Alyssa Mages, CVT, is a self-proclaimed “recovering marine biologist” who traded boats and ocean life for scrubs and emergency veterinary medicine. A graduate of Manor College, Mages spent 17 years as a successful veterinary professional and adjunct professor, but her career had not yet stopped evolving. She pivoted once again, this time adding entrepreneur to her résumé and teaming up with longtime friend Caitlin Keat to launch a business they are confident will have a lasting and positive impact on the veterinary industry.

In speaking with this dynamic duo, it is clear their passion is outpaced only by their drive. They are simultaneously insightful and sincere; there is no doubt you want Mages and Keat in your corner. Even the name of their budding company evokes their mission and values: Empowering Veterinary Teams (EVT). And that’s exactly what they do.

EVT provides comprehensive, multidisciplinary veterinary training and content that meets the industry’s ever-evolving needs and provides clients with the tools necessary to create positive and dynamic work environments.

“Our [adage] ‘Inspire, Instruct, Impact-Together’ is what we do for each other and what our ultimate goal is in the work that we do,” says Mages, the company’s chief visionary officer. Keat serves as the chief operating officer.

Mages’ career did not start with a veterinary rally cry, however. As a marine biologist, Mages could not shake the feeling that something was missing. She soon started volunteering at turtle and shark rescues on her days off and quickly realized veterinary medicine was her calling. Upon returning home at the end of the research season, Mages volunteered at the general veterinary practice where her cats were patients. “I was hooked and worked my way up,” she explains.

After working and volunteering at veterinary hospitals in both the United States and Canada, Mages earned her veterinary technology degree and acquired her CVT credentials in 2012. “It was the best decision I ever made,” she insists.

Mages thrived in her career in emergency medicine and went on to become an education development coordinator, which required her to oversee the onboarding, growth, and training of a 200-member practice. “It has definitely not been a straight line,” she concedes.

Although she enjoyed her position as an educator in the veterinary hospital, Mages felt constrained. “There was still so much I wanted to do,” she explains. “Being in veterinary medicine for 17 years, it was evident that there were things I would love to change.”

Her desire to branch out on her own and affect the industry came to a head 3 years ago as Mages and Keat discussed their roles as working moms in demanding industries. “I told her I could not do it anymore. I was working 60-plus hours a week, I didn’t see the kids, I did not feel like I was making a difference, and there was so much that needed to change. I had to do something,” she says. “That was the turning point.”

When it came time to make the leap, Mages knew exactly who she wanted to jump alongside her. Her friendship with Keat was formed by chance on a plane ride and solidified on the steps of the Taj Mahal (true story). “Alyssa’s ideas shoot for the moon, and I am the one who designs the rocket and maps out how long it will take,” Keat says.

Since launching in October 2019, EVT has worked with hospitals and veterinary companies to fine-tune aspects of their workplace standards that will keep them at the forefront of the industry. “Veterinarians go to college and veterinary school, but unless they have chosen to take a business path during their undergrad, they are not trained in management and business,” Keat explains. “Then they go out in the world and often find themselves managing people or buying a practice without a safety net. That is what we are here to be: the safety net. We bring our experience in managing and leading teams to make things easier for practices.”

“Veterinary support teams are the backbone of a practice and our industry,” Mages adds. “Not to take anything away from the incredible doctors that are out there, but the nurses, technicians, assistants, and client service representatives are running the day-to-day.” She and Keat work hand-in-hand with practices to provide the skills necessary to run more efficient, well-trained teams. “It gives them empowerment and grows the practice from the inside out, which creates an even bigger investment in what they do from day to day,” she says.

Included in their array of services are live and recorded webinars, leadership seminars, hands-on workshops (Mages crafts the manikins herself), training programs, and training materials designed for a hospital’s specific needs. Some clients choose to work with EVT for long-term projects, while others opt to take advantage of Mages’ extensive knowledge in one-day seminars. “We meet you where you are with what you need,” she says. “We can take practices from A to Z and everywhere in between.”

Whether meeting virtually or in person, for 1 day or 1 month, EVT strives to make their clients as excited about the tools and education they provide as Mages and Keat are. Mages recently led a 2-hour CPR class at a rural hospital in Pennsylvania. “Their practice manager is top-notch and the team is so keen to learn new things,” she explains. “They were very invested and excited.”

In working with a practice in Vancouver, British Columbia, EVT has created training materials that will set the standard for the hospital’s staff moving forward. “We are working on leveling and skills so that when you come into the job you know what you need to do to get to the next level and it doesn’t change from person to person,” Keat says.

The pair is also working closely with Scopio Labs to generate custom training materials, content, and videos. “It has helped cutting-edge AI technology get into practices and make a difference,” Mages says.

In addition to working one-on-one with clients, EVT hosted its first virtual conference in February. The I4 Intervention, which stands for "inspire, impact, and instruct with incentive," was held during lunch hours and at no cost to attendees. “The [conference] was really about starting the conversation around what we have been working on with our practices and bringing mental health into the forefront of our discussions,” Keat explains. The weeklong event focused on technical aspects such as mastering the process of teletriage as well as learning how to overcome imposter syndrome and incorporate wellbeing practices into the average workday.

The company hopes to host 2 virtual conferences each year, with the next tentatively scheduled for August 2021. “It is really to make sure we are recognizing that support teams need support more than 1 week each year. That is what it stemmed from,” Mages says, “Vet tech week is great, but they need more.”

Keep in mind, all of this was accomplished at the height of a global pandemic. Again, these are 2 women you want in your corner.

Mages says she could have never imagined her career taking the trajectory it has. “I have wanted to swim with the whales since I was 4. But you know what, I did. I swam with pilot whales, dolphins, sharks, and sea turtles. It was incredible, but it segued into a different path.”

Both women are thrilled their paths have led them to EVT and that they can now share their passion with industry peers. “Having flexibility and control over our schedules and the vision of the company is huge. It has allowed us to grow beyond the situations we were in professionally before this. We are not held back by titles or roles and we roll up our sleeves and get it done,” Keat says.

And Mages no longer has the feeling that something is missing from her career. “I can actually see and feel that we are making a difference,” she says. “We are connecting with so many like-minded people. I do not know if that would have necessarily happened if we were not forced into the virtual space. I appreciate the growth and the ability to have aha moments—both my own and to give that to people. It’s just so powerful.”

Amanda Carrozza is a freelance writer and editor in New Jersey.

Articles

Alyssa Mages, CVT, has found a way to combine her love of veterinary medicine with her passion for inspiring others to reach their full potential. 

Empowered women empowering others

Among the various bodily fluids, the pale yellow by-product of the urinary system is underrated. However, it has proved to be of considerable importance throughout history. In ancient times, urine was used as a fertilizer, applied in tanneries, and added to smelling salts, medicines, and mouthwash.

 In fact, physicians once called it the “divine fluid,” owing to its numerous applications, not the least of which was evaluating the health status of individuals. Urinalysis can provide valuable insights into the pathology of various conditions.

Urine can reveal the health status of the urinary system, particularly the kidneys. Strict hygienic measures should be maintained when collecting urine samples, and a fresh sample is always preferred. Urine samples can be collected by 3 methods:

Cystocentesis (preferred and most accurate method)

Urine samples should be evaluated within 30 minutes. If this is not possible, they may be stored at 4 °C (39 °F) for up to 24 hours. Refrigeration does not significantly alter the pH or specific gravity of urine but may result in the precipitation of crystals.

The color of normal urine can range from pale yellow to amber, depending on the amount of urochrome present in the sample. Brown-colored urine may suggest hemoglobinuria, and urine that is faint pink in color may indicate congenital porphyria or urolithiasis.

The transparency of urine in dogs and cats is affected by the presence of epithelial cells, crystals of calcium carbonate, and amorphous urates. However, in horses, cloudy urine may be normal owing to the presence of mucous membrane and epithelial cells. It would be useful to regularly observe or determine the normal color and transparency of a particular patient’s urine to detect any subsequent changes.

Urine that has a sweet smell may indicate diabetes. In patients with ketonuria, the urine commonly smells of acetone.

The solute concentration in urine is determined by its specific gravity. A higher specific gravity indicates more concentrated urine. A lower specific gravity indicates more dilute urine, which may be associated with renal diseases.

Estimation of the pH is useful in determining the efficiency of the kidneys to concentrate hydrogen ions and thus maintain the acid-base balance of the body.

Bilirubin is a by-product of the normal degradation of red blood cells (RBCs).

 An increase of bilirubin in the urine can indicate liver disease or the abnormal destruction of RBCs. Bilirubinuria (the presence of bilirubin in urine) is sometimes observed in dogs and can be due to a low renal threshold. In addition, canine renal tubular cells are able to catabolize hemoglobin to unconjugated bilirubin and then secrete it into urine.

Proteins in urine can be detected by the dipstick method, which primarily assesses albumin content based on a color change, using indicator dyes such as bromophenol blue. However, bromophenol blue poorly detects globulins such as the Bence Jones protein. The sulfosalicylic acid test is very efficient in detecting albumin and globulins such as the Bence Jones protein, even at low concentrations. However, the most accurate method of diagnosing proteinuria is by determining the protein-creatinine ratio.

Ketone bodies, specifically acetone, acetoacetate, and β-hydroxybutyrate, are by-products of fatty acid metabolism. Study results have shown that the dipstick test can efficiently detect acetoacetate to a great extent and acetone to a lesser extent, but is unable to detect β-hydroxybutyrate.

The presence of urinary sediments, casts, epithelial cells, hormones, and pus can be associated with clinical or subclinical renal disease, urinary tract infections, neoplasm, or pregnancy. Urine crystals, cells, and erythrocytes may disappear or disintegrate if the urine sample is kept for an extended period.

The diagnosis of neoplastic conditions can be aided by urinalysis. Various cancers of the urogenital system, including the urinary bladder, prostate, and cervix, can be detected in the urine. Even the early stages of pancreatic cancer can be confirmed through urinalysis.

The ancient technique of uroscopy was common practice almost until the 19th century. In more modern times, it has been replaced by more accurate and less time-consuming methods. Although advancements have been made, the pace at which technology in this sphere develops may still be lagging. Advanced techniques, such as the polymerase chain reaction, are now being used to detect a wide variety of bacteria in the urine and can thereby facilitate faster diagnosis of urinary tract infections. For example, tuberculosis can be diagnosed using urine samples.

Urinalysis is safe and simple, and as the only requirement from the patient is a urine sample, discomfort or pain is minimized. Greater emphasis should be placed on producing miniaturized point-of-care urinalysis instruments. These instruments should be designed for convenient use by clinicians, field practitioners, and clients and owners. Clients could perform the test and seek appropriate advice from their veterinarian.

The processes of urinalysis have evolved considerably. Further improvements are anticipated in the near future, with progressive scientific and technological advancements

Jove Jacob is a dvm360 Veterinary Student Ambassador and attends Rajasthan University of Veterinary and Animal Sciences in India.

Loeffler JM. The golden fountain—is urine the miracle drug no one told you about? Pan Afr Med J. 2010;5:13

Kumar M. From gun powder to teeth whitener: the science behind historic uses of urine. Smithsonian Magazine. August 20, 2013. February 15, 2021. http://www.smithsonianmag.com/science-nature/ from-gunpowder-to-teeth-whitenerthe-science-behind-historic-uses-ofurine-442390/#:~:text=Its%20high%20 pH%20breaks%20down,of%20flesh%20 from%20the%20skin.

Whitbread TJ. Urinalysis. MSD Veterinary Manual. February 15, 2021. http://www.msdvetmanual. com/clinical-pathology-andprocedures/diagnostic-proceduresfor-the-private-practice-laboratory/ urinalysis

Toribio RE. Essentials of equine renal and urinary tract physiology. Vet Clin North Am Equine Pract. 2007;23(3):533-561. doi:10.1016/j.cveq.2007.09.006

Chauhan RS, Chandra D. Veterinary Laboratory Diagnosis. 2nd ed. International Book Distributing Co; 2003:35-47.

Stockham SL, Scott MA. Fundamentals of Veterinary Clinical Pathology. 2nd ed. Blackwell Publishing; 2008:57-152.

Chew DJ, Schenck PA. Idiopathic feline hypercalcemia. In: Bonagura JD, Twedt DC, eds. Kirk’s Current Veterinary Therapy XIV. 14th ed. Saunders; 2008:236-241.

Constantiner M, Sehgal AR, Humbert L, et al. A dipstick protein and specific gravity algorithm accurately predicts pathological proteinuria. Am J Kidney Dis. 2005;45(5):833-841. doi:10.1053/j. ajkd.2005.02.012

Bhikane AU, Kawitkar SB. Handbook for Veterinary Clinicians. 3rd ed. Krishna Publication; 2010:295-298.

Investigators are examining urine to determine the causes and effects of disease.

The medical benefits of urine

A veterinarian recently discussed her challenges with curbside care with me. She explained that her team had finally adjusted to a new routine when one of her favorite patients was suddenly hit by a car and rushed into the clinic. Not only was she devastated, but her schedule was backed up for the rest of the day. There was so much she wanted to say to her clients that day but there was simply not enough time.

Perhaps the above story sounds familiar. In addition to curbside care challenges, many veterinary practices are experiencing a staff shortage during the COVID-19 pandemic. Some staff have caught the novel coronavirus and have had to quarantine for 2 weeks. Sadly, some veterinary professionals or their loved ones have succumbed to the disease.

Amid all the chaos, pet ownership has skyrocketed. Although we are thrilled that telework is inspiring more pet adoptions, clinics are overflowing with clients who have tons of questions we don’t always have the leisure of answering. Maybe you feel like the time-crunched veterinarian I was speaking with recently. If you’re feeling pressed, these strategies may help you maximize your day so you can provide the best quality of care to patients and the best service to their owners.

Telehealth is a simple way to add more time back into your day. For example, daytime triage shortens hold times. If you offer triage after your clinic closes, you can support your clients without personally answering calls.

Telehealth video allows you to see the pet in its home environment, which is especially helpful when there’s a mobility issue. (Cats love not having to get into the carrier to go to their vet!) Virtual visits also free up exam room space, save the client travel time, and usually shorten the time it takes to make a diagnosis. Another lifesaver is software that enables virtual appointments and electronic medical records to be made.

But even with all the above, some clinics feel they don’t have time to explore telehealth options due to the conversion process involved.

Employing technicians and assistants correctly can significantly help veterinarians in a time crunch. Much upfront information gathering can be done separately from the visit, whether by connecting face-to-face virtually, via telehealth or by telephone.

According to Bob Lester, DVM, veterinarians see around 15 patients a day on average, compared with 22 by optometrists, 24 by general practitioners (GPs), and 30 by dentists.

Why the variation? Optometrists, GPs, and dentists employ a team health care delivery model. Lester explains that back-of-the-envelope math shows that a clinic would see a 13% increase in patients if technicians took care of 2 daily. This would allow doctors to take on 2 additional patients.

When time is of the essence, information needs to be provided in briefer segments. It may be tempting to say a lot at once or within a shorter time period, but pet owners absorb information better in small doses. Think of enjoying a small chunk of food and taking the time to chew through it. Likewise, your client needs time to “chew” over the information you share. Before you deliver another chunk, ensure they understood what you said. Given the time crunch, it may mean providing the next chunk by email, phone, or a follow-up visit.

Have you ever dealt with a salesperson who rattled off a product’s benefits and rushed quickly to the sale? Your client is not purchasing a refrigerator, but rather entering into a long-term relationship with your clinic. That makes the “check” part an essential ingredient in your client discussions. Your responses will determine whether a relationship is ongoing or off-putting.

Even in good long-term relationships, there will be times when your clients are not complying with your recommendations. Was it because you provided too much information at once? Did they not understand? It’s your job to find out and make the necessary adjustments.

Let’s face it. Some client conversations are uncomfortable. That’s why choosing your words carefully is key. Avoid using offensive terminology. For example, pet obesity can lead to a wide range of medical conditions if not addressed properly. The problem? Many clients get confused or frustrated by the word “obese.” I recommend using vocabulary such as “a healthy weight,” as it takes the focus off the pet’s girth. Discussing body condition scores can also help guide your client to a data-based assessment. In some cases, you might use your hands to illustrate an ideal weight.

Additionally, try to avoid using “you statements,” as they can cause some clients to become defensive. Some examples include, “You’re being unreasonable,” or “You should call first,” or “You ought to switch to a prescription diet.”

Using alternative “I statements” is a great way to express your concerns while connecting emotionally with your client. For example, after sensing resistance, you might consider saying, “I want to work with you to find the right remedy.”

There is so much to say and so little time to say it. For more efficient and productive appointments, make full use of technology, technicians, and assistants, and choose your words carefully. This will not only save time but build strong and long-lasting veterinarian-patient-client relationships.

Dr Carolyn C. Shadle is the founder of Interpersonal Communication Services, Inc. Passionate about communicating with clients and teammates, she writes extensively and presents at conferences and hospitals frequently about various aspects of practice management. These include communicating in the virtual world, inclusive communication, gaining confidence when engaging with clients, and managing difficult conversations. She can be contacted at www.veterinariancommunication.com.

. April 2021. Accessed April 26, 2021. https://todaysveterinarybusiness.com/technicians-and-technology/

Being pressed for time can make you feel like your ship is sinking. Navigate the waves with these useful communication techniques.

So much to say, so little time

So many people are wasting time debating the “veterinary technician” versus “veterinary nurse” terminology. My thoughts? I honestly don’t give a hoot—I feel like it makes no difference to the public or nurses. What 

 worth fighting for is improving veterinary medicine education and shaping it to empower technicians.

I’m most passionate about discussing the numerous opportunities for technicians outside the clinic. It’s often drilled into our heads that we can’t do anything without a veterinarian (eg, perform surgery, make diagnoses, and prescribe medications), but that can be misleading. I challenge all veterinarians and licensing boards to think outside the box because this new movement of solo RVTs, The Vet Tech Society Movement, is spreading like wildfire across the country. My goal is to educate you on all the ways technicians 

As technicians, we play an integral role in assisting veterinarians in clinical settings. However, we should always encourage and uplift those technicians who wish to pursue a career outside of the practice. For example, I aid dozens of clients daily, on a call, or via Zoom. I educate them on how to supplement their income (or replace it, if they so choose) and create a more flexible work schedule.

Many of my clients have received a lot of pushback from veterinarians and their licensing boards. Some states go to the extreme, stating that an RVT outside of a clinic cannot be considered a registered technician. I would ask those who believe this to look at my business and explore what I do and how I am changing veterinary medicine.

I recently received a call from a frantic new client whose cat had developed Horner syndrome due to a ruptured eardrum from medication. Although her veterinarian had created a treatment plan, the owner was too nervous to medicate her cat. She was planning on leaving for a 7-day trip and asked the veterinarian if she could board and medicate her cat. But as there was no staff on-site on Sunday, she was told no.

On the bright side, 1 of her friends referred her to me. Soon after I received her call, I set up a consultation to discuss her cat’s needs and the veterinarian’s plan. She was very nervous initially, but I put her mind at ease by informing her about the treatment options for Horner syndrome. I updated the family regularly while they were away, as well as the veterinary practitioner. The cat recovered beautifully because she had access to a technician who was able to administer her medication properly.

I know things can’t drastically change in a day or even a year, but as a solo RVT and coach, I am an advocate for us and for change. New rules, new freedoms. Let’s do this!

Serena Pudelski, RVT, is a self-employed veterinary technician and owner of The Traveling Tech and Pet Consultant.

Why technicians are more than just in-clinic workers, plus a look at the many opportunities available to RVTs.

Amplifying the voice of veterinary technicians everywhere

When you applied to veterinary school, do you remember explaining why you wanted to become a veterinarian? During that time in my life, I viewed veterinarians as people who directly cared for their animal patients— and those who indirectly helped the people who rely on animals for milk, food, and/or companionship. 

Long before I heard of the One Health concept (the interconnection between animal and human health and that of plants and our shared environment), I was already demonstrating a One Health mindset. I answered that application question many years ago, and today, as a predominantly small animal clinician, I’m always considering One Health approaches to veterinary care.

When collecting a patient’s history for the subjective, objective, assessment/analysis, plan (SOAP), were you trained to learn about the patient’s environment? 

Is the cat indoor only? Is she the only pet in the house? What flea and/or tick preventive is given to her? When was her last dose? 

And when you find out that a client is pregnant or there is a young child in the home, do you think twice about prescribing a topical medication versus an oral one?

As veterinarians, we are very influential. People tend to trust us. We become part of families, receive thank you cards after euthanizing a geriatric pet, and can protect people from various zoonotic diseases through our one-on-one talks after we make a diagnosis.

Not convinced yet? Do these One Health-related questions look familiar?:

How many times have you discussed the risk of Toxoplasma in cats with expecting mothers?

Have you helped to ensure that a giardia-positive puppy does not inadvertently share this parasite with other animals and people?

Do you think about how can keep families safe when their dog has Leptospirosis? 

What do you say to elderly owners of a dog that you suspect has Methicillin-resistant Staphylococcus aureus infection?

If you answered yes, you've been applying a One Health approach without even realizing it.

Start educating your clients about One Health by simply discussing the pet’s condition, consequences of the illness, plus the possible impact the disease can have on the client and their family’s health. The answer to 

 we should educate our clients about One Health is also simple—we chose to join this great and influential profession to improve the health and well-being of others

By maintaining a One Health mindset—we can accomplish that mission and much more.

is the founder and president of One Health Lessons. She’s also a 2019-2020 AVMA Congressional Fellow and a practicing clinician in Virginia.

How to implement this global initiative at your veterinary practice, plus some strategies to get you started.

Why and how to educate your clients about One Health

“Keep on keepin’ on.” “Push through.” “When the going gets tough, the tough get going.” “You got this!” “Fake it till you make it.” “Dig deep.” “Every day I’m hustling.’”

Do any of those phrases actually instill peace? I’ve said them all at one point or another during times when, in all honesty, I didn’t have anything left to give. They soon became empty words poured into the hollowness that grew time over time. I was burned out, fried, and frazzled.

I recall a time when my peers looked to me for guidance and support, but my mental health was suffering. I asked myself, “What can I do to change this for myself and help those who rely on me? I started with research—and found more than I bargained for or was able to digest. I narrowed it down to my industry and, voila—I found validation that I wasn’t crazy.

Burnout is serious. Fortunately, there are many avenues to address it and better—prevent it. According to an article published in the 

Journal of Veterinary Emergency and Critical Care (JVECC),

 burnout is common among veterinary nurses/technicians, and (not surprisingly) it’s also associated with numerous undesirable outcomes – both personal and for our patients.

Researchers concluded that there should be more work-related interventions to reduce burnout and a greater focus on improving supervisor relationships and maintaining an appropriate patient-caregiver ratio.

 I agree with their points wholeheartedly but would also add that more supportive measures are warranted such as team wellness meetings, provisions for physical and emotional needs, and recognition of where the team is at as a whole, essentially being able to read the room and respond accordingly.

So let’s visit the concept of prevention. How can we stop burnout before it starts? Where you lie in the hierarchical structure at your practice likely determines the impact that you’re able to impart, initially. At the risk of being cliched, every journey begins with that proverbial first step, a small movement creating ripples onward, outward, and upward. Talk to your manager or supervisor about what you’re feeling, seeing, and experiencing. Then, offer a few solutions.

Having a private conversation can eventually lead to practice or company-wide discussion that will hopefully result in positive change. Assessing the care provider-patient ratio and setting protocols in place so that this isn’t overreached is key. Additionally, it’s crucial that you create a platform that allows everyone on your team to be heard. Provide physical outlets and emotional support options for team members. Ensure that personal days are encouraged and utilized. You could also try advocating to make sick leave and personal leave separate. These are just a few ideas and not all my own. Remember, research is your best friend.

The next part of reducing burnout is being able to identify when you’re singed before you burn up and out. What are some signs that you’re at the brink of burnout? Fatigue, irritability, making mistakes when that is 

 what you do, feeling ‘off’ – none of these should be ignored nor be a source of shame. Your feelings are valid, they are yours, and will impact not only you but your team.

Speak up, speak out, and you’ll not only help yourself but so many others. Take a deep breath, enjoy nature, or delve into a great book or movie. Get moving—ride your bike, run, swim, or do yoga. Call someone, journal, paint, bake or take time to be with yourself and be OK with who you are, where you are, and if you’re not OK, then you know it’s time to make a change and stop the fire that’s burning you out from spreading.

HayesGM, LaLonde-Paul DF, Perret JL, et al. Investigation of burnout syndrome and job‐related risk factors in veterinary technicians in specialty teaching hospitals: A multicenter cross‐sectional study. 

. 2020;30(1):18-27.doi: 10.1111/vec.12916

Reducing burnout in the veterinary profession, plus how to put out the fire before it’s too late.

Burning the candle at both ends

Many veterinary professionals agree that Fear Free is a great concept, but some argue that the protocols takes too long to be practical. I admit, I had my reservations when I became Fear Free–certified several years back, mainly because I was already comfortable identifying fear in dogs and cats. But it wasn’t until I became certified that I realized I had to rethink everything I knew about being a veterinarian, from exams to surgery to client education.

The more I incorporated Fear Free principles into my daily routine, the more instinctual the process became. Cats that were untouchable without injectable sedation could now be examined with feline-friendly handling and anxiolytics. Dogs that once thrashed during restraint were peacefully being vaccinated while licking a smear of squeeze cheese on the wall.

Fear Free emphasizes that a patient’s emotional health is just as important as their physical health. Whether you’re considering individual certification or seeking ways to save time, the following Fear Free techniques are a great place to start.

Have you ever started an exam on a patient only to find that the otoscope is across the room? Or maybe you forgot to pull up the vaccines. Not only does this waste time, but taking your hands off and putting them back on a patient can trigger a startle response. Save time and reduce stress by collecting samples in the exam room rather than bringing a patient to the treatment area. That way, they won’t be forced to adjust to new, high-traffic surroundings while waiting to be seen by a technician. Most exam rooms have a drawer that’s not being used, so fill them with syringes, needles, butterfly catheters, and sample tubes.

Who doesn’t love giving patients treats? Getting a fearful patient to take a treat from you during an exam can transform their emotional state. The more relaxed they are, the smoother the visit. If you’re seeing a patient for an annual exam or a concern that’s not gastrointestinal, try serving them pea-sized, tasty treats during the exam. If you need your hands to be free during vaccinations or when handling sensitive areas, spread squeeze cheese or squeezable treats on a surface at the level of the patient’s face to encourage positive reinforcement.

Fear and pain are often intertwined. For example, if you try to take x-rays of a limping patient without analgesics or sedation, you risk increasing their fear level and needing 3 team members to assist with restraining them. I never used to use pain medication for severe otitis, but then it dawned on me that there was a reason dogs with a history of recurring ear infections were head shy or tried to bite during routine otoscopy. They were afraid of the pain.

Even rethinking your approach to needle pokes can reduce fear among patients and promote efficiency in the clinic. How many times have you had to administer several vaccines to a patient only to find that by the second vaccine, it’s agitated and needs more restraint? Have you ever been unable to draw blood from a patient because they jerked every time you got the needle into the vein? Rethinking your needle size (my default is now 25 gauge for vaccines) and pretreating the area with an inexpensive lidocaine cream such as SuperNumb are both Fear Free approaches that can save time and reduce the patient’s stress levels.

The fear of falling is common among patients, yet we routinely put them on slippery scales or exam tables or grab them by their hocks and swing them through the air into dorsal recumbency for a cystoscopy. Instead, take 5 extra seconds to place a towel or a nonslip mat on the scale or exam table. Use the inclined plane approach for dorsal recumbency by angling the pet’s back against your kneeling body and let them slide down your chest and thighs into the trough. The more stable your patient feels, the easier they will be to handle.

When a technician comes in with a patient history on a clipboard with a page with multiple paragraphs on it, you know you'll be tackling several health concerns. If you try to work up every problem, you’ll get behind, and the result is an overwhelmed pet. Fear Free asks you to consider a patient’s wants versus its needs. Ask yourself these 2 questions first: (1) What is medically essential for that patient to have done during their visit? (2) What can wait until a recheck 2 weeks later with anxiolytics on board? Prioritizing what’s most important will help you stay on time for your appointments while minimizing fear, anxiety, and stress.

The COVID-19 pandemic has brought extensive changes to the veterinary profession, including an unprecedented number of owners who now are receptive to previsit anxiolytics for their pets. Remember, don’t wait until a patient shows signs of aggression to have that conversation. Just because the patient didn’t try to bite or scratch this time doesn’t mean they won’t during their next visit (especially if we continue to ignore the signals they’re sending). If you advocate for a patient when they’re showing mild to moderate signs of stress, you’re creating an insurance policy to help future veterinary visits go much more smoothly.

Julie Liu, DVM, is a Fear Free relief veterinarian in Austin, Texas. She’s also a freelancer and a mentor.

Simple and effective Fear Free strategies help your anxious patients feel more relaxed and save you time.


6 ways to save time with Fear Free

Although age is not a disease, it can be a risk factor when it comes to administering anesthesia. At the 

 virtual conference last week, Katrina Lafferty, BFA, RLAT, CVT, VTS (Anesthesia/Analgesia), a senior technician in the anesthesia and surgery department at the Wisconsin National Primate Center in Madison, talked about risk factors and considerations for anesthesia in neonatal, pediatric, and geriatric patients. 

A veterinary patient is considered neonatal from birth to weaning (about age 6 to 10 weeks) and pediatric from weaning to reproductive maturity (about age 5 to 6 months). It is important to remember that neonatal and pediatric patients are not just small dogs or cats. Rather, they should be thought of as still completing development of their organ systems. Lafferty noted that during the neonatal and pediatric phases of development there is a shift from placental/maternal control of circulation and organ function to the puppy’s or kitten’s own circulatory system and organs, and as a result these young patients have unique anesthesia considerations.

Although geriatric patients have fully developed organs, the organs begin to wear out as animals age. What age we should start to worry about this varies by patient size, with small-breed dogs being considered geriatric at about age 9 years, midsize canine breeds at about age 9 to 10 years, and cats at about age 8 to 10. Although some pets may seem “young at heart,” these are the ages at which we should start to consider that either overt or occult organ system comorbidities may be present.

Lafferty took the audience through the body system by system to discuss the various considerations when developing anesthesia protocols for these patients.

It is important to realize that baroreceptors are not fully mature until about age 12 weeks. As a result, blood vessels in puppies and kittens are unable to vasoconstrict to maintain blood pressure, so the only driver of cardiac output is heart rate. Whereas adults can increase contractility by 300% to offset deficits, neonatal and pediatric patients can only achieve a 30% increase in contractility. Further, hypoxia drives bradycardia, which perpetuates this cycle of low blood pressure. In a practical sense, this means a greater risk for profound hypotension, bradycardia, fluid overload, congestive heart failure, and pulmonary edema. In addition to normal physiologic risk factors, an estimated 17% of puppies and 5% of kittens may have undiagnosed heart defects. For this reason, all murmurs should be evaluated before anesthesia is performed.

Geriatric patients may have similar physiologic limitations but for different reasons. Instead of a cardiovascular system that is not yet fully developed, the risk in geriatric patients is that this system will fail to compensate because it is worn out. These older patients are similarly unable to cope with hypotension because their baroreceptors may be unable to compensate to the extent necessary.

Geriatric patients also have difficulty increasing cardiac output when necessary because of fibrosis and thickening of the heart or valves and altered cardiac conduction.

Physiologic and clinical anesthesia risks in geriatric patients are identical to those in puppies and include profound hypotension, bradycardia, fluid overload, congestive heart failure, and pulmonary edema. Geriatric patients are also at increased risk for cardiac defects, although these are degenerative rather than developmental. Twenty-five percent to 33% of dogs over 9 years of age have evidence of heart disease (eg, valvular disease, dilated cardiomyopathy, arrhythmias). Cats may similarly have increased risk for hypertrophic cardiomyopathy and arrhythmias with increasing age.

Young animals also have immature respiratory systems, in that their ribcage is very flexible and compliant, their intercostal muscles are weak and underdeveloped and can fatigue easily when taxed, they have an increased oxygen demand, and their chemoreceptors are less sensitive to changes in oxygen and carbon dioxide. Overall, young animals are less able to compensate when physiologic parameters require it. As a result, neonatal and pediatric patients are at greater risk for overinflation, atelectasis, respiratory fatigue, and hypoxemia. Clinically, this means we should always preoxygenate these young patients.

Geriatric patients also have similar concerns, but from weakened (atrophied) intercostal muscles, lower elasticity of lung tissue, pulmonary fibrosis, decreased elastic recoil of the lungs, decreased chest wall compliance, and decreased laryngeal and pharyngeal function. Although the reasons are slightly different, the anesthetic risks in geriatric patients are similar to those in neonates. Geriatric patients are at increased risk for atelectasis, impaired pulmonary diffusion, respiratory infections, and prolonged extubation and recovery. Just as with neonatal and pediatric patients, it is important to always preoxygenate geriatric patients.

Continuing the discussion of organ system development, Lafferty said that the immature hepatic system of neonatal and pediatric patients results in low glycogen stores, decreased gluconeogenic ability, and an immature cytochrome P450 system that limits drug metabolism as well as the ongoing metabolism of endogenous products. Clinically, with regard to anesthesia considerations, patients may have normal glycemic regulation when awake but are still at risk for hypoglycemia 1 to 2 hours into anesthesia. Further, extended drug elimination times and prolonged recovery should be expected due to the immature capacity for metabolizing anesthetic and sedative agents.

Geriatric patients also have a reduced capacity to metabolize drugs due to decreased microsomal enzyme activity, decreased liver mass, and decreased hepatic blood flow. Similar to pediatric patients, risks include hypoglycemia and prolonged recovery times; additional hepatic function risks in geriatric patients include hypoproteinemia, coagulopathies, and hypothermia.

The renal system is fully functional at approximately 3 weeks of age, so these very young patients may be at risk for prolonged recoveries or fluid overload due to decreased glomerular filtration and clearance rates, decreased reabsorption of amino acids and phosphate, and low concentrating ability. Geriatric patients are also at risk for renal insufficiency or renal disease. Clinically, geriatric patients may be less able to regulate blood pressure and more likely to have acid-base imbalances, azotemia, dehydration, and hypoproteinemia. Lafferty noted that even in normal patients, general anesthesia causes up to a 40% reduction in renal blood flow and glomerular filtration. So, caution is required in patients with the potential for renal impairment.

As a result of these immature or failing organ systems, including central nervous system, gastrointestinal, or endocrine system abnormalities, we must consider accommodating the pertinent risks when performing premedication, anesthesia induction, anesthesia maintenance, sedation, analgesia, fluid therapy, and perianesthetic monitoring and patient support (ie, temperature maintenance, intubation and extubation, and recovery). A key factor in evaluating risks in any patient is a complete and thorough physical examination. Lafferty mentioned a study in which a thorough physical examination in a population of geriatric dogs identified at least 1 previously unrecognized problem in 80% of cases.

Rebecca A. Packer, DVM, MS, DACVIM (Neurology/Neurosurgery), is an associate professor 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.

1. Davies M. Geriatric screening in first opinion practice—results from 45 dogs. 

. 2012;53(9):507-13. doi:10.1111/j.1748-5827.2012.01247.x

Old and young patients have unique needs when it comes to anesthesia. Understanding the pharmacodynamics of sedative, analgesic, and induction agents will improve safety and stability for all your anesthesia patients, regardless of age.

Pediatric and geriatric anesthesia considerations

Veterinary teams are comprised of a robust mix of individuals who share a common goal: to save and heal their furry patients. But what happens when their personalities and ideas clash? According to Family Vet Group’s Florida-based regional director of operations Emily Shiver, CVPM, CCFP, CVBL, things can get rather tempestuous. “In every practice, we have many different people that make up our team and each of those people have their own values, beliefs, attitudes, and behaviors,” she said. “Sometimes when you smush all of that together in a [animal] hospital, it can become quite turbulent.”

 virtual conference, Shiver identified common practice culture killers and offered guidance and solutions for nurturing a healthy and 

According to Shiver, if you’re experiencing an uptick in toxic behavior at your practice, the first place to look is management. “I always say it starts on top. So every single thing we in management positions do can affect our team. Whether we like it or not, that’s the truth,” she said.

So what causes this increase in negative behaviors? A few key contributors include a lack of structure (eg, policies, procedures, and scheduling discipline), no clear expectations (how your practice communicates with clients, each other, and job deadlines), no core values, and a lack of investment in your team.

If your practice is suffering from any (or all) of the above, consider doing the following:

Create/share core values, a mission, and a vision: 

These are the fundamental beliefs of your practice that highlight what will and won’t be tolerated. Shiver strongly recommends involving the entire team in this process.

Set and follow through with clear expectations

: Everyone should know the consequences of toxic behaviors and managers should immediately address those who practice them.

: Provide your team members with a platform to be heard, appreciated, and respected. If you take good care of your team, they 

perform at their highest level, said Shiver.

Additionally, she recommends taking time daily to listen to each team member —either collectively or individually—to discuss what went well and didn’t go well that day.

One of the most challenging hurdles within the profession is identifying and preventing 

. The current shortage of veterinary staff has led to increased burnout and compassion fatigue, causing many skilled people to leave the industry. To help avoid this scenario, consider changing up responsibilities. For example, if one of your team members is displaying increasing signs of chronic stress, switch up their role from a technician to either a receptionist or client service representative role (CSR). “Even if the change is for half a day, it can change that mindset,” said Shiver.

When it comes to improving mental health among your team, proper scheduling goes a long way. Shiver recommends trying out 

, which gives your team an extra day to unplug and reset. “Give regular check-ins [as well] and take the extra few minutes to see how you can help. Showing your appreciation and care can go a long way,” she said.

Practice managers tend to overlook toxic behavior, especially when it’s coming from a long-term team member. “When a technician of 15 years has their bad behavior overlooked, it brings me to the question: Who doesn’t like to have tough conversations?” Shiver said. As a manager, your job is to mediate complex situations and come up with solutions.

Here are some of Shiver’s strategies for approaching these challenging conversations at your clinic.

Teach your team how to have these tough conversations

: When team members have disagreements, your job as the mediator is to create a space for them to talk it out with each other. Encourage both parties to provide constructive feedback.

: In the beginning, there might be a lot of tears and a lot of people feeling attacked at first, but this is normal when building emotional intelligence, says Shiver. “Let them know this isn’t personal,” she said, “and that a solution needs to be created.”

: If you see team members competing with each other or breaking off into smaller groups, it’s your job to be the driving force and break them up. (Make sure you remain neutral. Don’t take sides.)

By improving your practice culture, you’ll not only observe a positive change in the attitudes and behaviors of your team but also in how your overall practice is run. Shiver leaves us with the following advice: “If your team comes to work every day and they are living in a positive practice culture and feel cared for and appreciated, they will take good care of your clients and stellar care of your patients. What that will do over time is create organic client growth."

Your veterinary team is integral to your practice’s success. Find out how to address negative behaviors and nurture a cohesive and positive workplace.

Firstline May June 2021