24 hour care

Re: 24 hour care

Niall Taylor — Fri, 22 Jul 2011 16:50:04 GMT

[quote user="alex gough"] ... much as I defer to the wisdom accrued by your centuries in practice... [/quote]

Cor blimey, youngsters these days!

Good grief, I go off to drop the dogs at the kennels and when I come back I find I've opened a whole can of worms!

[quote user="alex gough"]you are likely to miss some pathology without the light source to illuminate[/quote]

Ah well, for that I use what I recently saw referred to on another list as a "photon cannon", you may know it better as a "torch"

To paraphrase one of my favourite vetsurgeon.org members - I'm glad that you agree with me on every single point I've made Alex and that you think I'm completely correct and you are wrong. A triumph of experience over mere evidence.

Right, that's the need for evidence out of the way, I'm off to start a course in homeopathy, zero-balancing and radionics.

Niall

PS - [quote user="alex gough"] musings, thoughts and a review of the week's radio on the BBC Home Service[/quote] that sounds like my sort of article, the home service, those were the days, jumpers for goal posts...

... now, where did I put my slippers?

Re: 24 hour care

Anthony Todd — Fri, 22 Jul 2011 16:49:12 GMT

Now I knew a man, Andrew Carmichael of London, who could tube any dog whilst it was lying on its side, no gag, no opened mouth, no visualisation, just like putting a sword in a scabbard.

Gripped the larynx with one hand and slipped the tube in, time after time.

Said he's learnt it at the AMC in New York.

One for the grumpy dinosaurs, yeah!!

Re: 24 hour care

Alex Gough — Fri, 22 Jul 2011 15:38:43 GMT

Ok, I've checked with my ENT surgery colleague, and he agrees that intubating with a scope is unlikely to be any more traumatic than intubating without, but that you are likely to miss some pathology without the light source to illuminate, and the tongue depressing action of the scope to get the tongue and soft palate out of the way, particularly in some breeds.

Re: 24 hour care

Simon Neuhoff — Fri, 22 Jul 2011 15:10:06 GMT

[quote user="alex gough"]

Well, Niall and Martin, much as I defer to the wisdom accrued by your centuries in practice, I am sure we are all familiar with the seminal work of Boffin and Egghead (1934) with pygmy shrews which showed that use of a laryngoscope allowed insertion of an endotracheal tube into the larynx and/or oesophagus in at least 80% of cases with only 20% of cases being inserted into the rectum, which was significantly different when a laryngoscope was not used, the respective figures being 79 and 21 (p<0.05). I rest my case.

Seriously, I think new grads should learn to tube with and without, but generally tubing with is likely to be less traumatic, more accurate, and will allow you to identifiy pathology you might not otherwise see (polyps, tumours, ulcers etc). The risk:benefit ratio of using one seems to be fairly heavily weighted to benefit, as even if the benefit is small, the risk approaches 0.

Alex

Reference: Boffin and Egghead (1934) Laryngoscopy of the pygmy shrew: musings, thoughts and a review of the week's radio on the BBC Home Service. Journal of laryngscopy of the pygmy shrew, 325, 1020-1023 (supplement)

[/quote]

I genuinely don't understand - in 99% of animals I can see the larynx without a scope - in a room with decent light and the nurse holding the animal properly - I am not blindly entubating them. A laryngoscope is simply a bukly instrument that gets in the way.

I have one patient that I reach for the laryngoscopy - it is a 10kg Yorkie with a larynx that belongs on the 2 kg Yorkie - but wierdly elongated. The dog is a nightmare anaesthetic - done it twice now and am very much hoping not to have to get the scope out for it ever again!

Re: 24 hour care

Martin Atkinson — Fri, 22 Jul 2011 14:09:44 GMT

As a variation on the pygmy's rectum, I've actually found a use for the laryngoscope in assisting with the urinary catheterisation of a bitch.

Re: 24 hour care

Michael Woodhouse — Fri, 22 Jul 2011 13:54:18 GMT

Laryngoscope could have their own thread!

It's like the bitch spay ovarian retractor thread - you are setting yourself up for a fall always suing a laryngoscope to tube animals. I remember whilst on my rotations was with a nurse with an animal under GA having had a EMG in what was basically a cupboard. The qualified veterinary nurse caught the circuit and promptly extubated the dog. She wanted to rush through to induction to get an anaesthetist with a laryngoscope, I got her to hold the dogs head and put the tube down. She said she didn't even know that was possible. These people are training vet students FFS.

[quote user="alex gough"]tubing with is likely to be less traumatic, more accurate,[/quote]

How so? I don't do it blind, You can see the chords? How could that create more trauma?

[quote user="Niall Taylor"] I mean what happens when they have an emergency and the laryngoscope is out on a house visit or the battery has gone.[/quote]

I'm not sure they should be doing house calls, especially not the battery on its own!

Re: 24 hour care

Alex Gough — Fri, 22 Jul 2011 13:33:15 GMT

Alex

Re: 24 hour care

Martin Atkinson — Fri, 22 Jul 2011 13:13:32 GMT

Funny, one of my nurses found an odd piece of equipment lying in a drawer while tidying up the other day and enquired as to its purpose. 'Ah, a laryngoscope', I said, 'I wondered where that had been for the last 30 years, I got it free with some anaesthetic deal around the time Noah was building his ark. Better remember where it is now in case a locum needs it'.

Re: 24 hour care

Niall Taylor — Fri, 22 Jul 2011 12:51:09 GMT

[quote user="alex gough"]Ooh what's your laryngoscope rant? Might be you and I have a rare disagreement?

Alex[/quote]

[grumpy old man mode]Oh well, it's just that "youngsters these days" don't seem to be able to tube anything without reaching for the laryngoscope. I can understand how they might be useful in some cases where there is pathology in the pharynx and obviously exotics are different but I really fail to see the need to fill an animal's mouth with extraneous metal work just in order to intubate them. I mean what happens when they have an emergency and the laryngoscope is out on a house visit or the battery has gone. I've been in practice nigh on 30 years you young whippersnapper and I can count the number of times I've had to use a laryngoscope to tube an animal on the fingers of one hand!.. [/grumpy old man mode]

I'm off on a fortnight's holiday now so I may be late in replying to your inevitably brilliant, well reasoned and evidence based reply. But it's ok because this "works for me" and I'm sure if I tried I could find a web site which says it's fine!

Then I can do my legs under/over rant (and no, it's not what you're thinking!).

Cheers,

Niall

Re: 24 hour care

Alex Gough — Fri, 22 Jul 2011 11:26:46 GMT

Ooh what's your laryngoscope rant? Might be you and I have a rare disagreement?

Alex

Re: 24 hour care

Niall Taylor — Fri, 22 Jul 2011 08:42:29 GMT

[quote user="Anthony Todd"]... still it's what ICU do on the telly so it must be better.....[/quote]

LOL - don't get me started or I'll do my laryngoscope rant!!!

Niall

Re: 24 hour care

Anthony Todd — Thu, 21 Jul 2011 20:44:01 GMT

[quote user="bob lehner"] I think it is tantamount to torture[/quote]

Yes, it's a double whammy for the patient; a loud alarm and no fluid replacement, still it's what ICU do on the telly so it must be better.....

Re: 24 hour care

bob lehner — Thu, 21 Jul 2011 16:17:46 GMT

[quote user="Anthony Todd"]And I wonder whether, bearing in mind screaming drip pump alarms[/quote]

Yes - I think it is tantamount to torture to leave a dog with that awful drip pump alarm noise running constantly for hours on end right next to it. Bad enough for a human - but with a dog's more acute hearing it must be horrendous. I wish they could be disabled.

Re: 24 hour care

Clive Ansell — Thu, 21 Jul 2011 15:33:13 GMT

[quote user="Eamon McAllister"]

[quote user="plantagenet"]

I think honesty is the key - what I object to is practices that shout from the roof tops that their is a vet/nurse on the premises over night, when actually said vet/nurse is fast asleep in bed in the flat upstairs between checks.

[/quote]

I find it objectionable that they advertise in the yellow pages claiming that they have "full hospitalisation facilities" and "24 hour emergency cover" when in reality they work in a lockup 9am - 6.30pm and use an OOH provider.

[/quote]

I once did a locum in a PSS tier 2 practice that had a notice in the waiting stating that there was a flat upstairs for the night duty vet. No one had ever stayed in it to my knowledge -at best misleading, at worst an act of deception. Staff all go home at 7pm and return at 8.30am, no one on the premises. They would not offer transfer to their OOH provider for hospitalised cases instead preferring to keep them in house, and in fact I was carpeted for doing so. Terrified someone else might make twenty quid out of a case. I've not been back, thankfully.

Re: 24 hour care

Alan Tevendale — Thu, 21 Jul 2011 15:21:35 GMT

Couldn't agree more. One of my practices biggest selling points is that we do our own out of hours. The nearest out of hours provider is quite some distance away (but probably changing soon). We find that many clients from other practices try to come to us out of hours - duty nurse always advises them that their pet would be best seen by the vets who have access to history etc. We do not advertise that we have someone on site 24/7 but the vet/nurse will be there if the case requires it. We explain the the client that this is assessed by the vet on a case by case basis.

Re: 24 hour care

Eamon McAllister — Thu, 21 Jul 2011 15:15:12 GMT

[quote user="plantagenet"]

[/quote]

Re: 24 hour care

Clive Ansell — Thu, 21 Jul 2011 14:24:46 GMT

[quote user="Stephen Courtney"]

And I would absolutely balk at having such inflammatory wording on a consent form, it basically implies ' I am aware my vet will do a half-assed job because i can't afford any better' - terrible! Most ill animals can easily manage a night unattended, they probably get far more sleep that way for a start! It's stupid to legislate against common practice for a few cases that might benefit from being sent to a dedicated critical care center.

[/quote]

But in reality that is often how it is, may not use the term half-arsed, but that is the general way of it. People either get a higher level of care and pay for it, or a lesser level at a lower price - not ideal I know.

My 2 cases in my earlier post were both advised that the premises would be unmanned and there would be no overnight checks, and both were advised to take there pets to the local OOH centre for a good level of overnight care and constant monitoring (although in some OOH centres staff go to bed so "care" is only marginally better - but thats another debate though). Both declined on costs and one of lack of transport, and accepted a lesser or half arsed level of care. I would not have been happy sending either case home on IVFT, as not the most able of clients. Both cases are fine and none the worse for their 15 hours alone.

Re: 24 hour care

plantagenet — Thu, 21 Jul 2011 12:29:27 GMT

We do hospitalise pets and if needed, the nurses and I take it in turns to sit with them but otherwise we divide frequent (or less frequent) checks between us. I always tell the owner exactly what we will be doing.

I have never sent an animal home (except when the owner was a VN) on a drip but occasionally will send them with the iv bandaged in to return the following morning.

Re: 24 hour care

Robin Grimmer — Thu, 21 Jul 2011 12:24:56 GMT

The practice where I locum most has a very good policy on OOH care which I follow wherever I work. Between 8pm and 8am there is no-one on the premises and there is no 'popping back to check inpatients'. Therefore we never keep dogs in. They either go home or go to the OOH centre. I just don't think you can keep a dog in overnight with no-one on the premises. There's just too much that could go wrong with things being chewed etc and of course they won't be able to toilet outside which would cause distress to most house-trained dogs.

We do keep cats in on iv fluids if they are stable - but the owners are always told that there is no-one on the premises and they are given the option of taking their pet to the OOH centre. And we do keep rabbits in overnight - again if they are stable. I think if you follow this protocol you won't come a cropper. For a dog to hang itself by its buster collar while unattended overnight in a vet clinic is unacceptable.

I recall a case about ten years ago before we had OOH centres. I was on call one night when I was presented with an elderly westie with breathing difficulties. It was one of the senior partners regular clients. I did think about admitting the dog but with no-one to keep an eye on it I decided against it. I gave it a combination of drugs (AB, steroid and millophylline) and they had an appointment with their vet in the morning. I thought he would either investigate it or euthanase it, but he just repeated my injections! The following night the westie presented again, this time my colleague was on duty. He decided to admit the dog for investigation the next morning, but the dog died in the night. The owners went absolutely ballistic and complained to the RCVS etc.

Re: 24 hour care

Martin Atkinson — Thu, 21 Jul 2011 10:41:06 GMT

[quote user="Bob Russell"]

We have a variety of options that we chose based on need. Very sick patients we would try to get to our referral centre anyway (funds allowing) so they can get constant monitoring. We rarely send them to our OOH provider but this is still an option.

I have facilities at home for hospitalisation of those patients fit to travel and we have a magic Aerobed for the few occasions it is necessary for someone to stay with a very sick patient. On these occasions I also go for a curry next door but one and put it through the business as an expense - yummy!

We still do the pop back for 'healthy' patients staying overnight.

www.aerobed.co.uk - very comfortable I promise.

[/quote]

Notwithstandig the referral centre which I don't have easy access to this is much the same as my protocol and IMO it is a level of service that is appreciated more by most clients than the level of care available at 24hr hospital. It shows we do care personally about their animals and clients appreciate that even thought they know their pet won't be monitored continually. Its a pain when you have to do it but it doesn't happen very often and I get satisfaction from it. If I keep something overnight that doesn't require me or a nurse staying I will often nip back before I go to bed and even detour my late night run to go via the surgery just to check in. This is another reason why a high percentage of clients still choose small practices over corporates. I try not to keep dogs in overnight unless I cannot avoid it however but cats are rarely a problem.

Re: 24 hour care

Anthony Todd — Thu, 21 Jul 2011 10:28:41 GMT

Sorry for the repeated duplicated posts before. Usually I post and it jumps to it [then I edit all the mistakes] but recently it doesn't!

Bloody websites,We should have used the RCVS developers, wouldn't have this trouble.......

Re: 24 hour care

Anthony Todd — Thu, 21 Jul 2011 10:24:49 GMT

Any thoughts on sending the patient home on a drip etc.?

Most owners happy to nurse the patient and many able to understand drip hydraulics. I have patiently explained I/V fluids and haemodynamics to an ICU nurse......

And I wonder whether, bearing in mind screaming drip pump alarms, chewed and/ or tangled and/or dislodged giving sets, a bolus of fluids I/V or S/C just before you leave and first thing in the morning is, practically and logically, a better option.

How often to you come in to find a very full bag of fluid nearly the same as last night at 7-0pm???

Re: 24 hour care

Bob Russell — Thu, 21 Jul 2011 09:37:38 GMT

We still do the pop back for 'healthy' patients staying overnight.

www.aerobed.co.uk - very comfortable I promise.

Re: 24 hour care

Martin Atkinson — Thu, 21 Jul 2011 09:26:29 GMT

One local branch of a large multi-centre neo corporate practice near me refuses to keep animals in overnight for these reasons and this isn't a lock up shop the previous owners ran a 24hr service from there. I always explain that animals will not be attended overnight, however the odd occasion I will stay in the surgery flat and pop down every couple of hours or so but its hardly 24hr care. As a case in point though I had a Golden Retriever that tried to chew its way out fo the kennel overnight and fracture its mandible to the extent that it was the bloodbath at the house of death scenario when we opened up in the morning and resulted in the partial amputation of the mandible. The same dog was kenneled during the day on another occasion and although we were fully staffed it tried the same trick again and this time tore out an upper canine tooth in the space of a few minutes. How many people continually monitor in-patients even during the day ? Needless to say if that dog comes in again it will be on suicide watch.

Re: 24 hour care

bob lehner — Thu, 21 Jul 2011 08:00:22 GMT

[quote user="Clive Ansell"]eems like a good idea. I don't know any practices here in the UK that get clients to sign disclaimers in such situations, but maybe should.[/quote]

The G to PC says:

'In-patient care

23. Before leaving an animal at a practice, the owner, keeper or carer must be made aware of the level of supervision that will be provided to the animal, including the level of supervision during an overnight stay....'

Certainly some practices do spell this out in writing as part of the in-patient admission form which the owner signs - others do it verbally - but having it in writing has to be more sensible.

I think the whole issue of OOH care is interesting and reflects the changes in the way practices function these days. In the 'old days' everyone did their own OOH and even if they didn't have resident night staff I think there was more of a culture of 'popping back' at night to check in-patients.

Nowadays when many practices use OOH clinics I think this is being lost - indeed many practices have a policy of having no in-patients on the premises at night - everything has to go to the OOH clinic. This raises issues of sick animals on drips or whatever being ferried backwards and forwards - and also serious cost implications for owners. I had a case the other day in a practice which used an OOH provider - had a sick dog on i.v. fluids - the OOH clinic quoted £250 min for keeping it overnight under supervision - owner couldn't afford this - so it had to stay at the surgery overnight unattended. Very stressed owner says 'What if it gets tangled up in its drip line and hangs itself ?' What do you say ? Of course, as others have pointed out these sorts of mishaps can also occur in fully staffed clinics - day or night.