Left: A stress view shows a tarso-metatarsal fracture-luxation (see red arrow) in this eight-year-old maltipoo. Right: Not much is seen on a straight AP besides soft tissue swelling.Photos courtesy Phil Zeltzman After writing 155 Surgical Insights columns for this publication over 12 years, it is time for me to move on. I have enjoyed writing every single article, and hope it has helped colleagues. What follows is the best advice I can leave with my faithful readers. I hope you enjoy it and you always remember “a chance to cut is a chance to cure.” Disclaimer: What follows is not the opinion of this publication or the American College of Veterinary Surgeons. It is my opinion, based on years working with clients and referring vets in the trenches. Age Age is not a disease. Age should not be a factor in deciding if a patient should benefit from surgery or not. Why not repair a torn ACL in a 13-year-old pet? Why not do a tie back in a 14 year old? Why not remove a tumor in a 15 year old? After all, the Veterinarian Oath says we “will strive to promote animal health and… relieve animal suffering.” This includes the right to be pain free and to be able to breathe. As long as the surgery is ethical and the client is on board, be your patient’s best advocate and solve the problem. Barium Do you still perform barium studies? When is the last time you reached a clear, undeniable diagnosis? Patients and nurses alike hate barium swallows. Few things are less Fear Free than shoving barium down a sick patient’s throat. Worse: If there is a gastro-intestinal foreign body, then the surgery becomes riskier if barium leaks in the abdominal cavity. Whether you do it yourself or you refer to a mobile or local specialist, you will get a much more accurate diagnosis with ultrasound, without torturing your patient and your nurses. Biopsies Should you perform a biopsy on every mass before surgery? I am of the opinion if a test result is not going to change your treatment, there is no reason to waste time and money on it. What does this mean? If you and a client agree a mass should be removed, whether it is benign or malignant, then why biopsy it first? This includes a mass that is actively bleeding, one that impairs mobility or eating, or one that blocks the urinary or digestive tract. Skip the preop biopsy, remove the mass, then biopsy it. If it is malignant, you can discuss further treatment options. If it is benign, then relax and celebrate. Contralateral Take contralateral X-rays. Too much weight is often placed in subtle opacities or lucencies on X-rays. Are they real? Are they not? A commonly overlooked secret is to simply image the opposite bone or joint. If the same “lesion” is seen on the opposite side, there is a good chance it is a normal anatomic variation. Equipment Equipment is not an expense, it is an investment. Many practitioners have told me they cannot afford fancy monitoring equipment, or capnography, or a warming device. I would argue they cannot afford not to in 2021. Let us say you pay $1,000 for a piece of equipment. Let us also say you charge a mere $5 per use. Hardly a deal breaker for any procedure, right? And let us say you use this new piece of equipment on only one sedated or anesthetized patient each day, five days/week, 52 weeks/year. Five procedures/week x 52 weeks x $5/patient = $1,300/year. And you only charged $5 per patient. If you charged $10 per session, once daily, or if you did two sessions per day, at only $5, you would obviously generate $2,600 in a year, easily and ethically. Fear Free Make Fear Free part of your surgical life. We finally recognize our patients’ emotional well-being is as important as their physical well-being. Minimizing fear, anxiety, and stress results in faster healing, greater owner compliance, and better general overall health. And it is simply more fulfilling to work with happy patients than terrified ones. GIGO General practitioners are under the impression it is a waste of time to take X-rays because surgeons are prima donnas who always repeat their own X-rays. In many cases, this is not true. As the lovely saying goes, “Garbage in, garbage out (GIGO).” We do need the proper views and angles to reach the correct diagnosis. Learn how to take proper rads, and, more importantly, teach your nurses how to take proper X-rays. Taking X-rays of the stifle or the elbow is not rocket science, it is a skill easy to learn. Heat support Hypothermia is invisible. It is often underrated. Yet, it should be top of mind, both for nurses and practitioners. There are countless, simple, not necessarily costly modalities to prevent hypothermia. Here is a simple example: I commonly see some practices that own a heating blanket, but do not use it intraop. They only use it postop, so they play catch up after the patient is hypothermic. Why? Similar to pain, it is much easier to prevent hypothermia than to treat it. Please make it part of any procedure, start to finish: after premedication, on the wet sink, in the OR, on the X-ray table, and in the kennel. Hemostasis Do not agonize over tiny bleeding vessels. A patient with a normal clotting profile will handle clotting while you continue surgery and save precious anesthesia time. This said, know your anatomy and perfect your approach to minimize the risk of having to deal with big bleeders. Indications Surgery is a matter of indications, not dogma. Saying TPLOs are only for large dogs is incorrect. Recommending a lateral suture to the cash-strapped owner of a large dog often leads to disappointment. What matters is how steep the tibial plateau angle is. When all you have is a hammer, everything looks like a nail. A well-rounded surgeon will recommend the procedure most appropriate for each patient. For example, Westies may only weigh 20 lbs, but they are notorious for having steep tibial plateau angles (TPA). Therefore, they typically will do much better with a TPLO to flatten the TPA. Instruments The best surgeon in the world cannot perform optimal surgery without the proper equipment. It is really difficult to perform a thorough laparotomy without a Balfour retractor (a small one and a large one are usually all you need). Sharpen your scissors regularly. Tissues heal better when they are cut cleanly than when they are shredded or torn. Suction is an underrated piece of equipment, for both orthopedic and soft tissue surgery. If your practice does not have the proper equipment, this, by itself, may be a reason to refer a surgery patient. Knowledge Always keep learning. Knowledge changes all the time. Whether you are a new grad or a veteran, never stop learning and improving. New ideas, medications, and techniques emerge regularly. This does not only apply to surgery. It also applies to communication, pain management, and anesthesia. Limits Know your limits. Surgeons are not there to fix your messes when you are in over your head. Call your local surgeon and brainstorm before you take on a difficult case. It is much wiser to discuss a workup, a diagnosis, or a procedure than to refer after the fact. This is especially diplomatically sticky when the client is on a limited budget. Your patient and client alike will thank you for acknowledging your own limitations. It is not an admission of weakness. It is a sign of strength and intelligence. Monitoring Properly monitor your patients, both sedated and anesthetized. Empower your nurses to recognize what is normal and abnormal, and to act accordingly. Pulse oximetry alone is not adequate in 2021. This might be unpopular advice, but all patients should benefit from blood pressure monitoring and capnometry. Yes, the equipment is ridiculously expensive (see above). And yes, you should charge for it. It is much easier to prevent issues early on than to treat them—or lose a patient. Nurses Nurses are the underrated heroes of our profession. Use their skills. Empower them to do what you simply do not have time to do or should not be doing. This includes inventory management, pain management, catheter placement, taking X-rays, and a million other tasks needing delegation. As long as your state practice acts allow it, and you have trained them appropriately, your job should be to focus on diagnosis, treatment, and client communication. Pain Pain control is not negotiable in 2021. Being afraid of opioids because of respiratory depression or a number of other outdated reasons is so last century. Provide analgesia early, often, and in multiple ways. Use blocks, give CRIs, combine drugs. The vast majority of surgeries can involve a block: neuters, spays, mass removals, joint surgery, soft tissue procedures. Use them all—for your patients’ benefit. Stress views Learning how to take stress radiographs will make you look like an orthopedic genius. Yet, they are one of the most underused techniques in radiology. The general concept is simple: force the joint to “open up” medially by bending it laterally, and vice-versa (see images). Stress views allow you to diagnose a (sub)luxation by demonstrating asymmetry in a joint. They can also help diagnose growth plate injuries and articular fractures. They can be painful, so pain medications, sedation and/or anesthesia are required to minimize patient resistance. If in doubt, image the opposite limb for comparison. Surgeons Develop a good relationship with your mobile or local board-certified surgeon. Consult early if you are facing a difficult situation. Most surgeons are not as socially inept as they look. Most actually enjoy brainstorming about a tough case, and strategizing and solving problems. Most surgeons are also happy to review radiographs for their beloved referring vets. If your patient is not responsive to treatment, or if the issue persists, recurs or worsens, get your friendly neighborhood surgeon involved. As with anything else, the sooner you act, the more options you have. If you apply these humble suggestions, your patient care, the happiness of your team, and your own fulfillment will skyrocket. Keep up the good work. Keep changing lives. Farewell. Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified, is a board-certified veterinary surgeon and serial entrepreneur whose traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. He also is cofounder of Veterinary Financial Summit, an online community and conference dedicated to personal and practice finance (www.VetFinancialSummit.com). AJ Debiasse, a technician in Blairstown, N.J., contributed to this article.
