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With the number of opiates available and the various methods of delivery, choosing the best analgesia or premedication plan for patients can be overwhelming. As a result, it is easy to fall into the habit of using only 1 or a few protocols for every patient. At the 

virtual conference this week, Katrina Lafferty, RLAT, CVT, VTS (Anesthesia/Analgesia), discussed the many opioid options available and how best to tailor protocols to individual patient needs.

Lafferty, a senior technician in the anesthesia and surgery department at the  Wisconsin National Primate Center, started off by reminding the audience about the 2 main opiate receptors relevant in veterinary medicine: mu and kappa. Mu receptors, which are located primarily in the central nervous system and throughout the gastrointestinal system, have a stronger effect than kappa receptors, providing moderate to heavy analgesia. The primary effects of mu receptor stimulation are physical dependence, euphoria, analgesia, and respiratory depression. Sedation and constipation are also seen to a less significant degree.

 is the maximum response achievable from a drug under ideal circumstances. “This would be [the effectiveness of] a drug that is tested on a young, healthy animal in a perfect setting,” Lafferty said. “It is not a sick, compromised, extremely painful animal.” Efficacy is often confused with 

, which is the level of clinically achieved analgesia.

 have an affinity for binding to receptor sites and high efficacy. 

 also have a high affinity for binding but have no efficacy; rather they block the action of agonist drugs.

 acts as an agonist at 1 site, exerting a full effect, and as an antagonist at another, blocking any kind of effect at that receptor site. 

 typically have a strong affinity for binding to receptor sites but low efficacy. “This is one of those keys that doesn’t completely fit in a lock,” Lafferty said. “Partial agonists sit in the receptor but don’t fully activate it.”

Kappa receptors, also located within the central nervous system as well as in some peripheral sensory neurons, provide only mild to moderate analgesia. The primary effects of kappa receptor stimulation are sedation, analgesia, miosis (tiny pupils), and psychosomatic effects (eg, anxiety, hallucinations, and nightmares). It is unclear how these psychosomatic effects translate to veterinary patients.

The implications of agonists, antagonists, and mixed agonist/antagonists can extend farther than the immediate situation and decision at hand. Pure agonists have high binding affinity and result in a highly efficacious response. Pure antagonists have a high binding affinity but do not result in efficacy as they block actions of other drugs at the receptor. Partial agonists are able to bind to the receptor, but in a way that imparts lower efficacy than pure agonists. Finally, mixed agonist-antagonists act as an agonist at 1 receptor and as an antagonist at another receptor.

Exploring beyond these categorical characteristics, individual opioid medications have specific adverse effects and ranges of clinical effectiveness to consider. Lafferty presented several cases to illustrate how the various characteristics and mechanisms of action of individual drugs affect clinical decision-making.

Should morphine be used for premedication, sedation, or analgesia in a patient with a sharp esophageal foreign body? Given the high potential for morphine to cause vomiting, its use would be contraindicated in such a case due to the risk for perforation. However, morphine may be advantageous in a patient with a soft foreign body, such that the object may be vomited, avoiding the need for surgical or endoscopic removal in some cases.

Is butorphanol a good option for analgesia in a dog presented for a forelimb amputation? Given that butorphanol only has a mild to moderate analgesic effect, and the duration of action is only about 1 hour, butorphanol is not a good match for this clinical situation.

Is buprenorphine a good option for pain control prior to surgery in a kitten with a mandibular fracture that is being referred for emergency surgery? Although buprenorphine provides 6 to 12 hours of analgesia, it may not provide sufficient analgesia for the degree of pain involved in this case, and if surgery is anticipated during that time, the weak antagonist effect may interfere with the anesthetic and analgesic protocol.

In addition to determining the most appropriate medication for a particular clinical situation and patient, the best route of administration must also be considered. Potential routes include constant-rate infusions (CRI), epidurals, local blocks, transmucosal delivery, and transdermal delivery.

CRIs can circumvent the short half-life of some opiates and allow titration to a consistently effective dose, avoiding the peaks and troughs that result in respiratory depression and breakthrough pain, respectively. Local blocks that combine opiates with lidocaine or bupivacaine can extend the duration of analgesia from the block and minimize systemic side effects of opiates. Further, epidurals or local blocks may reduce the concentration of inhalant anesthesia required for procedures. Transmucosal delivery of buprenorphine is a useful option in cats, although onset of action is 60 to 90 minutes. In dogs, however, the dose requirements are much higher, rendering the transmucosal option impractical.

When naloxone is administered, it is important to remember that reversal agents reverse not only the adverse effects of opiates but also their analgesic properties. Lafferty noted that there is no true “half-dose” where naloxone is used. No matter the dose used, the reversal should be presumed to reverse all analgesia. It is also important to consider the duration of action of the opiates previously on board, as well as the reversal agents being administered. For example, the duration of naloxone is 30 to 60 minutes, so if the opiates previously administered have a longer duration of action, be prepared to re-dose the reversal agent if a relapse of signs occurs. Conversely, should additional analgesia be needed after administering naloxone, realize that additional opiates cannot be readministered until the duration of action of naloxone has elapsed. Due to this limitation, in some cases where analgesia is still required but reversal may be beneficial, butorphanol may be an appropriate option where partial reversal is sufficient.

Rebecca A Packer, DVM, MS, DACVIM (Neurology/Neurosurgery), is an associate professor of neurology/neurosurgery at Colorado State University College of Veterinary Medicine and Biomedical Sciences in Fort Collins. She is active in clinical and didactic training of veterinary students and residents and has developed a comparative neuro-oncology research program at Colorado State University.

Articles

The selection of opiates available and the various routes of administration provide a wide array of options for analgesia in veterinary patients. 

Understanding opioids in veterinary medicine

 magazine asked experienced practice manager Emily Shiver to answer your questions about life in practice for managers, technicians, assistants, client service receptionists, and others. Got a question for her? Email us at firstline@mmhgroup.com.

 “I’ve been waiting for 10 minutes. This is insane! I’m not going to tolerate this. I’m leaving and telling all of my friends, posting on every social media outlet, and leaving you a 1-star Google and Yelp review!”

Unfortunately, this exact scenario played out at my former clinic. The client walked in midmorning on a busy Friday. He had been written off 2 years earlier and demanded to be seen right away. My client service representatives were kind and warm, but he would not let up. The lobby was crowded with people and pets and he put on quite a show. After he exited the building screaming colorful language, the representatives approached me immediately to discuss how they could have handled that situation differently. So, what is the best way to deal with angry clients?

There are a handful of reasons why clients get angry. They love their pets but cannot afford the best care or they have unrealistic expectations or are under the influence. Sometimes emotions are high because, after all, pets are members of the family. No matter what has set off your client, here are some tactics to help defuse the situation.

Express the importance of your practice providing a good experience

See if you can come to a solution that is beneficial for both parties

Sounds simple? Far from it. The reality is that some clients will not be tamed that easily.

When dealing with an angry client, the first thing I do is ask whether we can move to a private area. Try not to come off forceful. Remember, they want an audience. You can say something like, “I can see how frustrating this is for you. I want to help you; come with me.” If they are really stubborn, they might not budge. At this point, I tell them that I am happy to help them, but that we need to step into an examination room or even go outside. If the result is still no movement or a higher volume, I ask them to leave the premises.

One of the best ways to defuse an angry client involves good listening skills. Be warned: You might hear things you either will not or do not want to hear about your practice, your teammates, or even yourself, but try not to take anything personally. The client probably has not read 

 nor taken the test, so practice social awareness and maybe they will eventually apologize.

Some of my go-to empathy expressions include the following:

“I completely understand. I would be frustrated, too.”

“Thank you so much for sharing this with me. We cannot improve without feedback.”

“I am upset as well. It is certainly not our goal to provide anything but a good experience.”

Sometimes the conversation takes a turn for the worst. The client might say, “There is no way you understand what I am experiencing right now” or “You aren’t upset, you just care about money and are going to let my dog die.” If the conversation goes in this direction, I typically let them know they are not in a place to discuss this. Then I excuse myself, letting them know I will return in about 10 minutes. Nine times out of 10, this works great, and when I return, they are ready to chat or have replaced themselves with someone more level-headed.

Share your practice’s mission and core values with angry clients. For example:

“Our goal is to care for your pet as if they were a member of our family.”

They may tell that you have clearly missed the mark on your mission. Take the feedback with poise and grace and respond, “I am truly sorry we have not met your expectations. I do hope we can regain your trust and continue to provide care for your pet.”

Once clients become less emotional, they usually can explain what would make their experience better. Then you can work on a reasonable solution or compromise.

There are untamable clients in every industry. The goal is to make sure your team is prepared to handle them. I do not tolerate blatantly rude or disruptive behavior from clients despite our efforts and will ask them to leave the premises. You can do this.

The good news? It is possible to turn these untamable lions into purring little kittens with empathy, emotional intelligence, and effort.

Emily Shiver, CVPM, CCFP, is regional director of operations at the Family Vet Group, headquartered in Chicago, Illinois. Shiver resides in Florida.

Experienced practice manager Emily Shiver explains how to defuse angry clients.

Ask Emily: I’m an angry client. Hear me roar.

“Mentorship matters” is a catchy use of alliteration, but what does it really mean? That is the question that Kate Boatright, VMD, and Tannetje Crocker, DVM, explored during a presentation this week at the 

 virtual conference. As both mentors and mentees, the doctors agreed that the role of mentors in the veterinary profession is pivotal to its continued success.

“Mentorship has been vital, especially early on in my career, to ensure a strong foundation,” said Crocker, who practices at Northwest Animal Hospital and the Animal Emergency Hospital of North Texas, both in Grapevine. “I think I could have potentially been a veterinarian who stopped practicing or burnt out. But instead, I had a group of people who were there to support me, cheerlead me, and guide me in a new direction.”

It is without a doubt a symbiotic relationship, added Boatright, an associate veterinarian, freelance speaker, and author in western Pennsylvania. “Being a mentor has helped revitalize my career from time to time when I start to get a little bored or burned out. Mentorship is all about the relationship. You can get so much more out of it than teaching someone or learning from someone.”

Early-career veterinarians, recent graduates, and veterinary students face myriad challenges in the transition from school to clinical practice that mentors can help guide them through successfully. According to Boatright and Crocker, novice veterinarians face several challenges that a mentor can help them overcome:

 The belief that they are a fraud is a feeling described by many new veterinarians during the first years of their career. “It is important to encourage mentees and remind them that they do know what they’re doing,” Boatright said. A lack of confidence should not be equated to a lack of knowledge.

 Recent graduates are often overloaded by student debt. “We choose this profession because we love the animals and the people we work with, but it can be daunting for a new graduate to have all of these bills,” Boatright said. Having a mentor who is reassuring and can relate to the burden of creating a financial roadmap is a huge relief.

 Many factors will affect a new veterinarian’s confidence in their skill level, including school curriculum, externships, internship training, and personality. A 

 conducted by dvm360® asked readers what areas of clinical practice they felt least prepared for as recent graduates. More than half of respondents said they felt unprepared for dentistry, 49% for behavior, and 33% for nutrition.

In a survey Crocker conducted through her Instagram account (@CrockerPetVet), she asked what graduating veterinarians look for when searching for their first job. Mentorship was consistently among top responses, she said, yet only 46% of respondents said they already had a mentor. “It is important to realize that there is a need out there and that you can help fulfill that need as a mentor,” Crocker added.

Crocker said she would like to see more hospitals promoting mentorship programs in their job listings and discussing the program during new-hire interviews. Not only does having an established mentorship program attract new staff to your practice, it helps keep them. Mentorship reduces turnover and drastically reduces the high cost that hospitals incur from hiring and training new associates. 

 reported that less than one-third of new graduates surveyed remained with their initial employer for longer than 12 months. Lack of mentorship and support was a primary reason for leaving.

 “We know that if we can provide mentorship we can help bond these veterinarians to our practices and retain them for longer,” Boatright said.

Mentorship provides opportunities for the mentor to learn by being exposed to new ideas and the current veterinary education curriculum. “I have fallen more in love with veterinary medicine since engaging as a mentor,” Crocker said. “It has reminded me of why I went into veterinary medicine and why I love what I am doing. I think the idea of mentoring can be overwhelming, but it is definitely worth it if you look into it.”

People are generally convinced that becoming a mentor is a big commitment. But that is not the case, Crocker said. Mentorship can be conducted in many ways, both virtually and in person. The doctors also reminded attendees that mentorship is not always a long-term relationship. There are 3 common types of mentors.

These are virtual relationships that are primarily communication-based and conducted via text messages, emails, and social media. This type of mentorship is ideal for a mentee seeking advice and guidance without hands-on skills training.

“I have veterinary students who I consider mentees but have never met in person,” Crocker said. “I think that even if you are very busy and don’t have a lot of face time to give somebody, you can still take a few minutes to say, ‘I am open and available if you have questions or concerns or need a listening ear.’ You can do all of that virtually.”

“A virtual relationship can be really valuable,” Boatright added, confessing that even she and Crocker have not had the opportunity to meet in person.

Some mentorships occur through a single event or brief time period to help a veterinarian get through certain stages in life. It is not a maintained relationship, but it is valuable in the short time that it lasts.

In some instances, mentorships may span for a year or more and may even extend through multiple phases of a career. These mentorships tend to vary between in-person and virtual communication as time progresses.

There are many ways to connect with potential mentees, Crocker assured attendees. She recommended attending job fairs or offering to speak at school events. “Clubs are always looking for practicing veterinarians to share what their life is like,” she said. “You don’t have to be a well-rehearsed speaker. The students are hungry for your stories.”

Social media offers a way to engage with numerous students simultaneously. “I have found it very rewarding to interact online,” Crocker said. Through Instagram, she has shared her professional experiences and received positive feedback. “That is the main way students will reach out to me and ask to come and spend time at our practice or just ask questions. People are fearful of social media, but it is a more positive place than you might imagine, especially when working with the younger generation of veterinary professionals.”

In some instances, a mentorship program might benefit from a structured guide and well-defined agreement. “But it doesn’t have to be that way,” Boatright explained. “It can be a more casual structure.”

When establishing a mentorship program or individual relationship with a new mentee, she encouraged attendees to ask the potential mentee about their expectations. Do they want to schedule regular meetings to review cases? Or do they want conversations to be more relaxed? The American Animal Hospital Association 

 provide a comprehensive framework for developing a structured mentorship program.

Mentorships apply to teaching clinical and technical skills as well as soft skills. Different clinicians have strengths in varying areas, and it can be beneficial to have several doctors in a hospital mentor a young veterinarian.

Boatright and Crocker hope to see an ongoing cycle of mentorship develop within the veterinary profession. “You meet young veterinary students and help to encourage them and invest in their careers, and then they will go on to become mentors and reach back to the next generation to want to give back to the profession,” Crocker said.

Be prepared: A look at what you didn’t learn in vet school. 

. May 7, 2018. Accessed February 26, 2021. 

https://www.dvm360.com/view/be-prepared-look-what-you-didnt-learn-vet-school

Jelinski MD, Campbell JR, MacGregor MW, Watts JM. Factors associated with veterinarians' career path choices in the early postgraduate period. 

Tait J, Carpenter T, Davidson S, et al. The American Animal Hospital Association mentoring guidelines. 

https://www.aaha.org/globalassets/02-guidelines/mentoring/mentoring-guidelines.pdf

Becoming a mentor can be easy, rewarding, and monumentally influential. 

Are you ready to become a superstar mentor?

Our Fetch dvm360 February virtual conference started yesterday and the fun continues tomorrow. We will continue to update you with our latest conference coverage and other news affecting the veterinary industry.

 Here's a look at some of our conference articles and other headlines from this week.

 at Fetch dvm360, Colleen Best, DVM, PhD, CCFP, explained why and how setting and asserting boundaries can improve your well-being, build resiliency, and shape how you engage with the world around you.

Fetch speaker Tai Ogg, DVM, MPH, shares everything you need to know before transitioning from an associate veterinarian to a relief veterinarian. 

Kate Boatright, VMD, and Tannetje Crocker, DVM, discussed the significance of mentorship yesterday during their lecture at the 

BluePearl Specialty and Emergency Pet Hospital

 has released 2 reports outlining how the coronavirus disease 2019 (COVID-19) pandemic has affected pet ownership and veterinary practices in the United States.

 announced the appointment of Amanda Landis-Hanna, DVM, to the role of vice president of veterinary and animal welfare outreach.

Stay tuned on social media and dvm360.com for conference updates, articles, and more!

Check out this week’s top stories and our latest conference articles.

News wrap-up: Fetch dvm360 virtual conference coverage, plus more veterinary news 

—the first video-based professional community created to connect the veterinary industry through conversation—welcomed 

 as chief operating officer. Last week, the organization announced the appointment of Amanda Landis-Hanna, DVM, to the role of vice president of veterinary and animal welfare outreach.

Amanda Landis-Hanna. (Image courtesy of The Bridge Club)

In her new role, Landis-Hanna will work closely with The Bridge Club Students, a new division dedicated to helping veterinary students engage in the industry and build networks. She will also work to give animal welfare organizations access to The Bridge Club Pets, a forum for educational conversations between veterinary professionals and pet owners that give real-time answers to questions about pet nutrition, wellness care, behavior, and life-stage needs.

“Amanda has been fortunate to experience all sides of veterinary medicine. She will be an amazing mentor and facilitator for our students and further connect new pet owners with the education they desperately need,” says Catherine Haskins, The Bridge Club founder and CEO, in an organizational release.

Landis-Hanna has nearly 20 years of experience in small animal and exotic medicine, as well as shelter and relief medicine, in both corporate and private practices. Prior to joining The Bridge Club, she served for nearly 4 years as senior manager of veterinary outreach for 

“I am delighted to be working with The Bridge Club team to increase visibility to veterinary schools and animal welfare organizations,” Landis-Hanna told dvm360

. “The Bridge Club provides high-quality education in a convenient, quick format.”

To learn more about The Bridge Club and view upcoming conversations, click 

In her new role, Amanda Landis-Hanna, DVM, will work closely with 2 of the organization's key audiences. 

The Bridge Club names VP of veterinary and animal welfare outreach

For veterinary professionals, setting boundaries is a crucial part of self-care. After all, if you don’t set boundaries, your clients, patients, and colleagues will set them for you. According to Colleen Best, DVM, PhD, CCFP, setting and asserting boundaries can improve your well-being, build resiliency, and shape how you engage with the world around you.

® virtual conference, Best explained that self-care involves filling your proverbial bucket, and creating boundaries prevents you from having a leaky bucket. So what are boundaries exactly? Generally speaking, they are rules or guidelines for how we interact with the world, allowing us to live more intentionally.

“We need more than a cup worth of resources. The fuller our bucket, the more personal resources we have to share, the better we can do our job, the better we can interact with our family, friends, and community,” she said.

Before you can create healthy boundaries at your veterinary workplace, you must understand the types of boundaries and how to assert them in a confident but respectful way.

When we don’t manage our personal resources, we can’t support other people.

Myth 2: Boundaries are meant to keep people out. 

Setting boundaries helps us manage our personal resources. When we are low on these resources, we are actually more likely to push people away.

Myth 3: Boundaries are guarded and inflexible. 

Outward-facing boundaries help dictate how you use your resources (eg, time, money, energy). They are influenced by your values, physical and emotional needs, past experiences, and unique life circumstances. Setting boundaries based on your needs and values helps to diminish stress and improve well-being, said Best.

To set outward-facing boundaries, you must know your purpose, your values, and what’s important to you. Think regularly about where your resources go on a given day. Find out where your humor, patience, compassion, energy, and decision-making go. Do these resources get allocated in a way that’s aligned with your values? Only you can answer that question.

We need inward-facing boundaries to protect our sense of self, Best said. To set these boundaries, you must know what is and isn’t your responsibility.

When a client blows up at you because they can’t afford a procedure and begin calling you names, remember that it’s your responsibility to provide your patients with compassionate care and your clients with diagnostic and treatment options. What isn’t your responsibility is that your client just got a new car or that they waited until their pet was very sick to come to the veterinary hospital.

At the end of the day, when you have boundaries in place, it is easier to recognize that the client’s outburst is an attempt to shift responsibility and to move past it with less distress. “By appreciating what is mine and isn’t mine, I can guard my sense of self. The things that live on your hand, thoughts, opinions, beliefs, those are yours,” Best said. “When people try to label you, know your sense of self.”

Once you determine your personal boundaries based on your values, asserting them can help avoid conflict and negative experiences. You can’t expect people to know what your boundaries are. You have to be proactive about sharing them with others. “It’s up to us to say, ‘This is what I need,’” Best said.

Use these tips for asserting boundaries at your clinic:

 Share boundaries proactively to avoid conflict. If you need to leave early, for example, let your team know a week ahead of time (if possible), and remind them again that morning.

 Use a calm and level tone in your interactions with coworkers and clients.

Don’t be so quick to think the worst of your clients or colleagues.

 Initiate open discussions about boundaries. Taking the time to practice how to communicate your boundaries respectfully and compassionately will make these conversations easier.

Consider a time when someone infringed upon your boundaries, then determine how to switch gears so that you can better assert that boundary going forward.

Boundaries are life-changing. When properly asserted, they can help you live out your life’s purpose. To get started, Best advises writing in a boundaries-based journal for a week. Spend time identifying what your boundaries are and when you feel they are being crossed. Finally, ask yourself what you need to assert your boundaries openly with others.

Find out how (and why) setting and asserting boundaries can help you live a more purpose-driven and fulfilling life.

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Fetch dvm360 kicks off 2021 with new virtual conference

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