Last January, I wrote about the strange things that veterinarians do in everyday practice. I’ve compiled eight more strange things along with suggestions to improve patient care and make practice life easier. 1) Placing the E-collar after extubation Trying to place an Elizabethan collar on a recently extubated patient may go smoothly, or it may be an exercise in frustration for the technician—and utter terror for the patient. Lee, a technician in Pennsylvania, learned this tip the hard way. “I was asked to place an E-collar before extubation,” Lee said. “Since I had never heard this request, and because I had 10 other things to do to recover my patient, the request never really registered. “Once my patient was awake, I tried to place the cone, but he started thrashing around,” Lee continued. “After multiple attempts, the only way we were able to place the E-collar was by giving him propofol. I felt really bad that we had to do this, so now I always place the E-collar on my patient’s neck before extubation, while he’s still sleeping on the surgery table. There is no downside, and it makes everybody happier.” 2) Speaking of E–collars… As a surgeon, I see E-collars as a necessary evil: important to prevent self trauma, but traumatic to clients and annoying for patients. I suspect a big part of the issue patients have is the sudden loss of peripheral vision. This is guaranteed to happen if the cone is opaque. So why do they keep making them opaque, and why do veterinarians keep buying them? A logical answer would be to either only purchase clear cones, or to switch to newer protective devices which have come to market. Just make sure they work for your individual patient or your particular surgery site. 3) Holding off a vein “like a maniac.” After we draw blood from a patient, or when we apply pressure on a bleeding vessel during surgery, we sometimes hold off the vein by pressing it firmly. When we do that, we obviously prevent the vein from bleeding, but we also stop blood flow to the area. This in turn prevents clotting factors and platelets from reaching the area of the vessel wall that has been traumatized by the needle. When the holder releases the pressure, the patient will often bleed, since there has been no blood clot formation at all. A better way to hold off a vein is to apply gentle pressure, just enough to prevent overt bleeding, while allowing blood flow to the area. This technique will allow the creation of a blood clot. In turn, this will ensure that the patient goes home without a hematoma, stained fur or an erroneous diagnosis of clotting disorder. 4) Squeezing an IV bag to generate pressure Whether we are flushing a wound or administering fluids to a shocky or dehydrated patient, we sometimes need to use fluids under pressure. Squeezing or twisting the bag is common, but it is not the most effective (or painless) way to achieve our goal. A pressure bag can be used to flush a wound or administer fluids quickly. A more elegant way to generate pressure in an IV bag is to use a pressure bag. The IV bag is surrounded by a pocket in which air can be manually compressed (see photo). Most of the time, you need to “pump it up” until you reach a pressure in the green zone. Interestingly, a recent article demonstrates that using a pressure bag is the ideal technique to flush wounds (Trent Gall and Eric Monnet, “Evaluation of fluid pressures of common wound-flushing techniques”; Am J Vet Res. 2010, Vol. 71, N. 11, p. 1384-1386). 5) Placing the heating source too far away Anesthetized patients who receive IV fluids are often doomed to become hypothermic. Think about it: We administer fluids at, say, 70 degrees to a body that is about 100 degrees. This 30-degree difference is very significant in small patients or with large volumes of fluids. An easy way to warm up the fluids is to use a commercial fluid warmer, or a dedicated warm IV bag. The IV line is then coiled around the bag. Many people know this trick, but I often see the bag being placed far away from the IV catheter, in a convenient location. This defeats the purpose because fluids have “time” to cool down before they reach the patient. So strive to place the IV bag close to the IV catheter, and always remember to avoid direct contact with the skin to avoid burns. 6) Placing the cooling source too far away The same reasoning applies to hyperthermic patients we try to cool down. We can use several techniques. For example, the IV line can be coiled around an ice pack. However, if the cooling device is placed too far from the body, then the fluids will have an opportunity to warm up before reaching the patient. So here again, place the cooling source as close to the IV catheter as possible for maximum effectiveness. 7) Violating asepsis rules (part 1) At most surgical clinics, walking into the operating room without a cap and mask is the ultimate cardinal sin. Rather than explaining (again) why this is important to your patient and your liability, let’s point out that many clinics have boxes of caps and masks inside the O.R. Caps and masks should be outside the O.R. Photos Courtesy of Dr. Phil Zeltzman Once you understand the reason behind the rule, you understand why caps and masks should be kept in the prep or scrub area, i.e., outside the O.R. 8) Violating asepsis rules (part 2) If you need a pack of suture material in the treatment room, and you keep your suture packs inside the O.R., what are your options? Walking into the O.R. without a cap and mask, thereby violating the rule we just discussed. Putting a cap and mask on for the 30 seconds it takes to get a pack. Unless you keep a cap and mask nearby, this can be wasteful. Here are two better options: Keep a few suture packs outside the O.R. It is very likely that you use the same type all the time. A fancier option, depending on your needs and your setup, is to place suture packs in a pass-through area (see photo). And by the way, the same concept applies to surgical gloves, gowns and laceration packs. Think about where you need them the most so you can decide on the most convenient location. Read Dr. Zeltzman's January 2012 column, Four Things We Do That Make No Sense.
