Telton Animal Hospital is an established suburban veterinary clinic in the Northeast that has served its community for 25 years. When COVID-19 hit, the practice continued to provide patient care while observing the social distancing mandates issued by the governor and recommended by the state veterinary medical association. Curbside visits were cumbersome initially but soon proved to be very efficient. In addition, the use of FaceTime and other telecommunication apps was well accepted by staff and pet owners alike.

When COVID-19 case numbers started to drop in the state, the governor began allowing a phased reopening of various non-essential businesses. Several weeks later, when retail stores had reopened with mask and social distancing requirements, the owners and staff at Telton Animal Hospital remained uncomfortable allowing pet owners into the facility. The clinic sent an email to clients and posted on the practice’s website and social media platforms that curbside pet care would continue for the near future to protect staff.

Continuing curbside care helped boost the morale of an already stressed staff. A staff member testing positive for COVID-19 would hurt the clinic’s ability to function, mandating the need to exclude contact with pet owners until a viable treatment or vaccine becomes available. These proactive steps, the owner reasoned, were the only way to ensure the viability and safety of the practice. Many pet owners understood the continued curbside policy, but many strongly disagreed.

Client complaints ranged from accusations of being unprofessional and unethical to insensitive and selfish. If the governor and state healthcare officials determined that entering a facility with caution was now safe, clients questioned why the practice was continuing to separate pet owners from their pets in their time of need. Several clients asked that their records be sent to a nearby veterinary hospital that was allowing clients to enter with their pets as long as they wore masks.

This was not the reaction the team at Telton Animal Hospital expected. Improved clinic hygiene and safety protocols had kept staff safe thus far, and the owner was not willing to roll the dice; curbside procedures would continue. A knee-jerk response to these disappointed pet owners simply stating that this is “clinic policy” was unacceptable, so every client who objected to the continued restrictions would be contacted personally and given an in-depth explanation of the clinic’s policy. In extreme situations, such as euthanasia and other dire circumstances, clients would be allowed into the clinic provided they were gowned, gloved, and masked. This policy would be reviewed monthly, with staff safety and clinic hygiene being the top priority. Unfortunately, a number of clients remained aggravated and disappointed enough to leave the practice.

This clinic owner felt that “better safe than sorry” was the right way to go. Do you agree with this clinic’s choice? We would like to know. Email us your thoughts at dvm360news@mmhgroup.com.

Phased and staged openings of cities and towns are based on both scientific healthcare recommendations and, to some degree, political pressures. Veterinary facilities are particularly vulnerable. For many practices, if a single staff member contracts COVID-19 everything will grind to a halt. This is not the case in most business models. For many types of businesses quarantines are instituted for an affected employee and business continues remotely. Veterinary workplaces require staff to work shoulder to shoulder to provide proper pet care. In view of the uniqueness of veterinary practice, I feel curbside care will be with us for quite a while and that our pet patients and their owners will do just fine.

Dr. Rosenberg is director of the Voorhees Veterinary Center in Voorhees, New Jersey. Although many of the scenarios Dr. Rosenberg describes in his column are based on real-life events, the veterinary practices, doctors and employees described are fictional.

Articles

As pandemic restrictions ease should veterinary practices get to choose whether they stop or continue curbside care? 

The Dilemma: the curbside care controversy

 scheduled for later this month combines three robust individual conferences (Fetch Baltimore, Fetch Kansas City, and Hospital Design 360), so it’s got something for absolutely everyone on the team. In this episode of the Vet Blast Podcast, Dr. Christman is joined by Jacqueline Whittemore, DVM, PhD, DACVIM (SAIM), who shares a bit about the lectures she will be doing in the conference’s gastroenterology track.

Dr. Whittemore, an associate professor at The University of Tennessee College of Veterinary Medicine, will cover four hot topics: probiotics, chronic hepatopathy in dogs, gallbladder diseases, and hepatic lipidosis.

“I think we’ve got a really great mixture of practical information,” Dr. Whittemore says. “Some of it involves really cutting-edge new research.”

Take a listen as Dr. Whittemore shares some nuggets from her talks and why she is so passionate about GI medicine. The virtual conference is scheduled for August 26 to the 31, so register 

Podcasts

In Episode 5 of The Vet Blast Podcast, Dr. Jacqueline Whittemore discusses the talks she is preparing for the virtual Fetch dvm360 conference later this month.

Episode 5: Highlights from the Fetch dvm360 virtual conference

New legislation and court opinions throughout the country are making what used to be a fairly clear prohibition on contractually specified competing practice instead a confusing puzzle of definitions, case-by-case interpretations, and newly enacted statutes.

In Massachusetts, for example, the enforceability of a noncompetition agreement may depend on whether it was entered into before or during the employment relationship. In Rhode Island, enforceability might hinge on whether the agreement is signed as part of a separation-from-employment deal. In Washington State, whether your noncompete will be upheld might depend on the salary you made when you signed the agreement or your pay rate when your employment terminated.

The increasing complexity around noncompetes creates just as big a challenge for practice owners (including corporations). On one hand, restrictions that are too broad could be struck down as not having a realistic relationship with the “goodwill protection” actually needed by the clinic that drafted it. On the other hand, if a noncompete is created with an insufficient duration or distance (perhaps for the sake of ensuring enforceability), the document offers little protection to the drafter.

Throughout the many years when practitioners’ noncompete terms were relatively certain to be enforceable in most jurisdictions, many drafters ignored or glossed over a potential companion or alternate provision known as a “client nonsolicitation language.”

Post-employment nonsolicitation clauses have existed for a long time. And in the new world of judicial and legislative distaste for noncompetes, these clauses may be moving to the forefront of veterinary employment law.

Simply put, a nonsolicitation agreement (NSA) expressly prohibits a former employee from reaching out to existing clients of their former employer for the purpose of encouraging them to quit that employer and instead come to the employee’s new employer (or a practice the employee might start up or purchase after exiting employment).

NSAs seem ideal at first blush. So why have they not been more widely used in the recent past? And, for that matter, if they weren’t popular before, why are they becoming more widely used nowadays?

A solid, enforceable noncompete still trumps an NSA

In a situation where a veterinary practice enters into an associate noncompetition agreement that is fair, reasonable, and signed in a state that “doesn’t hate” noncompetes, the train to enforcement is quick and fairly obstacle-free:

Obvious violation of the agreement may entitle the practice to an injunction or temporary restraining order. This stops the violator immediately, not a year or more later when the case might reach trial.

Proof is easily ascertainable. If the noncompete area is Manhattan and the associate goes to work near Times Square—boom, proof is complete.

The idea of hiring an associate who is burdened by a noncompetition agreement scares potential employers whose offices are within the noncompete radius. They don’t want to find themselves with no veterinarian (if a temporary restraining order is issued) and in the crosshairs of the new potential hire’s old boss, who might initiate a long course of noncompete litigation.

NSAs don’t carry the level of intimidation brandished by noncompetes. An NSA basically says: “Associate, you can work where you like but under no circumstances may you call up our clients or send them letters, texts, or emails suggesting that they come see you at your new spot.” That sounds fairly reasonable and, in fact, legislators look much more favorably on NSAs than on noncompetition agreements.

For example, the Rhode Island Noncompetition Agreement Act, which became effective January 15, 2020, places numerous limitations on noncompetition covenants in that state. However, it specifically 

There are three big drawbacks in enforcing an NSA:

Proving solicitation of clients is not easy. 

Evidence that an NSA has been violated often requires testimony from a client who has been “solicited.” Clearly, no client who leaves the old practice and has their records transferred is going to be willing to testify voluntarily that any solicitation occurred. That leaves the clinic that is trying to prove an NSA violation to identify clients who were solicited but chose to stay put.

The definition of “solicitation” is a moving target. 

Calling a former employer’s clients and recommending they change practices is clearly solicitation, but what if a client calls the departing clinician at home because he heard “through the grapevine” that she was moving to a new practice? Is it solicitation if the new clinic announces the arrival of the new doctor on its website? What if the veterinarian who is moving to a new practice states on her Facebook page that she is leaving her old job? If that is OK, can she also name her new clinic and say she is accepting new patients?

A new employer can take steps to mitigate the impact of an NSA. 

Once the departing DVM begins working at a new hospital, what is there to prevent the new boss from aggressively marketing the services of his or her new hire? The new employer was never a party to the NSA signed by his new associate. Further, nothing prevents an associate who has taken a new job under the cloud of an NSA from asking their new office to prepare a form to be signed by clients that they have come to that hospital to see that new vet entirely of their own volition.

Nonsolicitation law is developing and changing rapidly

The legal status of both noncompetition agreements and NSAs is in constant flux, owing to the strengthening of “right-to-work” advocacy. But just as powerful an influence is the rapidly emerging law of information technology. Competition and solicitation become very hard to define and control through legislation when social media and telemedicine challenge the imagination of even the most skilled drafting attorneys and judges.

The best advice for both private practices and corporate hospital chains looking to protect their client base and goodwill is this: Do 

 let your employment contractual language get stale; review it regularly and make an effort to see how your existing employment documents comport with developing and morphing law.

Christopher J. Allen, DVM, JD is president of the Associates in Veterinary Law P.C., which provides legal and consulting services exclusively to veterinarians. He can be reached via e-mail at info@veterinarylaw.com. Dr. Allen serves on

It’s no mystery that associate veterinarians, in an effort to figure out if their noncompete is enforceable, find themselves trying to solve, well, a mystery.

Understanding the limits of your noncompete agreement

As we all continue to adjust to this "new normal," we will continue to keep you updated with the latest news about the pandemic and our coverage of the veterinary industry.

View the video below for this week's top veterinary headlines:

Dr. Holly Sawyer says one of the best ways for clinicians to get more shut-eye is to 

have a competent, compassionate registered veterinary technician answer your after-hours calls for you

The UC Davis School of Veterinary Medicine has 

named Dr. Michael Ziccardi executive director of the One Health Institute

The veterinary student duo who co-founded the Association of Asian Veterinary Medical Professionals, or AAVMP, in April is 

 on a mission to showcase Asians navigating their way through veterinary medicine 

and to promote diversity and inclusion within the profession.

dvm360 is excited to announce that we be hosting 

on Tuesday, August 4, from 3:00 to 5:30 p.m. EDT.

Videos

News wrap-up: This week's veterinary headlines, plus our second virtual recruitment event 

, meaning penalty or fine,” began Mike Barletta, DVM, MS, PhD, DACVAA, during a recent 

 conference session. “It’s like you did something to your body, and now you’re going to pay the consequences.”

Pain is, of course, much more nuanced than its origin implies. According to Dr. Barletta, an associate professor of anesthesia at the University of Georgia College of Veterinary Medicine, pain can be either physiologic or pathologic:

, or acute adaptive pain—the kind that prompts you to pull your hand away when you touch a hot stove, can prevent injury and even promote healing after injury. 

 refers to chronic, maladaptive pain, which Dr. Barletta described as “an expression of the pathologic operation of the nervous system that can follow acute pain if not prevented or treated.”

“Nociception is everything that happens beforea noxious stimulus reaches the cerebral cortex,” explained Dr. Barletta. “It includes the periphery, nerves, and spinal cord—everything up to the cortex. Once that stimulus is processed by the cortex and the organism becomes aware of it, we start calling it pain.” Transduction, transmission, modulation, and projection are thus part of nociception. Pain occurs at the point of perception.

For Dr. Barletta, treating pain starts with an understanding of its anatomy and physiology, beginning with the difference between nociception and pain (see 

, followed by the five steps in the pain pathway: transduction, transmission, modulation, projection, and perception. With this foundation, the drugs to use for each step and why become more clear.

The first phase in nociception, called transduction, occurs in the periphery and involves special receptors called 

. “These nociceptors are the peripheral end-terminals of Aδ and C fibers,” explained Dr. Barletta. “Mechanical, thermal, and chemical stimuli open different potassium and sodium channels located at the end-terminal of these nerve fibers to activate transduction, in which energy is converted from one form (which can cause tissue damage) to another (an electrical impulse).” If transduction isn’t prevented or treated, he continued, tissue damage will cause the release of inflammatory mediators (histamine, bradykinin, tumor necrosis factor-alpha, interleukin-beta, interleukin-6, nerve growth factor, adenosine, hydrogen ions, adenosine triphosphate, and prostaglandin E2) that can bind to peripheral receptors and recruit more inflammatory cells, resulting in peripheral sensitization. Dr. Barletta referred to it as “inflammatory soup.”

According to Dr. Barletta, these inflammatory mediators can activate nociceptors that are usually silent to cause hyperalgesia (an overreaction to a painful stimulus) and allodynia (a painful reaction to a nonpainful stimulus, like touch). They also decrease the threshold for some receptors. “TRPV1 receptors are a really big deal in pain and usually have a temperature threshold of 45°C (113°F), which means you’re going to start feeling that a stimulus is really hot and painful when it’s at 42°C,” he explained. “Now that decreases to 35°C (95°F). If you’ve ever had a bad sunburn, for example, bathing in lukewarm water can feel super hot—like it’s burning your skin.”

Transduction can be prevented with local anesthetics, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids. “Local anesthetics block sodium channels, which is one of the reasons why we use local blocks when performing surgery,” Dr. Barletta noted. “As for opioids, most research findings concur that we have mu receptors in the periphery, and NSAIDs and corticosteroids decrease the inflammatory response.”

Dr. Barletta said he often gets asked whether animals should 

 be pretreated before a stimulus is applied. His response: “Ideally, yes. We definitely provide a local anesthetic and administer opioids before that.” Whether to give NSAIDs before surgery is a common conundrum, continued Dr. Barletta. “If I want to prevent pain, I should probably give as much as I can before the stimulus, but at that point, I don’t know how the surgery and anesthesia event are going to go down,” he elaborated. “What if the patient is going to be hypotensive for most of the surgery and now maybe its kidneys aren’t well perfused, and then I’m giving an NSAID on top of that? Those kidneys won’t be very happy.”

He explained that there are two options to choose from here: “Some say you should 

 wait to give NSAIDs until after surgery because you never know what’s going to happen. However, I’ve seen someone spay a healthy cat in 2 minutes. The animal doesn’t even have time to develop hypotension in 2 minutes, so in this situation it’s probably OK to administer NSAIDs before surgery.” However, he continued, if you’re performing surgery on an animal that’s pretty sick, such as a dog with hemoabdomen, it’s highly likely you’ll have to deal with hypotension. So, here’s Dr. Barletta’s rule of thumb on the matter: “If the animal is young and healthy and it’s a routine procedure, I don’t have any problem administering an NSAID before surgery. If it’s a critical patient, I’m probably going to wait until postop, as long as everything goes smoothly and pressures are fine.”

The myelinated Aδ fibers are thick (1-5 μm in diameter) and conduct impulses at a rapid rate (5 to 30 m/sec). “They have a small receptive field and are responsible for sharp, fast, transient, localized pain,” Dr. Barletta explained. “They can be either unimodal, in which they transmit only one type of signal (either mechanical or heat), or polymodal, meaning they transmit more than one type of signal (both mechanical and heat).” Aδ fibers are predominant in the skin, which is why you can localize pain pretty well when, for example, you cut your own finger.

The unmyelinated C fibers are thinner (0.25-1.5 μm in diameter) and conduct impulses more slowly (0.5 to 2 m/sec) than Aδ fibers. “Their receptive field is larger, and they’re responsible for the slow, diffuse, burning, gnawing sensation of second pain, which persists after a noxious stimulus is terminated,” Dr. Barletta said. “All C fibers are polymodal (mechanical and heat; mechanical and cold; and mechanical, cold, and heat).” C fibers are predominant in the viscera, which is why the pain from a stomachache can be difficult to pinpoint.

“In normal circumstances,” Dr. Barletta explained, “the myelinated Aβ fibers, which have a fast conduction velocity and a diameter ranging from 5 to 15 μm, are responsible for transmitting touch and pressure. But during chronic or pathologic pain, wide dynamic range neurons become activated and cause these fibers to start conveying signals as nociception instead of proprioception.” This changeup is caused by peripheral sensitization and central sensitization (also known as 

“After the nociceptors are stimulated in the periphery during transduction, the electrical signal travels to the dorsal horns of the spinal cord through the nerve fibers—Aδ, C, and (in chronic pain) Aβ fibers—via sodium, potassium, and calcium ion channels in a process called transmission,” Dr. Barletta said. “Aδ fibers synapse in lamina I-V of the spinal cord and C fibers in lamina II, which is also referred to as the substantia gelatinosa.” (See 

To block nociception during transmission, Dr. Barletta recommends local anesthetics, which primarily block sodium channels. “Interestingly,” he added, “alpha-2s can potentiate the local anesthetic effect, and some studies have shown that when you add dexmedetomidine to your local anesthetic it increases the duration of your local bock. Buprenorphine does the same thing.” When asked if he has a preference between dexmedetomidine and buprenorphine, Dr. Barletta explained that he prefers the former for economic reasons: “Buprenorphine is going to be more expensive. Dexmedetomidine is expensive, too, but the volume you use is very minimal, so you’re not actually spending that much money.” He does, however, make an exception if the patient is sick enough that he doesn’t think it will handle systemically administered dexmedetomidine.

Modulation occurs in the periphery, spinal cord, and supraspinal structures. Focusing on spinal modulation, Dr. Barletta explained that the response to peripheral nociceptive stimuli can be modified in the spinal cord by the release of local endogenous modulators and the activation of descending pathways. Opioids, serotonin, and norepinephrine, for example, can decrease the response to nociception, while glutamate, substance P, and prostaglandins can increase it. And when the response to nociception is enhanced, central sensitization can occur. “This can be the result of brief but intense nociceptor activity, such as a surgeon cutting through skin, or of inflammation and nerve injury,” he continued. “Over time, repeated impulse activity of C fibers, release of a variety of neurotransmitters by the Aδ and C fibers, and activation of N-methyl-D-aspartate (NMDA) receptors can cause central sensitization resulting in enhanced responses to impulses (e.g., hyperalgesia, allodynia).”

The presence of glutamate together with the depolarization of the cell membranes (which displaces Mg++ from the channel itself) in the dorsal horns activates normally dormant NMDA receptors. “This should ring a bell here,” Dr. Barletta paused to explain, “because there’s a drug we use every day in anesthesia that’s an NMDA antagonist: ketamine. Does it help prevent chronic pain? Unfortunately, that’s a hard study to set up. How can I really show that? Using it seems to make sense, but it unfortunately doesn’t work that well when used to treat chronic pain. It’s relief is very temporary.” Another unfortunate fact is that once these NMDA receptors are open and activated, it’s really hard to shut them down. This is one of the many theories that try to explain phantom limb pain, Dr. Barletta added. “You can remove the affected limb, but in the spinal cord all of this is still active. Neurons keep going into the dorsal horn where they release neurotransmitters that activate these NMDA receptors. The signal goes to the brain, and the cortex still thinks it hurts. That’s how nasty chronic pain is.”

Dr. Barletta noted that the downregulation of GABAergic and glycine receptor activity and the activation of microglia also occur during central sensitization. “All of this mimics what happens in the periphery for peripheral sensitization,” he said. “The microglia become activated and do exactly the same thing as white blood cells in the periphery—they start releasing interleukins, tumor necrosis factor, etc.—and all of this will recruit more microglia and it will just keep going on and on and you end up with this windup, or central sensitization.”

According to Dr. Barletta, NMDA antagonists, local anesthetics, opioids, alpha-2 agonists, and NSAIDs all work in the dorsal horns. He also noted that, while not often used clinically, antidepressants and anticonvulsants are used for the purpose in research settings.

“Projection,” explained Dr. Barletta, “involves the transport of the electrical signal from the spinal cord to the supraspinal structures.” Three main large tracts are involved: the spinothalamic tract (from lamina I-V to the thalamus), the spinoreticular tract (to the reticular formation and thalamus), and the spinomesencephalic tract (to the midbrain).

Once the electrical impulse reaches the cerebral cortex, it’s perceived as pain. Some of the drugs Dr. Barletta points out for blocking pain perception may seem strange, such as isoflurane and sevoflurane. “They’re not analgesic drugs,” he explained. “They act at the cortex, minimizing or stopping the perception of pain, but they’re not doing anything with nociception. That’s why if you’re anesthetized just with inhalants, I can perform surgery without you feeling anything, but nociception is still happening. So as soon as I turn the gas off and you start waking up, you’re going to be miserable.” Other drugs that work in the cerebral cortex include opioids and alpha-2 agonists.

Ultimately, pain is a multimodal problem requiring a multimodal plan for prevention and treatment. Dr. Barletta put it this way: “Multimodal analgesia is the idea. We’re trying to block, or even better prevent, these pathways at different locations and with different drugs to decrease the chance of creating chronic pain.”

In explaining how a noxious stimulus in the periphery becomes an electrical impulse in the cerebral cortex, veterinary anesthesiologist Dr. Mike Barletta ultimately makes a case for multimodal pain management.

From periphery to perception: the pathway to pain

The American Association of Veterinary State Boards (AAVSB) announced recently that the Florida Board of Veterinary Medicine has become the 44th US jurisdiction to accept the PAVE Certificate (Program for the Assessment of Veterinary Education Equivalence) as a part of the licensure process for international veterinary graduates.

PAVE evaluates the education equivalence of graduates of non-accredited veterinary programs outside the United States and Canada on behalf of participating AAVSB member boards. 

“The AAVSB is always laser focused on member boards having the right information at the right time to be able to make a licensure decision. This is especially pertinent today as our membership grapples with how to streamline the veterinary licensure process during the COVID-19 pandemic,” said AAVSB Executive Director James T. Penrod, CAE, FASLA, 

To attain a PAVE Certificate, an international student must prove they are proficient in English, pass the AAVSB’s Qualifying Science Exam (QSE), and complete an Evaluated Clinical Experience at an AVMA Council on Education–accredited institution.

In addition to North America, PAVE certification is also part of the veterinary licensure process in Australia and New Zealand.

Florida now accepts the Program for the Assessment of Veterinary Education Equivalence (PAVE) Certificate as part of the license process for international veterinary students.  