In the clinical research on human patient populations, the data suggest that the fastest way to induce and reinforce pathological panic is to remove any opportunity for self-control.
This column will focus on the extent to which we, as veterinarians, actually do harm and encourage problematic behavioral responses in our patients, using my neighbor's dog as an example.
This little dog, Tyler, is an intact male 12-month-old Cocker Spaniel.
Tyler, who belongs to a young couple renovating an old house on the hill above my house, periodically shows up to visit my dogs. These visits have decreased since his people put in a fence, but I don't complain because until he learned that my dogs were sometimes out in the yard and "available" he would wander in the opposite direction — toward active roadways.
This is a pretty dog-friendly neighborhood, but in the past year I've taken home a menagerie of neighborhood dogs including Tyler. (Some days I think that I am running a canine taxi service.) All of these dogs live with people who have fenced yards, but what the dogs are seeking is interaction, energetic play with other dogs and exploration of new turf.
Some of these dogs are neutered, but the Bloodhounds (show dogs) and Tyler are not. And, at the rate Tyler is learning to fear going to the veterinarian's office, he may never be neutered. Neutering decreases roaming in male dogs. Tyler would benefit from that association, but all he needed to know about avoidance he learned at the veterinarian's office.
I do much of my writing at home. My neighbors are terrific at respecting this, but they also know that if they have an emergency, it's always at least worth trying me at home before heading off to their veterinarian. When Tyler's owner called, she was pretty hysterical. She had not wanted to bother me, but she'd been intermittently trying to remove a deer tick from Tyler's head. She spent three hours looking for advice on the Internet. By the time I saw Tyler, he was missing a patch of hair over his left eye, was bleeding and was not happy.
I suggested that my neighbor sit at the kitchen counter and calm Tyler down while I found my hemostat. Tyler calmed down quickly, especially since my dog Flash, his buddy, began to lick him. So, I approached Tyler, reaching out a hand to steady his head, and he began to scream. Flash began to bark and to get between me and Tyler. My neighbor started to explain to the animal that no one was trying to hurt him as he jumped from her arms and ran around. When she caught him, we put on his lead and wrapped him in a towel. I again tried to approach him that engendered a more severe repetition of his frantic behavior. It was clear that removing this tick was not going to take five minutes. Of course, had it been easy, my neighbor would not have been trying to do it for three hours.
My neighbor then commented that Tyler hated to have his face, feet and ears touched. She no longer takes him to the groomer and instead chops off chunks herself because he becomes so distressed. She also told me that the last time she visited the veterinarian's office, it had taken four people to take blood from him, and he had been muzzled, while frothing and screaming the whole time. This blood sample was for a heartworm test. No wonder they had not wanted to take him to the veterinarian to be neutered. All they had previously told me was that Tyler became upset at the veterinarian's office. For a 1-year-old dog, Tyler takes "upset" to a whole new level.
Without even trying to work further on Tyler, I asked the client to get comfortable on one of the stools with backs at our counter. I put my dog Flash behind a gate, so that he could see Tyler, and Tyler could see him. Flash could not physically intervene. I double-checked that I saved the document on which I had been working and then found a small head collar, a spare lead, a jar of all-natural chunky peanut butter, a spoon to get the peanut butter out of the jar, and an additional hand towel on which my neighbor and I could wipe our hands. While Tyler was sitting in his mom's lap, feet nestled into a towel to prevent him from scratching her, I smeared peanut butter on the counter in front of him. He began to lick the peanut butter, so I smeared a little bit more on the counter close to him. When he finished that and looked at me, I put some on my finger and gave it to Flash while he watched. Then, I put some on my finger and offered it to Tyler. It took him a minute or two, but the more peanut butter I gave to Flash, the more Tyler became willing to lick my finger. I alternated between putting some peanut butter on my finger and offering it to Tyler while I continually moved my finger closer to him. Within about 10 minutes, I was able to rub the corners of his lips, his cheeks, and his back while he licked peanut butter from my fingers.
Then, I introduced the hemostat. All hell broke loose again.
I retrieved Flash's head collar and lead, and I put it on Flash. Then I re-wrapped Tyler, after he'd been allowed to run around with Flash a bit, and put him back in his mom's lap. Then, using the peanut butter and stroking his cheek, I gradually fitted the head collar. My neighbor was able to fasten and adjust the neck strap without any problem, but when it came to the nose loop, Tyler became anxious and reactive. I smeared peanut butter on the nose loop and let him lick it off. I allowed him to watch me take off and put on Flash's head collar multiple times. I fed Tyler through the nose loop until I could easily slide the loop all the way up his nose.
In another 10 minutes, Tyler was wearing a head collar. Why did I spend all this time fitting a head collar? I needed it because if he bucked or became distressed again, I wanted to be able to safely move him out of the room as quickly as possible, and when we actually got to the part when I removed the tick, I wanted to make sure that he couldn't flip up his head and fling the hemostat into my neighbor's face. After the head collar was fitted, we took Flash and Tyler for a little walk and romp around the kitchen while I showed my neighbor how to use the head collar. I then placed him back in her lap, feet in the towel.
I again started to accustom Tyler to the hemostat. First, I showed him that I could run it all over Flash's face and that Flash was fine with this. Then I smeared it in peanut butter and allowed Tyler to lick it clean. After he did this, I slowly moved the hemostat over his muzzle and around his lips, periodically adding a smear of peanut butter. I worked up to moving it to his head and ears only after he'd begun taking deep breaths, relaxed in his mom's arms, and started to blink calmly instead of staring bug-eyed at everything in reach. When I approached the region of the tick, Tyler began to shriek and twist, flailing at anything within reach. We were able to pick him up, comfortably suspend him in my arms and re-wrap him, close his mouth gently with the Gentle Leader, and calm him down in less than a minute.
We worked with the hemostat and the peanut butter again for a while. Then my neighbor took over holding the lead and began to put peanut butter on a finger positioned so that Tyler had to turn away from me — and expose the tick — if he wanted to lick the peanut butter. While he was taking the peanut butter from his mom, I began to move the hemostat all over his body again, while she rewarded him when he didn't react. Instead of going for the tick, I spent 10 minutes working around the region of the tick just touching him and telling him he was brilliant and giving him a lick of peanut butter every time he didn't react. Then, after once more moving the hemostat over his eyes and ears, while he focused on the peanut butter, I removed the tick. He didn't even notice.
None of Tyler's behavior was about the tick — it was all about panic. Just enclosing him to do his ears, check his teeth or wipe his eyes sent him in to frantic flailing. Holding his paw to cut his nails had become so problematic that his nails were no longer cut. And although the veterinarian had dispensed ear-cleaning solution, the clients had never been able to get close enough to the dog to use the cleanser once Tyler saw that they had the bottle. This is a Cocker Spaniel. He will need to have his ears worked on either to prevent otitis or to treat it. Ignoring his ears is not an option.
Because we are dealing with animals who don't understand what we are doing, a fearful response is a rational one from the dog's or cat's perspective. We are the members of the interaction with opposable thumbs and a well-developed neopallial cortex. When, in the course of doing our jobs thoroughly, we move at a pace in excess of that which allows the patient to learn about, understand, and not fear the procedure, we have caused the patient to suffer, and we may have created — at the least — a behavioral problem, and in the case of dogs like Tyler, a behavioral pathology. We supposedly do these things in the interest of time, efficiency, getting through our work day, and minimizing the potential for injury to humans. When I talk to veterinarians about changing the entire paradigm of patient care, I tell them that the reason for change is embodied in the phrase: "Pay me now, or pay me later". All the clinician has to do is decide which time period suits them.
By ensuring that a heartworm check took only 5 minutes, veterinarians treating Tyler have also been assured of a number of other consequences.
Yet, nowhere in this list have I yet discussed Tyler's overall well-being, his mental and behavioral health, or his sense of trust, reliance and self-control. The latter is critical, yet never discussed.
We often think animals have good self-control when they make our jobs easier for us, but true self-control allows the animals to have choices and to work with us. When we entrap them — behaviorally or physically — we remove the option of self-control. In both experimental situations designed to understand the underlying neurochemistry and neurobehavioral genetics of entrapment in afflicted rodents and in the clinical research on human patient populations, the data suggest that the fastest way to induce and reinforce pathological panic is to remove any opportunity for self-control.
Hysteria is an ugly thing, yet we see animals exhibiting it often, and we respond to it with some form of physical restraint. The one place where we can no longer use physical restraint to control potentially dangerous behaviors is in zoological medicine.
We now use only positive techniques to teach bears to offer their chests for auscultation, or primates to offer their arms for venipuncture. If we can learn to do this with animals that can kill us, surely we can learn to do it with animals that often would die for us.
Our pets deserve to be left undamaged mentally by us to the same extent that we assume we will not damage them physically. Tyler is 12 months old. How much more damage will he have to undergo during his life in order to ensure that he gets state-of-the-art veterinary care?
I know that practices are busy, but the choice is really whether you want to pay now or pay later. There are also hidden currencies. The participants of the Advanced Behavioral Medicine course of the North American Veterinary Conference - Post-Graduate Institute (NAVC PGI;
) elected to put together two "how to" articles for the veterinary and veterinary technician populations as their final project in the course. One article focuses on how to find a good trainer, and the other focuses on why veterinarians need to incorporate modern behavioral medicine into their practices. This group of about 30 veterinarians calculated the costs in actual time spent, in client good will, in staff burnout, and in overall job satisfaction when patients struggled compared with when they were compliant and calm. The course participants concluded that teaching the animals to be calm and meeting their behavioral needs was not only a smart humane choice, it was a smart fiscal one. The American Association of Feline Practitioners (AAFP) has just completed and submitted for publication Feline Behavior Guidelines, which recommend exactly the same thoughtful, measured and preventative approach to handling and treating cats in practice. Again, the joint goals are to minimize liability, injury and job stress, and maximize the mental well-being of all involved, including the patients.
Had someone realized that Tyler needed some special care, he might have learned to love the veterinarian's office. The veterinarian's office could have become the place where he went to lick peanut butter off the exam table and be played with. He could have had four- to five-minute visits where only good stuff happened for the same fiscal cost of a one- to five-minute visit where he learned that the veterinarian's office was a place to be feared.
Special-needs animals have special needs, and the earlier in the process we address these, the less often we'll have to do so.
Because Tyler was no longer acting like a spawn of Satan, I decided that I might as well check his ears and teach the client to trim his toenails. Because I had been using touch to his ears to desensitize him to the hemostat, it was relatively simple to switch to using my fingers to rub his ears on the outside, then to move on to rub the inside and outside of his pinnae simultaneously, then to lifting his ear in increments, until I had a good view of the inside of his ear.
This all occurred using tiny licks of peanut butter as a reward whenever he didn't react. I didn't clean his ears; I just looked. That's enough for the beginning.
When we had been trying to hold Tyler for tick-removal, it was clear that any pressure on his legs sent him into a frenzy. Accordingly, holding his feet for nail clipping was not likely to be helpful. Instead, I asked my neighbor to roll the towel and using the peanut butter we taught Tyler to put his feet flat on the roll. This extended his toes a bit and gave a good view of the nails. Then, without holding his feet, I was just able to trim a bit from each nail while he had his licks of peanut butter. Because my neighbor often played with Tyler by sitting him on his back feet while holding his chest, we were able to repeat the entire procedure on the back feet.
Finally, Tyler was allowed to play with Flash. I sent my neighbor home with instructions to smear the ear cleanser bottle in peanut butter and start to get Tyler used to it. She could uncap the bottle only when he stopped reacting to it. Ultimately, she'll be able to start administrating one drop and later an entire 'squish' into his ear and clean it. If she goes slowly enough and does it by herself, this process would take months, but she'll get there. She decided to get the type of good non-guillotine nail clippers to allow more control. I asked her to at least run the clippers over his toes daily and clip as needed. I also showed her how to sharpen the clippers. She's had no trouble since. I also sent her home with the head collar. Tyler still comes to visit, but when he is out and about in the neighborhood, he is walking confidently and without pulling on his brilliant blue Gentle Leader.
My total investment in time? One and a half hours.
How many Tyler's are out there? My conservative guess would be that far more than 50 percent of our patients who start out as a little uncertain, but happy-go-lucky cats and dogs learn to hate us quickly. I think that we most often use physical restraint in veterinary medicine because we can.
I am now on the faculty of a human psychiatry department at the University of Pennsylvania. Restraint is an ugly word and is always a last, and much struggled with, resort for the groups of human patients who are likely to be scared, confused and unable to comprehend what's going on: infants/children and those with profound mental/psychiatric disturbances. Given the damage we do, restraint should be a last resort for us, too.
If we accept that statement as true, we will do nothing more than revolutionize how we practice medicine. Tyler would approve.
Whatâs your question?Â Send your behavior-related questions to: DVM Newsmagazine, 7500 Old Oak Blvd., Cleveland, OH 44130. Your questions will be answered by Dr. Overall in upcoming columns.