Advocate Issue 4, 2020

F V M A ADVOCATE ISSUE 4 | 2020

In Loving Memory Philip J. Hinkle | 1961-2020

Decision Fatigue:

How the Amount of Decisions We Make Affects the Quality of Our Decision-making | Pg.12

High Demand?

CBD: A Grey Area of Research and Legality | Pg.16

Fatalities, Adverse Events and Accidents in Small Animal Anesthesia: Can We Do Better? | Pg.22

President's Message 7207 Monetary Drive Orlando, Florida 32809 Phone – 407.851.3862 Toll-free – 800.992.3862 Fax – 407.240.3710 info@fvma.org | www.fvma.org

Dear Colleagues, It is with a heavy heart that I write this president’s letter, as we recently lost our executive director and dear friend, Phil Hinkle.

Phil fought his battle against cancer with strength, determination and a positive attitude.

His wife Janet was at his side every step of the way. His passing was sudden and unexpected, as he had been deemed cancer free after the final phases of his treatment. It is a devastating blow to all who knew him.

OFFICERS

Dr. Mary Smart President Dr. Marta P. Lista President-elect Dr. Donald H. Morgan Treasurer Dr. Michael Epperson Past President

DISTRICT REPRESENTATIVES Dr. Scott Richardson District 1–Big Bend Dr. Thomas E. Hester District 2–Northeast Dr. Todd Fulton District 3–Central Dr. Donald S. Howell District 4–Tampa Bay Dr. Susan M. Carastro District 5–Treasure Coast Dr. Robert L. Swinger District 6–South Florida Dr. Barbara Lewis District 7–Southwest Dr. John R. Wight District 8–Northwest Dr. Christine M. Storts District 9–Space Coast Dr. Ernest C. Godfrey AVMA Delegate

Upon Phil’s passing, the FVMA staff have stepped in to carry on their many tasks in an uninterrupted fashion. They are doing an amazing job, continuing their work through this time of sadness. Phil created a strong succession plan, so that all areas of operational needs are still met with the usual excellence to which we are accustomed.

After much deliberation in early August and with the ongoing uncertainly of COVID, Phil, the FVMA Board of Directors and the continuing education team elected to cancel the in-person meeting for the Gulf-Atlantic Conference. The safety of all involved was considered when this decision was made. The FVMA is currently working on virtual options to obtain CE, and we hope to have these available very soon. We will, of course, resume in-person meetings when it is safe to do so.

I hope this finds you well and continuing with strength through these times.

My best to all,

Dr. Richard B. Williams AVMA Alternate Delegate Dr. Jacqueline S. Shellow FAEP Representative to the FVMA Executive Board

Mary Smart, DVM

Dr. Dana Nicole Zimmel Dean, Ex Officio

FVMA MISSION:

TO ADVANCE THE VETERINARY MEDICAL PROFESSION, PROMOTE ANIMAL HEALTH AND WELL-BEING, AND PROTECT PUBLIC HEALTH.

Opinions and statements expressed in The Advocate reflect the views of the contributors and do not represent the official policy of the Florida Veterinary Medical Association, unless so stated. Placement of an advertisement does not represent the FVMA’s endorsement of the product or service.

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Missing or Falsified OCVI? If your client does not receive or you are presented with a suspicious Official Certificate for Veterinary Inspection (OCVI), you can report it by emailing: Nelly Amador Jehn, DVM Veterinarian Manager-Small Animal Programs Division of Animal Industry Florida Department of Agriculture and Consumer Services Email: AnimalIndustry@FDACS.gov Tel: 850-410-0900 or 850-410-0950

For issues concerning noncompliance with The Florida Pet Law, Section 828.29, Florida Statutes, please contact Consumer Services at 1-800-HELPFLA (435-7352) or 1-800-FL-AYUDA (352-9832) en Español.

If you are issuing any Official Certificate of Veterinary Inspection, you are required to have both a current Florida veterinary license and be Florida accredited by the USDA.

In This Issue 4 | In Remembrance 5 | Florida Veterinary Medical Association Mourns the Passing of Executive Director, Philip J. Hinkle 6 | Member Spotlight 8 | Dr. José Arce Poised to Become the Next AVMA President 10 | 2021 FVMA Annual Awards

12 | Decision Fatigue: How the Amount of Decisions We Make Affects the Quality of Our Decision-making 16 | High Demand? CBD: A Grey Area of Research and Legality 22 | Fatalities, Adverse Events and Accidents in Small Animal Anesthesia: Can We Do Better?

28 | Practice Pulse 30 | Classified Advertisements

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In Remembrance James F. Aycock, DVM Dr. James F. Aycock of Hollywood, Florida, passed away at the age of 92 on June 23, 2020. The son of Itus and Lena Aycock, Dr. Aycock was a native Floridian. He proudly served as a U.S. Marine Corp captain in the Korean War. He loved fishing, entertaining and cooking for his family and friends.

Dr. Aycock earned his undergraduate degree from Tulane University and his DVM from Auburn University. He founded, owned and operated Aycock Veterinary Clinic in Davie, Florida, for over 50 years. Dr. Aycock was, as described by his mentee Dr.

Marlene Pinera, “years ahead of his time when it came to veterinary medicine.” He touched many lives and was loved dearly.

He is predeceased by his beloved brother John Aycock, and is survived by his sons, David and James (Tobi); his grandchildren (Alexander, Zoe, Zachary, and Wyatt); great grandchild, Oliver James; his beloved niece, Robin Bauman; and several other nieces and nephews.

Scott D. Bennett, DVM Dr. Scott D. Bennett passed away at the age of 66 on June 4, 2020.

groundbreaking work redefined the possibilities of regenerative therapy and equine veterinary medicine.

Dr. Bennett was born in Dayton, Ohio, and raised in Lebanon, Tennessee. He graduated with honors from Castle Heights Military Academy and attended the University of Tennessee for pre-vet studies. At 19 years old, he received early admission to The Ohio State University School of Veterinary Medicine. In 1977, at age 23, he received his DVM and became one of the youngest veterinarians in the US at the time. To this day, he remains one of the youngest graduates in the school’s history.

In addition to his work in treating lameness, Dr. Bennett was a pioneer in equine embryo transfers. In 1984, he executed an inter-species embryo transfer at the Louisville Zoo, successfully transplanting a zebra embryo into a domestic horse. Dr. Bennet also founded Alliance Stud, a multifaceted breeding and training facility in Simpsonville, Kentucky, where he raised many World’s Champion American Saddlebred horses. Because of his groundbreaking work and his passion and dedication to the veterinary profession, Dr. Bennett received several awards throughout his professional career.

He opened Equine Services in Simpsonville, Kentucky, in 1982 with the goal of offering a multifaceted medical-surgical hospital with state-of-the-art techniques and diagnostics. For 40 years, his

Dr. Bennett is predeceased by his father and survived by his wife, son, mother and two English Bulldogs.

Rossana Pérez-Freytes, DVM, DABVP Dr. Rossana Pérez-Freytes, 37, passed away in a tragic accident on July 31, 2020. She had served the veterinary community for over 10 years and was the medical director of Veterinary Healthcare Associates in Winter Haven, Florida.

Dr. Pérez-Freytes graduated with her Doctor of Veterinary Medicine and Master of Public Health from the University of Wisconsin-Madison in 2010. While pursuing her MPH degree, she acquired further training in epidemiology and risk analysis at Cornell College of Veterinary Medicine. She also completed a rotating small animal internship at the Veterinary Medical Center-University of Tennessee (Knoxville). In November 2019, she completed her specialty board certification (ABVP).

She was also an emerging infectious disease research fellow in 2007 at the National Center for Preparedness, Detection and Control of Infectious Disease (CDC) in Atlanta, Georgia. She went on to win the Edith Hambie Excellence in Public Health Award for her 4 | FVMA ADVOCATE

research on the “Experimental Approach to the Therapeutic Treatment of Rabies.”

Dr. Pérez-Freytes contributed to various publications and co-authored articles about veterinary treatments and pathologies. She was deeply passionate about educating pet owners and empowering them to make the best choice. She felt that it was “a gift to be part of their story.”

Dr. Pérez-Freytes enjoyed spending time with family and friends and being immersed in nature. She enjoyed traveling, cooking, salsa dancing, hiking, paddle boarding, gardening and was always looking for her next adventure. She is survived by her parents, Andres Perez Rodriguez and Edna Betzaida Freytes Rivera; by her siblings, Edna Betzaida Perez Freytes and Andres Israel Perez Freytes; and extended family and friends.

FLORIDA VETERINARY MEDICAL ASSOCIATION MOURNS THE PASSING OF

EXECUTIVE DIRECTOR, PHILIP J. HINKLE Philip J. Hinkle offered unwavering dedication to the profession for over 34 years.

It is with great sorrow that the Florida Veterinary Medical Association (FVMA) announces the passing of our Executive Director, Philip J. Hinkle. Mr. Hinkle had been with the FVMA for more than 34 years, serving as executive director since 2007. He was widely regarded as a pioneer, visionary and first-rate business leader who worked tirelessly to grow the Association and advocate for the veterinary medical profession.

Mr. Hinkle, 58, of Celebration, Florida, was a true Florida man. His career began with his family’s citrus business, Orange Ring, Inc, where he was vice-president of operations (1979 -1986). His leadership skills and business prowess were honed as he oversaw the day-to-day operation of the familyowned citrus groves.

In 1986, he became president of Hinkle Family Real Estate Holdings and joined the FVMA family as the director of finance and membership. He became the deputy executive director in 2006 and the executive director in 2007.

As executive director, Mr. Hinkle’s passion, work ethic and vision propelled the FVMA to become the third largest veterinary medical association in the U.S. When Mr. Hinkle became director, the FVMA’s annual operating income was less than $1 million and served a membership of 2,500. Since then, the FVMA has quadrupled its budget and, presently, the association services 6,000 members. In 2011, he successfully led the negotiated assumption of the Florida Association of Equine Practitioners, which now operates under the umbrella of the FVMA as its equine-exclusive division. Four affiliate membership associations for veterinary team members were launched in 2018.

Deeply passionate about public service, he served on numerous boards, councils and committees in Haines City, Florida. His history of civic service includes serving three terms as mayor of Haines City and 12 years as a city commissioner. Other positions he held included serving as a founding member of the Haines City Economic Development Council, Community Redevelopment Agency, City Housing Authority, Chamber of

Philip J. Hinkle 1961-2020 Commerce Board of Directors, and the Ridge League of Cities Executive Board and Legislative Committee. He was a board member and treasurer of the Veterinary Medical Association Executives, treasurer of Haines City Little League, and director/franchisee of Miss Heart of Florida.

Mr. Hinkle’s dedicated service led him to receive numerous awards including: the FVMA Distinguished Service Award (2006), the FVMA President’s Award “Service Before Self ” (2010), the FVMA Dedication Award “for 25 years of service” (2011), the Veterinary Medical Association Executives’ “Executive of the Year Award” (2014), and the FVMA Exemplary Service Award (2018).

In his personal life, Mr. Hinkle was a dedicated husband to Janet Fricke-Hinkle for 37 years and a wonderful father to their children; Amber Lynn Cameron (married to Dan) of Fort Mill, SC, Ashley Marie Jones (married to Charlie) of Gainesville, FL and Michael Philip Hinkle (married to Cynthia) of Winter Garden, FL. His parenting even led him to win Polk County Father of the Year in 2005.

Mr. Hinkle was predeceased by his father, Donald William Hinkle; mother, Rosemary Gloria Hinkle; and his beloved, first-born grandson and namesake, Elijah James Cameron.

He is survived by his wife, Janet; his children, Amber, Ashley, and Michael; his grandchildren, Jeremiah, Hannah, Jordan, Ella, and Austin; five sisters, and one brother. Many loving brothers-in-law, sisters-in-law, nieces and nephews also mourn his passing.

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MEMBER SPOTLIGHTS FVMA MEMBER DR. ANJANETTE CABEZA:

Photo courtesy of Doral Centre Animal Hospital.

Vet, Business Owner, Non-profit Founder

FVMA member Dr. Anjanette Cabeza, DVM, a very active and influential member of the South Florida Veterinary community, has worked for over two decades in small animal medicine and is the founder of the Cabeza Foundation.

Dr. Cabeza was born and raised in the Panama Canal Zone (a former U.S. territory overseas). She began working in the field of veterinary medicine at only 12 years old as a volunteer at a U.S. Military Clinic in Corozal, Panama. At 18, she moved to the U.S. to attend Colorado State University for her undergraduate degree. She later attended and then graduated from the University of Georgia College of Veterinary Medicine in 1994, where she was awarded the Upjohn Award of Proficiency in Small Animal Medicine. She then moved to Miami, where she started her first job and, eventually, opened her own clinic. She has never stopped learning and honing her knowledge of veterinary medicine.

This drive has led her to become certified to perform endoscopy procedures and Penn Hip Certifications.

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Dr. Cabeza is a member of the International Veterinary Emergency and Critical Care Society, the AVMA, the FVMA, and the SFVMA. She is also a USDA accredited veterinarian. For more than 23 years, Dr. Cabeza has owned and operated Doral Centre Animal Hospital, a successful emergency and trauma center in Doral, Florida. The center is open 24 hours a day to serve Doral and the surrounding area. She also opened a pet resort in 2017.

Located in Doral, Woodland Lodge Pet Resort was Dr. Cabeza’s brainchild, born from the need for a place she felt comfortable leaving her own pets when going out of town. Like most pet owners, she wanted her pets to feel safe and well-cared for while she was away. The outdoorsy, Colorado theme stemmed from her dream to design a place that was truly for dogs. She cites her border collie, Misty, as big influence. Rather than pets getting dropped off to stay in a cage, she created a true vacation destination, complete with spacious rooms, a pool and a yard area.

The resort is conveniently located near the Miami International Airport.

“The new direction has turned into a multilevel project involving a local high school, an architectural school, Miami Dade Animal Services and an IT company to create ‘PAK’ or the ‘Pet Adoption Kiosk.’ The coronavirus pandemic has put the brakes on this,” Dr. Cabeza says, “but we hope to continue on our venture in the near future and see it to fruition.”

She also created the Memory Lane Sidewalk, a brick dedication located at the Trails and Tails Doral Dog Park. Proceeds from the brick sales go towards the Cabeza Foundation.

Dr. Cabeza is married to Anthony Burke and together they have five children: Ashley, William, Andrew, Ryan and Ian; two wonderful daughters-in-law; and three grandkids. She also owns multiple pets: a Border Collie named Misty; two cats, Tiger and Slushy; 2 bunnies; saltwater fish; and a variety of wildlife that always seem to show up in the backyard!

Dr. Anjanette Cabeza.

Photo courtesy of Miami Pet Resort.

For Dr. Cabeza, the most rewarding part of her job is helping people and their pets. “This profession really embodies the trifecta of what I love: people, animals and medicine!” Dr. Cabeza says of her work. “The clinic was founded on the principal of trying to bring the highest standard of care and medicine to the clientele we serve. I attribute any success I have to Vistage, tithing and being surrounded by an amazing team of incredible individuals that I have the pleasure to work with each day.”

“It is a privilege and a pleasure to be a wife, a mom, a veterinarian and to serve the community,” Dr. Cabeza says of her many roles.

As so many veterinary professionals can understand, Dr. Cabeza cites the limits of medicine and time as the greatest struggles of doing what she loves. “The hardest part is twofold: one being when there are limits on what we can do to help people or a pet and the second being 'mom guilt,' that eternal struggle for worklife balance.”

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Photo courtesy of Miami Pet Resort.

On top of her hard work in the veterinary field, Dr. Cabeza founded the Cabeza Foundation to help fight some of the financial limitations that impacted her patients’ ability to receive needed care. When first founded, the nonprofit’s primary goal was to provide financial assistance to pet owners whose pet had a life-threatening condition that, with proper medical care, had a chance of returning to normal function. However, the rise of GoFundMe gave pet owners the ability to reach out and raise their own funds for pet care, making the foundation’s mission seem obsolete. With GoFundMe on the scene, Dr. Cabeza was ready to address a different issue in her community and began repurposing the foundation two years ago.

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Dr. José Arce Poised to Become the Next AVMA President Photo courtesy of AVMA.

Leading by example, the community oriented 2020-21 president-elect looks to take on the AVMA helm.

Dr. José Arce This summer, the AVMA House of Delegates elected Dr. José Arce as the 2020-2021 president-elect. He will succeed AVMA President Dr. Douglas Kratt in 2021.

Dr. Arce was born and raised in Puerto Rico. He is the first native Puerto Rican to serve on the AVMA Board of Directors.

Dr. Arce will also be the first Puerto Rican veterinarian elected president of the AVMA. “I am extremely proud of my Puerto Rican and Spanish roots; they are an intricate part of who I am and my perspective towards all things in life,” Dr. Arce told JAVMA News. “Becoming a Hispanic and minority president of AVMA will be an honor, but it also comes with some responsibility. I will do my best to lead by example, and hopefully my presidency will send a message of inclusiveness and inspire other minorities to become involved in organized veterinary medicine.”

In 1997, he graduated from the Louisiana State University (LSU) School of Veterinary Medicine and returned to Puerto Rico, where he immediately began working in veterinary clinics.

Dr. Arce became active in the Colegio de Medicos Veterinarios de Puerto Rico (PRVMA) and was named to the Ethics and Grievances Committee in 1998. In 1999, he represented the PRVMA to the AVMA Leadership Conference. Dr. Arce has been a board member of the PRVMA since 2000 and an active member of the Legislation Commission since 2001. These positions quickly snowballed into further involvement at the state and national levels. In 2011, he was chosen to take part in the AVMA House of Delegates Leadership Development Program. In 2012, he was selected for the AVMA Summit on Governance. Dr. Arce has been an active participant in organized veterinary medicine for 26 years now, from leadership roles in the Student AVMA to state (Puerto Rico VMA) and national (AVMA House and Board) positions. Dr. Arce served as the District 4 Director on the AVMA Board for six years. District 4 includes the states of Florida, Georgia and Puerto Rico. He

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has served on numerous councils, committees, advisory panels and AVMA trusts; as chair of the Committee on International Veterinary Affairs; and on the American Veterinary Medical Foundation board of directors.

All the while, he has continued to work as a veterinarian. In 2003, he founded Miramar Animal Hospital in San Juan, Puerto Rico, and remains president and co-owner of the hospital. Dr. Arce is actively involved in his local community and has served on boards and in leadership positions for various organizations, ranging from the PTA at his son’s high school and the Boy Scouts to his neighborhood’s resident association and the local pro-statehood party.

“I am truly passionate about our profession,” he said in his interview with JAVMA News. “I cherish every opportunity to educate, promote and advocate for our profession, whether it is in a kindergarten classroom or with members of the U.S. Congress.”

He has a deep love for soccer and continues to participate in the sport. From 2010-2019, Dr. Arce served as Director of the National Masters (over 35) Soccer League of Puerto Rico.

He continues to play and is team president of the Club de Internacional de Futbol. In his time both on and off the field, Dr. Arce strives to be a team player with an inclusive vision.

“AVMA members should anticipate a president who is a team player and who will work in collaboration with the Board and House to build consensus and promote a culture of unity; who is not afraid to speak his mind, but who, at the same time, is an active listener, and is willing to change his mind,” he told JAVMA News when asked what AVMA members can expect of his presidency.

Dr. Arce resides in San Juan, Puerto Rico, with his wife, fellow veterinarian Dr. Anik Puig, and their son, Diego.

Q &A

Q: Tell us more about the AVMA’s diversity, equity and inclusion (DEI) initiatives. How do you plan to continue or broaden these initiatives when you take over as president? What do these initiatives mean to you personally?

with DR. JOSÉ ARCE Q: What does this position mean to you?

A: The presidency of the AVMA, to me, is the culmination of my participation in organized veterinary medicine. I have held numerous positions throughout my career, starting at the LSU School of Veterinary Medicine, at the state level with the Puerto Rico VMA, and nationally, in the AVMA House of Delegates and the AVMA Board of Directors. These experiences, and the interactions that I have had with many colleagues throughout the past 27 years, have prepared me to be an effective AVMA president. A strong veterinary profession needs a strong AVMA, and, as president, I will be a staunch advocate for our profession in order to improve the lives of present and future veterinarians.

Q: What are some of the duties and roles of the president-elect?

A: I see my year as president-elect as a year to listen to the concerns and ideas of veterinarians and veterinary students. I will work in conjunction with President Doug Kratt, immediate Past-President John Howe, the AVMA BOD, HOD and staff, to build consensus and promote a culture of unity.

Q: What are you most excited about?

A: What I am most excited about are the opportunities that that I will have during the next couple of years to interact with my veterinary colleagues locally, nationally and globally. I look forward to communicating the values of our profession and educating the public about all aspects of veterinary medicine

Q: What advancements, changes, challenges, etc. do you foresee that the AVMA and District IV will have to tackle?

A: We all know that these are unprecedented times, but, as they say, with challenge comes opportunity. Whether it is the economic challenges facing our profession, wellness concerns, the technological advancements that are changing the practice of veterinary medicine, or the challenges that the COVID-19 pandemic has thrown at us; as leaders of our profession, we have a golden opportunity to become our most innovative, adaptive and resilient selves in facing all these challenges and making decisions that are in the best interest of our colleagues.

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A: I have been a dedicated advocate for diversity, equity and inclusion since I began my involvement with veterinary medicine in the early 90’s. Presently, we are living in times of social unrest, and I will do my best so that my work as president of AVMA will send a clear message of inclusiveness and inspire other minorities to become involved in organized veterinary medicine. I will make a point to reach out to those that feel that they do not have a seat at the AVMA table, and I will push the AVMA to strive for greater diversity, equity and inclusion as they give strength to our voice as advocates for veterinary medicine.

Q: What do you want members (both AVMA and FVMA) to know about you and your type of leadership?

A: They should expect a president that is passionate and deeply committed to veterinary medicine, and that will assume a leadership role in facing the issues that affect our profession.

Personally, I see myself as creative, empathetic, adaptable, positive and optimistic about what the future holds. I also have a great sense of humor, which in my opinion is an effective leadership characteristic that helps me connect with others.

Q: What would you say to veterinarians to encourage them to become a part of membership organizations like the AVMA and FVMA? How and why would you encourage vets to get involved in leadership positions?

Why are organizations like these so important?

A: To me it is plain and simple: we need you and we need you to be an active advocate for our profession. Your voice needs to be heard and heard clearly. If you stand on the side and do not contribute to the betterment of our profession, you are doing yourself a disservice and are not helping to shape your future and the future of those that will come after you. Start in your community or on a council or a committee of your local VMA. After that, move up to the state level and do the same. You will realize how fulfilling it is to contribute, and you will make many lifelong friends. Who knows, you might enjoy it so much that one day you could become president of the FVMA and/or AVMA.

Q: What’s your “take away message” for District IV?

A: What can I say? The FVMA is family to me. You have made me feel as one of you, and I am grateful for all the opportunities that I have had for the past six years to interact with Florida veterinarians. I hope that you all feel that I have represented Florida well during my term as District IV Director to the AVMA Board of Directors. I leave you in good hands; I am certain that Dr. Seyedmehdi Mobini will be a great representative of our district during the next six years.

As I stated before, I am committed to working with you, and the FVMA and AVMA leadership to make a difference in the lives of present and future veterinarians. I ask that you join me in that commitment, and work with me in leading our profession into the future.

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NOMINA T

CAL L

NS IO

R O F

Nominations Deadline

FOR THE 2021 FVMA ANNUAL AWARDS

FVMA SERVICE AWARDS NOMINATIONS DEADLINE IS NOVEMBER 20, 2020

Nominations are now open for the 2021 FVMA Annual Awards!

The Florida Veterinary Medical Association invites you to nominate deserving candidates for the 2021 FVMA Annual Awards!

Awards in several categories will be determined by a special committee in early December 2020. Award recipients will be publicly honored at an awards presentation ceremony on March 12, 2021, during the 92nd FVMA Annual Conference in Orlando, Florida.

This is an important program for our Association, giving us the opportunity to honor outstanding members and individuals who serve our profession with distinction and contribute to the advancement of veterinary medicine in the state of Florida. We invite you to participate in this valuable program to recognize peers, colleagues and friends of the profession for their achievements and contributions.

The Annual Awards also highlight exceptional service by Florida citizens who have dedicated their time, talent and services to the enhancement and protection of the veterinary profession.

Awards include a “Citizen of the Year” and nominated pets can be inducted into the “Pet Hall of Fame” with a Pet Hero Award.

Nomination forms and listings of past award recipients are available at www.fvma.org. Members of the FVMA are encouraged to nominate deserving colleagues and friends of veterinary medicine for an award.

Members may also call the FVMA toll-free at 800.992.3862 for assistance in nominating a deserving colleague or friend for an award.

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Thank you for answering the call to honor our exemplary veterinary medical professionals and those friends of the profession who contribute so much to the promotion of animal health and well-being.

2021 Award Categories • • • • • • • •

Distinguished Service Veterinarian of the Year Lifetime Achievement Gold Star CVT of the Year Team Member of the Year Citizen of the Year Pet Hero

SUBMIT YOUR NOMINATIONS BY NOVEMBER 20, 2020

SERVICE AWARD CATEGORIES & ELIGIBILITY CRITERIA DISTINGUISHED SERVICE AWARD

The Distinguished Service Award is awarded for exceptional achievements and contributions by a member toward the advancement of veterinary medicine and the profession. To qualify, a member must have been dedicated to veterinary medicine and given time and energy beyond reasonable expectations. To be eligible for this award, a nominee must have been an active member of the Association for at least the past 15 years.

VETERINARIAN OF THE YEAR AWARD

The Veterinarian of the Year Award is awarded to a member for distinguished, unselfish and dedicated service to the Association for the advancement of veterinary medicine and the profession.

To be eligible for this award, a nominee must have been an active member of the Association for at least the past 10 years.

LIFETIME ACHIEVEMENT AWARD

The Lifetime Achievement Award is awarded to senior active and retired members who have made outstanding contributions to the Association and veterinary medicine. To be eligible for this award, a nominee must have been an active or retired member of the Association for the last 30 consecutive years and must be at least 65 years old.

GOLD STAR AWARD

The Gold Star Award is awarded to members who have contributed much of their time and energy to the Association and/or a local association for the advancement of veterinary medicine and the profession. To be eligible for this award, the nominee must have been an active member of the Association for at least the past three years.

CERTIFIED VETERINARY TECHNICIAN OF THE YEAR

This award recognizes the many outstanding contributions made

by Certified Veterinary Technicians (CVT) to the overall success of the veterinary practice operated or staffed by an FVMA member veterinarian. To be eligible for nomination of this award, the individual must be a full-time employee of an FVMA member practice for a minimum of three years and demonstrates the following: • CARING – Provides animal health care services in a compassionate and clinically appropriate manner.

• COMMITMENT – Works in support of the employing veterinarian to achieve a high level of client satisfaction and established annual performance goals of the veterinary practice.

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• LEADERSHIP – Assumes a leadership role in creating and maintaining an efficient and highly motivated animal health care services delivery team among all employees.

• EDUCATION – Regularly strives to further develop his/ her knowledge and skills by participating in continuing education seminars; formal study at a junior college or university; or by undertaking self-directed study through journals, online programs, etc.

CITIZEN OF THE YEAR

The Citizen of the Year Award is awarded to any non-veterinarian who has made an outstanding contribution to the advancement of the Association and veterinary medicine.

PET HALL OF FAME

One inductee to the Pet Hall Of Fame will be selected for one of the following categories.

1. HERO – Pets who have unselfishly saved or preserved human life (non-professional).

2. COMPANION – Pets who have provided a benefit and contributed to the quality of life of their human companions.

3. PROFESSIONAL – Specialty trained as a physically challenged person’s assistance animal or used in law enforcement.

TEAM MEMBER OF THE YEAR

The Team Member of the Year Award recognizes the many outstanding contributions made by veterinary care team members to the overall success of the veterinary practice operated or staffed by an FVMA member veterinarian. To be eligible for nomination for this award, the individual must be a full-time employee of an FVMA member practice for a minimum of three years and demonstrates the following: • CARING – Provides animal health care services in a compassionate and clinically appropriate manner.

• COMMITMENT – Works in support of the employing veterinarian to achieve a high level of client satisfaction and established annual performance goals of the veterinary practice.

• LEADERSHIP – Assumes a leadership role in creating and maintaining an efficient and highly motivated animal health care services delivery team.

• EDUCATION – Regularly strives to further develop his/her knowledge and skills by participating in continuing education seminars; formal study at a junior college or university; or by undertaking self-directed study through journals, online programs, etc.

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DECISION FATIGUE:

How the Amount of Decisions We Make Affects the Quality of Our Decision-Making Beckie Mossor, BIS, RVT In a society of overwhelming choices, the concept of decision fatigue resonates with many. While one may not give much thought to how many decisions they make in a day, it’s easy to imagaine that the number is in the thousands. A study by Cornell University found that the average individual makes 226.7 decisions a day related to food alone.1 While there is a multitude of factors that go into the actual number of decisions a person makes in a day, it is estimated that the average adult makes 35,000 decisions a day.1 As this field of study emerges, psychologists and scientists studying decision fatigue are finding correlations between the number of decisions made and the quality of those decisions.2 Understanding the individual's limited stamina for quality decision-making, can help one create daily habits designed to reduce the number of decisions made, increasing the resources available for decision-making. Simple awareness changes can help identify areas of unnecessary decisionmaking energy and help create patterns that conserve decisionmaking energy and avoid decision regret.

Defining Decision Fatigue

Psychology recognizes decision fatigue (DF) as a pattern of an individual’s decisions deteriorating in quality after a long session of decision-making. This is caused by exhausted cognitive resources leading to decreased quality of decisions, self-control and task orientation.3 This state of fatigue is associated with decreased selfcontrol as well as a reduced capacity and willingness to perform.4 Increasingly, both psychologists and neuroscientists are studying the effects of decision-making on the brain and the body by examining the quality of fine-motor skills, mathematical problemsolving and even food choices after periods of mental fatigue. Their studies form baseline measurements for the effects of depleted mental stamina.

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Cause of Decision Fatigue

By definition, DF is caused by the depletion of mental stamina due to increased or prolonged mental fatigue. In other words, depletion takes place when there are too many decisions in too short of a time.

That said, DF can affect individuals differently, and there are other factors to consider (sleep, nutrition, stress, etc.) in determining mental stamina.

How much a decision contributes to fatigue is not clearly understood at this time, but there is evidence that larger or more important decisions take the greatest toll on mental fatigue. Therefore, the “cost” (monetary, emotional or otherwise) may influence the amount of fatigue imposed on the brain. A more direct correlation exists between the number of decisions in a period. For example, when buying a car, individuals were more likely to select default vehicle options when choosing them at the end of the car buying process than at the beginning, showing less engagement and increased reliance on decision shortcuts.5

For many individuals, decisions begin as early as the alarm clock does with the decision to hit snooze or not. Then, come the other decisions, such as: What to wear? What to eat? Is there time to do dishes before leaving? What is the best route to work today? All of these decisions occur before one has even left the house. With daily work decisions, the bombardment of various products, and a life full of other input devices, decisions are made up of even the smallest: Do I keep scrolling? Do I give that a like or a love? Which game should I play on the subway ride home? By the end of the day, it is not hard to imagine we have made tens of thousand of decisions, or maybe even more.

In the veterinary profession, our work also leads to DF. While most jobs require some level of decision making, many jobs lack autonomy through regulation, repetitive tasks or strict SOP (standard operating procedures). While there are varying degrees of autonomy throughout the veterinary profession and within various clinic cultures, from the front desk to the very back of the house, decisions are essential to the daily flow and success of many practices. There is no shortage of decisions from the prioritization of tasks and clients to the determination of the best equipment and deciding on the best outcome.

Even once a decision has been made, our tendency to overanalyze the decision we made, the outcome experienced and the various ways the situation could have played out, can contribute to DF. When we give more mental energy to the decision we have already made, we draw energy from the stamina we have for future decisions.

Consequences of Decision Fatigue

As discussed, DF leads to a worsening of decision-making quality, an increased likelihood of default decisions and decreased self-control.

For many, this may mean ordering pizza instead of preparing a healthy dish from the ingredients in the refrigerator or spending too much money shopping online in the evening. Manufacturers and marketing experts capitalize on DF with check-out lane offerings, which are less resistible after the prolonged mental strain of deciding between brands, sizes, sales and labeling in the grocery store.

Those consequences are typical and hardly severe. However, what happens when someone suffering from DF has the freedom or life of another in their hands? One study examined thousands of decisions made by parole judges, finding more favorable (granting parole) decisions were made in the morning when fewer decisions had been made by the judges already, and their mental energy was high. As the day progressed, the favorable decisions decreased by 10%.5 Likewise, physicians have been found to prescribe antibiotics more frequently toward the end of shifts for conditions they were less likely to do so for early in shifts.5 Another study determined that dermatologists were more prone to perform biopsies as the day progressed with the correlation between the increased number of biopsies and decreased positive findings.2 Dermatologists were showing more accurate identification and the necessity for biopsy early in the day when they were fresh than they were later in the day and less able to determine signs of malignancy confidently and more readily relied on biopsy for determination.

DF is not just about preserving mental energy and increasing the ability to make better decisions, engage more readily in decisionmaking, and preserve through mental fatigue; in many cases, it is the necessity to provide care and relay information in a way that is essential to professional life.

Correcting and Preventing Decision Fatigue There is some indication that motivational rewards may increase performance under fatigue. Therefore, if the metaphoric dangling carrot is sweet enough, one can find the ability to perform more readily when fatigued.4 However, for most, decision making is more about necessity than rewardbased systems, and therefore there are many simple steps one can take to decrease unnecessary decision-making and thereby increase the decision-making resources available to them for more important decisions faced in the day.

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• Eliminate Unnecessary Decisions Steve Jobs, Barrack Obama, Mark Zuckerberg and countless other successful individuals wear the same outfit every day or some version of the same outfit. This is simply to reduce the decision about what to wear. If an individual’s workplace requires uniforms, there is already one less decision to make.

If the clinic does not have uniforms, “assign” a set of scrubs for each day or pick a weekly wardrobe on the first day of the week, eliminating one decision for the day.

• Meal Planning Determining what to eat and when can eliminate a large portion of the over 200 food choices made in a day. That is a lot of mental reserves. There are many great meal planning apps, books, menus, etc. Use these tools to reduce even more decisions about what to eat.

• Take Advantage of Technology Using online tools can reduce a lot of unnecessary decisions.

Grocery shopping online reduces split-second decisions (and unnecessary purchases) by eliminating browsing through the grocery store. Purchase just what is needed and save time by not having to shop. Use navigation tools like Waze® to eliminate decisions about traffic and fastest routes. Online apps and tools often eliminate the need for unnecessary errands and running around town, therefore reducing mental expenditure.

• Stick to Decisions Once a decision is made, whenever possible, stick to it. This helps to train the brain that once a decision is made, that is the decision. This will strengthen the ability to move forward mentally and not dwell on or continually change decisions.

• Prioritize Self-Care The truth is, one cannot pour from an empty cup. Rest and rejuvenation are not optional and must be prioritized. Good nutrition and mental rest through meditation practice can help to build the ability to mentally override racing or charging thoughts, decreasing involuntary mental depletion.

While there will always be unexpected priorities and a need to make decisions, understanding the toll that unnecessary mental strain creates will help us be more aware of these issues. Finding areas to decrease decision-making and preserve mental energy can help increase the quality of the decisions we make, increase our selfcontrol, and increase personal care prioritization. This creates a cycle of positive momentum and self-determination.

References 1. Graff, F. (2018, February 7). UNC TV. Retrieved from UNC TV Science: http://science.unctv.org/content/reportersblog/ choices

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2. Seth, D., & Honda, K. M. (2017). Impact of time of day on dermatologists' decision to biopsy. Journal of the American Academy of Dermatology, 407.

3. Tian, F., & Exline, M. (2017). D24 Critical Care: The Other Half Of The ICU - Update In Management Of NonPulmonary Critical Care: Reduced Clinical Recall And Attentiveness Due To Decision Fatigue. American Journal of Respiratory and Critical Care Medicine, 195.

4. Massar, S. A., Csathó, Á., & Linden, D. V. (2018, May 30).

Quantifying the Motivational Effects of Cognitive Fatigue Through Effort-Based Decision Making. Retrieved from Frontiers in Psychology: https://www.frontiersin.org/ articles/10.3389/fpsyg.2018.00843/full 5. Polman, E., & Vohs, K. D. (2016). Decision Fatigue, Choosing for Others, and Self- Construal. Social Psychology and Personality Science, 471-478.

Additional References Smith, M. R., Zeuwts, L., Matthieu, L., Hens, N., De Jong, L. M., & Coutts, A. J. (2016, March 07). Journal of Sports Sciences. Retrieved from Journal of Sports Science: https:// doi.org/10.1080/02640414.2016.1156241 Welch, C. J. (2017, October 30). Telophone Triage Could Further Stress Primary Care. Retrieved from British Medical Journal (Online): http://dx.doi.org/10.1136/bmj. j4902

Beckie Mossor, BIS, RVT Beckie is a registered ve te r in ar y te chnic i an living in Southport, North Carolina. She has enjoyed a diverse career in small animal, large animal, and mixed practices, academia, management, and private c o n s u lt ing. B e c k i e i s co-founder of Veterinary Advancements, a private consulting firm, and is a professional medical responder with the ASPCA Disaster Recovery Team.

Beckie is host of Clinician’s Brief the Podcast and co-hosts the podcasts: Veterinary Viewfinder and Making Sense of Pets.

In support of her profession, Beckie is proud to serve as executive director for the Human Animal Bond Association, member at large for the Society for Veterinary Medical Ethics, and former executive board member for both the national and state tech associations. Beckie is also one of the minds behind Vet Team Global Stream 2020.

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HIGH DEMAND?

CBD: a grey area of research and legality.

By Katie Pearce, Content and Engagement Specialist

The budding industry of CBD has experienced explosive demand, for people and for pets. The industry's newness has led to many questions regarding legality, particularly what veterinarians can and cannot do when it comes to pets and CBD.

The popularity of CBD products has surged in recent years following anecdotal evidence of its claimed 'medicinal properties.'

These properties are said to help people and pets cope with issues like pain, anxiety, arthritis, allergies, inflammation and more.

Some products go as far as to claim marijuana and CBD products can cure cancer and Alzheimer’s disease. These therapeutic claims have led many eager pet owners to seek out CBD oil as a new, 'natural' way to treat their pets’ ailments.

Cannabis: Hemp vs Marijuana Cannabis, a taxonomic term that refers to a genus of flowering plants in the Cannabaceae family, is a broader classification that includes both hemp and marijuana plants. Much confusion has surrounded the distinction between 'cannabis' and 'marijuana' as often the terms are used interchangeably. However, while marijuana is cannabis, cannabis does not only refer to marijuana; it refers to the whole genus, which includes hemp. Oftentimes,

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hemp and marijuana are referred to as 'cousins.' Both hemp and marijuana look and smell the same, so cannabis plants are classified as one or the other based on how much THC (tetrahydrocannabinol) they contain. THC is the compound that gives marijuana its renowned psychoactive properties; CBD (cannabidiol) is non-psychoactive.1 Marijuana, by dry weight, contains about 5-20% THC, and hemp contains no more than 0.3% THC. In short, this means that hemp will not get someone 'high.'

The federal 2018 Farm Bill and the legalization of marijuana in a number of U.S. states, triggered an overwhelming interest in the potential health benefits of cannabis. While THC continues to be the dividing distinction between hemp and marijuana, a new boundary between the two has been drawn. These plants are now on two sides of the law. While some states legalized marijuana for recreational and/or medical use, the growth of industrial hemp was legalized with the passage of the Agriculture Improvement

Act of 2018 (2018 Farm Bill, PL 115-334). The 2018 Farm Bill made the growth of industrial hemp legal for the first time since the 1970 Controlled Substances Act, placing hemp-derived CBD under the jurisdiction of the U.S. Department of Agriculture (USDA) and not under the Drug Enforcement Administration (DEA). It should also be made clear that only hemp products have been descheduled under the 2018 Farm Bill. Any part of the cannabis plant and their derivatives that does not meet the definition of hemp, 0.3% THC or less on a dry weight basis, and is considered marijuana, is still a Schedule I controlled substance.1

The Crossroads of CBD Since industrial hemp’s legalization, the CBD industry has exploded. CBD is the second most prevalent active ingredient in cannabis. Most CBD products are derived from hemp and not from marijuana. Much interest surrounds CBD due to anecdotal reports of its ability to moderate anxiety, relieve pain, help with seizures and, potentially, help cancer patients.

With such grand claims, it is no wonder people are enthralled with CBD, not only for themselves but also for their pets. Pet owners feel that CBD represents a natural alternative for calming and reducing pain in their pets, and, due to a lack of THC, they don’t have to worry about their pets feeling 'stoned.' Unfortunately, besides anecdotal reports and some limited studies, not much is known about CBD. Research and clinical trials are still lacking, and anecdotal reports are simply not enough to know whether CBD is truly working or whether it is safe. Certain components of cannabis can also interfere with other medications the pet may be taking, resulting in not only therapeutic failure, but also adverse effects.2 Furthermore, anecdotal reports cannot

be fully relied upon as often pet parents are hoping for a good result (caregiver placebo effect). They may also be trying multiple other supplements in addition to CBD, therefore, which treatment helped is not clear. The lack of controls and thoroughly documented effects of CBD leave an uncertain gap that many are eager to bridge. It is in this grey area that veterinarians find themselves—at the crossroads of limited research, eager clients, a flooded product market and the law.

The 2018 Farm Bill explicitly preserved the FDA’s authority over hemp products.3 This bill did not make cannabis derived products legal for veterinary use and sale, as descheduling a substance does not automatically make its use in therapeutic products or food legal.1 Like all FDA-regulated products, hemp products must meet any applicable FDA requirements and standards. Before the 2018 Farm Bill, all cannabis was a Schedule I substance and controlled by the Drug Enforcement Administration (DEA).

Since the passage of the bill, there has been a misperception that all hemp products are now legal to sell through interstate commerce.3 To date, only one CBD product has been approved by the FDA—Epidiolex, an anti-epileptic for treating pediatric seizures, consists of a hemp-derived cannabidiol. However, CBD products, ranging from food, soaps, pet treats and veterinary products, have flooded the market—both in store and online.

Unfortunately, many of these products make unsubstantiated, therapeutic claims. These claims may lead people and pet parents to forego much needed professional, medical attention.

It is also currently illegal to market CBD by adding it to a food or labeling it as a dietary supplement.4 Further, under the Dietary Supplement and Health Education Act of 1994 (DSHEA), ‘dietary supplements’ are only for people and do not apply for

CBD marketed for pets comes in a variety of forms, including tinctures and treats. However, it is currently illegal to market CBD by adding it to foods.

To date, the FDA has not approved any animal drugs that are derived from, contain or are related to cannabis.1

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use in animals.1 Under the federal Food, Drug, and Cosmetic Act (FDCA), the “only evaluative route for veterinary products is as 'drug' or 'food.'” CBD cannot legally be added to animal feed that is distributed in interstate commerce as all additives must be approved or generally recognized as safe (GRAS) for the animal.

Feed intended for animal consumption containing an ingredient that is not approved or GRAS is “considered to be adulterated under the FDCA (21 USC § 342(a)(2)(C)(i)).”1 Before and since the passage of the 2018 Farm Bill, the FDA has been investigating companies that make these unapproved products. Any time a substance, such as CBD, is being used with the intention to cure, mitigate, treat, or prevent disease, or when they are intended to affect the structure or function of the body, they are considered a 'drug' under the FDCA. To date, the FDA has not approved any animal drugs that are derived from, contain or are related to cannabis; this includes CBD. "The use of unapproved drugs can put patients at risk and may create legal risk for veterinarians who administer, prescribe, dispense or recommend them because they have not been evaluated for efficacy and safety by the FDA. Risk may be heightened when approved treatments are available and are not utilized, or when patients for which unapproved drugs have been administered, prescribed, dispensed or recommended are adversely impacted (either side effects or treatment failures).”1 As the FDA has investigated these unapproved CBD products, they have also found that many did not contain the amount of CBD that the label claimed.3,4 In addition to inaccurate levels of CBD, some products may contain other unlisted and potentially dangerous compounds due to poor manufacturing practices.3,4 Unproven medical claims, questionable quality and a lack of FDA approval plague CBD products marketed for animals.4 Despite these issues, pet owner demand for CBD is high. Since it is readily accessible, pet owners are still able to obtain CBD easily and don't have to consult their veterinarian. This can put vets in a tough position, and, specifically in regards to CBD, for some vets it comes down to: If I cannot provide what my clients want, my clients will go elsewhere. An additional worry may also be that if a vet can't provide a recommendation or CBD option for their clients, their clients will purchase CBD anyways and it may be of poor quality. In Florida, medical marijuana and CBD are legal with some restrictions. The only regulation regarding the application of CBD in veterinary practice passed in Florida is Rule 5E-3.003, F.A.C., which addresses feed and treats. The Rule affects Florida licensed veterinarians in their daily practice by defining pet food, pet treats, specialty pet food and specialty pet treats that may contain hemp extract. It directs that veterinarians who promote the use of CBD/hemp products in their practices must ensure that labels of the products used do not make any medicinal-type claims. This was promulgated by the Florida Department of Agriculture and Consumer Services and took effect January 2, 2020. It is essential that a veterinarian understands their responsibilities and obligations on all legal levels. No state laws, to date, have lifted restrictions on, or given approval for, the use of cannabis in animals.1

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Furthermore, veterinarians using or promoting CBD products may be engaging in complementary or alternative veterinary medicine and should keep rule 61G18-19.002 (Complementary or Alternative Veterinary Medicine) in mind. While it is not clear whether the Board of Veterinary Medicine considers CBD as complementary/alternative, out of an abundance of caution, veterinarians are encouraged to follow the rule's protocol.

While pet stores and online retailers make CBD pet products readily available for purchase, laws surrounding the legality of a veterinarian prescribing or recommending CBD products to a client can still be a grey area since the FDA has not approved any CBD products for use in animals. The ultimate responsibility in the practice of veterinary medicine lies with the licensed veterinarian and professional discretion must always be exercised.

The FDA “encourage[s] consumers to think carefully before exposing themselves, their family, or their pets, to any product, especially products like CBD, which may have potential risks, be of unknown quality, and have unproven benefits.”4

COMMON SIDE EFFECTS OF HEMP-BASED CBD IN DOGS & CATS:5,6 Fatigue, lethargy Gastrointestinal upset (vomiting and/or diarrhea) Decreased coordination/ataxia Increased thirst Slower heart rate, decreased blood pressure Hyperesthesia

Urinary incontinence

safety of CBD, though we may not fully understand its long-term effects for years to come.

CBD Side Effects in Pets While official, documented CBD research is lacking, CBD for pets is readily available to consumers in pet stores and online.

From treats and tinctures to oils and capsules, CBD for pets is marketed to pet owners in a variety of ways that make it both intriguing and accessible to try. Unfortunately, these often unvetted products can create issues. If a pet owner has given their dog or cat CBD, there are key side effects to look out for.

References:

The known side effects of CBD are typically short term and often caused by an 'overdose,' though no official dosages for CBD are readily acknowledged at this time. If a pet owner reports issues with CBD, it is important to ascertain whether the CBD was derived from hemp or marijuana. While most CBD products are derived from hemp, as previously established, marijuana oil contains high levels of THC and can cause serious clinical signs.

The Future of CBD for Pets Not much is known about CBD and its long-term effects at this time, but explosive public interest and some limited but positive studies have ensured that many research institutions have begun to conduct animal studies.

Two such studies are being conducted at The University of Florida College of Veterinary Medicine (UFCVM).7,8 UFCVM is currently recruiting dogs with lymphoma for a pilot study to determine the safety and efficacy of CBD oil use during chemotherapy. As stated on the study’s recruitment page: “The use of hemp products including marijuana and cannabidiol (CBD) for medical conditions are becoming much more common for both people and pets. The use of nutraceuticals rich in cannabidiol (CBD) to help alleviate pain and improve quality of life as a global anti-inflammatory has been utilized, but poorly studied to date.”7 The investigational trial aims to find out whether a specific CBD oil has any effect on blood concentrations of the drugs taken by dogs undergoing chemotherapy for lymphoma and if CBD can improve the dogs’ quality of life during chemo protocol.7 Another study, “Use of Hemp Based Nutraceuticals as an Adjunctive Agent in Dogs with Epilepsy,” is recruiting dogs with refractory epilepsy with a similar intention to look at blood concentrations and find out if the hemp-based nutraceutical can decrease the number and/or duration of seizures.8 While studies, such as these, specifically target dogs with major diseases and conditions, clinical trials of this nature will begin to answer many questions surrounding CBD. Trials like these may also hold the key to FDA approval of CBD products for animals in the future. Until that approval has been given, CBD will continue to live at the crossroads of eager clients, a flooded product market and the law. Only as research builds will we learn the true merits, side effects and

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1. American Veterinary Medical Assocation (AVMA). Cannabis, Cannabis-Derived, and Cannabis-Related Products: Regulatory Status FAQ. Retrieved from AVMA: https://www.avma.org/ cannabis-cannabis-derived-and-cannabis-related-productsregulatory-status-faq 2. dvm360. CBD in Pets. Retrieved from dvm360: https://www. dvm360.com/cbd-in-pets 3. Amy Abernethy, M. P. (2019, July 25). Hemp Production and the 2018 Farm Bill. Retrieved from U.S. Food & Drug Administration: https://www.fda.gov/news-events/congressional-testimony/ hemp-production-and-2018-farm-bill-07252019 4. U.S. Food & Drug Administration. (2020, July 5). What You Need to Know (And What We’re Working to Find Out) About Products Containing Cannabis or Cannabis-derived Compounds, Including CBD. Retrieved from U.S. Food & Drug Administration: https://www.fda.gov/consumers/consumerupdates/what-you-need-know-and-what-were-working-findout-about-products-containing-cannabis-or-cannabis 5. McGrath, S., Bartner, L., Rao, S., Kogan, L., & Hellyer, P. (2018).

A Report of Adverse Effects. Retrieved from Journal of the American Holistic Veterinary Medical Association: https:// www.ahvma.org/wp-content/uploads/AHVMA-2018-V52CannabisAdverseEffects.pdf 6. ASPCApro. CBD, Hemp Pet Treat Dangers & Overdose Tre a t m e nt s . Re t r ie ve d f rom A SP C Apro: ht t ps:// w w w. a s p c apro.or g /re s ou rc e /cb d-hemp -p e t-t re atdangers-overdose-treatments 7. Amandine, L. D. A pilot study to determine the safety and efficacy of CBD oil use during chemotherapy in dogs with lymphoma. Retrieved from UF Veterinary Research: https:// research.vetmed.ufl.edu/clinical-trials/small-animal/a-pilotstudy-to-determine-the-safety-and-efficacy-of-cbd-oil-useduring-chemotherapy-in-dogs-with-lymphoma/ 8. Garcia, G. A. Use of Hemp Based Nutraceuticals as an Adjunctive Agent in Dogs with Epilepsy. Retrieved from University of Florida College of Veterinary Medicine: https:// research.vetmed.ufl.edu/clinical-trials/small-animal/use-ofhemp-based-nutraceuticals-as-an-adjunctive-agent-in-dogswith-epilepsy/

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Practices for Sale NEW! GA - Coastal Savannah: SA solo Dr., AAHA, Spacious facility. RE included. (GA20S) NEW! FL - Central: SA Solo Dr. $900K Gross in 2019. May 2019- May 2020 Prx grossed >$1M. (FL12A) NEW! SC - Greenville & Spartanburg Area: SA 2+ Dr. w/ RE. 4+ ac on major hwy. 2019 gross > $1,769K. (SC13W) NEW! NC – Piedmont Area: SA, AAHA practice open 4.5 days/week. 2019 gross $685K. RE includes +/-1.1 acres & 3,000SF facility. (NC15B) GA - South Central: Beautiful Historic Georgia practice grossing $959K+, up 5% in 2019, 1.5 dr. practice. Attractive facility and modern equipment. (GA14F) NC - Northeast, near VA: Immaculate, well-equipped facility- digital x-ray, in-house lab, companion laser. $1.1M+ gross, 2 dr., SA w/ LA capability. (NC66G) FL – Central: Valued SA, solo dr., $632K+ 2019 gross, RE available for $125K. Well-equipped with digital x-ray, inhouse lab machines, running Impromed software. (FL11S) 1610 Frederica Road, Saint Simons Island, GA 31522 Toll Free: (800) 333-1984 | www.simmonsinc.com Email: southeast@simmonsinc.com Licensed in Florida, Georgia, North Carolina, and South Carolina Real Estate Broker

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North Central Fl.– 1+ Dr. 2019 gross $700K, free standing clinic w/ 2 exam rooms, in-house lab, digital x-ray, great staff If you are concerned about how the Pandemic has affected your Market Value we are available for a phone conference to help you navigate those concerns

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Veterinary Practice Sales, Acquisitions & Valuations

VOLUSIA COUNTY: Small Animal Practice. $697K gross and $204K ADI in 2019. Approximately 3,368 SF leased facility. [FL96] LEON COUNTY: Small Animal Practice. $744K gross and $129K ADI in 2019. Approximately 1,978 SF facility with real estate. [FL97] HILLSBOROUGH COUNTY: Small Animal Practice. $790K gross and $136K ADI in 2019.

Approximately 4,300 SF facility with real estate.

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Fatalities, Adverse Events and Accidents in Small Animal Anesthesia: Can We Do Better?

Sheilah A. Robertson, BVMS (Hons), Ph.D., DACVAA, DECVAA, DACAW, DECAWBM (WSEL), CVA, MRCVS Introduction

„

Let us start with a quote from one of my favorite authors, Dr. Atul Gawande, who is an MD surgeon, which sums up the topic of how we can do better.

“

Better is possible. It does not take genius.

It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

-Dr. Atul Gawande in Better: A Surgeon's Notes on Performance

Dr. Gawande’s words are applicable to all areas of veterinary medicine, including anesthesia. Our patients and clients will benefit greatly from us working together as veterinary care teams, combining the advances and improvements in surgery, medicine and anesthesia with a determination to keep asking, “Can we do better?”

What Are the Risks of Anesthesia in Dogs and Cats Today?

It is easier to answer questions related to mortality (death) as this represents a clear endpoint. However, anesthesia is not just about the animal “making it” or “surviving.” It is also about how well that animal copes with the procedure, how fast it recovers and if it recovers with no lasting negative effects related to anesthesia; basically, was there any short or long-term harm to the patient?

Adverse events and accidents are not well-documented in veterinary anesthesia and are much more difficult to track than mortality.

The data generated by the Confidential Enquiry into Perioperative Small Animal Fatalities (CEPSAF) study, a prospective cohort study conducted in the United Kingdom between 2002 and 2004, is the most comprehensive information we have available for dogs (n = 98,036), cats (n = 79,178), rabbits (n = 8,209) and other small mammals for mortality covering a wide variety of procedures in healthy and sick animals. This study collected data from primary care veterinary practices, referral centers and universities. It recorded patient outcome (alive, dead or euthanized) after premedication and within 48 hours of the end of the procedure and calculated species-specific risks of anesthetic-related death.

Anesthesia or sedation-related death was defined as “death where surgical or pre-existing medical causes did not solely cause death.”

This study generated risk factors for different species and paved the way for improving anesthetic management in small animals.1-4 22 | FVMA ADVOCATE

Animals were assigned a “health status.” “Healthy” were animals assigned an ASA status of one or two and “sick” were animals assigned an ASA status of three to five. These classifications were based on the American Society of Anesthesiologist’s [ASA] classification. The CEPSAF study included 98,036 dogs and 79,178 cats. The overall risk of death was 0.17% in dogs and 0.24% in cats. In healthy dogs and cats, the risks were 0.05% and 0.11% respectively. In sick dogs and cats, the risks were 1.33% and 1.40% respectively.

SPECIES

OVERALL RISK ASA STATUS OF ANESTHETIC 1-2 (healthy) RELATED DEATH

ASA STATUS 3-5 (sick)

DOG

0.17

0.05

1.33

CAT

0.24

0.11

1.40

Table 1. Difference in mortality rates (%) between cats and dogs and based on health status. From Brodbelt, et al. 2007.2 ASA = American Society of Anesthesiologists Physical Status Classification.

The risk of anesthetic-related death in dogs and cats has decreased since the last comparable survey in the mid-1980s, but these numbers compare poorly to data for humans where the anestheticrelated death rate is reported to be between 0.02% and 0.005%.

Differences in the standards of anesthesia including the training of those administering anesthesia, having a person dedicated to anesthesia alone and sophisticated monitoring equipment are likely the reason between the human and animal data, rather than simply species differences alone.

In a review of 7,502 feral cat anesthetics, Williams and others reported an overall anesthetic-related mortality rate of 0.23%.5 A recent retrospective study from a high-volume spay-neuter clinic reported the risk of mortality in cats as 0.05% and in dogs as 0.009% with the latter approaching mortality rates in human anesthesia.

The risk of mortality in females (dog or cat) was twice that of males. In agreement with previous studies, most deaths occur in the early post-operative period. The lower risk of death in these patients compared to the Confidential Enquiry into Perioperative Small Animal Fatality study is probably due to a combination of factors including the young, healthy population and the experience and skills of veterinarians that specialize in specific surgical procedures.6

When Do Most Deaths Occur?

Analysis of the CEPSAF and the study by Levy, et al. reveals that most deaths occur post-operatively.6 In the CEPSAF study, 47% of deaths in dogs and 61% of deaths in cats occur during this time.

Within the post-operative period, the most critical time appears to be the first three hours after the end of anesthesia.

Figure 2: Mask inductions are associated with a higher death rate in dogs. In addition, this exposes personnel to waste anesthetic gases. Photo courtesy of Dr. Sheila A. Robertson.

Figure 1: Based on the Confidential Enquiry into Perioperative Small Animal Fatality study, most anesthetic-related deaths occur post-operatively or post procedure. Within that time frame, the majority occur in the first three hours. It is imperative to closely monitor during recovery.

What Are the Causes of Death?

An independent panel worked with the CEPSAF team and reviewed details of each anesthetic death and tried to ascertain a cause. Cardiovascular or respiratory causes accounted for 74% and 72% of deaths in dogs and cats, respectively. Human error played a role in some cases; for example, two dogs died after the adjustable pressure‐limiting (APL) valve - commonly termed “pop-off ” valve - was left closed.

Risk factors: General

In both cats and dogs, performing major and/or prolonged procedures led to an increase in mortality. Although there were fewer sedation-only cases in the study, it appears that there is less risk of death with sedation alone compared to anesthesia.

This suggests that when possible, we should try to think of ways to perform simple procedures under sedation combined with analgesics, especially local anesthetics.

Risk factors: Drugs

In previous mortality studies,7 the alpha-2 agonist xylazine was associated with an increased risk of death; however, in the CEPSEF study, medetomidine was not associated with an increased risk (dexmedetomidine was not available at the time).

Risk factors: Dogs

Risk factors in dogs have also been identified. Dogs with lower body weights (< 5 kg) are at an increased risk of anesthetic-related deaths (eight times more likely to die than dogs weighing between 5 kg and 15 kg). This may be a result of hypothermia, inaccuracies in drug dosing or perhaps because small dogs are more frequently “masked down” because IV access is more difficult. Mask induction was found to significantly increase mortality (a 5.9-fold increase in risk) compared to induction with an injectable drug or drug combination followed by maintenance with an inhalant agent (Figure 2). Mask inductions should be discouraged although there are times when they may be unavoidable, such as in a dog where venous access cannot be achieved. In these cases, sedation and the

use of low stress handling is recommended before inducing with an inhalant agent.

Inhalant agents are the most cardiovascular and respiratory depressant anesthetic agents we use. MAC (minimum alveolar concentration required to prevent movement in response to a noxious stimulus) sparing techniques are encouraged, including premedication with opioids, sedatives, or tranquillizers and infusions of opioids, ketamine, and lidocaine. Use of local anesthetic blocks will also allow the amount of inhalant agent to be decreased. There was insufficient data to compare sevoflurane and isoflurane because the former agent was new on the market at the time of the study. It was clear that the use of halothane (still in use at the time) increased the risks of dying compared to isoflurane.

It was reported that dogs over the age of 12 years had a significantly higher risk (seven times more likely to die than dogs aged between six months and eight years). However, the authors did not consider the breed or size of dog, which has an impact on their physiologic age as the life expectancy of large or giant breeds is much shorter than small breeds. Although it is not possible to assign a risk related directly to age in dogs, we do know there are physiologic changes related to aging, which results in a decrease in the functional reserve of major organs.

Risk factors: Cats

Overall, the risk associated with anesthesia in cats is significantly higher than for dogs. However, the mortality is similar in both species if they are classified as “sick.”1 The study by Levy, et al., also showed a higher mortality rate in cats compared to dogs.6 In cats, respiratory obstruction as a cause of death has been reported more frequently than in dogs, indicating that close attention to the airway in this species is important. Respiratory problems were more common in the post-operative period suggesting airway trauma and edema may be involved. The data indicated an increased complication rate related to endotracheal intubation (for procedures under 30 minutes); therefore, great care should be taken when intubating cats. This increased complication rate may be due to the propensity for cats to have

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laryngospasm. Intubation should be performed under the correct plane of anesthesia (deep enough not to move or gag when the larynx is touched) and under direct vision (laryngoscope). If lidocaine is used, it should be dropped carefully from a syringe onto the larynx without touching it. Patience is required and the tube should only be advanced when the vocal cords are open.

In addition, the cuff should only be inflated if necessary. The seal is usually tested by closing the pop-off valve and squeezing the reservoir bag — air is added in small increments to the cuff until there is no leak at ~15 cmH2O. However, in dogs this has resulted in improper inflation.7 The use of “cuff inflators”a, b is recommended, and, although a study has not been performed in cats, their use has been described in dogs; the AG Cuffill® significantly reduced improper cuff inflation.8 The use of a water-soluble gel on the cuff will decrease the likelihood of leakage around the cuff.9 Tracheal rupture following endotracheal intubation has been well-documented in cats and is often fatal.10,11 As an alternative to using an endotracheal tube (ETT), a supraglottic airway device (SGAD, Cat v-gel® Docsinnovent Ltd, London, United Kingdom) has been designed to conform to the shape of the feline larynx and pharynx and has been evaluated in clinical settings. The time to obtain a clinically acceptable capnograph reading, which verifies an airway has been established, was shorter when a SGAD (median time 44 seconds) was used compared to an ETT tube (median time 109 seconds) suggesting that the airway can be more rapidly secured using the former technique. Compared to placement of an ETT, less propofol is required to secure an airway with a SGAD.12 There was also less discomfort and stridor as well as a greater food intake after using a SGAD compared to an ETT.12,13 Cats that weigh less than 2 kg were “high risk” in the CEPSAF study.

The smaller size of cats may predispose them to hypothermia and its associated complications, especially with longer procedures.

The small size of cats may also lead to more problems with intravenous catheter placement, intubation and monitoring.

If cats are not accurately weighed, it is likely that relative drug overdoses also occur. At the other end of the spectrum, obese cats were also at risk, which may be due to a greater risk for respiratory compromise (reduced diaphragmatic excursions due to abdominal and thoracic fat, especially when placed in dorsal recumbency) and reduced cardiovascular reserves (an increase in cardiac output is required as body fat increases). Also, if drugs are dosed on actual body weight, rather than lean body weight, this can result in a relative overdose.

Cats age in a more uniform manner and older cats carry a higher anesthetic risk — cats older than 12 years are twice as likely to die compared to cats aged 6 months to 5 years.1 This increased risk was independent from the ASA status and may be a result of decreased respiratory and cardiovascular reserve in these patients or decreased anesthetic requirements.

One reason for the higher risk in healthy cats may be the presence of sub-clinical cardiac disease. In “overtly” or “apparently” healthy cats, the incidence of cardiomyopathy may be as high as 15-18%.14,15 Thus, cats may be misclassified. Since cats with cardiac 24 | FVMA ADVOCATE

Figure 3: A buretrol is a simple way to avoid accidental fluid overload in cats. This buretrol has been filled with 18 mL of fluid; the patient weighs 6 kg and the recommended administration in cats is 3 mL/kg/hour. After this has been administered the device automatically shuts off and can be refilled. If the device is filled to 100 mLs and is accidentally left on “full flow” (e.g. after flushing in a medication), the cat will experience a fluid overload – for this cat 100 mLs would be its fluid requirements for 5.5 hours (100 ÷ 18).

Photo courtesy of Dr. Sheila A. Robertson.

disease can appear clinically healthy and not all have murmurs, it is difficult to detect these patients without echocardiography. A surprising finding was that the use of intravenous fluids increased the risks in both healthy and sick cats. The blood volume of cats is lower than dogs (4-6% versus 8-9% of body weight); therefore, lower fluid rates should be used in cats during anesthesia. The American Animal Hospital Association and the American Feline Practitioners Fluid Therapy Guidelines suggest using 3 mL/kg/ hour for cats during elective procedures and decreasing this each hour.16 Another reason may be inaccurate administration and fluid overload, therefore, the use of infusion or syringe pumps or a buretrol is advised in cats to ensure accurate volume delivery (Figure 3). With the knowledge that apparently healthy cats may have underlying cardiac disease, it is possible that fluid overload potentially contributes to mortality.

Monitoring

The use of a pulse oximeter is strongly recommended. In cats, monitoring the pulse, for example with a pulse oximeter, reduced mortality significantly — likely because it alerted staff to a cardiovascular or oxygenation problem.1 When selecting a monitor, it is important to choose one with a good audible signal, such as a pulse oximeter or Doppler ultrasonic flow detector, because personnel respond more rapidly to a change in sound than to a visual display since, in a busy setting, it is also not always possible to continuously observe a visual display.

Hypothermia

Small veterinary patients commonly lose heat when anesthetized,17,18 but the impact of this on the patient is greatly underestimated. Maintaining body temperature within a narrow range is important for cardiac function, metabolism, normal enzyme activity, nerve conduction and hemostasis.

Adverse Events

Despite the large number of errors and “mishaps” that occur in veterinary medicine there is no universal agreement on how to classify (taxonomy) or describe (terminology) what constitutes an “error” or adverse event and, unlike human anesthesia, there is no system in place for mandatory or voluntary reporting.19 This makes it difficult to discuss and compare events that may or may not impact the outcome of the patient. Ludders and McMillan

have modified selected terms and definitions used in human medicine and provided clear descriptions of these to reduce confusion and encourage their adoption in veterinary medicine.19 This is essential for prospective studies so we can gain more insight into veterinary anesthesia and how to prevent and reduce the associated risks.19 For example, we do not currently know how many anesthetic accidents are due to human error alone or how many post-operative problems are due to intra-operative hypotension or hypoxemia. Only mandatory or widely embraced voluntary reporting will shed light on this. Accurate collection of this data and its analysis is the foundation for creating a patient safety culture, appropriate check lists, training of anesthesia personnel and for the practice of evidence-based anesthesia.20

detected 24 hours after surgery but had returned to preoperative baseline values by post-operative day 14. The authors suggest this reflects a low-grade positioning-dependent nerve injury. This begs the question: How many other injuries are we missing?

The most common adverse events encountered during anesthesia have been derived from an adverse event surveillance study and are shown in Table 2.

RELATIVE FREQUENCE % DOGS Arousal 21.9 Hypoventilation 19.9 Airway complications 4.9 Temperature regulation 5.8 Arrhythmias 8.3 Hypotension 16.9 Excitation / dysphoria 6.9 Desaturation 3.8 ADVERSE EVENT

RELATIVE FREQUENCY % CATS 10.7 9.7 9.4 7.7 4.7 3.0 3.0 3.0

Figure 4a.

Table 2. Relative frequency (%) of selected adverse events during canine and feline anesthesia. Adapted from McMillan and Darcy 2016.20

The number one adverse event reported in dogs and cats was arousal, or “break through pain,” which was defined as any event that required an unplanned bolus of induction agent or analgesic.20 This phenomenon has not previously been well-described in the veterinary literature and appears to be an important but underrecognized problem. Better analgesic protocols are likely to decrease the frequency of these events, especially the increased use of local analgesics. Hypoventilation and hypotension were also frequently recorded indicating that monitoring is essential and anesthesia personnel must be trained on the appropriate intervention needed for such events.

Positioning

Because our patients do not self-report, we have likely overlooked a lot of problems after anesthesia and surgery. This is changing, and studies have looked at the influence of positioning in one particular procedure: perineal urethrostomy in cats. The positions we place cats in for this surgery (Figure 4) alter the diameter of the vertebral canal as demonstrated by computed tomography (CT) studies.21 In a prospective, randomized study in cats that required a perineal urethrostomy, motor responses (patellar tendon reflex, gastrocnemius limb withdrawal and perineal reflexes) were tested before and after surgery.22 Lumbosacral pain, fecal continence and tail function were also assessed. Cats were placed in dorsal or ventral recumbency as shown in Figure 4. In both groups, perineal reflexes were less brisk, and spinal pain was

Figure 4b: These are two positions that cats are placed in to perform a perineal urethrostomy.

Both positions can result in post-operative spinal pain and decreased perianal reflexes.22 Extreme positioning should be avoided. Photos courtesy of Dr. Sheila A. Robertson.

Human Error Human error as a cause or contributor to a patient death is devastating. Anesthesia involves complex tasks and decisions, and these are often performed under pressure. While “to err is human,” these accidents can be reduced or eliminated. In a university teaching hospital, incident reports were collected over a 12-month period (e.g. esophageal intubation, medication errors and closed adjustable pressure limiting (APL) valves).

After this period, preventative measures were put in place to reduce errors — for example, the patient’s name, the drug, and the route of administration was spoken out loud and confirmed prior to administration. Data collection continued for another 12 months. Incidents decreased from 3.6% to 1.4% with these measures.23 Investment in high pressure alarms or “pop-off ” occlusion valvesc (Figure 5) are highly recommended.24

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Figure 5: If the adjustable pressure limiting valve (APL, “pop-off”) is accidentally left closed, pressure rises quickly in the patient circuit and can result in barotrauma and cardiac arrest. A popoff occlusion valve allows you to give the patient a breath by depressing the button on the valve – as soon as you lift your thumb the circuit is open again. With this device in place, there is no need to manipulate the APL valve during a procedure. Photo courtesy of Dr. Sheila A. Robertson.

Although anesthetic-related mortality in cats and dogs has decreased over time, there is still room for overall improvement and some key factors to focus on have been identified by the CEPSAF study. We have a lot more to learn and bigger improvements to make. As stated by Dr. Atul Gawande, “better is possible.”

References

1. Brodbelt DC, Pfeiffer DU, Young LE, et al. Risk factors for anaesthetic-related death in cats: results from the confidential enquiry into perioperative small animal fatalities (CEPSAF). Br J Anaesth 2007;99:617-623.

2. Brodbelt DC, Blissitt KJ, Hammond RA, et al. The risk of death: the confidential enquiry into perioperative small animal fatalities. Vet Anaesth Analg 2008;35:365-373.

3. Brodbelt DC, Pfeiffer DU, Young LE, et al. Results of the confidential enquiry into perioperative small animal fatalities regarding risk factors for anesthetic-related death in dogs. J Am Vet Med Assoc 2008;233:1096-1104.

4. Brodbelt D. Perioperative mortality in small animal anaesthesia. Vet J 2009;182:152-161.

5. Williams LS, Levy JK, Robertson SA, et al. Use of the anesthetic combination of tiletamine, zolazepam, ketamine, and xylazine for neutering feral cats. J Am Vet Med Assoc 2002;220:1491-1495.

6. Levy JK, Bard KM, Tucker SJ, et al. Perioperative mortality in cats and dogs undergoing spay or castration at a high-volume clinic. Vet J 2017;224:11-15.

7. Clarke KM, Hall L. A survey of anaesthesia in small animal practice.

AVA/BSAVA report. J Ass Vet Anaesth 1990;17:4-10.

8. Hung W-C, Ko JC, Weil AB, et al. Evaluation of Endotracheal Tube Cuff Pressure and the Use of Three Cuff Inflation Syringe Devices in Dogs. Frontiers in Veterinary Science 2020;7:39.

9. Blunt MC, Young PJ, Patil A, et al. Gel lubrication of the tracheal tube cuff reduces pulmonary aspiration. Anesthesiology 2001;95:377381.

10. Hardie EM, Spodnick GJ, Gilson SD, et al. Tracheal rupture in cats: 16 cases (1983-1998). J Am Vet Med Assoc 1999;214:508-512 11. Mitchell SL, McCarthy R, Rudloff E, et al. Tracheal rupture associated with intubation in cats: 20 cases (1996-1998). J Am Vet Med Assoc 2000;216:1592-1595.

12. van Oostrom H, Krauss MW, Sap R. A comparison between the v-gel supraglottic airway device and the cuffed endotracheal tube for airway management in spontaneously breathing cats during isoflurane anaesthesia. Vet Anaesth Analg 2013;40:265-271.

26 | FVMA ADVOCATE

13. Barletta M, Kleine SA, Quandt JE. Assessment of v-gel supraglottic airway device placement in cats performed by inexperienced veterinary students. Vet Rec 2015;177:523.

14. Cote E, Manning AM, Emerson D, et al. Assessment of the prevalence of heart murmurs in overtly healthy cats. J Am Vet Med Assoc 2004;225:384-388.

15. Paige CF, Abbott JA, Elvinger F, et al. Prevalence of cardiomyopathy in apparently healthy cats. J Am Vet Med Assoc 2009;234:1398-1403.

16. Davis H, Jensen T, Johnson A, et al. 2013 AAHA/AAFP fluid therapy guidelines for dogs and cats. J Am Anim Hosp Assoc 2013;49:149-159.

17. Waterman A. Accidental hypothermia during anaesthesia in dogs and cats. Vet Rec 1975;96:308-313.

18. Redondo JI, Suesta P, Gil L, et al. Retrospective study of the prevalence of postanaesthetic hypothermia in cats. Vet Rec 2012;170:206.

19. Ludders JW, McMillan M. Errors in Veterinary Anesthesia. Ames, Iowa: Wiley Blackwell, 2017.

20. McMillan M, Darcy H. Adverse event surveillance in small animal anaesthesia: an intervention-based, voluntary reporting audit. Vet Anaesth Analg 2016;43:128-135.

21. Slunsky P, Brunnberg M, Lodersted S, et al. Effect of intraoperative positioning on the diameter of the vertebral canal in cats during perineal urethrostomy (cadaveric study). J Feline Med Surg 2018;20:38-44.

22. Slunsky P, Brunnberg M, Loderstedt S, et al. Effect of intraoperative positioning on postoperative neurological status in cats after perineal urethrostomy. J Feline Med Surg 2018:1098612X18809188.

23. Hofmeister EH, Quandt J, Braun C, et al. Development, implementation and impact of simple patient safety interventions in a university teaching hospital. Vet Anaesth Analg 2014;41:243-248.

24. Robertson SA, Gogolski SM, Pascoe P, et al. AAFP Feline Anesthesia Guidelines. J Feline Med Surg 2018;20:602-634.

Equipment cited:

a. Tru-cuff b. AG Cuffill® c. Pop-Off Occlusion Valves

Sheilah Robertson, BVMS (Hons), Ph.D., DACVAA, DECVAA, DACAW, DECAWBM (WSEL), CVA, MRCVS Dr. Sheilah Robertson received her veterinary training at the University of Glasgow (Scotland) followed by time in mixed animal practice and specialist training in anesthesia. She completed her Ph.D. at the University of Bristol (England).

She is board certified in anesthesia and animal welfare by the respective American and European Colleges, and she is trained in small animal acupuncture. Her research and clinical interests include assessment of acute and chronic pain and their treatment, and improving the safety of anesthesia in older pets. In 2014, she completed her graduate certificate in shelter medicine from the University of Florida. She served as a faculty member at the Western College of Veterinary Medicine, the University of Florida and Michigan State University, as well as an assistant director in the animal welfare division of the American Veterinary Medical Association. She has published more than 100 peer-reviewed, scientific articles and numerous book chapters. She serves on the World Small Animal Veterinary Association's Global Pain Council and Animal Welfare and Wellness committees. She was co-chair of the AAFP Feline Anesthesia Guidelines Committee and serves on the AAFP Welfare Committee. Currently, she is the senior medical director for Lap of Love Veterinary Hospice Inc., a large network of veterinarians providing end-of-life care and in-home euthanasia services throughout the U.S.

When treating four-legged patients,

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Practice Pulse QUESTION: When can I start working after I have graduated and completed my application for a license to practice?

A: If you have graduated from an approved college or school of

veterinary medicine, completed your application, and taken the Laws and Rules examination, you may work under supervision while waiting for the test results. If you fail the examination, you cannot work under supervision until you achieve a passing score.

QUESTION: I bought a clinic. What do I need to know as the new clinic owner?

vaccinations shall conform to the vaccine manufacturer’s directions.

The cost of vaccination must be borne by the animal’s owner. Evidence of circulating rabies virus neutralizing antibodies shall not be used as a substitute for current vaccination in managing rabies exposure or determining the need for booster vaccinations.

QUESTION: I have a strange issue regarding a traveling surgeon who has received questions about why clients of different veterinarians are charged different amounts for surgeries that she performs.

A: The new owner is required to submit a new application for

For instance, Clinic A has her come out to do an orthopedic procedure and they charge the client $3000. They pay the surgeon $2000. Meanwhile, Clinic B has the surgeon come out for the same procedure and charges their client $4000 and pays the surgeon $2000.

QUESTION: During the COVID-19 pandemic, can I advise my employee that he/she will not be able to come to work if they go to large gatherings?

Apparently, the surgeon is fielding occasional calls from clients asking about the difference in costs between Clinic A and Clinic B. So the surgeon called us and said that she wants all the clinics she works with to charge no more than a $600 markup for her fee and then charge whatever else they want for everything else.

Our view is that would be price fixing, but the surgeon insists it is not, since clinics are free to charge anything and everything else they want.

a premise permit in his or her name, and a new inspection will be required. You will have 10 days to notify the board of veterinary medicine in writing that you are the new responsible veterinarian by completing and submitting form VM 13, which can be found on the DBPR website.

A: According to a recent article in the National Law Review, “many states prohibit an employer from discriminating against employees for their lawful, off-duty conduct, which would include travel to a location that is not prohibited by law.”

However, we would advise that you contact your local Department of Labor for specific guidance on this question.

QUESTION: What is the legal age that a pet must be to receive the rabies vaccine? My colleagues and I can’t seem to agree as while the rabies vaccine is licensed for 12 weeks and older, the Florida statute requires pets to be vaccinated if they are four months of age or older. We would like to know which is correct.

Should we vaccinate at 12 weeks or 16 weeks?

A: The statute is not seen as creating a “legal age” for the rabies

vaccine. If the animal is four months or older, then it must be vaccinated. There is nothing in the statute (below) that prohibits an animal younger than four months to be vaccinated. If the vaccine is approved for 12 weeks or older and it is within the medical judgment of the veterinarian that an animal at 12 weeks can be vaccinated, then it is up to the veterinarian.

828.30 Rabies vaccination of dogs, cats, and ferrets.— (1) All dogs, cats, and ferrets 4 months of age or older must be vaccinated by a licensed veterinarian against rabies with a vaccine that is licensed by the United States Department of Agriculture for use in those species. The owner of every dog, cat, and ferret shall have the animal revaccinated 12 months after the initial vaccination. Thereafter, the interval between

28 | FVMA ADVOCATE

Is the surgeon's desire to cap any markup of her fee appropriate, or would this be viewed as a version of price fixing?

A:

The term “price fixing” is usually defined as marketplace competitors conspiring among themselves to set a price. In this scenario, it is not the various clinics that are setting the price; it is the surgeon who is trying to set the price for her services. Nevertheless, what clinics charge for the service should be up to the clinics and the marketplace should be the ultimate check. The difference in markup depends on several variables that are not equal among clinics (i.e. quality of facilities, staff, etc.). We do not know enough about antitrust to offer an opinion on whether what the surgeon wishes to do is legal or not, but it seems that the end result is the same, i.e. the price is being “fixed;” although, the end price may be actually lower to consumers in some cases. This is a bit of a concern, and we would suggest that the traveling surgeon should not be trying to set the price or discussing the difference in fees from one clinic to the next with clients. It is up to the consumer to shop around.

QUESTION: We have had an incident involving a lost 10-monthold Italian Greyhound. One of our clients came in for a technician appointment with her pet for a booster. The client normally brings the pet in a carrier. In this case, she did not as she stated that the dog bit her husband through gloves. Our clinic is doing car-side service currently. We do send an email to our clients stating that they need to have the pet in a carrier or on a leash.

Our procedure is to put our own slip lead on as well. In this case,

GOT A QUESTION? THE FVMA CAN HELP.

One of the benefits of an FVMA membership is our helpline (800.992.3862), which is available to members Monday through Friday from 8 a.m.-6 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 as a part of an effort to keep our members up to date on current concerns, as well as regulatory and legislative changes.

when the car door was opened, the pet jumped out of the car; the technician tried to put the slip lead on and the pet circled and backed out of its harness several feet away from the car. The pet is very skittish, and the client has been afraid of being bitten, which is why the harness was not secured on the pet.

We notified animal control and the humane society. We notified PLITT. Up until now, we have been working with the client to try to find the dog, but now the client is taking the stance that it is our fault, and what are we going to do about it?

A: This is the first such incident that has been shared with us. From your description, you have done everything you were supposed to do to prepare for the proper handling of the dog and called upon the proper services after the dog backed out of its harness and ran away.

The veterinarian could not be faulted if he/she chose to discharge such a client.

QUESTION: I’m reaching out to get some information about releasing records to clients. We have a client that we will no longer be providing services to. This client has NOT paid their bill; are we required to release records to this client? Can we legally withhold records from clients that do not pay their bill?

A: You cannot withhold a client's records due to an unpaid bill. Please see F.S. 474.2165 Ownership and control of veterinary medical patient records; report or copies of records to be furnished. Sub Section (3):

Any records owner licensed under this chapter who makes an examination of, or administers treatment or dispenses legend drugs to, any patient shall, upon request of the client or the client’s legal representative, furnish, in a timely manner, without delays for legal review, copies of all reports and records relating to such examination or treatment, including X rays. The furnishing of such report or copies shall not be conditioned upon payment of a fee for services rendered.

Last fall, a new DVM came on board. In order to transfer control of the drugs from one DVM to the next, I sought the advice of the local DEA office in Orlando. The DEA advised transference of the Schedule II and III drugs should be accomplished by listing the new DVM as the “purchaser” and the former DVM as the “supplier” on the new veterinarian’s 222 form. The drugs were meticulously accounted for, listed on the form, the new DVM signed and I was instructed to keep this document on file for at least two years.

Our new/current DVM recently took an online course for continuing education/license renewal and reportedly learned that transferring Schedule II and III drugs from one veterinarian to another is not allowed by the State of Florida. She was led to believe that Florida has a rule that is more stringent than the DEA/federal rules. I’ve taken some time this morning to scan through documentation and links provided on the Florida Board of Pharmacy’s website but could not locate such a rule.

We would appreciate you providing some guidance on this matter.

A: The transfer of drugs from one practitioner to another is generally

not allowed in Florida. However, it is not allowed when used as a means of regularly supplying drugs from one practitioner to the other. The situation you have described is similar to one practitioner buying the practice of another practitioner and transferring the drugs as part of the sale. In other words, this is a one-time transfer, which is allowed by Florida law. The directions provided by the DEA are correct.

QUESTION: We run the municipal animal shelter and employ a shelter veterinarian (DVM). We have an animal control pharmacy permit that allows us to purchase and administer drugs specifically used for tranquilization and/or euthanasia.

We also purchase controlled drugs to assist with surgery and pain management under the DEA registration number of the current shelter DVM.

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

VETERINARIANS WANTED – JACKSONVILLE, FL: Julington Creek Animal Hospital is seeking a FT associate veterinarian at a well-established (45 years) small animal practice located on a one-of-a-kind 9-acre pet campus.

We are a progressive, 4-doctor hospital with professional support staff, digital radiography, full in-house diagnostic laboratory, and mobile ultrasonography.

We offer competitive salary and benefits. If you enjoy a team approach to clinical medicine and surgery, we welcome experienced and new graduates for consideration. Contact: jason_winchester@jcaw.com. (4/20; ID#5822) VETERINARIANS WANTED – CORAL GABLES, FL: Coral Gables Animal Hospital is seeking a full time Veterinarian to join our amazing team. We are a well-established Animal Hospital located in Coral Gables, Fl practicing small animal medicine and general surgery. We offer a competitive salary and benefits along with a great schedule.Interested candidates please send your resume to: employment@coralgablesanimalhospital.com. (4/20; ID#17238) VETERINARIAN WANTED - LAKELAND, FL: Do you want to enjoy coming to work? Award-winning 3-doctor SA/Exotic AAHA Independent Practice is seeking our next amazing Associate in Central FL (Lakeland).

• Competitive salary and benefits, commensurate with experience • New and experienced associates considered • Relocation bonus • In-house lab equipment, digital dental radiology, digital radiology, CO2 laser, cold laser • Must be open to Integrative medicine and open to treating Exotics • Check us out at: www.floridavet.com and www.facebook.com/mypetsah.

(4/20; ID#654) VETERINARIANS WANTED – LOXAHATCHEE, FL: Overnight Veterinarian for a Small Animal Practice in Loxahatchee, Florida.

Competitive salary available. We are family owned and offer in house labs, digital X Rays, ultrasound, and surgery. Must be licensed in the state of Florida. Please send your resume to palmswestvet@gmail.com.

(4/20; ID#1510) VETERINARIANS WANTED – DELAND, FL: We are a 5 doctor integrative veterinary practice in DeLand, Florida caring for small animals, exotics, and wildlife. Seeking full or part time associate. Please call or email for more information - full listing available. FloridaWild 386-734-9899 or drhathaway.floridawild@gmail.com. (4/20; ID#27671) VETERINARIANS WANTED – MELBOURNE, FL: Veterinary Wanted in Melbourne, Florida, $220,000 annual salary. Please contact Dr. Larry Adkins at (407) 529-5651.(4/20; ID#28095) VETERINARIANS WANTED – KISSIMMEE, FL: Veterinary Wanted in Kissimmee, Florida, $220,000 annual salary. Please contact Dr. Larry Adkins at (407) 529-5651.(4/20; ID#28095) VETERINARIANS WANTED – WINTER PARK, FL: Veterinary Wanted in Winter Park Florida, $250,000 annual salary. Please contact Dr. Larry Adkins at (407) 529-5651.(4/20; ID#28095) VETERINARIAN WANTED – LAKEWOOD RANCH, FL: 4-day work week full time veterinary position!

Ranch Animal Hospital is a progressive, private/family owned animal hospital located in Lakewood Ranch, Florida looking for new full-time associates! If you are looking for a fun, fast paced environment with a variety of cases you found the right place!

Ranch Animal Hospital is a very busy practice with 6 exam rooms, large surgical suites and treatment areas, the newest Cuattro radiograph technology, in house Heska blood machines that include progesterone, thyroid, and cortisol capabilities, therapeutic cold laser, ultrasound, tonopen, and more. Our clientele are loyal, compliant, and treat us like part of their family. We have a phenomenal support staff and operate as a team where everybody helps each other until the job is completed. We are looking for an outgoing doctor with strong communication skills and medical competency to fill a full-time position. We prefer doctors with surgical experience but are able to mentor those who wish to become more proficient. For new graduates we do offer longer appointment times and mentoring! 4-day work week with rotating weekends.

Our group of doctors is collaborative between our other facility, the Animal Hospital at Lakewood Ranch, with a variety of strengths and interests. We also have an extended support network of specialists (orthopedics, neurology, oncology, ophthalmology, emergency, and tertiary facilities) locally who are available for consults. There are no after-hours/on call duties and a generous salary that is commensurate with experience, range 90-125k. In addition, we offer dental/medical/

30 | FVMA ADVOCATE

vision, CE/Licensure stipends, and paid vacation.

If you are interested in interviewing with us for a position please contact me by email (ocean.r.cohen@gmail.com) or phone at 941-228-0465 (cell - call or text). 4/20; ID#30474) CHIEF OF STAFF VETERINARIAN WANTED – FORT LAUDERDALE AREA: We represent one of South Florida’s most trusted non-corporate Veterinary Hospitals. Since 2001, their pledge has been to provide the Ft. Lauderdale community the highest quality animal medical care at an affordable price, 7-days a week, no additional costs on weekends.

The Chief of Staff will oversee all aspects of veterinary care including physical examination, diagnostics, treatment recommendations and delivery, major/ minor surgery, prescriptions and discharge information. In addition, they will assist in managing a small group of Doctors and support staff, cultivating a supportive and collaborative team environment. This is an opportunity for a Doctor to provide compassionate pet care to an extremely loyal community.

The Veterinary Hospital is operated by a dedicated and supportive owner with a desire to grow the facility and its already large clientele. The Chief of Staff will have constant, direct support from ownership in addition to the following: • Competitive base salary plus bonus • 100% paid health insurance • All Veterinarian dues paid - License and AVMA PLIT License • Continuing education allowance • Fully stocked kitchen – lunch provided daily Relocation assistance will be provided, if necessary. Chief of Staff leadership duties: • Training doctors on customer service • Planning and management of 5 Doctor staff schedule • Conduct periodic rounds and review facility cases • Conduct Doctor performance reviews: • Client satisfaction / client complaints • Productivity • If necessary, hiring or firing doctors Requirements: • Doctorate: Veterinary Medicine (Required) • Five or more years of experience in general animal practice, shelter medicine or animal hospital • Florida State Veterinary Board License and in good standing with the state • Strong surgical experience • Experience in high quality, high volume spay/neutering environment strongly preferred • Ability to work 18 shifts per month, preferably including 3 Saturdays per month (negotiable) • Experience managing a Veterinarian staff Please email resumes to Jason.pike@bps-world.com or contact @ 561569-2320. (4/20; ID#49005)

RELIEF VETERINARIAN

RELIEF VETERINARIAN: "Got to get away? "VetRxRelief , 37 years experience small animal Veterinarian.Please call 321-508-3879 or Vetgator@gmail.com. (4/20; ID #2187)

MISCELLANEOUS

BOOKKEEPER WANTED – TAMPA, FL: Looking for experience Bookkeeper if you are interested. email gregaustin20019@gmail.com.

(4/20; ID #19854)

PRACTICE FOR SALE

PRACTICE FOR SALE - ALTAMONTE SPRINGS, FL: Extremely busy and profitable one Doctor, small animal Practice within the busy Altamonte Mall shopping center near Orlando. Free standing building with ample packing. 3 exam rooms. Digital X-ray /Dental equipment. Gross earnings last 5yrs –$850,000. Case load – 70% Vaccines, Heartworm testing & Sales of parasiticides. 20 % Internal medicine & Dermatology, 10% Soft tissue surgery.

Perfect for a Doctor that hates dull moments and loves challenges, or a Doctor looking for a more relaxed lifestyle in the sunshine state of Florida. Contact Dr. Kuria by phone or text - 310 -936-3005 or email - emkuria1@hotmail.com.

(4/20; ID#19693) PRACTICE FOR SALE - MELBOURNE, FL: Turn Key, fully equipped hospital , Space Coast, close to beach, marina, and shopping. Equipment also for sale separately. Call 321-508-3879 or VetGator@gmail.com. (4/20; ID#2187)

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FLORIDA LISTINGS JUST LISTED! MIAMI GROSSING OVER $1MILLION! NEAR BUSY PARKWAY LEASED FACILITY

REBECCA ROBINSON DAVIS, CBI BRENNAN MCGOLDRICK, DVM, MBA

CENTRAL FLORIDA GROSSING OVER $700K! $50K UPGRADE ALLOTMENT ATTACHED LIVING QUARTERS

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YOU’LL NEVER BE THE LEAD DOG WORKING FOR SOMEONE ELSE. Being an owner will help you retire debt faster while creating the practice of your dreams. You can establish the quality of care and service, choose your schedule, and achieve significant financial success.

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Since 1977, the experts at Simmons have helped veterinarians buy their own practice – even those burdened with student debt. Trust Simmons to guide you through the buying process.

Call us today at 800.333.1984 for a complimentary and confidential conversation.

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