FVMA Advocate Issue 6 2019

F V M A ADVOCATE ISSUE 6 | 2018

There is Hope...Together Finding Strength to Overcome The FVMA Addresses Mental Health Evaluating Your Need for Health Care Clinic Establishment (HCCE) Permit Page 11

2019 FVMA General Elections Page 12

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The 90th FVMA Annual Conference May 16-19, 2019 Tampa, FL

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President's MESSAGE “It always seems impossible until it’s done.” - Nelson Mandela 7 207 Monetary Drive Orlando, Florida 32809 Phone – 407.851.3862 Toll Free – 800.992.3862 Fax – 407.240.3710 info@fvma.org | www.fvma.org

OFFICERS

Dr. Marc A. Presnell President Dr. Michael Epperson President-elect Dr. Donald H. Morgan Treasurer Dr. Alex M. Steverson Past President Mr. Philip J. Hinkle Executive Director

DISTRICT REPRESENTATIVES Dr. Scott Richardson District 1–Big Bend Dr. Todd Fulton District 3–Central Dr. Rachel Klemawesch District 4–Tampa Bay Dr. Susan M. Carastro District 5–Treasure Coast Dr. Marta P. Lista District 6–South Florida Dr. Mary Smart District 7–Southwest Dr. James M. Brechin District 8–Northwest Dr. Kelly J. Sloan-Wade District 9–Space Coast Dr. Ernest C. Godfrey AVMA Delegate Dr. Richard B. Williams AVMA Alternate Delegate Dr. Jacqueline S. Shellow FAEP Representative to the FVMA Executive Board Ex Officio Dr. James W. Lloyd, Dean UF College of Veterinary Medicine

As we look forward to the new opportunities for veterinary medicine in 2019, may we take heart from the words of Nelson Mandela. What is it that seems impossible for you in 2019? Owning your own practice?

Achieving greater wellness and well-being for yourself and your practice?

Paying down your student debt? Adding a new associate or owner?

Successfully making a transition in ownership of your practice? Adding new diagnostic or therapeutic technology to the practice? Achieving new legislation to advance the veterinary profession, promote animal health and wellbeing, and protect the public health? Let us remember that it always seems impossible until it is done, so we must focus on achieving the new and not surrendering to the old.

The FVMA just concluded the Sixth Annual Gulf-Atlantic Veterinary Conference in Boca Raton in December 2018 with record attendance by members of the entire veterinary team. Only six years ago, the FVMA launched this conference offering world-class CE and wet labs to better meet the needs of our members in Florida, especially in South Florida. It seemed an impossible undertaking at the time, yet each year the conference has continued to grow and exceed expectations. If you missed TGAVC in 2018, mark your calendars now for the Seventh Annual Gulf-Atlantic Veterinary Conference at the Boca Raton Resort and Club from December 5-8, 2019. If you have already been to TGAVC in the past, you know that you don’t want to miss out!

If you are looking to enhance or expand your professional skills, you may want to investigate the newly relaunched Charlie Bild Visiting Practitioner Program. This partnership program between the FVMA and the UF CVM will allow participating Charlie Bild practitioners to fully engage as learners for periods of two to four weeks, side-by-side with veterinary medical students, in one of several specialty services available at the UF Veterinary Hospitals. Contact the FVMA office or the UF CVM for more information on how you can participate in this program.

If you are looking to enhance your leadership skills for your practice or in the profession of veterinary medicine, consider submitting an application for the FVMA Power of Ten Leadership Training Program, which will launch at the 90th FVMA Annual Conference in Tampa, Florida from May 16-19, 2019. The conference will provide enriching continuing education (CE), and will cover the most current scientific information and newest techniques and advancements in veterinary medicine. Perhaps this is the year to join the FVMA in Tallahassee as part of Legislative Action Days from March 13-14, 2019. It may seem impossible that you can play a role in the decisions that impact veterinary medicine in Florida, but just one opportunity can make the impossible possible.

There is so much more coming up for the FVMA and also the FAEP, including the 12th Annual Dr. Harvey Rubin Food Animal Conference and a variety of resources provided by the Professional Wellness Committee to enhance our practices and personal well-being. The newly developed FVMA Foundation Strategic Plan will allow the Foundation to focus on promoting animal health and well-being, public and professional education, and enhancing the human-animal bond. You will be seeing a much more focused and effective Foundation as this new strategic plan is implemented.

As always, it is an honor to serve you. Please feel free to contact me if you have suggestions about how the FVMA can better serve you, if you want to find ways to become more involved in your FVMA or if you have questions about what the FVMA is doing on behalf of your profession. Together, let’s tackle the impossible!

Marc Presnell, DVM

FVMA MISSION THE MISSION OF THE FLORIDA VETERINARY MEDICAL ASSOCIATION IS TO ADVANCE THE VETERINARY MEDICAL PROFESSION, PROMOTE ANIMAL HEALTH AND WELL-BEING, AND PROTECT PUBLIC HEALTH. 2 | FVMA ADVOCATE

In Remembrance Billy S. Austin, DVM Dr. Billy S. Austin passed away on December 27, 2018, at the age of 92, having served the veterinary community for more than 65 years. Dr. Austin was very involved in the veterinary community, both through involvement in various associations and clinical research.

Dr. Austin graduated from Alabama Polytechnic Institute (now Auburn University), School of Veterinary Medicine in 1950.

Upon graduation, he ran a farm practice in East Tennessee for seven years, did tuberculosis research for the U.S. Public Health Service in Georgia for two years and did pharmacology research for the University of Miami School of Medicine’s Pharmacology Department for two years. His research at the University of Miami led to the discovery that trachea-bronchial carcinoma is directly related to smoking.

After this, he purchased a small animal practice in South Miami, Florida and practiced there for 37 years. He was very involved in the South Florida veterinary community, serving as the president of the South Florida Veterinary Medical Association for a term. He

also was a founding member and served as president of the South Florida Veterinary Foundation, and a founding member of the South Dade Emergency Clinic, later serving a term as president for this organization as well.

In addition, he was also a Life Member of the AVMA, a member of the FVMA since 1961 and an associate member of the AAHA while he practiced in Miami, Florida. The FVMA presented him with the Lifetime Achievement Award in 2007.

Dr. Austin and his wife moved to Seminole County upon his retirement, yet he still stayed active in the community by attending the Central Florida Association’s monthly meetings.

Through this involvement, he helped fill in for local veterinarians with health-related problems. This led to him starting a limited house call practice, which he continued until May 2018.

Susan T. Munn, DVM, Ph.D. Dr. Susan T. Munn passed away at the age of 63 on December 31, 2018. She was an active practitioner who was devoted to her practice and known for her endless amounts of compassion. Dr. Munn received a Ph.D. in molecular biology and a post-doctoral degree in biochemistry from the University of Florida. She then continued on to receive a DVM degree from UF CVM in 1999.

She owned North Florida Equine Veterinary Service, which provided veterinary care services to those in the Alachua County area. She also mentored veterinary students through the use of

practice-based equine courses in her spare time. She was involved with many veterinary associations, including the FVMA, Florida Association of Equine Practitioners (FAEP) and American Association of Equine Practitioners (AAEP). She loved sports, which was a passion she shared with her husband Terry Munn. They loved to ride bikes, camp and explore the outdoors.

In This Issue 3 | In Remembrance 5 | Member Spotlights 7 | Mental Health and Well-being in the Veterinary Profession 11 | Evaluating Your Need For Health Care Clinic Establishment Permit

12 | 2019 FVMA General Elections 14 | The 90th FVMA Annual Conference 16 | Safety in Anesthesia for Senior Pets Series: Part 3 20 | Practice Pulse 24 | Classified Advertisements

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Happy Retirement Dr. Brechin The FVMA joins Dr. Jim Brechin, FVMA past president, in celebrating his retirement effective Tuesday, February 5, 2019, after 45 years of dedicated service to his community. He retires from his clinic, Destin Animal Clinic in Destin, Florida, but not his profession. He continues to diligently serve veterinary medicine as District 8 Representative on the Executive Board of the FVMA. Dr. Brechin is originally from Birmingham, Alabama, and a graduate of Auburn University College of Veterinary Medicine.

After graduating from veterinary school, Dr. Brechin practiced in Jacksonville and Nashville, Tennessee before opening his practice in Destin. He has been active in his community through various other organizations including the Lions Club, Destin United Methodist Church, Destin Fishing Rodeo (Chairman), Chamber of Commerce (President), and Rotary Club. He was the founding member of the Miracle Strip Veterinary Medical Society and served as its first president.

Author Elvin C. Bell writes with great warmth about our colleague in his memoir published in 2014, Friends, Patriots, and Scoundrels: "When people in the Florida Panhandle talk about Dr. James M. Brechin, the words 'difference' and 'million' are often used, such as 'He’s made a difference in this community because he’s one in a million.' Disguised angels, I’ve found, have a way of doing just that."

On behalf of the FVMA Executive Board, membership and staff of the FVMA, we wish him a long and rewarding retirement!

Congratulations!

90

THE

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FVMA ANNUAL CONFERENCE MAY 16-19, 2019 | TAMPA, FLORIDA

TAMPA CONVENTION CENTER AND TAMPA MARRIOTT WATERSIDE HOTEL & MARINA

REGISTRATION NOW OPEN! SEE PAGES 14 & 15 FOR MORE DETAILS!

WORLD-CLASS CONTINUING EDUCATION FOR EVERY MEMBER OF THE VETERINARY TEAM! (P): 800.992.3862 | (F): 407.240.3710 WWW.FVMA.ORG |

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MEMBER SPOTLIGHTS FVMA STUDENT MEMBER PUBLISHED IN VETERINARY ACADEMIC JOURNAL FVMA student member Caroline Reckelhoff, a UF CVM Class of 2020 DVM candidate, was published in the September 2018 issue of Veterinary Comparative Oncology Journal for her research that was funded through the FVMA Research Scholar program.

Reckelhoff ’s article — “In vitro effects of the chemotherapy agent water‐soluble micellar paclitaxel (Paccal Vet) on canine hemangiosarcoma cell lines” — presented the findings from her study that evaluated the in vitro effect of Paccal Vet on two canine hemangiosarcoma (HSA) cell lines and their expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF).

“Having this research published is such an exciting opportunity

for our team to share this new and insightful information with the veterinary oncology community,” Reckelhoff said. “I am grateful to the FVMA for providing me with the 2017 Kugler Student Research Grant to carry out this project and the amazing support I received from the co-authors of this paper.”

Hemangiosarcoma is a highly malignant tumor and associated with a poor prognosis even with current treatments available.

Her research adds to the veterinary profession because it gives new insight into the use of the drug paclitaxel (micellar) for treatment of hemangiosarcoma in dogs. By having this research published, it provides veterinarians with new information regarding use of this drug as a future treatment option.

One of Reckelhoff 's favorite classes in her undergraduate program was eukaryotic and cellular biology, focusing on the pathways of processes. She also learned about hemangiosarcoma during her undergraduate studies. This grant afforded her the opportunity to get involved in research and focus on these areas of interest. Reckelhoff had the opportunity to present her research project at the Sixth Annual Gulf-Atlantic Veterinary Conference (TGAVC) in Boca Raton, Florida in December 2017.

2018 UF CVM, FVMA KUGLER RESEARCH SCHOLAR FVMA student member Seth Locker, a UF CVM Class of 2021 DVM candidate, was selected as the 2018 FVMA Research Scholar. He spent the summer being mentored by Dr. Amara Estrada, who is a professor and associate chair for instruction for the Department of Small Animal Clinical Sciences at UF CVM. Locker said he was excited to do summer research to see what it's like to do research as a clinician. He said he would like to possibly split his time working in both a clinical and academic setting after graduation.

“To have been chosen as a research scholar meant a great deal to me,” Locker said “It gave me my first glance at what it is like to be a veterinary cardiologist in a research setting, which I feel was an invaluable experience. Also, knowing the potential of the research itself, I felt incredibly fortunate to be able to be a part of it.”

Locker chose to work with Dr. Estrada because she is a boardcertified cardiologist, and he believes that her research has significant clinical benefits for the future of the profession.

He is also interested in pursuing a residency in cardiology, so his experience working alongside an established cardiologist, doing research, was invaluable. Locker worked with Dr. Estrada on research involving dilated cardiomyopathy in Doberman

pinschers. He studied nonischemic idiopathic dilated cardiomyopathy in Doberman pinschers. Another interesting component was that they used new technology — a RNA scope — that allows them to look at the messenger RNA (mRNA) and look specifically where this mutated protein is being messed up in its sympathies.

At UF CVM, Locker is the treasurer of the Surgery Club, the meeting coordinator for the Veterinary Business Management Association, the Student American Veterinary Medical Association representative for the Class of 2021, and a student ambassador for UF CVM. He looks forward to what his research can add to the knowledge of the veterinary community and improving veterinarians’ ability to understand diseases and treat patients.

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Mental Health and Well-being in the Veterinary Profession

By Samantha Rosenthal, FVMA Communications In recent years, there has been a growing concern regarding mental health across the entire medical profession. This issue has also started to gain awareness within the veterinary profession, with increased research and conversations about mental distress and suicide within the population.

As the profession continues to invest time into exploring this issue, many organizations like the AVMA, FVMA and other veterinary groups worldwide have started to incorporate wellness and well-being into their missions with a focus to help bring about a positive impact for mental health in veterinary medicine.

The FVMA spoke with some of its members who are a part of this movement of bringing the current state of mental health in veterinary medicine to the forefront of people’s minds. Many of these individuals have experienced mental distress at points in their career. They’re now using their experiences and expertise to help others who might be experiencing these issues relearn how to enjoy and love their veterinary careers, and educate veterinary students who are about to start their professional journeys.

The Current State of Mental Health in the Profession

While it may not have always been talked about, distress and concerns for wellness have been issues that the veterinary profession has had for years. Veterinarians are often faced with the task of balancing the needs of their patients and clients alongside what medically and/or biologically can or can’t be done. The compounding stress of knowing what can and can’t be provided to a patient based on certain limitations – whether that be financial or client preferences – has been an ongoing battle with veterinarians across the country and worldwide.

“It’s important – in a well-being sense – to understand that we have to know limitations and be able to not take things personally,” FVMA Wellness and Well-being Committee Chair Dr. Phillip Richmond says. “Sometimes when people say things to us, we don’t have to internalize that and take it as someone being directly upset with us.”

Dr. Richmond explains that one of the first steps of understanding this issue is knowing what exactly it means when we talk about wellness and well-being, because often veterinarians aren’t aware it is inclusive of much more than our mental health. When we refer to wellness, it encompasses the care and value we place on our bodies, including eating right, keeping an active lifestyle, staying hydrated and making sure we’re getting enough sleep. The concept of well-being refers more to an individual’s emotional, spiritual and mental health on a day-to-day basis.

Due to the high demands of those in the veterinary profession, things like wellness and well-being are often put to the wayside when individuals struggle with maintaining a healthy work-life balance, in addition to the stresses that are encountered on a daily basis.

“When we have wellness and well-being in conjunction with this career, it makes us love being a veterinarian again,” Dr. Richmond says. “I still act like a kid. I love what I do, but it took learning about wellness and well-being and putting those things into practice to get to that point.”

Another important thing to take into account is how much the veterinary profession has changed over time. The shift in focus on the type of medicine that is now predominantly practiced has also influenced the state of mental health within the profession.

“The dynamic of veterinary medicine has changed to where there’s a much larger focus on companion animal medicine versus food animal medicine,” Dr. Richmond says. “When we deal with farmers, dairy farmers, ranchers and professionals in the food animal industry, they are looking at the livestock versus a family who has a companion animal — how they perceive that animal is different. There’s more of a human-animal bond with the family pet than there is with beef cattle.”

But one of the most important changes has been the fact that more individuals are starting to normalize having discussions about mental health and working toward eliminating any stigma that may be associated with the issue. Through the use of research and open discussions on a national level at many conferences and meetings, it has helped allow for veterinary students and practicing veterinarians, alike, to be more open about their experiences.

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areas that are often present but not addressed by veterinary students and practicing veterinarians.

Personality Factors

As noted in the Merck Animal Health Veterinary Wellness Study (February 2018), there are many personality traits that contribute to the state of mental health in the veterinary profession. Schools select veterinary students that tend to be very driven, intelligent perfectionist types — but they often don’t always have the resilience needed or the mental coping abilities to deal with failure, which is inevitable once you begin practicing in the field.

“I think it’s really excellent that we are starting to look into this in a scientific way,” says Dr. Cherie Buisson, who is a member of the FVMA Wellness and Well-being Committee. “We are applying our scientific minds to this problem, and we’re starting to try to figure out what causes this, where we can go from here and what to do.”

Dr. Buisson, who is a veterinarian in Largo, Florida, owns a mobile end-of-life care practice called Helping Hands Pet Hospice. She also runs a website called “A Happy Vet,” which is dedicated to wellness in the veterinary profession. She says that a big part of addressing this growing issue is by looking at the root of the cause – the contributing factors, including the personalities of those who enter the profession – that attribute to the levels of well-being in the profession.

Contributing Factors to Veterinary Well-being

In recent research regarding veterinary wellness and well-being, there has been a focus on identifying key contributing factors to this problem. Like many careers, components like stress, finances and hours worked are taken into consideration, yet the veterinary profession has many unique factors to it that contribute to the issue of mental health.

With the unique factors of veterinary medicine and patient care where the patient is having their decisions made for them, and how often care plans may be unattainable by clients for a variety of reasons, veterinarians are more often than wanted put into situations of ethical distress. Many veterinarians have expressed how they can be sometimes villainized as people who don’t care because there is a treatment that can be done, yet the client can’t afford it. The blame is then shifted toward the veterinarian as not trying their hardest.

“The nature of veterinary medical training and practice can be inherently stressful. In addition, this is further exacerbated by certain personality factors that are characteristic of individuals who go into veterinary medicine. Overall, they are predominantly very high achievers and tend to be perfectionistic," says Dr. Christy Monaghan, a licensed psychologist working with UF CVM's Student Counseling and Psychological Services Department within the Office of Academic and Student Affairs.

"Those qualities can be viewed as very positive, and they often enable individuals to get into these training programs and to be quite successful. However, it [perfectionism] becomes problematic when the individual holds that as a very rigid selfimposed standard, that ‘I have to be perfect all of the time and when I’m not I am therefore inadequate.’”

She adds that oftentimes individuals struggle with “feeling an overwhelming need to attempt to present this façade of being perfect – and being invulnerable to even typical human frailties,” which is where a substantial percentage of the resulting emotional and psychological distress originates. Dr. Monaghan emphasizes how learning and maintaining healthy coping skills and stress management practices can be effective in helping these individuals deal with inevitable life stressors.

“There are circumstances in veterinary practice where we are not able to provide the desired outcome for the patient, whether due to factors related to the client – such as finances – or to the patient’s medical status, that in it of themselves puts one at a vulnerability for moral distress in terms of not always being able to achieve the outcome you desire,” says Dr. Monaghan.

Imposter Syndrome

“When you throw emotional clients that are lashing out in anger or pets that are lashing out in fear on top of that, it just doubles and triples the level of anxiety that you experience trying to just figure out how to be a good veterinarian,” explains Dr. Buisson.

Imposter syndrome is a phenomenon that many students going through school experience, and it is highly prevalent within the veterinary student population. Imposter syndrome is when an individual often exhibits a pattern of doubts regarding their accomplishments and achievements, fearing they will be exposed as “fake” or a “fraud.” Due to this, this phenomenon is often accompanied by mental health issues, including anxiety, stress or depression. And while it is very prevalent in the academic world, it is also persistent in the medical field among recent graduates who are just beginning their careers.

Other contributing factors include financial distress (debt owed), social support, sleep deprivation, and the lack of engaging in selfcare or self-compassion. Among these factors are three pivotal

“I spent the first eight years in practice just feeling like I was letting every one down, and that was just a combination of anxiety and imposter syndrome,” Dr. Buisson says.

8 | FVMA ADVOCATE

A lot of the talks and educational videos that Dr. Buisson has on her website address imposter syndrome, where it often stems from veterinarians’ inabilities to set boundaries and say “no.” She also says people find comfort in knowing that people from all walks of the veterinary profession attend her talks because many of them just want to know how to make that feeling better or diminish. While as hard as it may be, learning how to not say “yes” to everything helps maintain a healthy work schedule and allows veterinarians to not put patients at risk because they’re trying to see too many and handle too much at once. She also insists that the concept of being worthy and being OK with being unsure about yourself needs to be normalized with individuals when they’re children so that it doesn’t develop into issues later in life when they’re adults and working in their career.

clients about your medical abilities and their general expectations about medicine can help decrease the risk of compassion fatigue.

“It was most stressful for me was when I was brand new,” Dr. Buisson explains “I had extreme levels of anxiety when I first got out of school because I felt like I didn’t know anything — and that’s common. You have a foundation but you don’t have a lot of clinical, basic practical experience, so that’s something you kind of learn as you go.”

One thing can be certain, which Drs. Buisson, McVety, Monaghan and Richmond all agreed on: This is an issue that many are dealing with, so no one struggling with mental wellness or wellbeing should feel like they’re alone. There are many of individuals who have gone through this and have found ways to be happy again after seeking mental health treatment or recovery. In recent years, there have been more open discussions about mental health, the stigma surrounding it and encouraging individuals to not be afraid to seek help if they’re suffering. The amount of resources, initiatives and mental health care options has also increased, including efforts by organizations to make those aware of the resources out there.

Compassion Fatigue

Another often-cited component that contributes to the state of mental health in veterinary medicine is what is known as compassion fatigue. It is when an individual experiences the emotional residue or strain of being exposed to those suffering or the consequences of a traumatic event(s). It can occur from just one incident an individual experiences or over a period of time. It differs slightly than burnout, but the two can exist and be present together. Dr. Dani McVety, who is a member of the FVMA Wellness and Well-being Committee and a nationally recognized speaker on the topic of compassion fatigue, explains that veterinarians often end up feeling drained by the people and expectations that they have externally placed on themselves instead of just living by their internal expectations and not apologizing for them.

"We want to do everything right and perfect – the perfect wife, the perfect mother, the perfect business owner, or the perfect employee or the perfect manager,” Dr. McVety says. “We forget that there’s this balance that has to happen, and when we are imbalanced that does not mean compassion fatigue. It just means we need to add something else and reprioritize and live by our priorities and stop apologizing to others who think that our priorities should be different.”

Compassion fatigue symptoms can include loss of self-worth, isolation, loss of morale, an increase in emotional intensity and even sometimes a feeling of existential despair due to a loss of hope. In order to create awareness about this issue so that we do not fall victim to compassion fatigue, it is important to ask ourselves: What types of incidents increase your stress level?

What other issues or contributing factors negatively impact your workday? By asking these types of questions, it helps lower the risk of experiencing compassion fatigue. Dr. McVety also says that having an open, honest and clear relationship with your

There are many resources and outlets to deal with compassion fatigue and other issues of mental health too, including attending compassion fatigue support groups or talking with a life coach on a routine basis.

“When you demystify the struggle like that, knowing that there’s other people out there that are going through it, I think that just adds so much to our lives,” Dr. McVety says. “None of us should be afraid to ask for help or admit that we’ve received help.”

Moving Forward: Helpful Resources & Initiatives

Veterinary schools are starting to implement wellness activities and check-ins with their students into their programs and extracurricular activities. They’re also establishing their own counselling programs to provide students with professionals who can specifically speak to the issues they’re facing. Organizations across the entire spectrum of medicine, including veterinary medicine, are starting to provide services and resources to help facilitate those in both the academic arena and those working in the profession. There’s a renewed focus on selfcare, stress management, communication, work-life balance, addressing compassion fatigue and learning how to maintain positive relationships. It is also important to acknowledge there are instances of substance abuse, so trying to find an avenue to address those in a helpful and clinical way, as opposed to a punitive way, is also important.

The AVMA has been one of the key organizations in the forefront of bringing awareness to the issue of mental health in veterinary medicine. They have an entire section of their website dedicated to veterinary well-being, including a self-assessment, well-being programs and a list of resources on where to get help. The FVMA has also begun to address and bring awareness to this issue in Florida. The FVMA is working to compile a list of state-wide mental health professionals who are familiar with issues of mental health in the veterinary profession, including medical professional burnout and compassion fatigue, and that list will be made available to FVMA members. The FVMA website will also have informative articles along with links to resources regarding mental health, wellness and well-being. Future FVMA conference,

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including the upcoming 90th FVMA Annual Conference, will also feature wellness tracks with nationally recognized speakers presenting on topics regarding mental health.

"Take advantage of the resources that are out there,” says Dr. Richmond. “This is a growing area that is getting a lot of needed attention. My hope is 10 years from now, students that are graduating are going to know all these things and have the tools

before they graduate to hopefully address these issues and enjoy being a veterinarian.”

If you or someone you know is suicidal or in emotional distress, contact the National Suicide Prevention Lifeline at 1-800-2738255 (TALK). Trained crisis workers are available to talk 24 hours a day, 7 days a week. Your confidential and toll-free call goes to the nearest crisis center in the Lifeline national network.

The Merck Wellness Study (February 2018) and recent CDC study done in conjunction with the AVMA (January 2019) provided meaningful data regarding mental health, wellness and well-being within the veterinary profession.

MERCK WELLNESS STUDY IMPORTANT RESULTS More psychological distress found in younger veterinarians

Reported Distress

8.7%

2.8%

About 1 in 20 veterinarians suffers from serious psychological distress.

O NL

4

es 55-6 Ag

4

es 18-3 Ag

O NL

Veterinarians experience slightly lower levels of well-being than the general population.

Y

50% Y

41%

of those reporting actually receives treatment of medication for any mental health conditions recommend a career in veterinary medicine

Serious psychological distress increased with number of hours worked, especially those working in the evening hours

CDC AND AVMA SUICIDE STUDY IMPORTANT RESULTS

Icon graphics from thenounproject.com

Veterinarians had a higher proportionate mortality ratio (PMR) for suicide, compared with the general US population.

MOST COMMON METHODS OF SUICIDE

Firearms 45%

Pharmaceuticals 39%

154 of 398 (39%) deaths by suicide over the 36-year study period were the result from pharmaceutical poisoning

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Male Veterianrians:

Female Veterianrians:

2.1 times

3.5 times

(51%) died from firearm wounds

(64%) died from pharmaceutical poisonings

2.5 times that for individuals among the general US population who died by suicide in 2016

EVALUATING YOUR NEED FOR HEALTH CARE CLINIC ESTABLISHMENT (HCCE) PERMIT

“Veterinarians must be aware that the DDC has statutory authority to inspect ANY establishment where drugs are sold or held, which would include any veterinary practice. Taking all of the various laws and regulations into consideration, it is my opinion that veterinarians are better off by obtaining the HCCE permit, as this will be a sign of compliance that may reduce the risk of an unannounced inspection.”

– Edwin A. Bayo, Counsel to the FVMA

A Health Care Clinic Establishment (HCCE) Permit is required for the purchase of prescription drugs by a place of business at one general physical location owned and operated by a professional corporation or professional limited liability company, or a corporation that employs a veterinarian as a qualifying practitioner. HCCE Permits are granted by the Division of Drugs, Devices and Cosmetics of the Department of Business and Professional Regulation (DBPR).

The law, Section 499.01(2)(t) Florida Statutes, pertaining to the HCCE became effective 10 years ago, on January 1, 2009.

How does the HCCE permit requirement affect licensed practicing veterinarians in Florida?

In summary, the HCCE Permit is required for veterinarians who want to order prescription drugs in their clinic or corporation name.

Veterinarians who order prescription drugs under his or her own name and license number do not need the permit, regardless of other associates or relief veterinarians also using the drugs. Also veterinarians who are in a partnership do not qualify for the permit. They have to either order in one veterinarian’s name or incorporate and obtain the HCCE Permit.

DO YOU NEED AN HCCE PERMIT? You need an HCCE Permit if: • A corporation purchases and maintains prescription drugs in one corporate inventory to be dispensed by qualifying practitioners who work with them.

• You will order prescription drugs for a multi-veterinarian clinic through the clinic’s name.

• You are a solo practitioner who will order prescription drugs through a corporation or clinic’s name.

You do not need an HCCE Permit if: • You will order prescription drugs for your practice under your name and license.

• You are a sole practitioner who will order prescription drugs under your name and license.

• You are in a partnership with another veterinarian(s).

Please Note: 1. All licensed veterinarians have the legal authority to purchase and own prescription drugs.

2. An HCCE Permit covers all the veterinarians in a clinic, but requires a “qualifying practitioner” to be named on the permit. That “qualifying practitioner” is responsible for all record keeping, storage and handling of all prescription drugs ordered and dispensed under the HCCE. 3. The law does not prohibit the use of Rx drugs by practitioners in a group practice that were purchased by another member of the group at that establishment.

4. A veterinarian who was previously issued an HCCE Permit, but who decides to purchase prescription drugs under his/her individual license instead, should return the HCCE renewal notice to the Department of Drugs, Devices and Cosmetics Division of the Department of Business and Professional Regulation, along with a letter or simple note stating he/she is not renewing the permit.

5. If a veterinarian orders prescription drugs under his/ her name and license for his solo practice or his practice where other veterinarians are employed must be careful to separate payments for these transactions from the business. A business entity cannot order and pay for prescription drugs if it does not have an HCCE Permit.

For help and other information concerning HCCE Permits, contact the Department of Drugs, Devices and Cosmetics Division of the Department of Business and Professional Regulation at 850.717.1800, 8 a.m. to 5 p.m. Monday through Friday, or the FVMA helpline at 800.992.3862.

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2019 FVMA General Elections Dr. Alex M. “Steve” Steverson, Chair According to the bylaws, nominations for president-elect shall be made by a Nominating Committee composed of four District representatives and the FAEP representative (in even years) or five (in odd years) District representatives to the Executive Board and chaired by the immediate past-president. During even numbered years, the representatives from Districts 2, 4, 6 and 8, and the FAEP representative shall serve on the Committee, and during the odd numbered years, Representatives from Districts 1, 3, 5, 7 and 9 shall serve.

Officers on the FVMA Executive Board

2019 Nominating Committee Members • Dr. Alex M. Steve Steverson, immediate past-president, chairman • Dr. Scott Richardson, District 1 • Dr. Todd Fulton, District 3 • Dr. Susan M. Carastro, District 5 • Dr. Mary Smart, District 7 • Dr. Kelly J. Sloan-Wade, District 9

Treasurer Dr. Donald Morgan Dr. Morgan has completed his first term and is eligible to be re-elected.

Committee Charge It is the duty of the Nominating Committee to submit the names of candidates for election. Nominations for president-elect, treasurer, alternate delegate to the AVMA and Executive Board shall be made by the Nominating Committee. All members of the Association are encouraged to suggest names of possible candidates to the Nominating Committee.

District Representative on the FVMA Executive Board

Nominees for District representative to the Executive Board shall be submitted by the local associations located within the respective districts to the executive director at least sixty (60) days before the annual meeting of the Association.

12 | FVMA ADVOCATE

The following seats will be open for election to the FVMA Executive Board in 2019: President-elect To be eligible for nomination as the president-elect, a member must have served as an executive board member for three (3) years and shall have been a member of the Association for at least the past five (5) years proceeding nomination.

The treasurer shall be elected for a three (3) year term and may be re-elected to serve one additional three (3) year term. The treasurer shall be a resident of the State of Florida and a member of the Association in good standing.

The following District representative seats will be open for election to the FVMA Executive Board in 2019: District 1 Dr. Scott Richardson will have completed a first term and will be eligible to be elected to a second term.

District 2 This seat is vacant.

DISTRICT I DISTRICT II DISTRICT VIII DISTRICT IX

FVMA DISTRICTS

DISTRICT IV DISTRICT III DISTRICT V

DISTRICT VII

DISTRICT VI

District 5 Dr. Susan Carastro will have completed a first term and will be eligible to be elected for a second term.

Each district representative to the Executive Board shall be elected for a three (3) year term from a slate of nominees brought forward by the Nominating Committee and who reside in the given District. District representatives may be elected to two (2) successive terms.

Nominees must be submitted by local associations located within the respective districts to the executive director by March 18, 2019.

2019 FVMA Nomination and Election Timeline The bylaws establish a timeline for nomination deadline, as well as when the general election ballots must be mailed, tabulated and recorded. In the event there is only one nominee for a specific office, that nominee shall be considered to be elected by a unanimous vote and a ballot for that office shall not be sent to the membership. However, if there is a contested seat in any of the above open seats, the following actions and calendar have been established in the bylaws:

March 18, 2019 - Sixty (60) days prior to the annual meeting of the Association, the Nominating Committee shall submit the nominee(s) for president-elect and treasurer to the executive director.

March 18, 2019 - Nominees for District representative to the Executive Board shall be submitted by local VMAs within the respective districts at least sixty (60) days before the annual meeting of the Association.

April 2, 2019 - The FVMA Executive Director shall prepare a ballot listing the candidates for each office as provided by the Nominating Committee. The ballot shall be mailed to all voting members of the Association at least forty-five (45) days before the date of the annual meeting.

April 17, 2019 - For ballots to be valid, they must be postmarked no later than thirty (30) days before the date of the annual meeting.

May 2, 2019 - Fifteen (15) days before the annual meeting, a Tallying Committee composed of two (2) active members, appointed by the president and the executive director, shall open the envelopes and tabulate the vote.

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2019 OPEN SEATS EXECUTIVE BOARD President-Elect Treasurer

DISTRICT REPRESENTATIVES District 1 District 2 District 5

Send Nominations To:

FVMA - 7207 Monetary Drive Orlando, FL 32809

NOMINATION DEADLINE

March 18, 2019

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SAFETY IN ANESTHESIA FOR SENIOR PETS SERIES: PART 3 RALPH HARVEY | DVM, MS, DACVAA

The final part of this series addresses other safety considerations when using anesthesia in the geriatric patient. The previous two articles focused on physiological changes that occur with aging that should be considered, along with the pharmacology that needs to be noted when making decisions regarding anesthesia in senior pets. The final and third part dives into the clinical application of the principles guiding veterinarians when it comes to anesthesia in older patients.

CLINICAL APPLICATION OF THESE PRINCIPLES FOR OLDER PATIENTS

Any geriatric dog or cat presented for anesthesia should be considered on an individual basis. Each geriatric patient will have specific physiologic alterations or diseases unique to that individual; thus, the anesthetic protocol needed for one aged patient typically may be quite different from that needed for another aged patient.

As with any patient, a thorough and complete preanesthetic examination should be done and a complete history should be taken. Special emphasis should be placed on noting any present and past medical or surgical problems, along with any current medications the patient is receiving. Any previous anesthetic experience the patient has had should be noted, and close attention should be paid to any anesthetic complications or abnormal responses that occurred. A thorough preanesthetic physical examination should be performed to determine physiologic baseline values for future monitoring, as well as to help ascertain any existing pathological conditions within the patient. The 2005 AAHA Senior Care Guidelines3 serves as a valuable guide based on both evidence and expert opinion and as an important referenced paradigm for recognition of risk factors and a suggested minimum data base for both healthy and sick older cats and dogs. A complete blood cell count and serum biochemistry profile — with special emphasis on renal and hepatic function and electrolyte balance — should be obtained.

Thoracic radiographs and a baseline electrocardiogram should be considered. Additional imaging — including potentially ultrasonography, cardiac ultrasound, CT and MR imaging — will be indicated for some geriatrics, as in many other patients, based on discovered signs, practical availability and client consultation. Any abnormal preanesthetic findings should be thoroughly evaluated, as possible, and delaying the anesthesia and surgery should be considered to address the potential problem areas identified. Finally, a veterinarian must be in tune

16 | FVMA ADVOCATE

with their clients, with an older patient’s psycho-social issues and with the existing human-animal bond. Often, an older animal doesn’t thrive at the veterinary practice, away from its family and home. Considerations should be made to make the stay brief and less stressful. Gentle approaches, both in pharmacology and in the application of clinical techniques, will particularly benefit geriatric patients. Their psycho-social well-being is often fragile.

Support of the existing human-animal bond is an important goal.

Dedicated emphasis on the reduction of fear, stress and pain is always warranted.

Regardless of the anesthetic techniques used in a particular geriatric patient, certain protocols should be incorporated.

Geriatric patient care requires increased vigilance in anesthetic and perioperative monitoring and physiological support. The limited reserve of the aged patient increases susceptibility to adverse outcomes that must be prevented when possible and recognized early when they occur.

Changes in daily routine are less well tolerated in the older animals. The lack of restful sleep increases fatigue and may lead to a negative outcome through subtle interference with immune function, nutrition and hydration, and the neuroendocrine response to physiological stressors. Muscle weakness in the older pet complicates recovery, particularly from the trauma of surgical experiences. When possible and consistent with medical goals, outpatient techniques with prompt return of the patient to familiar settings and routine are highly desirable.

Maropitant (Cerenia) administered before other preanesthetic medications reduces or eliminates the perioperative vomiting that is otherwise often associated with opioids and which can increase risks of aspiration pneumonia and contribute to patient distress. Important for stressed geriatric patients, the return to spontaneous feeding is enhanced, presumably supporting nutritional status, maintenance of gastrointestinal tract function, wound healing, and immune function, when maropitant is administered before anesthesia.

For geriatrics, it is useful to select anesthetics that either: (1) typically provide for a rapid and complete recovery (propofol or alfaxalone), (2) can be fully reversed (diazepam, midazolam, opioids and dexmedetomidine), (3) can be totally eliminated by supported ventilation (isoflurane, sevoflurane or desflurane), or (4) have neither substantial intrinsic toxicity nor significant adverse effects should the drug effects persist

level of support during anesthesia and surgery.1 Post-anesthetic administration of supplementary oxygen by breathing circuit and endotracheal tube and then via mask adds substantially to improved outcomes.

Adequate fluid replacement should be given to prevent a renal crisis and to help maintain a proper hemodynamic state in the geriatric patient. The specific fluid used will be dictated by the particular patient's needs. In most situations, a balanced electrolyte solution is an appropriate and best choice. Since hypoglycemia during and after anesthesia can be a problem in some geriatric patients, administering fluids containing glucose may be warranted based on determination of hypoglycemia.

The rate of IV fluid administration will depend on the particular patient's needs but will generally be in the range of 3-5ml per kg per hour.2 The rate should be decreased in geriatric patients where the risk of hypoproteinemia or cardiovascular overload is a concern. Fluid therapy and other physiological support, as well as critical care, may need to be continued for several hours to several days following anesthesia and surgery.

Excessive fluid therapy is not acceptable as a compensation for excessive anesthetic-induced loss of sympathetic and vascular tone. A better approach for many patients is a more balanced or multimodal anesthetic technique, relying more on injectable agents and less on inhalant anesthetics. Both evidence-based medicine and the consensus of expert opinion have led to a general reduction of anesthetic fluid therapy volumes and the rates of fluid administration. Excessive fluid therapy is associated with renal and vascular endothelial injury, coagulopathy, and a myriad of previously underappreciated deleterious effects. (diazepam, midazolam, butorphanol). In situations where inadequate metabolism or elimination is recognized, physiologic support — including judicious fluid therapy, support of body temperature, ventilatory support and extended post-anesthetic care —should be provided as indicated.

Geriatric patients should be preoxygenated for two to five minutes before anesthetic induction to help prevent hypoxia from developing during induction. Every anesthetized patient should be intubated to protect and maintain a patent airway. The safety that often has been associated with inhalants, as opposed to injectable anesthetics, is in part due to the customary, if not, obligatory provision of supplemental oxygen as the carrier gas for the volatile anesthetics. Endotracheal intubation and administration of supplementary oxygen can easily be incorporated into injectable general anesthetic techniques and can add substantially to patient safety. If anesthesia is deep enough to allow for placement of an endotracheal tube, then the patient is no longer able to protect its airway from either obstruction or aspiration of regurgitated or foreign material.

Practically any time that an endotracheal tube can be placed, one is needed. Although not all anesthetized animals will require supplemental oxygen administration, the geriatric patient, and many other higher risk patients, should be considered for this

Close monitoring of cardiovascular and respiratory parameters is essential for geriatric patients. As necessary, the patient's hemodynamics and ventilation should be supported. Methods should be used to prevent or decrease hypothermia during and after the surgical procedure. The intraoperative monitoring techniques should be continued well into the postoperative period, beyond the point at which the geriatric patient has returned to the preanesthetized state.

SYNOPSIS

The anesthetic and perioperative care of geriatric animals requires increased vigilance and support. The margin of acceptable physiological variation is probably narrower than in younger patients. Underlying disease, which is often subclinical, influences metabolism and recovery from anesthetics and also predisposes the patients to adverse outcome. Limited respiratory and cardiovascular reserve diminishes the ability of many older patients to meet the challenges of anesthesia and surgery or other stressful medical procedures. The psychological, as well as physiological, stress of hospitalization is increased in many geriatric patients.

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References

1. Bednarski R, Grimm K, Harvey R, Lukasik VM, Penn WS, Sargent B, and Spelts K. AAHA anesthesia guidelines for dogs and cats. Journal of the American Animal Hospital Association 2011; 47(6): 377-385.

2. Davis H, Jensen T, Johnson A, Knowles P, Meyer R, Rucinsky R, Shafford H. 2013 AAHA/AAFP fluid therapy guidelines for dogs and cats. American Association of Feline Practicioners; J Am Anim Hosp Assoc. 2013;49(3):149-59.

3. Epstein M, Kuehn NF, Landsberg G, Lascelles BD, Marks SL, Schaedler JM, Tuzio H. AAHA senior care guidelines for dogs and cats. J Am Anim Hosp Assoc.

2005;41(2):81-91.

Ralph Harvey, DVM, MS, DACVAA

Dr. Ralph Harvey teaches anesthesia and pain management in the Department of Small Animal Clinical Sciences at the University of Tennessee College of Veterinary Me d i c i n e ( U T C V M) i n Knoxville, Tennessee. He previously served as the section head for the Small Animal Surgical Services and is a member of the University Faculty Senate. His veterinary degree is from the UTCVM and his post-graduate training includes an internship, residency and fellowship at Cornell's Veterinary and Medical Colleges.

Dr. Harvey has worked in private small animal practice.

He is certified as a specialist by the American College of Veterinary Anesthesia and Analgesia, and he has served as their executive secretary and as a member of the ACVAA Board of Directors. He is currently a member of the Fear-Free Advisory Panel and Executive Council.

INTERESTED IN LEARNING MORE FROM DR. HARVEY? He will once again be presenting at the 90th FVMA Annual Conference in Tampa, Florida from May16-19, 2019.

18  |  FVMA ADVOCATE

CASE REPORT

provided by Dr. Ben Kinney Miniature Schnauzer Presented with periodontal disease, oral pain and malodorous breath. Client requesting dental care.

Body weight 6.4 kg, body condition score 5/9, male neutered, 25 years old as confirmed by breeding registry.

History of 2 kg weight loss and progressive difficulty eating (progressing to anorexia) over past year, cataracts and recurrent UTI. Yearly physical exam findings and health care were reasonable for extreme age. Serum chemistry values had been normal until the previous year, then ALT 130, ALP 350; three months later: ALT400, ALP600; and six months later: ALT 750, ALP 900. Serum creatinine normal, thoracic radiograph normal. Supportive medication for liver disease for past nine months.

Abdominal ultrasound examination normal.

Client consent obtained for anesthesia and dentistry after thorough discussion including risk factors and prognosis.

Perioperative Patient Care Plan and Anesthesia: Balanced electrolyte IV fluids, 5 ml/kg, prior to sedation and anesthesia. Hydromorphone 0.1 mg/ kg (IV), midazolam 0.5 mg/kg (IV), ketamine 5 mg/ kg (IV), propofol prepared but not required for endotracheal intubation, incremental doses of 1.5 mg/kg periodically during procedure. Isoflurane in oxygen, at vaporizer setting 1.0%. Monitored parameters during dentistry included: mean blood pressure greater than 72 mmHg, heart rate 85-100, SpO2 96-98% throughout dentistry. Two extractions of incisors. Total anesthesia time less than one hour. Recovery from anesthesia smooth and uneventful with continued monitoring and delivery of supplemental oxygen. Discharged within three hours to clients.

Patient follow up: The patient was later referred to a regional specialty hospital for evaluation of seizures. A large frontal lobe mass was revealed by CT scanning. The clients elected euthanasia two days later.

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PRACTICE GOT A QUESTION? THE FVMA CAN HELP.

One of the benefits of membership in the FVMA is our Helpline, (800.992.3862), available to members daily, Monday to Friday, 8:00 a.m. to 6:00 p.m.

Our Helpline also provides insight to the FVMA staff of the challenges and concerns of our members.

In this feature, we will highlight topics from the questions we received in preceding weeks, in an effort to keep our members up-to-date on current concerns as well as regulatory and legislative changes.

QUESTION:

I was under the impression that the interpretation of the Practice Act prevented technicians from performing dental extractions? I have had many technicians apply for a job with my hospital and list on their resume that they perform extractions and one even said suturing. When discussing with them that this is against the Practice Act and, thus, illegal, they seemed very unaware of this. Is my interpretation still correct that extractions are not permitted by technicians? If so, do many area Florida veterinarians know this and just don't care?

A: Technically speaking, the only tasks that can't be delegated are vaccinations for the four diseases listed below: 61G18-17.006 Diseases which Only a Veterinarian May Immunize or Treat.

For the purpose of implementing the exemption provisions of Section 474.203(5)(a), F.S., the Board recognizes that the following diseases are communicable to humans and are of public health significance, and that only a veterinarian may immunize or treat an animal for these diseases: (1) Brucellosis.

(2) Tuberculosis.

(3) Rabies.

(4) Equine Encephalomyelitis The rule on delegable tasks does not specifically prohibit delegating a tooth extraction, or anything else for that matter, as long as it is under immediate supervision.

61G18-17.005 Tasks Requiring Immediate Supervision.

(1) All tasks which may be delegated to a veterinary aide, nurse, laboratory technician, intern, or other employee of a licensed veterinarian shall be performed only under the “immediate supervision” of a licensed veterinarian as that phrase is defined in subsection 474.202(5), F.S., with the exception of the following tasks which may be performed without the licensed veterinarian on the premises: (a) The administration of medication and treatment, excluding vaccinations, as directed by the licensed veterinarian; and (b) The obtaining of samples and the performance of those diagnostic tests, including radiographs, directed by the licensed veterinarian.

(2) The administration of anesthesia and tranquilization by a veterinary aide, nurse, laboratory technician, intern, or other employee of a licensed veterinarian requires “immediate supervision” as that phrase is defined in subsection 474.202(5), F.S.

20 | FVMA ADVOCATE

(3) The administration of any vaccination by a veterinary aide, nurse, technician, intern or other employee of a licensed veterinarian which is not specifically prohibited by Rule 61G1817.006, F.A.C., requires “immediate supervision” as that phrase is defined in subsection 474.202(5), F.S. A veterinarian can be disciplined for: (hh) Delegating professional responsibilities to a person when the licensee delegating such responsibilities knows or has reason to know that such person is not qualified by training, experience, or licensure to perform them.

Taking all of these different laws and rules into consideration, a veterinarian that delegates a tooth extraction to a qualified technician who performs it under their immediate supervision is on safe ground.

QUESTION:

Our Sarasota County Animal Control act/ordinances require that all dog and cat bites AND scratches be reported to either the health department or animal services. I have been informed that any health care provider, physician or veterinarian is required to report all bites and scratches, even a two-month-old puppy play biting, currently vaccinated animals biting their owners, accidental owner bites when giving treats and/or anything that breaks the skin. Where is my liability if these are not reported? These bites are discussed with the owner for consultation or in passing in the confines of the exam room during the VCPR; thus, am I required to turn over that information/ knowledge to the animal services? Furthermore, does the veterinary Practice Act prevent me from turning over that information if the owner doesn't want me to?

I understand the goal of reporting, but our ordinances seem very broad and not specific. I assume many of the area veterinarians are not reporting every single incident they hear about that breaks the skin. I assume they are using professional judgement case by case.

But then again, where is my liability should something happen and I didn't report?

A: I have not read the Sarasota Animal Control act/ordinance, so I can’t specifically comment on it. Nevertheless, I am familiar with similar laws/ordinances. The reporting requirement is usually applicable if emergency or other medical care is required as a result of the bite. In other words, physicians treating persons at the hospital or their office for a dog bite

must report. A significant rationale for such reporting is so that the person who was bitten can find out if the dog/cat is up to date on vaccinations, including rabies.

The types of bites mentioned in the question are not the types of bites contemplated by the ordinance. The owner that has been bitten is well aware of the vaccination status of his/her pet. Such bites do not require emergency or other medical care, and they are almost always discussed after the fact. If there is a bite at the clinic that requires emergency or medical care, then such a bite should be reported. If the owner mentions that the dog is biting frequently or aggressively and there is a concern for the safety of children in the household or other persons, then reporting a bite may be appropriate. This is a case-by-case situation that requires the use of professional judgment.

QUESTION:

Can products that contain THC or cannabidiol (CBD) be sold as dietary supplements?

A: No. Based on available evidence, FDA has concluded that THC and CBD products are excluded from the dietary supplement definition under sections 201(ff)(3)(B)(i) and (ii) of the FD&C Act, respectively. Under those provisions, if a substance (such as THC or CBD) is an active ingredient in a drug product that has been approved under 21 U.S.C. § 355 (section 505 of the FD&C Act), or has been authorized for investigation as a new drug for which substantial clinical investigations have been instituted and for which the existence of such investigations has been made public, then products containing that substance are outside the definition of a dietary supplement. FDA considers a substance to be "authorized for investigation as a new drug" if it is the subject of an Investigational New Drug application (IND) that has gone into effect. Under FDA’s regulations (21 CFR 312.2), unless a clinical investigation meets the limited criteria in that regulation, an IND is required for all clinical investigations of products that are subject to section 505 of the FD&C Act. There is an exception to sections 201(ff)(3)(B)(i) and (ii) if the substance was "marketed as" a dietary supplement or as a conventional food before the drug was approved or before the new drug investigations were authorized, as applicable.

However, based on available evidence, FDA has concluded that this is not the case for THC or CBD. For more information on this provision, including an explanation of the phrase "marketed as," see Draft Guidance for Industry: Dietary Supplements: New Dietary Ingredient Notifications and Related Issues.

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FDA is not aware of any evidence that would call into question its current conclusions that THC and CBD products are excluded from the dietary supplement definition under sections 201(ff) (3)(B)(i) and (ii) of the FD&C Act. Interested parties may present the agency with any evidence that they think has bearing on this issue. Our continuing review of information that has been submitted thus far has not called our conclusions into question.

QUESTION:

I am a shelter veterinarian and currently work at a municipal shelter.

I had a situation at work recently and am not sure what to do and was hoping the Association can provide insight. The director of the shelter was asked if the agency could provide vaccines to several dogs owned by homeless people who were being placed into homes. The director made the decision to provide the rabies vaccines for those dogs, and they asked two staff members to administer them. The staff members expressed that in the State of Florida only licensed veterinarians are able to administer rabies. She responded she understood and would take responsibility and asked them to administer the rabies vaccine anyway. She did not consult with me or the other veterinarian that works for the agency. Microchips were also placed into these dogs, and there was not a veterinarian on the premises. The staff members made me aware of the situation and also stated that rabies certificates were not provided to the dog owners. I am terribly concerned that my boss made such a decision and that she hid it from me. In such a case, what are the legal repercussions? Could I be held liable for this should someone report it to the DBPR? What possible actions could be taken against my place of work given that it is a government agency?

A: There is no liability/responsibility on the part of the veterinarian/member for the intentional violation of laws/ rules by others in the shelter. The question then becomes whether this veterinarian should continue working there. The boss made a bad decision and tried to hide it. At the very minimum I would tell the boss that pursuant to §474.214(1)(aa), a veterinarian is subject to disciplinary action for: (aa) Failing to report to the department any person the licensee knows to be in violation of this chapter or of the rules of the department or board.

So in the event of a similar future occurrence, the veterinarian will have to report.

END NOTE: The ultimate responsibility in the practice of veterinary medicine lies with the licensed veterinarian. Professional discretion must always be exercised.

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CLASSIFIED ADVERTISEMENTS VETERINARIANS WANTED

FULL-TIME VETERINARIAN WANTED – COCOA FLORIDA: Full time veterinarian needed for a 2 plus doctor small animal and exotic animal practice - fully equipped surgical, dental, radiography, ultrasound and more.

Our hours of operation are M-F 7:30-5:30 and Sat 8-12. We are located in Cocoa Florida - an ideal location between Orlando west and Cocoa Beach east as well as Titusville (the Space Center) / Daytona north and Melbourne/ Vero Beach south. For more information call Dr. Sarah Guttery 321-917-2670 and/or email sguttery@cfl.rr.com (6/18; ID#19114) VETERINARIAN WANTED - CENTRAL FL: Fully equipped including ultrasound, laser surgery, digital x-ray, AVImark software etc.

How does 140 K annual salary with three weeks paid vacation sound? Please call for information (352) 389-1588. (6/18; ID#28095) VETERINARIAN WANTED – DESTIN, FL: The Emergency Veterinary Clinic of Destin, with an anticipated opening date of March, 2019 is accepting applications for 3 full-time emergency veterinarians. Beautiful Destin, Florida, nestled directly on the Gulf of Mexico between Pensacola and Panama City in Florida’s Panhandle, boasts sugar white sand beaches and a laid back lifestyle.

The new Destin facility will have state of the art equipment including digital radiology, ultrasound, and full in-house lab equipment, with 35 referring member clinics and an excellent support staff.

The Emergency Veterinary Clinic of Destin has well established roots with 20 plus years of ER experience serving Okaloosa and Walton Counties at our flagship location in Niceville, Florida. Our veterinarians can expect an excellent salary ($100k+) based on production and benefits with a rotating schedule of 12-14 shifts per month. We are open nights, weekends, and holidays when all other area clinics are closed.

Please email your resume to kyoung@nevc.gccoxmail.com or send to Emergency Veterinary Clinic at 212 Government Ave. Niceville, Florida, 32578. Please contact Kathryn Young with any questions at 850 729-3335.

(6/18; ID#1429) VETERINARIAN WANTED – KEY LARGO, FL: The Island Hammock Pet Hospital is looking for the right candidate with several years of experience to help us continue to grow and achieve our goals of providing exemplary medicine to our patients and outstanding service to our clients.

We are a new, fast growing, three doctor companion animal practice located in Key Largo, Florida. We offer a strong compensation package, an experienced staff and a rewarding work environment. We operate a new, AAHA accredited, state of the art facility and utilize efficient business practices. You can learn more about us at www.IHPH.net.

The fabulous Florida Keys offers some of the best fishing and SCUBA diving available in North America. Island life is a laid back, semi-rural lifestyle. All of the advantages of a large metropolitan area are within a 45 minute drive.

If you love the water and sun, the Florida Keys is a great place to live.

To learn more about the position, please send your resume to careers@IHPH.net. (6/18; ID#10524) VETERINARIAN WANTED – JACKSONVILLE, FL: San Juan is a familyowned private practice currently with 4 full-time veterinarians on staff (one Georgia, one Auburn, one Florida, and one Ross grad). All our toys are quite new, and our 11,000 square foot building has just been remodeled. We offer daytime hours only and are fully equipped with onsite Ultrasonography, Digital Radiography, as well as, Digital Dental Radiography, In-House IDEXX Laboratory, Companion Therapy Laser, and a Surgery Suite. Please contact gbennett4519@gmail.com. (6/18; ID#25897) VETERINARIAN WANTED – GAINESVILLE, FL AND OCALA, FL: Country Critters Veterinary Clinic is a full-service hospital located inside select Rural King stores. We are looking for motivated and experienced veterinarians to join our team! Our mission is to provide top quality, compassionate care to our patients and their families at an affordable price.

Our clinics have digital x-ray, hematology equipment, and spacious surgery suites. No after-hours emergencies and both full/part time positions are available. We offer a rich benefit package including medical, dental, and vision insurance and a matching 401K in addition to a generous compensation plan

24 | FVMA ADVOCATE

that includes an annual stipend for CE and licensure. We have openings at both our Gainesville and Ocala locations. Mentorship for a new graduate available in Ocala. Please email resumes to jstewart@ruralking.com (6/18; ID#37347) VETERINARIAN WANTED - MIAMI, FL: Enjoy an ideal work-life balance in Miami, FL! Country Club Animal Hospital is one of the area’s most established private small animal veterinary practices with a 25-year exceptional reputation. Health services include preventive care, general medicine, routine surgeries, dental care, in-house laboratories, laser therapy, digital radiology, ultrasound, in-house pharmacy, and experienced support staff. Our 2-doctor team is seeking an experienced veterinarian (confident new grads considered) to join us as we expand and grow. Competitive schedule (three day weekends every other week), salary and bonus potential; medical, dental and vision insurance; 401K; generous CE allowance; professional liability coverage and more. Fluency in English required. Fluent or conversational Spanish is a plus. For consideration, please email your cover letter and resume to Nikole Augsten at ccah_nea@outlook.com. For additional information on the practice, visit www.ccahweb.com. (6/18 & 1/19; ID#609) VETERINARIAN WANTED - NAPLES, FL: Come join my privately owned and highly respected hospital and become part of a strong team of compassionate, skilled veterinarians with over 110 years of combined experience. My four associates have been with me for 18, 17, 13 and 5 years with no plans of leaving. 9 of my current staff members have also been with me for over 10-15 years. Retention speaks volumes!! My current hospital was established in 1971; however, we are moving into a state of the art 9500 sq. ft facility in early May 2019. We are equipped with digital x-ray, ultrasound, dental X-rays, strong community ties with almost ALL our local rescue groups, internal medicine specialist on-call, sign on bonus AND 5 minutes from the beach. Must have strong surgical/dental skills to be considered. Please contact Dr. Bob March at 239-774-3701 or bobmarch706@gmail.com. Check us out at harborsideanimalclinic.com. (6/18; ID#27240) VETERINARIAN WANTED – HOUSTON, TX: Do you crave a collaborative workplace that provides ample room for career development?

If so, joining the veterinary team at the Houston SPCA could be your best career move yet. This is a great opportunity to work with mission-driven staff providing excellent care to animals in need. We treat companion pets, wildlife, farm animals, and the occasional exotic. Veterinarians at the Houston SPCA also participate as clinicians for the Texas A&M College of Veterinary Medicine in their Animal Welfare and Shelter Medicine rotation. Our compensation package is extremely competitive exceeding the top 75% percentile* (*per USAwage.com) in Houston for base salary - $115k, paid time off, Continuing Professional Education, 403(b) retirement plan, professional dues and license fees paid, a 4-day work week, and an outstanding work environment. Additionally, the Houston SPCA is a 501(c)(3) and an eligible organization for the federal student loan forgiveness program. Visit our Careers page to learn more and apply: www.houstonspca.org/about-us/employment/. (6/18; ID#44387) VETERINARIAN WANTED – TAMPA, FL Full or part-time associate veterinarian needed for our 100% small animal practice located in a northern suburb of Tampa. We are a rapidly expanding practice located in a brand new, state-of-the-art 10,000 s.f. facility on a major thoroughfare. Hours are M-F 8 til 5:00, and Saturdays until noon. All emergencies are referred to a local ER, and no animals are housed overnight.

The new associate should look forward to working with the most advanced equipment available to the general practitioner. This includes a complete Idexx lab facility, a Nikon cytology microscope, SonoScape ultrasound, Rayence digital x-ray, K-laser Cube 4 cold therapy laser, Tono-Pen AviaVet digital tonopen, sevo gas anesthesia, and much more. Advanced equipment requests beyond these are always considered.

We are a family-owned business, with no corporate ties. And although busy, ours is an extremely friendly and low-stress work environment. The successful candidate will be one who is people oriented, enjoys working with

others, and expects to bring a smile to work every day. We stress making sure all employees have maximum time off, and emphasizing that all team members have a fulfilling family life is as important to our management team as is any aspect of productivity or customer satisfaction.

The position is open to new/less-experienced doctors as well as experienced individuals. Interested candidates should apply with resume and cover letter to acupet@acupetvetcare.com, or call 727-863-2771, and we'll be happy to discuss more details in person. (6/18; ID#27544) VETERINARIAN WANTED – TAMPA, FL: Enthusiastic, full-time small animal/exotic veterinarian needed for busy, well-established practice in the Tampa Bay area. We pride ourselves on progressive, high quality medicine and surgery. Candidate must be professional, knowledgeable, and courteous with a focus on excellent patient care and client communication. Professional/ personal balance is important and we provide a schedule that emphasizes quality of life with no after hours emergencies or holiday work. Digital radiography and in-house laboratory machines are part of the tools we use to offer high quality medicine. Salary is very competitive with benefits including paid health insurance, CE, holiday, sick and vacation days. Our patient load balances out at roughly 50% dogs and cats, and 50% exotics.

The Avian and Animal Hospital has been caring for cherished pets in Pinellas County since 1987. We care for dogs, cats, birds, rabbits, ferrets, reptiles, and other exotic pets. The Avian and Animal Hospital provides veterinary services to Largo, Clearwater, Pinellas Park, Seminole, Bellair Bluffs, St. Petersburg, and all of west central Florida. Your pet’s health is our life’s passion. Please contact/send resume to Krista Donovan krista.donovan@avianandanimal.com (6/18; ID#3927) VETERINARIAN WANTED – WAKULLA COUNTY, FL: Shepherd Spring Animal Hospital has a new staff veterinary position available. We are currently a 4 doctor, growing practice that is looking to add a fifth veterinary professional that is motivated to grow and succeed in our practice. We are a 10 year old small animal hospital in Wakulla County, Florida. We occupy a 5,000 square foot, stand alone, hospital with ample parking and fast growth.

We have a complete Idexx lab station, digital radiology, five exam rooms and dental suite+radiology. We are only open M-F 8:00 am-5:00 pm (No Weekends!!). We are a true small animal veterinary hospital, no grooming or boarding, We believe the weekends should belong to the staff, not the business.

The successful candidate is expected to be clinically competent in small animal medicine and routine soft tissue surgery. A great opportunity for a veterinarian with an interest in learning to perform complex soft tissue and orthopedic/neuro surgery exists for a candidate. We have an experienced surgeon who is willing and anxious to mentor a veterinarian candidate. We also provide medical treatment at no cost to our wildlife patients at a local museum and also to the sea turtles at our local marine lab.

Wakulla County offers exceptional natural beauty and outdoor recreation opportunities including fishing, kayaking, hiking, boating, and snorkeling.

Please contact me, Dr. Norm Griggs or the hospital Shepherd Spring Animal Hospital (850) 926-1475 and we can get together for a tour and talk about your future in a veterinary hospital that is part of our community in many ways. (6/18; ID#5471) VETERINARIAN WANTED – JACKSONVILLE, FL: We are seeking a small animal veterinarian for a clinic located in the south side of Jacksonville, Florida. We have a newly renovated clinic along with new equipment. We are looking for a veterinarian who wants to practice progressive, compassionate medicine in an environment of a closely-knit team who wants the best for our clients. We are located close to the beach and are convenient to shopping, restaurants and golf courses. We are offering a competitive salary along with production bonus and multiple benefits tailored to the right candidate. There will be a buy in option for those that are interested. Contact Deloris Stamm at 904 294 8384 or email deloris@paradiseoga.com. (6/18; ID#40490) VETERINARIAN WANTED – DAYTONA BEACH, FL: We are seeking a full time veterinarian for our well established small animal hospital that has been anchored in the community since 1962. At Driftwood Animal Hospital we serve a large diverse client base in Daytona Beach, FL and surrounding communities. Minutes from Florida’s beautiful beaches and a conveniently located near the region’s major metropolitan areas (Orlando, Tampa, Jacksonville, Miami). Our area also enjoys a reasonable cost of living. A three vet practice with over 50 years of experience combined, all with varying interests including internal medicine, dermatology, surgery

(soft tissue and orthopedic). We work hard in a relaxed environment with a consistent and enthusiastic support staff. We are looking for a vet that will add to our collaborative work environment and continue to help us evolve along with veterinary medicine. Applicants should have an interest in diagnostic medicine as well as surgery. Experience is a plus, but new graduates are encouraged to apply. No emergency or on call hours. Florida license required. Salary is negotiable based on experience.

Benefits include: paid vacation, paid CE time off, CE stipend, paid license, professional membership dues, and liability insurance. Please send Resume/ CV to Dr. Kyle Wolfersteig at: KyleWDVM@mail.com Visit our website: www.driftwoodanimalhospital.com. (6/18; ID#20608)

PROPERTY/PRACTICES FOR SALE

PRACTICE FOR SALE – CENTRAL FLORIDA: Central Florida small animal practice. Gross is in excess $1 million. Owner will finance a qualified buyer. Call 352-389-1588. (6/18: ID#28095) PRACTICE FOR SALE – TAMPA, FL: Small animal practice for sale in Tampa. Established since 1960. 2018 gross $700,000. Owner retiring.

Call Dr. F.R. Tellekamp- 813-971-7668. (6/18: ID#4672) PRACTICE FOR SALE – HOMOSASSA, FL: Located on Highway 19 on the Nature Coast this approximately 2500 sq. ft. building was once an animal hospital but has been a boarding and grooming facility for the last 20 years. It could function as either. The building needs improvements but the price of the property reflects these needs. The property comes with a second small building that is currently a business rental. Call 3652-422-7858 for more information. (6/18: ID#2771)

EQUIPMENT FOR SALE

EQUIPMENT FOR SALE – CROSS CITY, FL: MinXray HF 100, w/ table, can be fitted for digital, is portable. CO2 powered CapChur Equip: 2 pistols, 1 rifle, various needles, syringes. Idexx Vet Test 8008 & Autoreader. iM3 Dental system & scaler. Contact: Dr. Linda Stoddard, 507-456-3697 or lgstoddard@bellsouth.net. (6/18: ID#44379)

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