THE NEW ZEALAND
VETERINARY
NURSE
I SS U E 5 9 V O LUME 1 7 A U T UMN - SEPTEM BER 2011
Dark horse, dark night www.nzvna.org.nz
Volunteering with Sun Bears in Cambodia
Post-operative Pain Relief
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NZVNA COUNCIL President Julie Hutt P.O. Box 19-700 Woolston, Christchurch Home 03 384 1713 021 599 059 president.nzvna@gmail.com Vice President Michelle Parkin Home 06 347 1385 Work 06 349 6195 027 741 8780 vicepresident.nzvna@gmail.com Treasurer Kathy Waugh 1 Taroka Close Pinehill, Albany Auckland 0632 Home 09 478 6171 Work 09 410 5169 021 843 277 treasurer.nzvna@gmail.com k.waugh@xtra.co.nz National Secretary Joanne Robinson 459 Barrington Street Spreydon Christchurch 8024 Home 03 960 0465 Work 03 338 7400 029 432 4975 secretary.nzvna@gmail.com COUNCIL MEMBERS Membership Secretary Anne Lascelles P.O. Box 1314 Palmerston North Home and fax 06 358 6448 vetnurse@ihug.co.nz Fiona Hastie Work 09 624 2817 021 993 045 fiona@vaj.co.nz Lara Angevine Work 09 815 4321 ext 7352 langevine@unitec.ac.nz Heather Gudsell 09 578 0788 0274 792 788 gudsells_place@xtra.co.nz Hayley Langford 03 315 8445 hayleyandjase@clear.net.nz Sarah O’Hagan 6 Sedcole Street Pahiatua Home 06 376 6101 Work 027 622 6655 john_sarah@xtra.co.nz JOURNAL EDITOR Amy Ross Home 09 636 7925 021 852 664 journal.nzvna@gmail.com COVER CREDITS Sun Bear at Phnom Tamao Wildlife Rescue Centre by Donna Barlow PRODUCTION Printed by KM Print www.kmprint.co.nz Design by Murray Lock Graphics murray@mlgraphics.co.nz
THE NEW ZEALAND
VETERINARY
NURSE
I SSU E 59 VO LU ME 1 7 AU T U MN - SE P T E MBE R 2 0 1 1
The New Zealand Veterinary Nursing Association strives to PROTECT, PROMOTE and PROVIDE the highest standard of veterinary nursing care. ISSN 1177-3553
President’s Report by Julie Hutt....................................................................
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Council Meeting Report....................................................................................
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Letter From The Editor by Amy Ross.......................................................
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Book Review by Lara Angevine..........................................................................
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An Interview with the New NZVNA President by Amy Ross...........................................................................................................................
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Volunteering With Sun Bears in Cambodia by Donna Barlow.................................................................................................................
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Changes to ACVM: Veterinary Operating Instructions by Nick Twyford...................................................................................................................
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Advertising Rates.....................................................................................................
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An Important Health and Safety Issue to Consider............
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NZVNA Conference Report by Amy Ross............................................
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Post-operative Pain Relief by Natalie Bain..........................................
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Dark Horse, Dark Knight by Steph Mann................................................
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Quiz..........................................................................................................................................
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NZVNA forms
The Qualification badge order forms, merchandise order forms and new membership forms can now all be found on the website www.nzvna.org.nz or by emailing k.waugh@xtra.co.nz Disclaimer The New Zealand Veterinary Nursing Association Journal is published by the New Zealand Veterinary Nursing Association Incorporated (NZVNA). The views expressed in the articles and letters do not necessarily represent those of the NZVNA or the editor, and neither the NZVNA nor the editor endorse any products or services advertised. The NZVNA is not the source of the information reproduced in this publication and has not independently verified the truth of the information. It does not accept any legal responsibility for the truth or accuracy of the information contained herein. Neither the NZVNA nor the editor accepts any liability whatsoever for the contents of this publication or for any consequences which may result from the use of the information contained herein or advice given herein. The provision is intended to exclude the NZVNA, the editor and its staff from all liability whatsoever, including liability for negligence in the publication or reproduction of the materials set out herein.
T h e N e w Z e a l a n d V e t e r i n a ry N u r s e S e p te m b er 2 0 1 1
PRESIDENT’S REPORT It has been an interesting year, and coming from Christchurch it has been a year of challenges and heartbreak. Learning to live with the changes and also the uncertainty of what is to come. As I write my report it is snowing outside, very cold but also very beautiful. I will quote something I read on Facebook “Icing on the quake” it made me smile. What I did notice when we ventured out was that I could see all the empty spaces where buildings had gone, they were just white, a blank canvas, reality of how much we have lost. In April I was very fortunate to be able to travel to the VNCA Conference in the beautiful city of Perth. This was also a welcome break from home and it was very novel to have a hot shower and toilet that worked, such luxury. I received a very warm welcome from the VNCA and also made some good friends. It was a time of sharing ideas and just realising the challenges we face in our profession are very similar. This trip was made possible because of the support of Hills Pet Nutrition NZ, I cannot thank them enough. We had been looking forward to holding conference in Christchurch but the earthquakes made it impossible, our convection centre and hotels are still in the “red zone” a no go area and it will be some time before we get them back, if at all.
It was a time of sharing ideas and just realising the challenges we face in our profession are very similar. So the conference this year was held in Hamilton, and World Veterinary Year 2011 marks the start of the veterinary profession and 250 years since the world first veterinary school opened in Lyon France in 1761 by Claude Bourgelat. Over the past 250 years of the veterinary profes-
COUNCIL MEETING REPORT August 20th-21st 2011 The NZVNA Council met in Auckland on the 20th and 21st of August. Fiona Hastie, and Hayley Langford, were not present at the meeting due to other commitments, both were missed, and we look forward to catching up with them and hearing their input at our next meeting. The two days were full-on and packed with a lot of discussion. A big thank you 4
sion, veterinary nurses have had a key role in animal welfare, educating the public and supporting the Veterinary Surgeon. As a profession veterinary nursing has faced challenges, but with enthusiasm and the continuing developments we will only become more recognised and therefore make a huge contribution to the veterinary profession. We were very honoured to have Jo Hatcher, President of the VNCA and Gill Montgomery Immediate Past President of the VNCA attend our 2011 Conference in Hamilton, to have their support and also the development of communication between our organisations has been very rewarding. It was unfortunate that they were not able to leave New Zealand as scheduled because of the ash cloud so spent a few days seeing the sights of Auckland. I would also like to thank Marie Hennessy who over the years has done such a lot for the NZVNA, and her last role being our journal editor. Marie has dedicated much of her time over the years and she will be greatly missed. The NZVNA Council would like to wish Marie and her family all the best for the future and we look forward to seeing you at conferences and other events. I would like to just leave you with a quote from Mahatma Gandhi “Be the change you want to see in the world”. Warmest regards Julie Hutt
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out their conference surveys as this information was very beneficial to us. 2012 Conference and the World Small Animal Veterinary Associations (WSAVA) Conference in 2013. Website update. Possible changes to our constitution. The potential of receiving E copies of our Journal.
to the council members that gave up their weekend so that this meeting could happen, and thank you also to Provet NZ, for allowing us to use their boardroom over these 2 days.
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Our discussions included: • Portfolio reports and reviews. • This year’s conference – what worked and what needs improvement. We would like to thank everyone who filled
A lot of these topics are still in the planning and development stage and we will let you know of any decisions that are made.
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LETTER FROM THE EDITOR Wow, when I received my very first NZVNA Journal 14 years ago it never crossed my mind that one day I would become editor. Back then they were black and white copies that were stapled together, not the high quality glossy magazine that you now receive. Marie Hennessy has had a lot to do with how far our journal has come over the last 5 years, and she has left a high precedent for me to follow. This is both scary, and exciting at the same time. I have not done this sort of thing before, but I think it is good to give something a go when you have the opportunity. I would like to challenge each and
every one of you to have a go at doing something new. Whether it is continuing your studies and completing the Accredited Veterinary Nurse Program (AVNP), learning a new skill such as catheter placement, or something to do with your personal life. You may surprise yourself and it may be the start of many great things to come. As editor, I hope to continue to improve our journal so that it is viewed world-wide as a top quality and informative resource. To do this I need your help, as I would like to continue to fill the journal with articles that come from New Zealand veterinary nurses. While it is great to read about those surgical or medical cases that you do not see
BOOK REVIEW Laboratory Procedures for Veterinary Technicians should be included in the reference library at every clinic in New Zealand. There wasn’t a single test I could think of that wasn’t covered by this manual. It includes not only step-by-step directions as to how to perform these diagnostics (the majority of which a qualified vet nurse is able to perform in-house), but also excellent discussion of why these would be run, and what the results tell us.
Laboratory Procedures for Veterinary Technicians By Hendrix CM, Sirois M Softcover 400 pages 5th Edition Imprint: Elsevier Publishing Retail Recommended Price: $89.83 (NZ$ plus GST)
One of the other reasons I found this book to be worthwhile is that they discuss several different methods for performing diagnostics. For example, when doing a white cell count they show use of a hemocytometer and unopette along with use of an automated cell counter. For clotting tests they discuss methods ranging from the buccal mucosal bleeding time to use of the supersexy SCA2000 coagulation analyser. There are plenty of photographs, table and diagrams to help guide you through a procedure, or illustrate cell identification through a wide range of species. Authors Drs. Charles Hendrix and Margi
very often, it is also great to read about cases that you may see on a regular basis. Other nurses may not see those particular cases regularly, and by reading your article may pick up skills that they can use to improve the nursing care of their patient when they do. I also look forward to reviews on continuing education seminars that you have attended and textbooks that you have read. If you are interested in writing an article for the journal (maybe this can be your new challenge) but are unsure where to start, please contact either myself, or one of the other council members, and we will happily help you. Amy Ross Sirois both have extensive teaching experience and it shows in the easy style with which this book is written. Charles Hendrix DVM, PhD, has been a veterinarian for nearly forty years. Among his many professional acheivements he has worked is a professor of parasitology at Auburn University, Alabama, USA since 1981. He has worked closely with the public heath sector as well as the veterinary community. Margi Sirois EdD, MS, RVT, is the head of veterinary technology at Penn Foster Career School in Pennsylvania, USA. She has twenty years of experience in veterinary education and is licensed as both a veterinary technician (the US equivalent of the diploma in veterinary nursing) and a lab animal technician. Her teaching background includes serving as past-president of the Association of Veterinary Technician Educators. She has authored several high-quality books including authoring one of my favourite reference books, Mosby’s Veterinary PDQ. Get this book and start putting those lab skills to work for you and your practice! Lara Angevine 5
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An interview with
Julie Hutt
The New NZVNA President by Amy Ross
At the 2011 NZVNA AGM, Julie Hutt was nominated for and passed in as the association’s new president, taking over the reins from Sarah O’Hagan. Julie has been a member of the Council for the past 6 years. Julie, can you please tell the members a little about yourself?
I am from Christchurch and have lived in Canterbury most of my life. My two children have long since left home, but one back at the moment due to the earthquakes, also a very understanding and supportive husband Geoff. Last, but not least, another very important member of our family is Kitty a 23 year old ginger DSH. We also have two grand dogs, let me explain; Odie and Kingston live with my son and his family but spend time with us. With Kitty being so old it is a little bit much for her to have the excitable lads around all the time. What motivated you to join the NZVNA Council and then stand for President?
I was at a conference and listened to Jan Bedford speaking about the veterinary nurs-
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ing profession. She was so passionate and inspirational; I then knew I wanted to join council. It has been a progression and I have learnt a lot during my time on NZVNA, it was a natural progression to stand for President. How has your first month as President been?
My first month has been a busy one. Looking back over our last conference and starting planning for the next. I have also set some goals for the next year and getting ready for our next meeting with the rest of council in August. As President, what are your goals for the NZVNA during your 3 year term?
I have so many things I would like to achieve but one that is very important is the changes that will be happening with veterinary nursing training. The government has changed its funding model and we are now going to be looking at a “New Zealand” qualification which will put everyone on a similar level. This will make it easier for employers trying to work out what type of qualification their nurses have. I would also like to see all veterinary practices employing only qualified nurses and also fair pay for the work the veterinary nurses do.
Can you describe one highlight you have had in your Veterinary Nursing career?
Just one, there have been so many. The fantastic people and their pets I have met over the years, it is hard to just single out one. I have been very lucky to want to go to work in the morning; it’s been such a rewarding profession. Working with such inspiring people over the years, Dr Chris Steel who I was lucky to work with for many years was a great mentor and Dr Fiona Richardson who showed me that teaching was such fun and I get to meet such a great group of students. I just never stop learning and I think this is a major high light. I now thoroughly enjoy working with Dr Linda Sorenson and teaching surgical and clinical skills out in the clinic. Is there anything else that you would like to share with our members?
I would also like to make a mention about all the work the veterinary nurses and animal care workers in Christchurch have done during the months of earthquakes. Most of this has gone unnoticed with no new paper headlines or TV coverage. They have worked in Clinics, and out in the field, sometimes going into areas of danger making sure animals are cared for. Also a big thank you to veterinary nurses around the country for the support they have given during the last few months, it has been a big morale booster.
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Volunteering with Sun Bears in Cambodia
Farmed bears are kept in coffin sized cages unable to move freely or turn. They have non-surgical steel pipes inserted directly into their gall bladder. A syringe can be inserted into the pipe and the bear “milked” of its bile.
by Donna Barlow
Ursidae Helarctos malayanus, the Malayian Sun Bear. This magnificent little bear is found in several countries throughout Asia and can lay claim to being the smallest bear species in the world. Not a great deal is known about the Sun Bear. In the wild they tend to live a rather reclusive existence away from human populations. What we do know, however, is that they have been mercilessly hunted for centuries. They are hunted for their meat and fur, for use in traditional medicines, for the exotic pet trade and trade in body parts – e.g. bear paw soup. I first became aware of the plight of the Sun Bear in Asia a couple of years back while working at Matang Wildlife Rehabilitation Centre in Borneo. Matang have eight Sun
Bears in residence and the longer I was there, the more captivated I became, spending many hours at the bear enclosure observing, photographing, and returning home eager to learn more about the species. Sun Bears are listed as vulnerable on the IUCN Red List of Endangered Species. Fortunately, there are a number of NGO’s worldwide, working towards improving the long-term outlook of these bears and other bear species inhabiting the Asian continent. One such NGO is the Australian organisation Free the Bears Fund Inc. The fund was formed in 1993 by Mary Hutton, whom after watching a local current affairs program on television, made a decision that would change her life along with the lives of her family and friends. The current affairs segment contained horrific footage of Asiatic Black Bears being milked for bile. Gall bladders have been used in Asian medicine for centuries; however bear bile farming is a relatively new procedure whereby, instead of producing only one gall bladder from a bear carcass, the bear can be milked of its bile for its entire adult life. Farmed bears are kept in coffin sized cages unable to move freely or turn. They have non-surgical steel pipes inserted directly into their gall bladder. A syringe can be inserted into the pipe and the bear “milked” of its bile. This sickening and unnecessary practice continues today, unchecked by authorities in countries such as China, Vietnam, and Laos where thousands upon thousands of bears are kept in appalling conditions, subjected to pain and suffering for the duration of their entire life. Nowadays, Free the Bears Fund is active in several countries in South East Asia including Cambodia, India, Indonesia, Laos, Thailand and Vietnam. Their work involves not only the conservation of Asiatic black bears, but also Sloth bears and the gorgeous little Sun bear. In Cambodia, 40 kilometres south of Phnom Penh, you will find Phnom Tamao Wildlife Rescue Centre. This rescue centre was set up by the government in 1995 but also serves as Cambodia’s primary zoological collection. Phnom Tamao comprises 2,500 hectares of protected forest and of this approximately 1,200 hectares has been set aside by the For7
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estry Administration for wildlife rescue. It is here that Free the Bears Fund has been allocated 9 hectares to operate their Cambodian sanctuary for Sun Bears and Asiatic Bears. The fund currently supports 21 large forested enclosures and a nursery for orphaned bear cubs. Altogether providing a safe haven for 113 bears: 78 Sun Bears, 34 Asiatic Bears and 1 hybrid. Once I discovered that Free the Bears Fund also manage a successful volunteer program at Phnom Tamao, I was keen to participate, so set about organising some other like minded volunteers to form a group trip. The volunteer program at Phnom Tamao can accommodate up to six volunteers at any one time. Participation is for a minimum of two weeks and can be up to eight weeks. Our small New Zealand contingent of six arrived in Phnom Penh on the 2nd April excited about being able to work closely with the bears over the subsequent two weeks. Volunteer accommodation is a modern two level house on the outskirts of Samranjoven village. Phnom Tamao Wildlife Rescue Centre and Zoological Park is about 20 minutes 8
drive away and volunteers are transported there each morning at 8am and leave the park at 4pm. Australian Emma Gatehouse is the Free the Bears Volunteer Coordinator at Phnom Tamao. During induction, Emma went through health & safety procedures, introduced us to the Keepers and the Bears, showed us around the different enclosures and explained the work we would be doing. We also had a brief tour of the Zoological Park. The park has many other species on display including Leopards, Gaur, Elephants, Lions, Tigers, Samba Deer, Crocodiles, various exotic bird species, several Gibbon species and Dhole (Asiatic Wild Dog) to name but a few. However our volunteer group was there to help with the bears only, and as time progressed, we discovered that the majority of bears at the sanctuary have been confiscated or voluntarily surrendered; unwanted pets that have grown into unmanageable size and temperament. In Cambodia it is illegal to keep bears as pets but as with all Asian countries, the law is loosely enforced.
Note the sickle-shaped claws that the Bear uses to climb trees
Sadly those larger pets that do not make it to the sanctuary are often sold to restaurants to be made into bear paw soup. Other bears that are extremely lucky these days to be residing at Phnom Tamao have been rescued from the wildlife trade; live Sun Bears and their body parts are commonly available for sale in most countries in which they inhabit including Cambodia. Skin, meat, bone, paws, lung, heart, liver, intestines, gall bladder and blood are widely used for food and medicine. A “cure all� for anything from skin problems to low blood pressure to lung disease to arthritis to fatigue... the list is endless! The majority of bears at Phnom Tamao are Sun Bears. After entering the sanctuary they spend their first month in quarantine in order to safeguard against possible disease transmission to other bears. Very young bears often require expert care around the clock, with their growth rates
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and health status closely monitored. Once they are of a suitable age and a little more independent the bears are moved to the quarantine area. Adult Sun Bears can stand around 70 cm tall and weigh up to 75kg. (Females are slightly smaller). They have a solid body with short dense black fur and a distinct yellow/orange crescent shaped patch on their chest. This patch is sometimes dotted with black spots and can vary in size, shape and colour. There is no hair on the soles of their feet and sharp sickle shaped claws enable the bears to be excellent climbers. Sun Bears have a very long, slender tongue which aids in the extraction of honey and treats from difficult places. In the wild their diet would consist of fruit, termites, ants, earthworms, small birds and rodents, lizards and insects. The bears vocalise with a short, medium intensity “dog like� bark, so are often referred to by locals as the dog bear. Sun Bears are noticeably different from their cousin, the Asiatic Black Bear (or Moon Bear) Ursus thibetanus. These bears can weigh in at up to 200kg and have much longer fur. They are normally black, but can sometimes be brown and in fact there is a stunningly beautiful reddish/brown Moon Bear at Phnom Tamao called Brandy. The job of a volunteer is to help with all duties relating to the care and welfare of each and every one of these bears. First thing each morning, after being assigned to a Keeper, volunteers commence daily cleaning and feeding routines. The bears are brought inside for their morning feed and any medication that may be required. While they are locked inside the volunteers and the Keepers do a clean and check of the outside enclosures. All of the enclosures have climbing towers, platforms, ropes, a plunge pool, and many other structures to keep the bears amused. They are free to roam all day and at night have the choice to stay inside or out, as some night dens are left open for them. The enclosures are protected by solar powered electric fences. This stops the bears climbing out and escaping. Some young trees are also protected by electric fencing. We pick up all bear poo (there is tons of this!) and spread dog biscuits around. Once a week the pond is emptied, cleaned and filled with 9
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These bears are so beautiful that it is heartbreaking to think that humans could hurt them and treat them so appallingly fresh water. Inside the bears are munching away on boiled rice, eggs and dog biscuits. Once the bears are released back outside, the night dens are cleaned. This involves picking up more bear poo, and other rubbish like left over fruit skins. The dens are then hosed down with a high pressure hose, scrubbed with disinfectant, then hosed again. Volunteers also wash all the metal food bowls in dish-washing liquid, rinse them and hang them up to dry. The morning cleaning routine normally finishes around 10:30 - 10:45am. We then go to the kitchen where the daily food supply is delivered. All food is weighed and recorded. Depending on what is available at the market and the price, the contractor arrives with bananas, melons, turnips, beans, dragon fruit, carrots, tomatoes and rose apples. After the bulk weighing, turnips, apples, carrots, tomatoes and dragon fruit are all chopped up. Melons and banana bunches are counted. After lunch we return to the kitchen and measure out the food into buckets for the Keepers to collect later on. There is a chart on the wall which tells us how much of each fruit or vegetable goes to each “house� (enclosure). The buckets are all colour coordinated with each house having a different colour. Daily rice allocation is also cooked in the kitchen by one of the Keepers in huge pots over gas fired stoves. The gas used for cooking the rice is Bio-Gas derived from the bear manure. This is an excellent system for re-cycling the endless supply of manure.
This young sapling can easily be broken by a Sun Bear 10
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After the food is organised for the afternoon feeding, we return to the compound. We spend time preparing enrichment, large Kong toys stuffed with dog biscuits, jam, bananas, beans and morning glory. We make up one ball for each bear and the number depends on which house is receiving enrichment that day. There is normally time for other jobs like painting or making hammocks before returning to our allocated house and Keeper at 3pm to help with the afternoon feed. The bears are once again locked in their night dens so we can safely enter the outside enclosure to place/hide the food and enrichment balls. It is a thrill to watch the bears race back out of their dens and hunt down the food. The younger ones can be really amusing struggling to get the treats out of pipes, balls and other hiding places. These bears are so beautiful that it is heartbreaking to think that humans could hurt them and treat them so appallingly. Our Sun Bears trying to get food out of enrichment balls
final day came around all too quickly, encased with a pang of sadness. It is amazing how easily you become attached to these animals and each one of us had our favourite bear. An unexpected highlight of our last afternoon was getting introduced to Lola who is currently housed in the quarantine area, but due to be moved into another enclosure very soon. Lola is now a feisty, healthy 8 month old cub. She was brought to the centre at 2 months old, weighing only 2 kilos, severely ill and not expected to live. Lola was cared for around the clock by FTB staff for weeks, until finally there was a glimmer of hope that she was going to make it. And she did! And what a beautiful little bear she is, just full of personality, mischief and charm. Here is a picture of Lola at the bars of her enclosure posing for photographs. Free the Bears Fund continues to tirelessly campaign against the cruel practice of bear bile farming, the capture and dismemberment of wild bears for the restaurant trade, and the poaching and illegal trade of various bear species throughout Asia. The volunteer program helps to raise awareness while also
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Above, from left to right: Louise Quartley, Arron Dyer, Rochelle Pryde, Emma Gatehouse FTB Volunteer Co ordinator, Donna Barlow, Joanna Cranness, Darren Cross Right: Lola was not expected to survive when she first arrived at the rehabilitation centre giving participants the chance of a lifetime to work alongside these beautiful bears. I highly recommend giving it a go if you can. Of course our trip to Cambodia was not all work and no play. Weekends were spent sightseeing: it did not take long to decide that Cambodia and Phnom Penh are well worth a visit. If you enjoy travelling to Asian countries, there is still a lot of “old” Asia here, mixed with the new and developing. The Killing Fields of Choeung Ek Tuol and the Sleng Genocide Museum were a pretty sobering experience. Not a place for everyone I guess, but worth visiting if you are interested in understanding a little about the history of Cambodia and its people. We also flew to Siem Reap and spent a few days exploring Angkor National Park and the spectacular array of Cambodia’s Khmer Temples. For more information on volunteer trips to either Cambodia or Borneo contact Donna Barlow at back_of_beyond.volunteers@xtra.co.nz 12
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Changes to ACVM: Veterinary Operating Instructions Changes That Affect You
Veterinary authorisation means that in order to sell/dispense the product a veterinarian needs to have met a number of requirements, most important of which is to have gathered sufficient information to support their authorisation (or prescribing) of the product.
by Nick Twyford Veterinary Council New Zealand PO Box 10563, Wellington
Front of Clinic (Shop)
The New Zealand Food Safety Authority (NZFSA) regulates agricultural compounds through its administration of the Agricultural Compounds and Veterinary Medicines Act 1997 (ACVM Act). The purpose of this Act is to: 1. prevent / manage the risks associated with the use of agricultural compounds; and 2. protect against residues in domestic food; and 3. ensure that consumers are provided with sufficient information about agricultural compounds. Agricultural compounds include all substances used in the direct management of plants and animals. Of most interest and relevance to veterinarians and veterinary nurses and technicians, in the course of their work, are those compounds applied or administered into or onto animals.
Back of Clinic (Pharmacy)
Products administered in or on animals in order to treat or manage them (Agricultural Compounds)
Products not needing to be registered under ACVM Act
Products registered under ACVM Act as OTC
Registered Veterinary Medicines (RVM)
Human Prescription Medicines
Consider all of the animal treatments in a veterinary clinic. Ignore all of the equipment, implements, bandages and consumables, and focus on all of the substances used for the treatment or management of animals which are applied topically or administered orally or by injection. These products (including pet food, nutritional supplements, worm treatments, flea treatments, shampoos, antibiotics, painkillers and anaesthetics) are all agricultural compounds and fall under the regulation of the ACVM Act. In order to manage the risks associated with agricultural compounds some of these products are required to be registered under the ACVM Act. Agricultural compounds that are used for the direct management (treatment) of animals and which need to be registered are classified as veterinary medicines. The risks associated with the use of some agricultural compounds are sufficiently low that they do not have to be registered, for example pet-foods, some nutritional supplements and most topical washes that do not make therapeutic claims. For the purposes of illustration (see Figure 1), divide your clinic into two parts – the front retail/shop area, and out the back in the pharmacy/treatment rooms of the clinic. The agricultural compounds found in the shop are all open sellers, or, over the counter (OTC) products – anybody can sell them and anybody can buy them – there are no restrictions. Some are exempt from registration (pet foods and most topical washes and shampoos). Others products have to be registered under the ACVM Act because certain therapeutic claims are made in relation to their use (worm treatments, fl ea treatments, medicated shampoos etc). These registered products (veterinary medicines) are still considered to be open sellers. The agricultural compounds in the pharmacy and treatment areas of the clinic are all likely to be classified as restricted veterinary medicines. All require registration under the ACVM Act, and all are likely to have restrictions applied in terms of the circumstances in which they can be sold and used.
Veterinary Medicines
Unrestricted
Restricted
Figure 1. Agricultural Compounds in Veterinary Clinics 13
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A number of the products found in the pharmacy will be human prescription medicines. When these are used on animals they are considered to be veterinary medicines and fall under the regulation of the ACVM Act in terms of how and when they may be used.
veterinarian (AV) to a non-veterinarian to hold restricted veterinary medicines RVMs in anticipation of their use, and to use RVMs only in accordance with the AV’s instructions in circumstances in which the AV will not be carrying out a case-specific consultation.
Whether a product is registered, and therefore whether restrictions exist in relation to use or sale can be determined from a number of sources. The packaging of the product must show whether it is registered and, if relevant, whether the product is restricted. The IVS annual will usually record that information. The online ACVM (Agricultural Compounds and Veterinary Medicines) register (https://eatsafe.nzfsa.govt.nz/web/ public/acvm-register) allows you to search by product and provides the most current information.
Veterinary Operating Instructions are not a new idea. The concept has been described within documented ACVM standards previously as ACVM Operational Procedures Standard (AOPS). AOPS is referred to in the New Zealand Veterinary Association (NZVA) Best Practice requirements for Production Animal Practices in relation to the standards expected for the authorisation of farmers to hold RVMs in anticipation of use. The protocol has been identified by the NZFSA as the mechanism they would prefer to see veterinarians using to authorise restricted veterinary medicines to farmers in place of what is colloquially referred to as the ACVM Consult. AOPS have not been widely known about or used by the profession.
The naming and classification of veterinary medicines has changed. The traditional Prescription Animal Remedy (PAR) naming system has been replaced by Restricted Veterinary Medicine (RVM). The previous PAR1/PAR2/PAR3 classification system is no longer used to group these products and all now fall under the same RVM grouping. Whereas unrestricted or OTC products can be sold by anyone to anyone, Restricted Veterinary Medicines and human prescription medicines require veterinary authorisation before they can be sold. Veterinary authorisation means that in order to sell/dispense the product a veterinarian needs to have met a number of requirements, most important of which is to have gathered sufficient information to support their authorisation (or prescribing) of the product. The most common form of veterinary authorisation involves a consultation. This is a process that includes gathering and recording information, being satisfi ed that treatment is justifi ed and appropriate, obtaining consent for treatment, ensuring that the person administering the treatment is able to carry out treatment competently, and making provision for the management of adverse events.
In the past, NZFSA approved a number of Codes of Practice under section 28 of the ACVM Act. Some of those Codes were written to document how certain animal treatment outcomes could be achieved by a particular organisation. Those organisations which owned approved Codes included the New Zealand Veterinary Association, New Zealand Police, Research Teaching and Training Organisations and privately owned organisations. A consistent feature of the Codes of Practice was the documentation of the authorisation process for the use of restricted veterinary medicines by non-veterinarians. The Codes documented how identified organisations would train and approve non veterinarians, and authorise them to use RVMs in specified groups of animals under specifi c circumstances, for example the Grooms Code which allowed grooms travelling by air or sea with horses to make the decision to administer restricted veterinary medicines to their charges in certain circumstances.
There is an alternative mechanism for veterinarians to authorise restricted veterinary medicines – Veterinary Operating Instruction.
The Codes of Practice dealt with a lot more than the authorisation of restricted veterinary medicines, but the parts relating to the holding, storage and use of restricted veterinary medicines mirrored the requirements found now in VOI.
A Veterinary Operating Instruction (VOI) is a set of instructions from an authorising
As a part of the review of the ACVM Act by NZFSA in 2007, AOPS were given a new
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name and profile. The new name is Veterinary Operating Instructions. VOI (and the historical AOPS) are actually based on the concept of Standing Orders as used in human medicine. They were not invented by NZFSA or the Veterinary Council. There is plenty of information readily available on the internet about the regulation and standards applicable to Standing Orders in the human medicine sector. AOPS and VOI are closely based on the human model. Standing Orders were developed in the early 2000s in hospitals to allow nurses under the direction of doctors to have the authority to administer prescription medicines and controlled drugs (such as opioids for post-operative pain relief ) to patients without having to find a doctor to authorise the treatment. The doctor would write a set of instructions authorising a person with the appropriate competencies to administer a specified drug at a specified dose under specified circumstances. Records of treatment would have to be noted on the patient’s chart and the doctor was required to sign the chart within 24 hours. The protocol proved very successful and the use of Standing Orders has been expanded to incorporate many more types of situations – dental therapists, rural nurses, paramedics, practice nurses, specialist diabetes nurses etc. The Ministry of Health is currently reviewing Standing Orders and is considering changes to get around the need for doctors to sign the patient’s chart within 24 hours. At the time of writing, it seems likely the Ministry of Health will move towards monthly checking which can also be carried out remotely. Standing Orders exist to make the best use of the available skilled work force while continuing to ensure the risks around prescribing are managed appropriately. There is no requirement under Standing Orders that doctors must only authorise registered health practitioners such as nurses. Despite that they do. The actual requirement is that the person working under standing orders has the necessary competencies to carry out the instructions. Government has indicated that it is not likely to maintain or introduce any regulation which is not considered necessary in terms of appropriate risk management, which might be described or seen as patch
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protection, or which adds any unnecessary cost associated with the provision of a service. Standing Orders and VOI legitimately fit comfortably within those requirements – they increase the effectiveness of delivering health/veterinary services in a cost effective manner while satisfactorily addressing risk management. The NZFSA has documented standards for VOI which closely mirror Standing Orders. The ACVM document Veterinary Operating Instructions ACVM Guidelines No 65 can be found by searching for the title on the NZFSA website (http://www.foodsafety. govt.nz/index.htm). The Veterinary Council’s, soon to be issued, revised Code of Professional Conduct (COPC) recognises VOI as an mechanism by which a veterinarian can authorise restricted veterinary medicines, as an alternative to consultation. The Council’s expectations around VOI are based on the ACVM standards but the COPC is more explicit about the particular requirements veterinarians must meet – in particular in the areas of monitoring, record keeping and documenting the competencies/training of the person named in the VOI. The VOI documentation on the ACVM section of the MAF website provides a useful template for creating VOI. The essential elements include: 1. Unique identification and life of the VOI 2. Reason/Purpose for VOI 3. Personnel named. Skills/qualification
New Zealand Veterinary Nursing Association Journal Rates for 2011 Journal printed in March, June, September and December
required 4. Animals described 5. Veterinary medicines specified 6. Equipment/Techniques for adm inistration 7. Expected treatment outcome 8. Anticipated adverse events, unexpected treatment outcomes and how these will be managed. 9. Storage of veterinary medicines 10. Specification about records and reconciliation Important features of VOI include: 1. The owner of the animals does not have to be a bona fide client of the veterinarian. The veterinarian writing the VOI does not have any responsibilities to communicate with the owner of the animals to be treated, keep records about the owner, or provide emergency care for the animals treated under the VOI. The animals to be treated can be geographically distant from the veterinarian. 2. The veterinarian’s responsibilities lie in developing adequate instructions, using sound judgement in deciding that the person will comply, monitoring appropriately and withdrawing the VOI in the event of non compliance etc. 3. It is not appropriate to use VOI in situations where a veterinary diagnosis or judgement is required in order to make decisions on how to treat an animal. There are 3 main types of situations likely to be applicable to VOI: i. Prophylactic treatment of healthy Rates
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animals e.g. vaccination ii. Chemical restraint of animals so that a procedure can be undertaken. iii. Therapeutic treatment when the condition being treated is so obvious that a veterinary diagnosis is not required. 4. There are few situations where it would be appropriate to authorise antibiotics under VOI. VOI offer veterinarians and veterinary nurses in particular new opportunities to consider how they might deliver certain animal health services; provide possible solutions for particular client’s needs and quite possibly will enhance animal welfare outcomes. Veterinary nurses and production animal technicians are well placed to be the most likely personnel authorised by veterinarians under VOI. Because of their training they are more likely to have the competencies required to deliver the veterinary outcomes prescribed under VOI. The recent changes to the regulation of veterinary medicines (including VOI) will allow the legitimate development of more challenging (and hopefully more fulfilling) roles for veterinary nurses and technicians both inside and outside veterinary clinics. Reprinted with permission from the Proceedings of the Annual Conference of the NZ Veterinary Nursing Association. FCE Publication No. 286, Pp 8.10.1−8.10.5, 2011
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An Important Health and Safety Issue to Consider I had quite a bit of blood across the back of my hand and fingers. It was at this point that the owner advised me of some horrifying details. He said “I should probably let you know, I am Hepatitis C positive and on the methadone programme. You should get yourself checked out. I would like to share with fellow veterinary nurses a personal experience I recently encountered. For obvious reasons I will remain anonymous throughout this article, and so also will the clinic at which I am employed. A normal day’s work began with admissions for morning surgery, post op checks and a few consults thrown in to the mix. This day may have began normally but it was about to have possible life-changing consequences for me. I was called into the consult room to assist with a blood collection procedure on an unwell cat. I restrained the cat to enable the veterinarian to access the jugular vein in order to draw the blood sample. The owner was present in the consult room and was watching from the side of the table. As the veterinarian began to extract blood the cat became fractious and I had difficulty restraining further for her to continue. The vein was lost and consequently only a very small blood sample was obtained. Unfortunately we didn’t receive enough for the tests required so a repeat attempt was necessary. As I began to hold the cat in the required
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position the owner offered his assistance for restraint purposes. This seemed appropriate at the time as things weren’t going well and the cat was becoming agitated to say the least. The owner held the cat’s head while I controlled the forelegs and firmly cradled the body into my side. Things were going well at this point, with the vein accessed successfully by the veterinarian and the vital sample slowly filling the syringe. However things were about to take a turn for the worse when suddenly the cat lunged and bit the owner on the finger. Blood literally poured from a wound to the owner’s index finger which was punctured on both sides. It bled so much that the blood dropped from his finger to the back of my hand which was below. My initial thought was “wow that’s a fair amount of blood” and was unsure really where the source was. I immediately asked if the owner was ok and offered some assistance with paper towels to clean himself up. I then proceeded to clean myself up as I had quite a bit of blood across the back of my hand and fingers. It was at this point that the owner advised me of some horrifying details. He said “I should probably let you know, I am Hepatitis C positive and on the methadone programme. You should get yourself checked out”. I removed myself from the room unsure what had just happened and began to frantically scrub my hand with iodine. The previous night I had been playing with an over-zealous puppy which had nipped me with his sharp teeth which left a small tear on the back of my hand. I didn’t know a great deal about Hepatitis C or the potential diseases I could have been exposed to, but I knew enough to know this incident could be serious. I phoned the local medical centre for advice and was told I should come straight down and somebody would see me.
Hepatitis C – What is it? Hepatitis C refers to an inflammatory process that occurs in the liver and can be caused by viruses, toxic substances or immunological factors. This can include viruses (HBV, HCV ), Metabolic (Gilberts syndrome), Autoimmune (CMV, Mono) and drug induced, e.g. Alcohol. There are various viruses that are specific to particular species and Hepatitis C is a human only virus classified as a separate genus (hepacivirus) belonging within the flaviiviradae family that includes yellow fever and dengue fever. It infects the liver cells. Viruses can damage the body in two ways: 1. They may damage and destroy cells directly. This process is termed cytopathic. 2. Or the virus may provoke an immune system response which causes the host cell injury and death as well as causing systemic effects. This process is referred to as immunopathic. Current research indicates that the Hepatitis C virus is thought to be largely immunopathic, both in terms of liver cell injury and the effect it has on other body systems inducing immune disorders, although cytopathic mechanisms of liver injury cannot be excluded.
The Liver This vital organ is essential for good health of the body; it has a number of functions which include: • Manufacturing bile (these are utilized to break down fats in the digestive system). • Storing glucose and controlling the amount of glucose in the blood. • Manufacturing proteins, and blood clotting factors e.g. fibrinogen. • Removal of toxins, drugs, hormones, etc from our blood stream. If there are insufficient liver cells to maintain effective liver function, there will be a deterioration of essential body systems.
Hepatitis Infection Rates From evidence available to date this would suggest that if 100 people were infected with Hepatitis C virus the outcome would be as follows: • About 15 to 35 people would clear the virus spontaneously within two to six months of infection, and will neither develop a chronic infection nor risk devel-
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could avoid this happening again. The incident was simply something that we never though could occur as we are a veterinary clinic not a medical centre.
Risk factors: • people who share needles • health workers who are exposed to infected blood
Review of Practice At the clinic we reviewed our procedures when taking blood samples. • We now insist when blood sampling animals, the owner can either wait in the consult room while the veterinarian takes their pet through to another room or they can leave the animal with us and call back later for collection. • Cover any cuts or abrasions with a waterproof dressing. • Wear protective clothing e.g gloves when handling samples. Don’t forget about the zoonotic diseases. • Be careful when handling sharps. • Ensure tetanus vaccinations are current and consider vaccinating against Hepatitis B.
Possible symptoms: • pain in the upper right quadrant of abdomen • nausea and vomiting • loss of appetite • jaundice • itching
• •
•
•
oping advanced liver disease. They can, however, be re-infected with hepatitis C if they are re-exposed. About 65 to 85 people will develop chronic hepatitis C infection. About 5 to 10 people with chronic hepatitis c infection will progress to cirrhosis after 20 years of infection (rising to 40 people after 40 years of infection). Among the factors associated with an increased risk of cirrhosis are alcohol consumption, HIV or hepatitis B coinfections, older age at time of infection, and being male. About 3 to 5 people with hepatitis C-related cirrhosis will be at risk of liver failure or hepatocellular carcinoma after 30-40 years of infection. Among people with cirrhosis the risk of liver cancer is 1-4% per year. The majority of people with chronic hepatitis C infection will probably not progress to advanced liver disease but their quality of life may be diminished.
Blood Samples Upon my arrival at the medical centre I was quickly escorted off to a consult room with a nurse. She asked several questions regarding how the incident had occurred, time and type of exposure. The nurse explained a blood sample would be required today to provide information on my levels of Hepatitis B Antibody, Hepatitis C Antibody and HIV Human Immunodeficiency Virus Antibody. This test would be repeated in 3, 6 and finally 12 months post exposure. If the antibody levels were to increase, particularly
Healthy
My Results I am pleased to report all of my blood samples were normal. My Hepatitis B Virus Antibody levels were ideal due to a previous vaccine I had two years earlier. There was no change in the Hepatitis C and HIV Antibodies. This was a huge relief as there were many months of uncertainty regarding my health.
Cirrhosis
This was a huge lesson for all of the staff at our clinic and I sincerely hope this doesn’t happen to any fellow veterinary staff elsewhere.
at the 6 month test then this could indicate a presence of the virus. The initial blood sample must be obtained within 24 hours of exposure to enable an accurate result. This information is forwarded to a District Health Board Infection Control Nurse who monitors test results and advises patients of impending blood tests. Following my consult I devoured a much needed strong cup of tea and gathered the strength to inform my fellow workmates about my situation. “No one will want to drink out of my cup anymore” I laughed as I explained as best I could without trying to think of the possible consequences that may be ahead for me. At the next staff meeting I explained to everyone what had happened and how we
One thing I may suggest is that we as veterinary nurses can’t be too complacent in our jobs. Always be on the lookout for potential hazards in your workplace and remember it’s up to you to look after your own health.
References www.hepc.org.nz/index.php.Category: HepatitisC www.hepfoundation.org.nz/hepatitisc WCDHB Clinical Nurse Specialist – Infection Control A note from the editor: I would like to thank the author of this article for sharing their experience with us. It must have been a very scary time in their life, waiting for the test results and is an important reminder to all of us that health and safety considerations are not always obvious. 17
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S u p e r i o r n u t r i t i o n f o r t h e l i f e l o n g h e a lt h o f y o u r p e t
Understanding Pet Food Labels PART 2 Nutrient excesses are just as harmful as nutrient deficiencies.
a cheap, palatability enhancer that can be excessive in poorer quality pet foods.
Feeding pets for their specific life-stage helps to avoid nutritional excess in their diet. A food formulated for growth will have excess calories for maintenance.
A highly digestible food means that more of the food that is ingested is actually being utlised by the body. This is the big difference between cheaper grocery type foods and “premium” foods. The pet needs less of a high quality, highly digestible food to meet their nutritional requirements. This has two significant benefits:
A good resource to help you know what nutrient levels are appropriate for different situations is to consult the Key Nutrition Factors (KNFs) in the textbook “Small Animal Clinical Nutrition” (SACN). This is published by the Mark Morris Institute. This text gives a range of recommended levels of nutrients in foods for specific conditions. Can a food contain too much protein? Good quality protein is essential for growth and for maintenance of body organs and metabolic functions. However once the protein/amino acid requirements are met, additional protein provides no additional benefits. SACN suggests that dog foods for adult maintenance should not exceed 30% dry matter (DM) protein and cat foods for adult maintenance should not exceed 45% DM protein. Is all fat bad? Fat is in fact essential. The fatty acids that fat provides are essential nutrients. Fat is very energy dense (about two and a half times the energy content of protein or carbohydrate). The problem is when the fat content is excessive for energy needs. This is when fat is stored and leads to obesity. Fat is a cheap way of making pet food highly palatable, just as it is for human food. A good quality pet food is not always the one the pet likes the best! What about salt? Sodium and chloride are essential nutrients. Excessive salt is harmful. This is especially important for older cats that may have underlying, sub-clinical kidney disease. SACN suggest 0.2 to 0.4% DM sodium or 0.5 to 1% DM salt for adult dogs as the recommended range. For adult cats the recommended range is 0.2 to 0.6% DM 18 sodium or 0.5 to 1.5% DM salt. Salt is also
NutrieNt digestibility
Lets try an example: Food A has 78% moisture. This means it contains 100-78= 22% DM Food B has 82% moisture. This means it contains 100-82= 18% DM Now you can use the DM percentage to calculate the nutrients on a DM basis.
• Less food eaten means the cost per day is reduced • There is less waste produced and this means less stool to pick up in the backyard or in the litter box. Digestibility becomes critical in certain situations. A working farm dog required to work at peak performance or an actively growing puppy cannot obtain the energy and nutrients they need for work and growth from a poor quality food. They simply can’t eat enough to satisfy their needs. You should be able to obtain information on digestibility of nutrients from the pet food manufacturers. If this information is not available it is difficult for you to know if the food is appropriate for specific requirements.
If Food A is 8% protein then the protein content on a DM basis is; 8%/22%=36% protein dm If Food A is 5% fat then the fat content on a DM basis is; 5%/22%= 23% fat dm
CompariNg NutrieNt levels OK so you have done your homework and you know what nutrient levels are appropriate for specific life-stages and conditions. Now you need to be able to look at a pet food label and see if it stacks up! This becomes a problem as different types of food contain different amounts of moisture (water). You first need to look at the Guaranteed or Typical Analysis statement. Remember this is the percentage of the nutrient on an ‘as fed’ basis. To compare foods with different moisture contents you need to convert the ‘as fed’ basis to a dry matter (DM) basis. All you need is a little time and a calculator.
If Food B is also 8% protein then the protein content of a DM basis is; 8%/18%= 44% protein dm If Food B is 3% fat then the fat content on a DM basis is; 3%/18%= 16.6% fat dm
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Can you imagine a pet owner in a supermarket isle trying to compare two cans of dog food, each with 8% protein in the Guaranteed analysis? It is a big ask for the person to be able to compare foods. This is a powerful reason for you to give a specific nutritional recommendation using a brand you know and trust. Most canned food are about 80% (6087%) moisture. Most dry pet food are about 10% (3-11%) moisture. Now let’s use our knowledge to compare a canned and a dry pet food for nutrient content on a DM basis. A pet owner has been told that she needs to feed a low fat diet. She is trying to compare a canned and dry food. Which food has the lowest fat content? The canned food has 7% protein and 4% fat and is 80% moisture on an ‘as fed’ basis. The dry food has 22% protein and 15% fat and is 10% moisture on an ‘as fed’ basis. First; what is the DM% of both foods so that we can compare the nutrient levels. The canned food has 100-80=20% DM The dry food has 100-10=90% DM The fat content on a DM basis of the canned food is 4%/20%= 20% fat DM The fat content on a DM basis of the dry food is 15%/90%=16.7% fat DM. So the dry food has a lower fat content than the moist food. This is not obvious from the Guaranteed analysis on an as fed basis.
priCe versus value of pet foods Many people think that pet foods from the supermarket are cheaper than those that can be purchased from vets. Pet owners look at the cost of a bag or a can of food.
They need your help to realize that it is not the price per kg of the food that is most important, it is the price to feed the pet per day that will determine the cost of feeding. You have excellent tools available such as “cost per day calculators” to help you work out this essential information for owners. Have these charts at the ready or even better, have the spreadsheets on the desktop of your reception computer so that you can quickly calculate the cost per day once you have the pet’s ideal weight, and know their energy requirements.
Remember foods may be cheaper to buy per kg but increased amounts may need to be fed to provide the correct calories if: • Poorer quality ingredients are used (these cost less) • The food is less digestible and therefore not as much can be used by the pet Work out cost per day for the specific food you will recommend for an adult cat of average weight. Compare this to something the owner will easily understand - such as the price of a newspaper or a cup of coffee. Your client’s will be amazed at how cost effective high quality pet food can be.
palatability Just because a food tastes good does not mean it is good for you! The palatability of a food does not relate to a food’s nutritional value. However of course a food must be palatable to be a useful source of nutrition. Pets generally eat to meet their energy requirements. Some high energy dense foods require only a very small amount to be fed to satisfy the pet. Some pets will eat above their needs if fed “ad lib” such as always keeping the bowl full of dry food. This will lead to obesity. Palatability is a big issue for pet owners. Many pet owners associate feeding of their pets with showing love. This makes it very hard when a therapeutic food is prescribed and the owner reports back to you, the vet nurse, that the pet is not eating the new food. What do you do?
• Reinforce that the vet has prescribed the food to help the pet’s health issue or quality of life. Encourage the owner to understand that the food is like a medication and it is worth persisting to help the pet in the long run. • Reinforce the need to slowly introduce a new food. This is particularly important for cats and critical for ill cats. Ill cats in particular must not be starved so the old food should generally be fed side by side or mixed with the new food. It can take months for cats to accept change!
• Encourage the owner to spend time with their pet, especially if ill. Hand feeding can help. • Some pet’s like the food slightly warmed. A low salt soup stock can flavour the food. Dogs generally like sugary foods and cats like acidic food. If the food has been through an AFFCO food trial then you can be confident that it IS palatable. The individual pet may just need more time to adjust. Premium pet foods are usually subject to palatability testing before they are distributed. However if you are confident that the client has tried everything and the pet is not cooperating, try a different flavour and if that is not available, a different brand. Note that it is vital to check with your vet before making any brand substitutions for therapeutic foods. Just as you would not change a pet’s medication without consulting the vet responsible for the case, you should not change a therapeutic diet. The different brands can be quite varied in the way they approach therapeutic nutrition. Some diet’s may not be appropriate for the unique combination of problems that an individual pet is suffering from.
summary What makes a pet food truly ‘premium’ • AFFCO feed trial tested • Complete and balanced with controlled nutrients • Fixed formulation • High quality ingredients • Highly digestible • Life-staged avoiding nutrient excesses • Based on scientific evidence • 100% Guarantee
Nutrition is therapy Make a specific nutritional recommendation: every pet/ every time
for more information on precisely balanced nutrition for your clients’ special needs call the hill’s Vet Consultation Service on 0800 344 557 or visit www.hillspet.co.nz
Vets’ No.1 Choice to Feed Their Own Pets™ ®/™ Trademarks owned by Hill’s Pet Nutrition, Inc. ©2011 Hill’s Pet Nutrition, Inc.
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NZVNA
Conference Report When Vetlearn approached the NZVNA council about holding our annual conference, at the same time as the NZVA and their Special Interest Branches (SIB’s), we thought this was a fantastic opportunity. The proposal that was put forward for this year’s conference was completely different to how the NZVA/NZVNA conferences have been held in the past. Not only are we celebrating 250 years of the Veterinary profession but with input from all of the SIB’s we were going to be holding a multi-stream mega conference.
by Amy Ross DVN
After the NZVNA council chose the speakers and topics, that we felt would be beneficial for New Zealand’s veterinary
nurses, Julie Hutt and Fiona Hastie took these to the first of many meetings, that had representatives from all of the other SIB’s to organise the speaker schedule. The proposed SIB speaker lists were put forward to the representatives, and it was determined which speakers would be beneficial to more than one stream, and from here the speaker schedule was formed. This year’s conference was originally going to be held in Christchurch, but after February’s earthquake our venue was in the Red Zone, and so Vetlearn were required to quickly find a new location, they were able to secure the newly refurbished Claudelands, Hamilton. Because of the change of venue, two of our speakers had to pull out, and we were lucky enough to have Simon Goodall from Dog Guru Ltd and Dawn Seddon from Gibbles, Hamilton fill those places for us. This year early bird registrations were offered to conference delegates, this meant a $150.00 dollar discount for veterinary nurses that registered before the dead-line, and it was pleasing to see that many of you did take advantage of this. On Wednesday the 22nd June the first day of the veterinary nurses program started, and the topics chosen for this day catered for veterinary nurses and rural animal technicians working in mixed and large animal practices. Because of the multi stream aspect to the conference, it meant that those whose interests lie elsewhere were able to attend lectures held by the Special Interest Branches (SIB’s) of the NZVA. After listening to a fascinating talk on the use of Hyperbaric Oxygen, I and the other members of the NZVNA council were lucky enough to meet Jo Hatcher, the president of the Veterinary Nurse council of Australia (VNCA), and Gill Montgomery, their immediate past president and we talked about how we can work together for the benefit of both associations. Thanks to the ongoing support of Hills Pet Nutrition, Provet, SVS, Bayer, Virbac, Merial, REM Systems, Norbrook, Ethical Agents and Pfizer we were able to hold our Veterinary Nurses Awards Dinner that evening. Delegates arriving for the NZVNA dinner
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After a welcome to both New Zealand veterinary nurses and veterinary nurses from Australia, Jan Bedford and Jonathon White the country manager for Hills Pet Nutrition New Zealand, presented the Hills Buddy Award to Donna Stevens a student from SIT, who showed great aptitude on the use of Hills nutrition and the nursing care involved for her patient. Julie Hutt then presented Sharyn Aiyappan with the Angela Payne award for the best journal article by an NZVNA member for 2010. If you have not yet read Sharon’s article, it is entitled Post operative monitoring – accountability in the workplace, and it appeared in the December 2010, issue 56, of the NZVNA journal and is now available to members on SciQuest. Julie also announced the winner of the Norbrook student award, Sara Angelo who was unable to attend the conference due to illness. I hope you are feeling better Sara. Above: Left to right, Gill Montgomery and Jo Hatcher from the VNCA Right: Jonathan White from Hills Pet Nutrition NZ and Donna Stevens 21
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I have to admit that I probably did a little too much talking at the dinner as the next day I had no voice and it did take another five days for it to come back completely. This year, the NZVNA held a silent auction at our dinner to raise money for the Companion Animal Health Foundation (CAHF). CAHF funds research that is undertaken by both veterinarians and veterinary nurses to help improve the care of companion animals. Throughout the evening delegates at the dinner, were invited to place bids on items that had mainly been donated by NZVNA members. Items to bid on included textbooks, a signed copy of Shaun Quincy’s biography, stained glass artwork, paintings on canvas and jewellery. A big thank you goes to the veterinary nurses that supplied the items for the auction, and those that bid at the auction as we raised an impressive $642 for CAHF. Thursday bought another day of great lectures, including seminars held by our keynote speaker, Sue Crampton. We also heard from Nick Twyford on the changes to the ACVM and the use of Veterinary operating instructions. The conference proceedings from Dr Twyford’s talk have been reprinted with permission from the Proceedings of the Annual Conference of the NZVNA, in this copy of the journal and I strongly encourage you to read them to see how these changes affect you! On Thursday afternoon we had the NZVNA’s AGM. Thank you to the few members that did stay for this, as this is where we have the opportunity to let you know what has been happening with your association throughout the year, as well as giving you the opportunity to raise issues that need to be discussed. Sarah O’Hagan stepped down from her three year term as President. One nomination was received and accepted for President and Vice President of the NZVNA. Julie Hutt accepted the position of President and Michelle Parkin accepted the position of Vice President. No other changes were made to positions within the council. The NZVNA award for excellence was presented to Lisa English, who unfortunately was unable to attend the AGM. Lisa has recently completed the qualification Veterinary technician specialist – small animal internal medicine and is the first New
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Zealand veterinary nurse to achieve this specialist qualification. SVS presented the Eilidh Trumper Memorial Scholarship Award to a shocked Jen Tooman from Whangamata Animal Hospital. Jen did not realize until her name was called that her boss had even nominated her, and she felt that all of us were worthy of being nominated and winning this award. That evening was the NZVA Gala Dinner and though I did not go myself, I heard the next day from a lot of veterinary nurses that did attend that it was a great night. On the Friday morning I attended a seminar held by Pru Galloway on Senior Cat Health, and it was great to hear Pru encourage other Veterinarians to take advantage of their nurses skills, and get them to perform tasks such as monitoring blood pressure. I then heard from the very knowledgeable Bridey White about the care of New Zealand natives and rehabilitation of seabirds. Bridey has a wealth of knowledge that she has gained by working at Napier’s Marine land and where she is currently based, the Wildlife ward at Massey University. It is great to see a fellow veterinary nurse share what they know with not only fellow nurses but Veterinarians as well.
Dawn Seddon then talked us through how to interpret blood results, and how not only species and age can affect results, but the breed of an animal can as well. For example, athletic dogs such as greyhounds have higher PCV, and this is why it is not only important to fill out the history of the case on your lab forms but also as many details as possible about your patient. Lara Angevine began her session by saying that while she talks in front of 150 students on any given day in her job as a lecturer, that she was a little nervous about speaking in front of us. But as soon as Lara began her talk on urinalysis and ear swabs, there was absolutely no sign of her nervousness. While working in the United States, Lara routinely performed in house lab work. And as well as explaining the importance of these procedures, she also explained how easy they are to perform and gave a few tips on how to complete them around the rest of your workload. This then promoted others in the room to give tips too, such as placing a slide on top of the coffee machine to dry – a nice warm spot to dry slides faster but also a reminder
Below: Nicki Cox from SVS and Jen Tooman
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Lab Wilson
Trish McIntosh
Bridey White
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that the slides need to be viewed under the microscope. Members from the NZVNA, Companion Animal Society and Veterinary Business Management Group, that did not have to rush off to catch flights home before the ash cloud put a stop to domestic flights. (International flights were already on hold, so our Aussie friends had to stay in NZ for a few more days), all came together for a merged seminar with Sue Crampton. Sue talked about how we could “Harness the Potential for the Future” and how we, as individuals, could take what we had learnt over the past three days back to our workplace and continue to make improvements in the care of our patients. As always, I came away from the conference with my head full of new information and ways that I can apply it in the workplace, so all in all I feel that it was a successful conference.
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The NZVNA council is now back at the drawing board to plan and organise not only next year’s conference, but also the Veterinary Nursing stream for the World Small Animal Veterinary Associations (WSAVA) conference in 2013.
Above: Donated items for the silent auction Below: Sue Crampton, our Keynote speaker
We would like to thank the following companies for their on-going support of the NZVNA
ETHICAL AGENT S LT D VETERINARY MARKETING
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Post-operative Pain Relief A veterinary nurse’s perspective
Pain is the most horrible sensation! When it is persistent it can prolong hospital stays, increase the potential for secondary illness, and can cause inappetance and immune suppression.
Natalie Bain Veterinary Nurse Veterinary Specialist Orthopaedic Services (VetSOS), Hamilton, New Zealand
Introduction: Patient assessment is probably the most important daily duty for any veterinary nurse. Pre-anaesthetic assessment and monitoring of the patient during anaesthesia is often our sole responsibility. However, an area of nursing which is often over-looked is the meticulous and accurate assessment of the patient for pain in the post-operative period. This is often because the animal has been moved back to its cage and out of our direct supervision however, it can also be due to the difficulties in accurately assessing pain in some animals. The purpose of this article is to revisit the assessment of post-operative pain in our small animal patients and to discuss some of the analgesics we regularly use at VetSOS. I would urge you all to give more thought and attention to this area of nursing. After all, owners expect us as veterinary nurses to give the utmost of care and compassion to their pets during their stay and this includes ensuring that they are kept pain-free to the best of our ability at all times. Pain is the most horrible sensation! When it is persistent it can prolong hospital stays, increase the potential for secondary illness, and can cause inappetance and immune suppression. So, the ultimate goal is the prevention of pain altogether. To
do this we must anticipate the amount of pain the patient will be in post-operatively and treat with an analgesic appropriate for the level of pain that we perceive would be associated with that particular procedure. Remember that each animal is an individual and will subsequently react to pain and stimulus individually. Many will effectively disguise their pain so we should treat to the level of pain anticipated regardless of whether we think the animal is in pain or not. Table 1 can be used as a guide to determine the amount of pain an animal might be expected to be in following some common surgical procedures or conditions. Ask yourself, “is this procedure likely to result in mild, moderate or severe pain?”
Pain Assessment: When assessing animals for pain, there are many parameters to consider. Physiologic parameters such as: heart rate, respiration rate and temperature are basic guidelines. An increased TPR (temperature, pulse and respiration) is often associated with pain. General behaviour patterns are also important. Is your patient eating, sleeping, dreaming, purring (cat), and wagging its tail (dog)? Is there any unusual behaviour relating to the painful area e.g. lameness, guarding the limb, reluctance to sit/lay on that side etc? Table 2 outlines behavioural characteristics consistent with varying levels of pain in cats and dogs. This scale is not exhaustive but is a useful starting point. Be aware that some of these signs may be present in anxious or excited patients. Many cats and geriatric animals tend to withdraw and remain quiet through a wide range of painful experiences. Something I find useful in helping me to remember an appropriate strategy for identifying and treating pain in patients under my care is the five “R”s of post-operative care.
Table 1: Anticipated levels of pain associated with surgical procedures/conditions
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Severe
Moderate to Severe
Moderate to Mild
Neuropathic pain such as spinal injuries, disc herniation and nerve inflammation. Multiple fractures. Bone cancer.
Osteoarthritis. Single fracture repairs. Soft tissue injuries. Thoracotomies. Diaphragmatic hernias. Total ear canal ablations.
Skin mass removals. Urethral obstruction. Castration. Dental procedures. Ovario-hysterectomy.
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Table 2: Pain Assessment Scale Scale
Pain Level
Signs
0
No pain
Patient is normal, happy, eating, sleeping, dreaming. Heart rate None is normal and patient is interactive with caregiver.
1
Probably no pain
Patient appears normal but condition may not be as clear cut as above. Heart rate may be elevated.
None
2
Mild Discomfort
Patient will still eat and sleep but may not dream. May resist palpation of the surgical site but otherwise show no signs of discomfort. There may be a slight increase in respiration rate and heart rate.
Reassess within an hour then administer pain relief if condition appears worse.
3
Mild Pain or Discomfort
Patient will limp or guard surgical site. Looks a little depressed and uncomfortable. Trembles or shakes. Appears to be interested in food but picky. RR and HR increased.
Administer analgesia
4
Mild to Moderate Pain
Patient will resist touching of the surgical site or injured area. May look or chew at painful area. The patient may sit or lie in an abnormal position and is not curled up or relaxed. May tremble or shake and not interested in food.
Administer analgesia
5
Moderate Pain
Condition progressing from above or patient reluctant to move. Administer analgesia Depressed, inappetant and may attempt to bite when the caregiver approaches the painful area or attempts to move the patient. Trembling, shaking and vocalizing.
6
Increased Moderate Pain
Similar to previous category but patient may vocalize or whine frequently without provocation or when attempting to move. Heart rate may be increased or within normal limits if an opioid was administered previously. Pupils may be dilated.
The Five “R”s: Rest: Observe the patient at rest. Are there any behavioural signs of pain? Rate:
What is the patient’s heart rate and respiration rate?
Reaction: How does the patient react to palpation of the affected site? Rx:
What treatment is required (choice of analgesia) for the pain perceived?
Review: Assess your patient every 15 minutes after analgesia administration by repeating the initial three R’s. Is additional treatment required? Are there any adverse side effects?
Suggested Analgesics for Post-Operative Pain Relief The following is a brief summary of the analgesics we use commonly in our practice. 1. Opioids: Pure agonist opioid analgesics such as morphine, fentanyl and tramadol are the most effective drugs for controlling moderate to severe pain pre-operatively, during and post-operatively. Opioids exert their effectiveness via opiate receptors located in
Treatment
the central nervous system in the dorsal horn of the spinal cord and the brain where impulses from the periphery are modulated. Opiate receptors are also found in peripheral tissues such as the synovial membrane of joints. Opioid administration is preferred immediately after or even before any surgical procedure due to its analgesic and sedative effects. This latter effect ensures a smooth recovery post anaesthetic. Buprenorphine (Temgesic®) is a partial agonist, meaning that it does not induce the same degree of effect as a pure agonist such as morphine. Therefore it is useful for treating only mild to moderate pain. It is often the drug of choice in general practice because of its potentially longer duration of action (8 to 12 hours), although it is not necessarily the best form of pain relief and in practice its duration of effect rarely exceeds 6 hours. It is important to note that Temgesic® will displace a pure agonist from the opiate (mu) receptors, further reducing the effect of the agonist. Also Temgesic® binds to the receptors so well, that when a pure agonist such as morphine is administered, its action is blocked. Temgesic® also has a ceiling effect meaning that if doses are increased in
Requires increased analgesia
an attempt to improve pain relief, the analgesic effect will reach a maximum and then further increasing the dose will result in a reduced analgesic effect. As with any analgesia, opioids have side effects. These include bradycardia, vomiting, physical dependence (if used for prolonged periods) and respiratory depression. 2. Epidural Analgesia: Epidural analgesia is very useful in controlling pain during and after surgical procedures such as hind limb surgery and pelvic fractures. The most commonly used drugs we use are a mixture of morphine and a local anaesthetic (bupivacaine; Marcain®). Morphine acts on the spinal cord by crossing the dura and binding to the opiate receptors in the dorsal horn of the spinal cord segments. Local anaesthetics act at the epidural level by blocking nerve impulse conduction in the nerve roots of the spinal cord segments. The analgesic effect typically lasts for 12 to 24 hours, which means a very long period of complete postoperative pain relief. Contraindications for epidural analgesia are septicaemia, coagulation disorders, hypovolemic shock, skin infections at the puncture site, meningitis and trauma to the spinal cord. 27
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3. Local Anaesthetics Blocks: Anaesthetics such as lidocaine, bupivacaine and mepivacaine are used for specific nerve blocks, local infiltration, regional blocks, and brachial plexus blocks. We tend to use bupivacaine (Marcain®) as it has the longest duration of action but it has a slower onset therefore it is usually given intra-operatively rather than post-operatively. The most common form of local block we use is in (any) joint surgery where a mixture of bupivacaine and morphine is injected into the joint prior to closure. By injecting local anaesthetic combined with an opioid such as morphine intra-operatively, excellent analgesia is provided both during and post surgery. Toxic side effects can include cardiovascular compression, bradycardia and salivation 4. Transdermal Patches: Transdermal administration is a method of delivering a drug such as fentanyl (Durogesic®) from a patch applied to the skin through an intact cutaneous surface to the systemic circulation. The drug is administered in a slow continuous manner, providing constant pain relief. Transdermal fentanyl patches can produce high levels of analgesia and are an excellent delivery system for continuous administration in cats and small dogs for up to 3 to 4 days. There is a long lagperiod following application and reaching therapeutic drug concentrations, with cats taking 6 - 12 hours and dogs 12 - 24 hours, and therefore additional analgesia is needed until the patch becomes effective. Fentanyl patches are available in different concentrations e.g. 25, 50, 75 and 100ug/hour and care must be used to select the most appropriate dose for the weight of the animal as overdose can occur (FIGURE 1). The hair must be clipped (usually over the thorax) prior to application and the skin is cleaned with water (NOT soap or detergents) and allowed to dry. The patch is applied and held firmly against the skin for about 2 minutes. We then spray the surrounding area with an adhesive spray and apply a Hypafix dressing. The Durogesic® concentration, date, and time of application are recorded on the Hypafix dressing. 5. Constant Rate Infusion (CRI): CRI is a precisely calculated amount of drug which is added to a specific volume and type of fluid. The mixture is then delivered as a continuous intravenous infusion. The efficacy of constant rate infusion drugs is
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increased through maintenance of steadystate concentrations of the drug. Calculations must be exact to avoid overdose. We use CRIs to treat very severe acute pain immediately until other forms of analgesia become effective e.g. the first day following severe road trauma. 6. Non-steroidal Anti-inflammatories (NSAIDs): NSAIDS such as meloxicam (Metacam®) and carprofen (Rimadyl®) are the two most commonly used oral analgesic drugs we use in our practice. NSAIDs alleviate pain and inflammation and are indicated for controlling post-operative pain and for treating acute and chronic musculoskeletal disorders. They provide pain relief by inhibiting the production of prostaglandins, which sensitize pain receptors at the surgical/painful site. NSAIDs may also act centrally on spinal pain pathways as well. NSAIDs can be used alone for the management of mild to moderate post-operative pain however we frequently combine their use with drugs such as opioids (e.g. tramadol, Temgesic® or fentanyl) for additive analgesic effects. The NSAIDs such as the ones listed above are generally very safe however all NSAIDs have the potential of toxic effects such as gastrointestinal irritation and renal damage among others. Therefore prudent clinical judgement must be utilised in their use and this is based on physical examination findings, hydration status, consideration of concurrent drug therapy and pre-existing diseases. In middle-aged and older patients,
Cat showing signs typical of fentanyl overdose or traumatised animals, we regularly perform a full urine and blood analysis to help identify animals with blood anomalies, renal or liver disease, which may mean the use of NSAIDs is contraindicated. To help prevent renal complications during anaesthesia, we monitor blood pressure and maintain IV fluids to ensure there is a good blood supply to the kidneys. In our practice, where surgical procedures and general anaesthesia can be quite prolonged, NSAIDs are generally only administered after the animal has fully recovered from anaesthesia. Gastrointestinal adverse effects from NSAIDs might include vomiting, diarrhoea, darkened stools (melaena), inappetance or anorexia and abdominal tensing. 7. Non-drug treatments for pain (for nurses!). Bandaging can be a very effective way of reducing pain. A Robert Jones bandage, for example, can be used to reduce pain by reducing or preventing limb swelling or immobilizing a painfully unstable fracture. Ice treatment (or cryotherapy) is something we use regularly in our clinic to reduce pain, swelling and inflammation. A cold compress is often applied to the surgical site during the anaesthetic recovery. We use a 10min ON, 10 min OFF, 10 min ON treatment cycle and this is repeated twice or three times a day for the first 48 to 72 hours post-operatively.
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Table 3: Drug Dosing Chart Drug
Dose (dog)
Dose (cat)
Duration
Notes
Morphine Morphine Morphine
0.5-1.0mg/kg 0.1mg/kg 0.1mg/kg
0.5mg/kg 0.1mg/kg 0.1mg/kg
3 - 5 hours
IM or IV analgesic dose Epidural dose Intra-articular dose
Temgesic® (buprenorphine)
0.01-0.02mg/kg
0.01-0.02mg/kg
6 - 8 hours
Same dose may be given orally in cats
Tramal® (tramadol)
2-4mg/kg
2-4mg/kg
6 - 12 hours - pain dependant
Injectable or tablet form
Metacam® Injectable 5mg/ml
Loading dose 0.2mg/kg Maintenance 0.1mg/kg
Loading dose 0.1mg/kg Maintenance 0.05mg/kg
24 hours
Metacam® Oral (meloxicam)
0.1mg/kg
0.05mg/kg
24 hours
Rimadyl Injectable (carprofen)
4mg/kg
1-2mg/kg
12-18 hours
®
Rimadyl Tablets (carprofen)
4mg/kg
12 hours
Not licensed for use in cats
Marcain® 5mg/ml 5% (bupivacaine)
0.22ml/kg
0.22ml/kg
12-24 hours
Epidural dose
Marcain (bupivicanine)
2mg/kg
2mg/kg
4-6 hours
Intra-articular dose
Durogesic (fentanyl)
2-5mg/kg
2-5mg/kg
72 hours duration
6-12 hours to become effective in cats and 12-24 hours in dogs
®
®
®
Case Study 1 Name: George Species: Cat: Age: 1 year Weight: 4kg History: George presented to VetSOS with a history of being hit by a motor vehicle two days earlier. George had been hospitalised at the referring veterinary clinic where a full clinical assessment had been performed including radiographs which revealed a fractured pelvis. George was treated symptomatically with NSAIDs until referral to our clinic. Assessment: Examination revealed he had a heart rate of 200 bpm and his respiration rate was increased. His pelvic area was bruised and swollen and any palpation of the area was strongly resented. Pain assessment =6. Radiographs revealed a left sacro-iliac subluxation, a right caudal ilial fracture, and a right acetabular fracture. Pre Anaesthesia: Pre-anaesthetic bloods and a full urinalysis revealed no significant abnormalities other than a raised CK. A 25ug/hr fentanyl patch was applied to a clipped area Cold compress from vaccine packing used for 10min on, 10 min off, 10min on again ice packing protocol post-surgery 29
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of George’s chest wall. A constant rate infusion of a combination of morphine (0.1mg/ kg/hr) and ketamine (0.2mg/kg/hr) was administered via an IV fluid bag of Hartmans 1000ml initially to control pain whilst we waited for the fentanyl patch to become effective. The next day, George was first on our list. A pre-medication of acepromazine (ACP)/morphine was given 40 minutes prior to induction. Anaesthesia: An induction agent of a mixture of ketamine and diazepam was administered and George was maintained throughout surgery on isofluorane and oxygen. IV Cefazolin was given at induction and IV fluids were maintained throughout the procedure at a surgical rate of 10ml/ kg/hr. Pulse oximetry, capnography and blood pressure was monitored throughout the anaesthesia. Blood pressure monitoring and fluid therapy was considered essential as George had had NSAIDs administered prior to arrival at our clinic. Post Surgery: Metacam® was administered by injection on recovery (0.1mg/kg). Metacam oral (for cats) was dispensed for
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five consecutive days and treatment began on day 2 after surgery (0.05 mg/kg). On examination the day after surgery, George was comfortable and stable. He was discharged into his owners care with instructions of strict cage rest for six weeks. George made an uneventful recovery.
Case Study 2 Name: Jake Species: Dog Age: 4 years Weight: 27kg History: Jake was referred to our clinic following a history of being run over by a motor vehicle. Assessment: Examination revealed a bright and alert dog. Cardinal signs were within normal limits. He had a very swollen and painful left shoulder. Pain assessment = 5. Radiographs were taken and these revealed a comminuted articular fracture of the left scapula. Pre Anaesthesia: Pre anaesthetic bloods and a full urinalysis revealed no significant abnormalities. A Pre-medication of ACP/
Morphine was given 40 minutes prior to induction. Anaesthesia: An induction agent of Thiopentone (1ml/10kg) then Diazepam (0.8ml/10kg) was administered. Jake was maintained throughout surgery on isofluorane and oxygen. IV Cefazolin was given at induction and IV fluids were maintained throughout the procedure at a surgical rate of 10ml/kg/hr. Blood pressure, pulse oximetry and capnography were monitored throughout. Intra-operative: Intra-articular morphine (0.1mg/kg) and marcain (2mg/kg) mixture was administered prior to soft tissue closure. Post Surgery: Metacam® (0.2 mg/kg) was administered by injection on recovery. Metacam® oral tablets (0.1 mg/kg SID for 14 days) and tramadol (Tramal®, 4mg/kg BID for 5 days) was dispensed.
Jake on presentation at our clinic. Note the swollen left shoulder and reluctance to weight bear
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Jake was discharged the following day with instructions for strict cage rest for six weeks. He made an uneventful recovery.
Left: Lateral radiograph of Jake’s fractured scapula pre-surgery
Conclusion: So what do we know, and what are important points to consider?
Right: Post-operative radiograph of Jake’s shoulder
• Be familiar with the various analgesic drugs, dosages and treatment intervals. • Take time to observe behaviours that could be associated with pain. • Assess and record pain regularly - every 15 minutes post surgery. • Establish protocols for establishing and treating pain in your practice. • Titrate doses of analgesic drugs until the pain is relieved, become familiar with appropriate doses for different painful states. • Don’t be afraid to use more than one approach to alleviate pain. • Individualise treatment. • Look for potential adverse effects. • Establish protocols for monitoring and treating adverse effects in your practice.
mine appropriate analgesics and dosages for perceived and apparent pain. Remember (and use) the five “R”s of post-operative care. Monitor individual patients actively and alert your vet to any signs of pain and adverse effects. Be the best nurse that you can be and remember a veterinary clinic is not a veterinary clinic without us nurses!
Centre: Intra-operative view of Jake’s shoulder showing the articular fracture line following reduction and fixation
References: Hardie, E.M. Kyles, A.E. Pain management in the small animal patient. In: Current Techniques in Small Animal Surgery,
Fourth Edition. Ed Bojrab, M.J. Williams and Wilkins, Baltimore, USA 1998, pp 3-18. Kaestner, S. Perioperative analgesia. In: Feline Orthopaedic Surgery and Musculoskeletal Disease. Eds Montavon, Voss, Langley-Hobbs, W B Saunders Co. 2009, pp 199-205. Mathews, K., A. Pain assessment and general approach to management. In: The Veterinary Clinics of North America, W.B.Saunders Co. July 2000, pp729-55.
Perhaps the next time a severely traumatised and injured patient presents at your practice requiring surgery, you could assess your analgesia regime with your veterinarian. Consider a constant rate infusion (CRI) initially and the use of a fentanyl patch. Use an opioid such as morphine in the pre-medication. Is an epidural or local anaesthetic block appropriate? Consider the combined use of an opioid and a NSAID post-operatively.
Top: The opioid drugs used at VetSOS
Have a copy of the above Pain Assessment Scale in your clinic to refer to. Be proactive. Refer to the Drug Dose Chart to deter-
Below: The NSAIDs drugs used at VetSOS 31
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Dark Horse, Dark Night
A curious equine nursing case-study
The early autumn day dawned fine but chilly. It took a few hours to warm up, but by about 10:30am I was out in the paddock with my three big, brown geldings, taking their off covers and hanging them over the fence. The three boys all vied for some attention. All was well as I scratched their itches, rubbed soft muzzles and fondled long ears. It was a busy day for me, and not until lateafternoon did I find some time to get in an enjoyably long ride with my daughter and her pony, fulfilling a promise to us both that I’d made earlier in the day. Once we were done, I had a horse to clip, several others to feed and suddenly the day was almost gone. It was 7:00pm before I took my horse back to his paddock and called the others over to have their covers back on, feeling relieved daylight savings hadn’t yet ended. Beans, the boss of the paddock, was at the gate, demanding to know why it wasn’t his turn to be ridden. Samson was smug and needed his face rubbed after his ride, but curiously, Pye was in the far back corner of the paddock, seemingly asleep on his feet. Sighing, I shouldered his heavy cover and trudged over to see him.
by Steph Mann NCEq (Com Coach), RAT, DipVN
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As I approached Pye in the paddock to put his cover on, I could see he was unwell. He lifted his head and responded to me when I called him, but was unwilling to move. He had some epiphora (discharge / tearing of the eyes), and generally looked miserable, but nothing I could put my finger on. I covered him, and decided perhaps his cold was back. Back at the house, over the evening meal, I was uneasy about Pye. I decided to check on him, and then I could be sure if he could be left for the night, or if I needed to call the duty veterinarian to attend. I had been inside all of an hour, enough for the last of the daylight to leave.
The light of the motorbike revealed Pye hadn’t moved and was considerably worse. Under his cover he was lightly sweating and I wondered if he was pyretic (feverish). His head was down, and he was photosensitive, squinting and blinking in the light, but not moving away. He was not particularly responsive to me as I moved about him, cursing I hadn’t brought a stethoscope, thermometer or even a halter and lead-rope with me. I pressed my ear to Pye’s abdomen laterally, listening for gut sounds. An absence of gut sounds can indicate colic. I couldn’t hear much, but without a stethoscope I couldn’t really be sure. It was time to call the veterinarian. At 8:30pm I’m haltering Pye in the headlights of the ute for Richard, the duty veterinarian to examine. Clinical Examination – Pye – 8:30pm Heart Rate: Increased at 64 bpm Respiration Rate: Not taken Temperature: Low at 35.6oC MM: Injected with a toxic line evident CRT: Approximately 1 second Conjunctivae: ++ Injected Gut Sounds: Very little audible Under his cover, Pye’s diaphoresis (profuse sweating) was now evident, although both the sweat and the horse were cold to the touch, and his body temperature hypothermic. Other than the sweating, Pye is not showing any classic signs that might indicate abdominal pain. Consequently colic is ruled out almost immediately. Clinical signs of colic in horses Signs of colic in horses vary according to the underlying cause, and therefore pain experienced. It is important to spend time observing the horse in a suspected case of colic. Clinical signs include: Inappetence, facial grimacing, scraping with front leg (NB more violent ‘pawing” with the front leg can indicate marked gastric distension), flank watching / kicking at abdomen, posturing to lie down, lateral or dorsal recumbancy (tends to be an attempt to relieve tension on the mesentry), constantly going down, rolling, getting up, pacing etc., (often associated with sweating) and violent thrashing (usually associated with profuse sweating). (Phillips, 2009)
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Introduction of the case study subject: PYE, a 16hh, 6 year old dark brown Thoroughbred gelding Work status: currently being spelled (ie not in work). Vaccination status: unknown. Worming status: up-to-date. Previous History: 1. Owned by me for past 14 months. 2. Just prior to being bought by me, Pye was tied up under a wooden awning at a stable. Another horse kicked out at him and he reared up to avoid it. In doing so, Pye suffered a trauma caudally to the nasal bone, just rostal to the nasal / orbital junction. This injury created a large bony process, which was treated with Equissage. (Equissage is Cycloid Vibration Therapy [CVT] which stimulates blood circulation, assists with lymphatic drainage, relaxes muscles and helps with increased joint mobility). No radiographs were taken of the skull and no veterinary treatments, pain relief or attention were sought or administered at the time of the injury.
3. Just a week ago, I noted a small amount of bi-lateral nasal discharge that is seen in horses in the early stages of having a cold. I duly changed covers and the discharge seemed self-curative without signs of progression of the disease. Frontal
Orbit
Maxilla Nasal Premaxilla
Mandible
Image: http://www.pasofinohorsedirectory.com/Forum/comments.php?DiscussionID=771
Pye has a very stiff stance, resembling a sawhorse, and some muscles are quivering. He has a mouthful of unchewed grass, and seems to have forgotten that it is there. His teeth are clenched, and it is with some difficulty that the grass is removed. However, Pye relaxes his jaw once we take out the grass from his mouth. Initial thoughts: Laminitis; Tetanus; Toxic reaction to something ingested. Clinical signs of Laminitis: The most common presenting signs are: reluctance to move or increased time lying down. The horse will attempt to carry all its weight on its heels because this is less painful, resulting in the characteristic leaning back stance, and a hell-first foot-fall when walking. There will be marked digital pulse and heat in the feet. (Coumbe, 2001) Laminitis is discounted as there is no heat in the hooves, and the digital pulse is not evident. Although he is standing with a peculiar posture, it is not the classic stance of a horse with laminitis. Richard administered 11mls IV of Flunixin Meglumine (NSAID for systemic inflammatory diseases) (Davis, 2009) (CMP Medica, 2009); and 25 mls IV of Engemycin (Antibiotic for the treatment of septecaemia) (Davis, 2009) (CMP Medica, 2009)
After a few minutes, Pye unexpectedly becomes coherent and ‘flips out’ by straining against the lead rope and running backwards. We are forced to move the vehicles out of the way as the horse has gone from being completely immobile, to moving irrationally at speed. Suddenly he stops still and swings his head around to the right, holding it very still there, and mouthing in a foal-like manner. Are we seeing a neurological sign, or is this the stiffening of muscles because of toxins that are being released by the bacteria Clostridium tetani (Tetanus)? Clinical signs of Tetanus: Tetanus progresses rapidly once signs appear. Early signs are a stiff, slow gait, hyperaesthesia (extreme sensitivity) to sound and touch, spasm of the third eyelid if stimulated. Later signs are marked hyperaesthesia to sound and touch, anxious expression, sawhorse stance, dysphagia (difficulty swallowing), regurgitation. (Coumbe, 2001) Richard quickly administers 5mls IV of Xylazine 10% (a non-narcotic sedative, muscle relaxant and analgesic) (CMP Medica, 2009) and 0.2mls IV of Dormosedan (an analgesic / sedative) (CMP Medica, 2009) to prevent Pye from injuring himself if he has another explosive episode.
I remove Pye’s clammy, wet cover and replace it with a polar fleece rug, which will wick away the moisture and help keep Pye dry and therefore warmer. I send my husband for more rugs, and dispatch my daughter to the neighbours for the night. It’s not looking good. Blood samples are harvested into Ethylenediaminetetraacetic acid (EDTA, purple top) and serum (red top) Vacutainer ™ tubes. Once the EDTA tube is gently inverted to mix, both tubes are marked with client / patient details, time and date. They will be processed later. We examine Pye closely for signs of any wounds, especially puncture wounds that would support the Tetanus theory, but find only a slight graze to his forehead. After examining Pye again, Tetanus is discounted. Pye is not responding to loud sounds (we had to clap and shout a lot to try and get him to take just one step forward (before his unprovoked, explosive moment), and he doesn’t mind being handled or patted – quite the reverse, he is seeking my touch. There is no reaction to stimulation of the third eyelid. As there are no signs of obvious pain, colic and rhabdomyolysis are ruled out. Toxicity is considered. Pye’s gums are showing a clear toxic line, which is seen as a
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purple line around the teeth, similar to that shown below.
(Coonley & Kootnz Equine Hospital, 2011) There is also a strange, abnormal sweet smell on Pye’s breath. Is this some sort of septicaemia (an infection in which pathogens are circulating in the blood); an endo-toxaemia (toxins released into the blood by gram-negative bacteria) or an idiopathic (unknown source) toxicity? The paddock is scoured twice by torch and vehicle headlight for poisonous plants or other potentially hazardous objects. We live alongside a road, and unfortunately it’s not uncommon to find objects thrown in the paddock, but this time the paddock is clean. Richard calls Massey University Equine Clinic and Hospital, for suggestions – there is no way possible we can get Pye there, as he is barely able to stand and if he is unpredictable in the truck he could go down, suffer a serious injury, or even cause the truck to swerve and have an accident. The veterinarian on duty at Massey has nothing further to add that we haven’t already considered. Gastric stasis backs up the endotoxaemia theory, as does the toxic line. Could this be endotoxaemia caused by some gastro-intestinal condition, such as a perforated ulcer, or similar? Clinical signs of Endotoxaemia: The most common findings in horses presumed to be endotoxemic include abnormalities in mucous membrane colour, with one of the initial findings being a ‘toxic line’; prolongation of capillary refill time; increased heart and respiratory rates; reduced borborygmi (gut sounds); fever and hemoconcentration. Some horses may exhibit clinical signs of abdominal pain, whereas others will appear to be depressed. ( James Moore DVM, 2001) 34
The sedative administered to Pye is expected to have an effective time span of approximately 40 minutes (Pablo, 2009), and Pye has started to show some signs of being more aware and lucid. 45 minutes have passed since the sedatives were administered. There seems little overall change in his health. Just as we are considering our next move, Pye goes down. Again, he turns his head, but this time to the left side. Are we seeing a response to pain, some sort of spasm, or something neurological? Before we can answer this, he suddenly stretches out in full lateral recumbancy. I lay a cover under his neck and head to help prevent the ground chilling him further, and layer covers over him in an effort to warm him up. He is non-responsive to me as I work around him, manually lifting his head and laying out covers under him as best I can, and he seems barely conscious now. The veterinarian passes a nasal gastric tube, but Pye is showing signs of dysphagia (difficulty swallowing), making the task difficult. My muscles are aching from holding up the full weight of Pye’s head, when suddenly he swallows, and the tube passes down the oesophagus, sliding easily. No abnormalities are noted from the placement of the tube, other than that strange sweet smell. We remove the tube and I set it aside to clean it later. Richard dons an examination glove, and for safety’s sake I put a leg rope on Pye’s uppermost hind leg, around his pastern, but the horse is immobile and completely relaxed – so much so that I check his palpebral reflex to check that he is still conscious. Oddly there is no resistance to the rectal examination – the rectal sphincter and muscles are usually very strong in a horse. Normal anal tone is still present, however. A large amount of apparently normal, well formed faecal matter is raked out of Pye’s rectum, though this is not likely to be the cause of Pye’s illness. Using a lubricated 32-French rubber catheter introduced to the penis, a urine sample is collected. Visually it is unremarkable. I label it and set it aside, out of harm’s way. The catheter is removed and soaked in water, to be attended to later. Pye remains seemingly fast asleep and a clinical exam is repeated. A skin tent returns slower than normal turgor, but that’s not
unexpected, as he hasn’t been either grazing or drinking for some time now. The sweating has ceased, and he seems to have warmed slightly. Clinical Examination – Pye – 10:30pm Heart Rate: Increased at 60 bpm Respiration Rate: Not taken Temperature: Low at 36.1oC Heart Rate: Increased at 60 bpm Respiration Rate: Not taken Temperature: Low at 36.1oC MM: No change CRT: No change Conjunctivae: ++ Injected Gut Sounds: None audible Perhaps Pye has eaten something toxic that he is now recovering from. I pack some more covers under and around him and we head inside for coffee to warm up and regroup. The night is getting chilly. In our departing headlights Pye is lying very still and looks peaceful. At 11:00pm we head back out to the paddock, hoping to find Pye where we have left him. The plan then will be to leave him sleeping, and monitor in an hour, collecting vital signs and reporting back to Richard by phone. As we approach, Pye is still, and Richard toots the horn to see if there is any reaction in the horse that is lying so motionless. Pye raises his head. Still photophobic, he blinks and squints in the light and sits up to sternal recumbancy. Richard goes to check Pye’s heart rate, but before the 30 seconds are up, Pye stands up, unwilling to be examined quite so readily this time. Pye appears not as stiff, but is nowhere as coordinated as he was a few hours ago. He pulls back suddenly, reaches the end of the lead rope and lurches forward stumbling, nose first and almost pinning me against the vet’s ute, then lies still, in lateral recumbancy, gasping hoarsely in the headlights, with his mouth open from the effort. I comfort him, talking to him, rubbing his ears, and rearranging the covers back on him, while we wait for his heart rate to return to normal, noting his immobility and sleeping were masking his actual state, and his condition has not been improving at all, but is still in obvious decline.
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We decide to leave him to rest as planned, and recheck him in an hour, but as we start to leave he staggers to his feet, spilling covers to the ground. I climb back out of the ute and approach him warily to reaffix the covers, but his ‘flips out’ once more, running backwards and fighting the lead-rope. All three of us (large husband, veterinarian and I) strain against 500kgs of horse and manage to stop Pye from falling into or over the nearby fence. I insist Richard sedates Pye again before leaving. We consider meningitis, or some other neurological disease. Richard administers more drugs,15 ml IV of Kynoselen (muscle tonic and energy restorative properties) (Ethical Agents, 2010) and 10ml IV Dexol-5 (short-acting corticosteroid for neurological, meningitis, stress etc). (CMP Medica, 2009) Pye’s blood pressure seems to have dropped as we are having difficulty in finding a vein now for administration of the IV injections. He is also now showing signs of urinary incontinence, and urine flows and drips unchecked, but otherwise it appears normal. Feeling helpless we leave again, husband and I to worry at the house, and Richard to do some online research for an hour until he hears back from us. Its 12:35am and husband and I are back in the paddock checking on Pye by the headlights again. He hasn’t got up since we left him an hour ago, but he is definitely more awake, and seems restive and fidgety. Clinical Examination – Pye – 12:35am Heart Rate: Lower, but still high at 54 bpm Respiration Rate: Not taken Temperature: Increased, but still hypothermic at 36.4oC MM: No change CRT: No change Pye stumbles to his feet as I’m examining him and shortly afterwards flips out again, running backwards – very fast this time. He hits the post and batten fence at speed and for an instant starts to topple up and backwards over it – eerily in slow motion, but just in time my dear husband grabs the lead rope with me, and we manage to change his direction. Instead he crashes heavily to the ground at our feet, lying now up against the fence, where I finish collecting biological data.
With shaking hands and feeling both numb and slightly nauseous, I phone Richard and give him the news and the vitals. The only thing that Richard has found in the past hour online that possibly fits with Pye’s clinical findings is the dumb version of rabies, an exotic disease in New Zealand with a incubation of 9 days to 1 year. ( Judd, 2005) While rabies seems on the surface very unlikely, it is worth considering... the people I bought Pye from do travel – and compete – their sporthorses internationally, including countries that do have rabies, such as the US.
Far too soon its time to wake up and realize the traumatic night was real, not just a nightmare. Just after 8:00am Richard calls round mid way through my first cup of coffee to conduct a post mortem.
Clinical signs of Rabies – Dumb form: Clinical signs of dumb rabies in horses include depression, inability to eat, head tilt, circling, incoordination, blindness, paralysis and urinary incontinence. The only technique to diagnose rabies is testing of the brain after death. ( Judd, 2005)
Back down to the paddock, we start with Pye lying laterally on his right side by pulling him away from the fence with a suitable rope attached to the towbar, to allow full and unrestricted access to the body. Pye is lying in right lateral recumbancy.
We make the decision to euthanize Pye before he injures himself or one of us; and I sit in the headlights, holding Pye’s head and rubbing his ears while we wait for Richard’s return, whispering my good-byes. In short order Richard arrives, and administers 0.2ml IV Dormosedan (sedative), and then, after a brief pause, 60ml promptly by IV of Pentobarb 500 to sedate, then immediately the second half of the dose, a further 60ml IV to euthanize (the recommended dose rate being 10ml/50kg BW ) (Knottenbelt, 2006). We then monitor heart and respiratory rates and corneal reflex until clinical signs of life are extinguished and death has been confirmed. We stumble back to the house and try to sleep. It’s 2.30 before I close my eyes, sad and exhausted.
The dogs whine their indignation at being stuck into kennels – they are house dogs after all, and used to being close to my heels day and night! But they can stay in there for the day. I want there to be no chance at all of them lapping at blood that has been contaminated with Sodium Pentobarb, as this would cause more deaths.
The foreleg is incised under the scapula so it is attached just by a small amount of skin and connective tissue at the proximal tip of the shoulder, to allow abduction of the whole limb. Likewise, the hind-leg is cut away, including cutting into the hip joint, (where a sample of synovial joint fluid is collected). This allows Richard full access to the entire lateral side of the horse. A sample of deep muscle tissue was taken from the rump. An incision the length of Pye’s barrel is made approximately at the anteroposterior axis including cutting through the ribs, and adjoining incisions are made at each end dorsoventrally, creating a flap. This is folded towards the horse’s belly so a gross GI Tract as observed during the necropsy
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examination can be made with everything in situ. This examination revealed a fair amount of petechiae (tiny red or purplish red spots appearing as a result of pinpoint haemorrhage). We unfurl the gastrointestinal tract and note that there were no lesions, obstructions or twists, and sift through the stomach contents for any clues. Asides from the presence of fluid and petechiae haemorrhage, the gastrointestinal tract appeared unremarkable, and even more so the kidneys and liver. There were thoughts that a perforation of the GI tract, or perhaps a liver abscess could be causative, but there was no evidence of either. A gross examination revealed that there were no obvious intestinal parasites, but pathology would give a better indication.
tion. There was some swelling and evidence of haemorrhage, but nothing distinctive. The brain was removed, but there were no lesions, abscesses, major haemorrhage or clots, or any other abnormalities evident. The brain samples were sent as firstly swabs, and the entire brain was also fixed in 10% buffered formalin solution for five days before it was sent for histology, and it was, consequently, the final results we received back. The lab did note if any other horses on my property developed similar signs, MAF should be called.
The laboratory concludes the most likely cause of death was a head trauma. This could have been caused by a knock to the weakened area on his head, or to the poll. Given the paddock contains some railing fences, it is possible he may have been grazing under a rail and lifted his head suddenly, or that he was struck by the hoof of a paddock mate, either by investigating a horse while it was rolling, or from a kick. Our conclusion of the strange, sweet smell on Pye’s breath was that was related to gut stasis due to an interruption of normal parasympathetic nervous system activity.
List of samples and laboratory findings, (comments have been edited): (Gribbles Veterinary Lab, Apr 2011) Haematology Test type
Pye’s results
Normal range
Leaving the abdomen, we turned our attention to the chest cavity, taking samples from the pericardium, cardiac and pleural tissue. Again, we are struck by the ordinariness of everything. Repeatedly we have recorded NAD (No Abnormalities Detected).
RBC (Red blood cell count)
High - 12.10
6.8 – 12
HB (Haemoglobin)
High – 212 G/L
100 – 180
HCT(Haematocrit)
High – 0.61 L/L
0.32 – 0.55
NEUTAB (Neutralizing anti-bodies)
High – 8.3
2.7 – 7.4
LYMPHAB (Lymphocyte anti-bodies)
Low – 1.4
1.8 – 4.4
We had to remove Pye’s head to take it back to the house, as we needed an electrical saw to remove the brain. We collected spinal fluid at the site of the incision as the head was removed. Personally, this was the hardest part, removing the head, taking it away and cutting into it with a reciprocating saw to access the brain.
MONOAB (Monocyte anti-bodies)
High – 0.8
(0.0 – 0.3)
BASOAB (Basophil anti-bodies)
High – 0.3
(0.0 – 0.2)
Once the top cap of the skull was removed, the brain was exposed for gross examina-
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Histology I Sample
Findings
Pericardial Fluid (Swab)
No growth
Stomach (Tissue)
Eosinophils, lymphocytes and plasma cells mildly expand the lamina propia and submucosa.
Small intestine (Tissue)
Eosinophils, lymphocytes and plasma cells mildly expand the lamina propia and submucosa. The submucosa is moderate oedematous.
Colon (Tissue)
Eosinophils, lymphocytes and plasma cells mildly expand the lamina propia and submucosa. There is moderate congestion and oedema of the submucosa and serosa. Lymph nodes are depleted.
Lung (Tissue)
There is diffuse congestion and multifocally intra-alveolar haemorrhage. (Likely from agonal change)
Heart (Tissue)
There is marked diffuse haemorrhage within the coronary groove adipose tissue.
Liver (Tissue)
Portal areas are expanded by low numbers of lymphocytes, plasma cells and haemosiderin-containing macrophages.
Skeletal muscle (Tissue)
No significant changes.
Lymph node (Tissue)
There is marked expansion of the medullary and subcapular sinuses by erthocytes and haemorrhage within the perinodal adipose. Follicles contain increased clear space (oedema).
Kidney (Tissue)
The renal vasculature is diffusely congested.
Comments
Cause of death not evident from these samples. The haemorrhage around the heart and lymph node is quite marked but is probably an agonal change.
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Histology II Sample
Findings
CSF (Smear and cytospin)
Smears of cytospin preparations of the fluid are mostly erythrocytes. The finds are consistent with haemorrhage if the sample was not contaminated. I wouldn’t recommend anaerobic culture at this stage. If any other horses show clinical signs I recommend you contact MAF.
Meninges (Swab)
Scant growth of Escherichia coli. No anaerobes isolated.
Histology III Sample
Findings
Fixed brain
Throughout all sections of brain, blood vessels are surrounded by variable levels of clear space (oedema) or haemorrhage. There is mild vacuolation of the cortical and brain stem white matter tracts, with rate vacuoles containing axonal debris. Acute, diffuse perivascular and periventricular oedema and occipital laminar cortical degeneration. The changes in the brain are suggestive of vasogenic oedema resulting in brain swelling. There is no evidence of infectious encephalitis or toxic/metabolic disease, leaving the most likely cause of death as head trauma. This could also fit with the clinical and CSF findings. Gross lesions in cases of traumatic brain injury may not be remarkable – in some cases where horses flip over and impact the poll there is only a small fracture of the basilar bone.
We called in an earth mover, who I am so grateful to for coming out on a Sunday afternoon. He buried Pye where he lay, taking care to scrape and bury the top layer of soil, as this was contaminated with blood containing sodium pentobarb.
Appendix One
At the end of the weekend, which had started so normally, I was left with two horses, standing with heads bowed at the fresh earth under which their friend lay.
Equine Physiological Data – normal ranges (Bonnie S Barr, 2009) Heart rate
28 – 44 bpm
Respiration rate
8 – 24 rpm
Temperature
37.2 – 38.6°C
MM Colour
Pink
CRT (Capillary refill time)
>2 seconds
Bibliography Bonnie S Barr, D. B. (2009). AAEVT ’s Equine Manual for Veterinary Technicians Chapter 11: Nursing Care. Iowa, USA: Wiley Blackwell. CMP Medica. (2009). NZ Index of Veterinary Specilities (IVS) Annual . North Shore City: CMP Medica (NZ) Ltd. Coonley & Kootnz Equine Hospital. (2011). Coonley & Kootnz Interesting Surgery Pictures. Retrieved Apr 18, 2011, from Coonley & Kootnz Equine Hospital: http://www.ckequinehospital.com/ photo-gallery?gallery_id=1 Coumbe, E. b. (2001). Equine Veterinary Nursing Manual. Oxford: Blackwell Science Ltd.,. Davis, J. L. (2009). AAEVT’s Equine Manual for Veterinary Technicicans - Chapter 7: Equine Pharmacology. Iowa, USA: Wiley Blackwell. Ethical Agents. (2010). EA The Book. Auckland: Ethical Agents (online). Gribbles Veterinary Lab. (Apr 2011). Lab results - Pye Mann, Apr 2011. James Moore DVM, P. (2001). ii: A Perspective of Endotoxaemia. Proceedings of the annual convention of the AAEP 2001 (pp. 61 - 74). San Diego: International Veterinary Information Service. Judd, D. B. (2005, May 16). Rabies in Horses. Texas. Knottenbelt, D. C. (2006). Saunders Equine Formulary. Liverpool, UK: Elsevier. Pablo, E. M. (2009). AAEVT ’s Equine Manaul for Veterinary Technicians - Chapter 9: Equine Anaesthesia. Iowa, USA: Wiley Blackwell. Phillips, T. (2009). Colic: Initial Assessment and Management. Proceedings of the New Zealand Equine Veterinary Association of the NZVA , 85-97. Vet Tek. (2011, Apr 2). Flunixin Meglumine Injection Veterinary Information from Drugs. com. Retrieved Apr 18, 2011, from http:// www.drugs.com: http://www.drugs.com/vet/ flunixin-meglumine-injection.html
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QUIZ 1.
2.
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– Dark Horse, Dark Night
What is epiphora? a. Prolapse of the eye b. Ulceration of the eye c. Equine recurrent uveitis d. Discharge/Tearing of the eye Which of the following is not a clinical symptom of colic? a. Pacing b. Inappetence c. Extreme hunger d. Facial grimacing
3.
Which class of drugs does Flunixin Meglumine fall under? a. Opiod b. NSAID c. Antibiotic d. Analgesic
4.
What colour are the tops of the serum blood tubes a. Red b. Blue c. Grey d. Purple
5.
What colour is the line around the gums that can indicate toxicity? a. Purple b. Dark Red c. Bright Red d. No change in gum colour
6.
Gram positive bacteria cause endo-toxaemia a. True b. False
7.
Dysphagia is a. Difficulty in urinating b. Difficulty in breathing c. Difficulty in swallowing d. Difficulty with giving birth
8.
The dumb version of rabies is found in New Zealand a. True b. False
9.
The incubation period for dumb rabies is a. 9 days – 1year b. 19 days – 1year c. 9 months – 1 year d. 19 months – 1 year
10. What is the recommended dose rate for Pentobarb 500? a. 5ml/100kg Bodyweight b. 10ml/50kg Bodyweight c. 50ml/50kg Bodyweight d. 100ml/100kg Bodyweight 11. Diaphoresis is a. Grinding of the teeth b. Profuse salivation c. Profuse sweating d. None of the above 12. A horse with laminitis will attempt to carry all of its weight on its a. Heels b. Fore legs c. Even weight on all 4 limbs d. Hooves that are not affected
13. The only way to diagnose rabies is a. Blood tests b. Clinical symptoms c. Incubation of a saliva sample d. Testing of the Brain after death 14. The medical term for gut sounds is a. Borbirygmi b. Borborygmi c. Barborygmi d. Barbarygmi 15. To avoid the dogs ingesting blood contaminated with Sodium Pentobarb, which of the following occurred: a. The top layer of soil was scraped away during the burial b. They were stuck in their kennels throughout the necropsy c. They were taken off the farm throughout the necropsy and burial d. A & B
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