13 tips to energize your practice

Successful practices and practitioners are alive; they vibrate with positive energy and enthusiasm.

These types of people usually have good ideas to share and to incorporateinto your practice.

This column is just for fun. Normally we run an episodic quiz of thingsthat practitioners might like to know. But this month, we will skip thequiz and just go to some favorite practice bits that might help light thingsup in your practice.

These are some of my favorite practice tips-they may not be perfect andthey may not be documented. Some are just plain testimonials.

* Tip 1. Trimethobezamide. TBZ is for vomiting and comes as asuppository. The trade name is Tigan and it comes in two sizes, 100 mg and200 mg. For 15 or more years we have used this product for vomiting dogsand pups. Hard to believe it is inexpensive and, in our hands, beats everythingfor vomit control, especially in parvo pups. If a dog continues to vomitwith this suppository on board, look for something like an intussusceptionor foreign body.

We currently use a 100mg suppository every six to eight hours in a 30pound dog.

* Tip 2. ESR (erythrocyte sedimentation rate.) From the archivesof Duke's and Schalm's textbooks come this commonly used human test. Fordogs, we need to make a correction for the packed cell volume to get theappropriate number.

As a screening test it has to do with EDTA blood settling in Winthroptubes. A reading is taken at one hour and is correct for the PCV. The datawe have collected shows -3 to +3 is normal. And if the corrected valueis -35 or +35, the patient will die or has a life-threatening illness. If the reading is +4 to +15, take it seriously; +16 to +34 means 50 percentwill die or have a serious illness.

The ESR, with the limitation being that it is a general screening test,when used daily, enables practitioners to avoid surgery on some day patientsand renders a clue as to when to be diagnostically aggressive. When thetest is really abnormal, one can advise a family that "no matter whatwe eventually find, the prognosis is poor;" nice information to havebefore spending a whole bunch of client resources.

* Tip 3. Finding cardiovascular irregularities in dogs. Listento a heart for five full minutes in cardiomyopathy suspects. It has beensaid that up to 200 irregularities per day are OK in a Doberman, but 400is clearly abnormal. So listen to a heart for five minutes as a screeningtechnique. At 1,440 minutes per day, if an irregularity occurred every fiveminutes that would be 300 per day.

And guess what? Those patients ought to have an ECG, and be checked everythree months.

* Tip 4. Finding cardiovascular problems in cats. Listen fors3 s4 in the cat. If you find the s3 s4 sound, you might be on to a hypertensionor hyperthyroid or hypertrophic cardiomyopathy patient. This seemingly simpleidentification task takes a little practice, yet proves worthwhile withthe discovery of these clinical issues. Diltiazem is the way to go forcardiomyopathy and the WelchAllyn Meditron computer stethoscope is a joyto behold.

* Tip 5. DEA balance sheet woes getting to you? Try insulin syringesfor controlled drugs to mitigate the loss. While the world stage has tonsof illegal drugs flowing in our streets, if you have the DEA drug "troll"around, they are going to get you for failing to count the missing drugsin the hub of the needle.

Use of the 1/2 cc insulin syringes permits precise administration ofdrugs and lowers the disparity of drugs lost in the hub of the needle creating,of course, less hubbub at physical inventory time.

* Tip 6. PPN or TPN can save a patient or two. In the past decademuch has been written and put forth concerning partial parental nutrition.Yet the pragmatic administration of these products intravenously could usea boost.

So try the 10 percent amino acids, 20 percent Liposyn and 50 percentdextrose to be mixed and administered daily to ill patients on intravenoussupport. A guideline is that a patient that is anorexic for three days willbenefit, recover faster and appear more interested in living from the PPN.

It does a take a little outside reading to get this to be part of regularpatient care, but the benefits are a joy.

And just another little "*" to go with these hypertonic solutions;go to 2.5 percent dextrose and 0.45 percent saline for the basic maintenancefluids. It is just a tad hypotonic. The importance of this issue is thatthe body just has a difficult time adjusting when hypertonic solutions areconstantly coming in. This shows up on about the third day on total IV supportas "depression" (maybe a headache).

* Tip 7. Infusion pump blues getting to ya? Well, keep it on allthe time. Certainly one of the curses of technology is the failure of someof these devices when we most need them. Then, everyone in the hospitalmight not be prepared, inclined or trained to set up the infusion pump.So try this little challenge.

Keep the pumps on 24 hours a day at 1cc per hour. Reload the bag withyour favorite and most common fluids and pump the fluids into another empty,but sterile bag hanging nearby. The convenient part is that when a patientcomes in and needs fluids quickly, roll up the pump, put in the catheterand presto!- administer emergency fluids without the need to stop and setup the pump, get it running or mentally figure the calculations. Try it,you will like it.

* Tip 8. Respiratory problems in the kennel? Set or change theair system so that the kennel air changes 15 times per hour. All we needis a few kennel cough patients to sully the hospital reputation. Certainlycommercial-only boarding kennels can get away with the problem to a smalldegree, but a veterinary hospital, by name, suggests to the public thatthe place is healthy.

It is understood that it can be somewhat expensive to heat and cool aroom with multiple air changes, but filters do exist to clean the air oflots of stuff, yet there is little substitute for fresh air changes. Radiantheaters work nicely. Kennels and ward areas put on separate air systemshelp. And a complete clinic air flush system can be put into place to daily,or more often, completely flush the clinic air.

Some controversy seems to exist as to eight, 12 or 15 times per hourair changes in the kennel. But testimonials have it that with 15 changesper hour, two dogs or two cats in a contaminated kennel, one each with respiratoryillness will not infect the other.

Reputation preserved.

* Tip 9. Cold cages, cold run floors, slippery surfaces for the geriatrics.Try rubber mats from horse trailers. Run floors, steel cages and Formica-coveredcages can be slippery and uncomfortable, especially for our geriatric patients.We can use towels, yet they still get pushed into the corner and are slippery.Put a towel on the rubber and a nice environment emerges immediately.

Travel over to the local horse trailer dealer and get an allocation oflightweight 1/4 inch trailer matting. It comes in 40-ft. rolls, too muchfor many clinics. Purchase 10 feet and cut it to fit in some of the cagesand runs. Make the sizes easy to move about. Carry outside to clean andsun dry.

This material is loved by old dogs, fragile cats and appreciated by clientsand staff who hate to see their friends on cold, uninviting floors.

* Tip 10. Radiant panel heaters. Aztec International came up withpanel, radiant heaters. One can find them in the ceilings of ski lodgesand in pediatric intensive care facilities. These panels heat objects -not the air.

For pups, cats, post-surgical patients and old timers who just need alittle heat, these units can be mounted on the ceiling, or hung on the frontof a run or cages.

One can get real fancy and tape thermisters to the patient and set arheostat to help regulate the warmth.

* Tip 11. Talwin Nx works. There's a lot of interest these daysin pain medication. One article stated that chronic and significant painmanagement must include narcotics. Clearly this wouldn't work for humans-theyabuse such things. But dogs? Not a chance.

With our valid client-patient-doctor relationship we can monitor thepatient pain, the use of drugs and we can go for the synergy of the useof non-steroidal anti-inflammatory drugs and narcotics with the nutraceuticals.

Morphine does come in an oral form, yet most, perhaps all, narcoticsare associated with sedation, an unwanted side effect. But Talwin Nx haspentosocine and naxloxone. The latter reverses adverse side effects of thenarcotic component making this product a smooth addition to pain managementof dogs. We currently recommend an NSAID with Talwin Nx. Start with thegeneric at one tablet every eight hours for a 60-pound dog in severe pain.

* Tip 12. Puppets for kid entertainment. This is kind of a sillylittle thing, but it is in keeping with a basic premise of life and business, "make it fun, they will come." It's also a nice icebreaker withsome shy children, as well as for practitioners who may not know how tointeract with children.

Our clinic has possums, mother and baby with Velcro tails, great fun!Tune up one's imagination, by watching the Muppets - Kermit and Miss Piggy-Sesame Street's Big Bird or Oscar the Grouch and other television programswith puppets to get some ideas.

* Tip 13. Cytology - 100 pairs. It is really easy to give up oncytology, and even easier to over-read slides. But the usefulness of clinicalcytology for a practice makes it mandatory to really make an effort to relearnwhat we think we know about cytology.

So to facilitate this service, make a slide collection of four slides.Send two to your favorite clinical cytologist and keep two. When the pathreports come in over the FAX line, make two copies, one for the patientfile and one for the ever-growing list of reference slides.

Learning made simple.