Originally published in the October 2015 issue of Veterinary Practice News. Enjoyed this article? Then subscribe today! Previously, we discussed ways to reduce the stress level of patients during the car ride and their visit to the veterinary hospital. This month, we review Marty Becker’s Fear Free techniques to reduce stress around hospitalization, anesthesia and surgery. Restraint is becoming more and more archaic. It is designed to protect us without much regard for the physical or emotional well-being of the patient. If you are not successful in your “stress-less” or gentle control techniques, then consider sedation. The board-certified anesthesiologists and behaviorists who are part of the Fear Free movement have two interesting sayings: “Think of sedation early and often.” “If you can’t abate, you must sedate.” Asking five technicians to sit on a fearful patient during a nail trim, blood draw or X-ray should be considered taboo. Would you do it if the owner were watching? Every patient has an anxiety threshold for what he can tolerate. You must work hard to remove or reduce the anxiety triggers that affect a specific patient, and use various products and procedures designed to keep him calm. If you push him over his threshold into fear, it will only make him worse that day and in the future and could prevent you from providing necessary treatments. In fact, if the pet shows extreme fear, there is a good chance the pet owner will not bring the pet back. She will either go to another veterinary hospital that looks after the pet’s physical and emotional well-being, or she’ll use Dr. Google. Phil Zeltzman Check your pride at the door when drawing blood or placing IV catheters. Reduce Stress Do not wait to use sedation. If you keep the patient under her threshold, not only will she usually not get worse for subsequent visits, but she may even improve. Few colleagues want to hear this, but more often than not, patients should be sedated for radiographs. In some states, humans are not even allowed in the room while taking X-rays. When an animal requires a hospital stay for treatments or additional testing, there are ways to cut down on stress. When drawing blood or placing catheters, make sure everything is collected and ready before the patient is brought back to the treatment area: syringes, blood tubes, flushes, scrubbing material, clippers, tape, etc. When clipping for an IV catheter, clip all the way around the leg so that removal doesn’t require ripping off mounds of fur. When placing catheters and taking blood samples, check your pride at the door. If you are having difficulty, be humble and follow the “three strikes, you’re out” rule. There is no reason to stab a patient 27 times just to make you feel better about yourself. This has nothing to do with ego; it has to do with proper patient care. While clipping and during venipuncture, use distraction techniques, such as letting the pet lick a tasty substance. Doing so will help him focus on the treat, not on what’s happening to him. During the patient’s stay in the hospital, having a variety of housing options is helpful. Cat-specific kennels sprayed with pheromones — with no dogs allowed — places to hide and calming noises are preferred. The sound of beeping IV pumps, employees interacting and other patients vocalizing can be lessened by providing music or species-specific sound tracks. Some hospitals report great success with showing DogTV in wards or kennel areas. If you have mixed housing, you can use feline and canine pheromones in the same room. If your hospital has a lot of air exchange, make sure to use several diffusers. For dogs, traditional cages with adequate room and bedding can appease many. However, you can customize this as well. Some dogs who are vocalizing, trying to escape their cage or twisting their IV lines by circling constantly may be appeased by a change of location or given a sedative. Smaller breeds can be confined and content in playpens. Larger dogs can be set up and controlled in smaller rooms, corners or cubbies with the use of baby gates. As much as staff members dislike being responsible for personal items, toys and blankets left with the pet can help. A familiar smell in a strange place can soothe the patient. When inducing, proper restraint is key. Using as little gentle control as necessary usually works best. You can minimize stress while your patient waits by having all your supplies ready. Avoid shining the overhead light you need to intubate until the animal is induced. This is induction, not an interrogation. Every patient’s sensitivity to anesthesia is different. Don’t fight to intubate. Use more induction agent if needed. Titrate induction agents to effect, rather than defaulting to using a universal recipe. Once your patient is under anesthesia, you still have work to do. It’s now time to reduce the harmful effects of anesthesia. There are countless ways to maintain body temperature. Always use a towel between (most) warming devices and the skin to prevent burns. Make sure patients are perfusing properly. Monitor patients and document vitals in writing to recognize problems early on. Adjust your anesthetic depth based on your patient’s needs; one setting does not fit all patients. Just because your patient is asleep does not mean the depth is appropriate. Using constant rate infusions can control pain before, during and after surgery. They also lessen the amount of gas anesthesia necessary. Atraumatic surgery is one of Halsted’s basic principles. Strive to minimize iatrogenic trauma to tissues. Grab tissues delicately and avoid crushing them. Knowing anatomy is key in order to reduce unnecessary trauma. Postop, waking patients up in a quiet area is helpful. Placing the E-collar, or a more Fear Free equivalent, prior to extubation reduces the stress of placing it as the patient comes back to his senses. Continue to monitor vitals until they are normal. Warming efforts often need to be continued postop. The use of NSAIDs can be introduced if the patient did not have any perfusion issues during the procedure. Use of pet-specific music can be used to lessen background noises during recovery. Pay attention to sudden changes in behavior or vocalization. They could be related to pain or simply mean the patient needs to urinate or defecate. Pain levels should be assessed every couple of hours and addressed before windup. CRIs can be very effective in providing steady pain control for the entirety of your patients’ stay. Dr. Phil Zetlzman Decrease stress during anesthesia by adjusting anesthetic depth. Client education for post op care can help. Advising clients to leave the E collar on instead of removing it and having them fight to put it back on is helpful. The use of special treats to hide drugs and compounded medications can assist in lower stress treatments. A proper transition period for diet changes to avoid gastric upset is important. Having owners spend time in the confinement area so the patient does not feel left out — or, worse, causes trauma while trying to escape — makes the pet still feel involved in everyday life. These are all simple suggestions that don’t always occur to owners. In the stressful world of veterinary surgery, many steps can be taken to lessen the tension. Reducing stress in your patient likely will reduce stress in your team. Fear Free practices report fewer on-the-job injuries, higher work satisfaction, higher client satisfaction and higher profits. Aren’t these good enough reasons to implement this philosophy at your practice? AJ Debiasse, a technician in Stroudsburg, Pa., contributed to this article.
