I've worked in a few practices that don't have access to in house bloods, and some that have biochem and haematology but no electrolytes. One practice has recently got rid of its blood machine, they figured that with the easy access and the fast turn around with same day results, a local commercial lab was a better bet.

With haematology, I prefer to use an external lab with a haematologist or pathologist examining a film and reporting on cell morphology rather than a machine that just counts cells.

Re: Vets Now utterly overcharging.

Charlotte Marshall — Thu, 08 Jul 2010 21:06:35 GMT

This has been an interesting discussion about the management of blocked cats though not quite what the thread started as ! However I am starting to get a bit worried - surely I am not working in the only practice in the country without access to in house electrolyte measurement. I am afraid some of us while we would love to be able to monitor the potassium in these cases do not have that luxury. That said the only blocked cat I recall dying in the last 12 years was also one which had obviously been blocked for more than 24 hours and came in collapsed.