More on the essential work veterinary practices are doing right now and the key role they play in slowing the spread of the virus.
dvm360's Chief Veterinary Officer Adam Christman, DVM, MBA, continues his conversation with Beth Davidow, DVM, DACVECC, and Scott Weese, DVM, DVSc, DACVIM, about the what the COVID-19 pandemic means for the veterinary profession now and in the future.
Dr. Davidow, clinical assistant professor of emergency and critical care at Washington State University College of Veterinary Medicine, and Dr. Weese, professor of internal medicine, zoonotic disease, public health and microbiology at the University of Guelph Ontario Veterinary College, share their insight on these important topics:
To listen in on their whole conversation—or just bits and pieces—click on the video below.
Dr. Christman: Thank you. So, what we're going to talk about in this module is essential services, PPE (personal protective equipment), and a little bit of telemedicine, and veterinarians … using their due diligence and washing their hands. I'll ask both of you this: Is veterinary medicine classified as essential service, to let those of us know what that may be, and what are essential services?
Dr. Davidow: So, I'll go first, and I would say veterinary medicine for sure is an essential service for lots of different reasons. There's both the zoonosis and public health issues that we have to deal with. But there's also the human-animal bond, and our pets—especially in times of stress—are really important to us, and taking care of them is definitely critical. I think what we have to balance in this time is that PPE is something that is in short supply right now, and we need to make sure that we're not using it more than we need to. And even more important than that is, I think, that social distancing is how we're going to get through this crisis and get this virus to spread less. And so, as veterinarians, we have a responsibility to really only see those patients and those clients that we need to and put off those things that really don't need to be done right now, in this moment.
Dr. Weese: Yeah, I think there's certainly a moving target aspect of essential versus elective. I think we're all on the same page that veterinary medicine … is essential. There are certain things that are life-saving, there are certain things that have profound welfare issues for animals. There are zoonotic disease aspects. And there's human animal bond aspects. Many areas are kind of in the middle; we don’t really understand what to do, but that's where we need to keep thinking about it and talking about it.
And part of it is just sometimes we just need a pause, or we need to slow down for a couple of weeks. As Beth mentioned, PPE is one of the big concerns and PPE production is being ramped up. So, we need to kind of let things settle in and see what's going on. If human health care facilities all of a sudden get flooded with PPE, all their orders come in, then it's easy for us to, you know, maybe bring in more elective procedures, if we can maintain social distancing. If you're in an area where your human hospital is short of surgical masks, the last thing we want to do is burn through more of them.
So, we need to kind of reassess this, you know, week by week, if not day by day, to determine when we can start phasing back in, like this is going to get better, it's going to stop at some point. It's not going to be fixed in the next week or so. And it's probably going to vary with the measures that we do, we may back things off a little bit, we may have to implement them again, as disease rates go up. It's really one of the key things we're trying to do here, as a population, is keep the number of very sick people below the number of ventilators. Essentially, at the end of the day, that's the key. The number of people to get sick isn't really the question. It's when they get sick. Because if you're sick and you need a ventilator and there are none left, you're gonna die. So that's why you can see these rolling closures coming in. So, this is something we may need to be thinking about for quite a while.
Dr. Davidow: The other thing, I guess I would say, about social distancing, that there was an article in The New York Times that really brought this home to me where there was a party in Connecticut that had about 50 people at that party. And there was somebody at the party who actually did have COVID-19. Those people ended up being people from all over the world. And almost everybody at the party ended up being positive, and they took [the virus] as far away as South Africa. They were able to track those 50 and then they found out one of those 50 went to a party the very next night with 420 people and public health gave up at trying to track the outbreak at that point.
And so one of the things I thought about when I thought about that is that right now, as veterinarians, there's some veterinarians that during the course of the day might see 50 or 60 people. If you could actually cut that down so that your personal contact was much, much less than that, that does a big thing in terms of changing how public health tracks positive cases. And so even though you feel like maybe you can see that many clients in a day, I don't think that's the right thing for our communities to be seeing that many people and having that many points of contact. So it's really important to flatten the curve.
Dr. Christman: I was just going to say that because I like what Scott said. We really do just need to put a pause on things for now, and flatten the curve. So, elaborate a little bit further about flattening the curve out. Tell us a little bit more about what that truly means.
Dr. Davidow: Well, basically what it means is that we don't want the spread of this virus and the number of cases to be exponential. And so one of the things I've been looking at is if you look at New York City and you look at Seattle, Seattle instituted social distancing just slightly before New York did. And we're lucky in that we are a less populous state. Well, over the last 48 hours, the number of deaths in Seattle has increased by 25%, but the number of deaths in New York City has doubled. It's gone up 200%. Right now, the hospitals in Seattle, from what I've heard, are kind of OK. They have plans in place, they're going to be able to handle things as long as things don't grow. In New York City, they're very, very overwhelmed. And so I think the lesson to the rest of the country who hasn't had this yet, the way Seattle and New York have, is social distancing matters. And even if it means that your business is going to take a huge hit, the government is about to pass relief. We're going to be able to make it through this but as you said, we need to pause. It's important
Dr. Weese: And that's a key thing. Social distancing is what we need to do. If you look at the models, that's what works and it needs to be not just a little bit it needs to be a lot and it needs to be sustained. The only way we're going to keep things near capacity is with really aggressive social distancing. And this is where we get into the elective/essential discussion. OK, veterinary medicine is declared essential, which is good, but it can't be business as usual, at least at the start. Because, you know, we need to be able to do as much as we can. Social distancing for us doesn't mean no contact, but we can do a lot to reduce the number of contacts and the closeness of contacts. And part of it, is to think about how this impacts everyone else beyond our clinic.
So think about vaccination, right? One of the things we talk about with vaccination of people is we want to vaccinate as many people as we can to get herd immunity because there's some people we can't vaccinate, and we want to protect them. And we've got the same thing with social distancing. There's some people that can't social distance. If you're a health care worker, you can't social distance, at least as much as you want. If you're a paramedic, there are a lot of essential services where we can't social distance. A grocery store worker can't social distance as much as we want. So, everyone has to help and do as much social distancing as they can to help reduce that critical mass of transmission, so even though we say, yeah, we're an essential service, we still really need to be aggressive in our social distancing to make sure that we're not feeding the fire.
Dr. Christman: What are some things, then, that you know, when they talk about elective versus nonelective procedures? I mean, we know in our minds what that is, but do we clearly have a line that’s drawn between certain things so that way we can protect and save some of the PPE?
Dr. Davidow: I think there's some things that are very clear. If your pet’s been hit by a car, if they can't breathe, if they are in distress for some other reason, they got into a toxin, I think all of us would say that going to the vet is clearly essential. I think that rabies vaccines, getting your first one, is definitely essential. We know that those rabies vaccines probably last longer than we think so whether you're a couple days late or a couple weeks late is probably less important.
I think what's less clear is what about the pet who almost has an abscess tooth, but doesn't quite. Is that dental essential? I don't know. What about kennel cough vaccines? Certainly, kennel cough is rarely fatal, but a kennel cough outbreak is a real bummer to deal with in a metropolitan area. What about chemotherapy in an 18-year-old cat? Is that essential? Does that make sense given the amount of PPE? And I don't think we have the answers to those questions.
Dr. Christman: And Scott, what is your take on certain facilities that are running a little bit low on their PPE? You know, trying to stretch out to surgical masks or reusing gowns and things like that. What do you have to say about that concern?
Dr. Weese: You know, PPE is a big question and every facility needs to be really good on inventorying their PPE. You need to know how much you have, and you need to know how quickly you burn through it. And you need to consider locking some of it up. Clinics are seeing masks, in particular, disappear because people are freaking out and they're hoarding, or they’re selling them or whatever. We know multiple clinics that are losing PPE. So, you need to know what your plans are, if you've got lots versus you're running low versus you have almost none left.
Now there are things that we can do to stretch our PPE supplies, and we need to be thinking about it, because, you know, maybe as production ramps up internationally, we're going to be, you know, well stocked in PPE in a couple of weeks. But we've also heard it might be June, July or longer. It really depends on how much production happens and how much the human health care system needs. They're going to get it before we do, obviously. So, we need to think about how we can function without that. And that might be conserving.
So, basically, the three [ways] we want to approach it are its conservation as much as we can, extending use as much as we can, reusing where applicable. And then I guess the fourth thing is alternatives. And the problem is no one really knows a lot about this—who would do a study on reusing surgical masks four months ago? It's like, why? They're cheap, they're easy to get, we can get them by the billions, they're made in China by whatever numbers. We never thought about having to reuse things or doing alternatives to surgical gloves like we're in the 2000 whatevers and this is, you know, a historical issue. We've realized we need to know some of this information.
So, there's some things that we can do though. Surgical masks we can reuse, we don't crease them, we let them dry out. Gowns we can think about how we reuse them, we have alternatives. We have extended use, where you can use something on multiple patients, if they're in the same risk category. We can get into things like cloth masks, which might be okay, as we run out of surgical masks, they're not going to be as good, but they're better than nothing. So, we just released a document the other day about how to stretch PPE supplies, alternatives. There's not a lot of information that's out there, but everyone's realized that we're going to have to do things that we haven't done in the past. And even in the human health care side, CDC, various groups are coming out with no kind of limited guidance saying. Yeah, we know you're going to have to reuse it if you're running out. These are things you would have to do even though they're not great, but we're going to have to do them.
Dr. Christman: And what about gowns?
Dr. Weese: Gowns? Well, it depends on what we're using a gown for. And one of the things to think about PPE is what's it designed to do? Is it designed to protect the user or protect the patient? And for us, that's a big difference, right? Because something that's designed to protect the user, that's an occupational health thing. So, I'm very wary about saying, OK, well, we're going to be lax on that. Because I don't want to put staff at risk, versus some things we do to protect our patients. Well, you know, we want to protect them as much as we can. But there is that animal human difference. And there are things that we can do that maybe increase the risk in animals, but not by a whole lot. So, reusing a surgical gown, reusing a surgical mask, we're not putting our patients at much or any risk. So, if we're using the same gown in multiple procedures, and the gown is not soiled, it's not a big deal. We're using it again in surgery. And then we use that gown as a protective thing for an infectious case. there's basically no risk there.
But we need to think about how we use those things, how we save them and situations where it's not going to make sense, right? The kind of flimsy, yellow gowns we often use for infectious cases, trying to reuse them is a problem because taking it off without contaminating yourself, without tearing it, hanging it up somewhere where you're not going to contaminate the environment or someone that walks by, and then having the next user put it on properly, you know, sometimes they get inside out, which is actually the opposite of what we want. There are a lot of complicating factors there. So, I think everyone needs to think about what they can do with all their items. And we've got some guidance on that. But you have to figure out what works with your facility.
Dr. Christman: And probably the easiest thing that we all can do, right Beth, is literally washing our hands and helping to keep or the viral load down essentially or transmission. Right?
Dr. Davidow: I think that's one of the things. There were some studies done with the SARS virus, where they showed that the transmission of SARS was actually decreased by 30% to 50% just by the act of washing your hands. What's scary is actually if you look at health care, and especially in veterinary medicine, how few of us actually wash our hands properly or wash our hands at the right time. There was a study around the SARS epidemic in Hong Kong where they actually looked at medical students. And when they initially looked before the SARS epidemic, it was only like 35% of them actually wash their hands. That went up to 60% by the end of the epidemic, but still not 100%.
There was a similar study done actually in veterinary medicine where they looked in a veterinary school at how well people wash their hands. Twenty percent of us did it right, and that was it. With an educational campaign went up to 40%, but that's still not very much. And so I think a couple of things: One is soap kills this virus, soap in and of itself. And so washing your hands for 20 seconds before you touch a pet, after you touch a pet, before you eat your food, before you leave for the day, when you get to the clinic in the morning. It's a lot of times but if we actually did wash our hands before and after touching pets, and we wash the treatment tables before and after dealing with a pet, we’d do a huge amount to decrease the risk to us.
Dr. Weese: The scary part is some of those studies you talk about disease or when people were there watching people wash their hands and our rates are that low even though someone standing is there by the sink with a clipboard. It's amazing. We've done webcam-based studies in clinics and we got lower numbers, not surprisingly, because people forget about the webcams. But it's the vast minority of situations where they wash their hands and then when they do them, right, you know, the median time for washing hands and one of our webcam studies, I don't remember the number but it was low. You know, it's a swish, swish, wipe it on your pants and off you go, is often the way we do things even when we're dealing with high-risk situations. And then there's alcohol and sanitizers. soap is great soap and water will kill this virus nicely. But if you have to take more than two steps to get to a sink, you know, we tend not to do it even though we know it's important. And so that's where I got flooding the place with alcohol and hand sanitizers, so you can't turn around [without] bumping into one or you've got them in your pocket. The more we can use those, the better.
Dr. Christman: You know, and transitioning over that into our animals and pets, there has been a little bit of concern about this virus potentially living on fur of the animals or the animals acting as a fomite. Is this something that's possible? Or what are your thoughts on that?
Dr. Weese: Yeah, we have no idea. We’ve spent a lot of time talking, there's just no evidence to go by either way. No one looks at this stuff. There are very few people that look at companion animal infectious disease, which is the problem, and no one really thinks about that type of it. So we know it's an envelope virus, and doesn't survive very well. But there's a recent study showed up to a couple of days, two to three days on plastic and stainless steel. Now our pets aren't made of plastic and stainless steel. So what does that mean for a dog’s or a cat’s hair coat? Probably a shorter duration. But you know, if I'm infected and I've got my cat sitting on my lap, and I cough on him or I, you know, touch my face, which you do all the time, and I touch his face, which you do all the time, certainly there's gonna be some duration of survival there. So, from a veterinary standpoint, what we're worried about is that animal going right from the house, so you’ve got a positive person coming in right to us, and then we're … handling that animal. Is there a theoretical risk? Yes. Is it a realistic risk? We have no idea.
Dr. Christman: Right.
Dr. Davidow: So, I think this comes down to one of the things that's really important is that changing our protocols, and really making sure that we have a way that we're talking to clients is something that's going to be really helpful. So, the biggest questions that veterinary hospitals need to ask is, Are you sick? And is anybody in your household sick? Does that mean do you have a fever? Do you have a cough? Has anybody had a positive test? Even if you haven't had a positive test, you know, are you coughing? If that's the case, then what many veterinary hospitals are doing is that's when they're using their PPE to gather those animals to then bring them into the hospital and certainly those people should not be in your vet hospital if at all possible. And asking can somebody else bring in the pet but still realizing that that pet could have something on it.
If you have nobody in the household who's sick and nobody in the household who's had a COVID-19–positive test the risk that the animal is going to have something is much lower. And that's when really good hand washing is going to be probably what makes the most sense, as a way of not using that PPE when we really need it.
Dr. Weese: Yeah, I think that's a key point. This is a human-associated disease, right? There might be an animal side, that's niche, we need to sort that out. But the more we can screen, the more you understand what's going on in your area. So, your area, Beth, is different than ours because you have more disease and more community transmission. In an area where you've got more known cases and less community transmission, screening can be incredibly effective. Ask them and when they get here, or we do the 24-hour before call about their appointment to say, do you have any of these risk factors and, if so, okay, well, then it's like you said, Beth, do we have someone else bring it in, do we postpone [because] it's elective and it's high risk? Do we change how we admit, or do we know just to come out in our PPE? And even though we don't know there's a risk, we can do some simple things, but only do them on a small subset of the population. So, we're burning through maybe a couple sets of gloves and gowns a day as opposed to dozens.
Dr. Christman: Right. We're having such a problem where we are in Jersey, we're right outside of New York. And the biggest thing with us now are the testing kits. Now they have so many tests that they're doing to identify, obviously, the positives. Do you think that that is obviously probably a better indicator than asking those kinds of questions? This is more not as subjective this stuff was more quantitative. It gives us more indication if we have a coronavirus-positive human patient.
Dr. Davidow: Well, I think the testing is critical for communities for us to understand how widespread the virus is, understand a little bit better of how many people are asymptomatic versus symptomatic. We need all that testing information. Even more valuable would be getting not just the PCR testing that tells if somebody is infected, but it would sure be nice to know who has antibodies and who's therefore protected and less at risk. It's going to be a [while] until we get that information.
On the veterinary side, I think what's really important is, again, when we're talking about couldn't animals be a fomite that gives a veterinary staff member a disease, I think understanding, really, you know I honestly think that we should be doing curbside check-in with everybody at the moment. And that's what most of the hospitals in Seattle are doing. But how careful do you need to be with that pet is really, you know, how many respiratory secretions are they doing? So, if you're coughing or you have a fever, I need to be really, really careful with your pet. If you're asymptomatic and haven't had any reason to be tested and aren’t positive, then I'm a lot less worried.
Dr. Weese: Yeah, we can't really rely on testing because it's so variable in some places, how much is getting done and, and really, they're backing off testing in some places. If someone's really mildly affected, you don't want them going out in public and waiting in line and getting a test. Testing is useful to understand the epidemiology. But once you know it's out in the community, you'd rather have everyone that's sick just stay at home, unless you need to go to a healthcare facility, stay home.
So, we need to be aware of people that have risk factors and there are ways to screen. In Ontario, there's a website that government has set up; it goes through a series of questions and says okay, you should self-isolate or various things. So different places have tools like that that people can use. So that's one thing. If we have staff member that's not feeling well, okay, well stay home first, do the online screening tool. Let us figure out if there is a risk, because this is hitting in cold and flu season. If they’ve got flu I don't want them in our hospital anyway, because I don't want everyone getting sick with flu. I don't want new fevers, new coughs freaking people out and confusing the situation. The more we can control flu and colds, the more we can manage our things better in clinics so any respiratory disease is a big flag that there might be something going on and we're erring on the side of “if we're not sure stay home.”
Dr. Christman: Absolutely. And one thing I just want to follow up on, finally, is we're talking about curbside check-in as a means of social distancing. Another thing that we're doing a lot of is telemedicine. Have you guys had any experience with using telemedicine in the past and I know it's exploding now?
Let's say if this doesn't change telemedicine in veterinary medicine, nothing will. Because if we haven't come out of this in a year or two years with more, it's just not going to get applicable. I think telemedicine has a lot of potential. We can't do anything, everything—we can't do surgery—but there are a lot of patients that we can manage with phone, FaceTime, Skype, whatever it is, because common things occur commonly and an animal that's got mild disease, and you can get enough history, people can drop samples off if it's urine or feces, we can leave medications. A lot of self-limiting diseases we just need to talk to people about so I think there are a reasonable number of things that we can do. Someone does surgery and they're worried about the pet’s incision. Well the first thing we do is call up, stick your phone on and let us take a look at it. ‘Oh, that's a normal suture reaction. Here's what you do if it gets worse or changes,’ but we can keep a lot of these people out of the clinic.
So, I think telemedicine is going to change. I think we're seeing some regulators being a little more lax now, saying it's not just something for this stable patient that’s well maintained and for this disease we know about. If we can use these for kind of newer conditions, within reason, like we have expectations of being wise, but this will open the door to people, I think, really thinking about telemedicine that hadn't in the past.
Dr. Davidow: Yeah, I think it's been interesting in Seattle because there were several clinics who had already started to use some telemedicine and so they were very easily able to just convert very quickly to using it in a much more widespread way. Everybody else is starting to try to use those platforms. I think one of the things that's important in this time of crisis or if you have to make a quick pivot is realizing that there are some platforms out there, but sometimes telemedicine means that I'm going to a Zoom Room or using Google Hangout or having a FaceTime chat with somebody. And so there are things that all of us can do right now, to try to minimize, again, how much personal contact we're having. I think it's, again, as Scott said, really good for simple things. Again, there is still [the] need [for] a veterinarian-client patient-relationship. This is not something I would be doing with somebody with some pet I have never met before. But if I have a client who's come to my hospital, they've been in the last year. I think this is a really good opportunity to see what we can do with the technology. And I think until you try it, we don't really know how well it works exactly. And what are its limitations and it's positives.
Dr. Christman: Absolutely. I think our profession sometimes we're a little bit slow for change, but now this is really putting a match under us to say, okay, we really need to give telemedicine a try and see how it goes.