Q&A: A vet tech with heart

Portrait of the artist as a young veterinary technician. (Photo courtesy of Ed Durham)Inspired by his stepfather DVM's cardiology knowledge, Ed Durham, CVT, RVT, LATG, VTS (cardiology)-today senior veterinary technician at Ross University School of Veterinary Medicine (RUSVM) and editor of Cardiology for Veterinary Technicians and Nurses (Wiley Blackwell, 2017)-has made a decades-long career of studying the heart and proving to veterinarians that veterinary technicians can do more than anyone ever thought possible.

In this exclusive interview with dvm360, Durham shared with us his origin story (up in the sky, it's a bird, it's a plane … it's an ECG!) as well as thoughts on his new textbook and exactly what vet techs should be learning-and practicing-when it comes to affairs of the (pet) heart.

dvm360: Why cardiology, of all things? What inspired you to learn so much about it? A particular patient, a particular event, a particular mentor, a particular passion?

Durham: My love of cardiology started when I was working with my stepfather. He was the go-to veterinarian for cardiology in Mesa, Arizona, in the 1970s and 1980s, when there were no cardiology specialists in the area. He also worked with a local human cardiothoracic surgeon in research, and I came to work with the same surgeon at a human hospital. I was privileged to work with some of the best human open-heart surgeons in the Phoenix area in research that led in 1985 to placing a non-FDA-approved “total artificial heart” in a human patient until a new donor heart could be located.

Cardiology is that mystery, that unknown thing in a black box.

Then I took a position at the University of Missouri, working with John Bonagura, DVM, MS, DACVIM, in the veterinary teaching hospital. He showed me the intrigue of internal medicine over surgery and spurred my career with his mentorship. I became fascinated with the structure and fine function of the heart and vascular system. Over the years, with cardiologists Alan Spier, DVM, PhD, DACVIM, and Deborah Fine, DVM, MS, DACVIM, we performed cardiac catheterization, including implantation of pacemakers.

One patient that stands out for me was a dog named Molly. Molly was a search-and-rescue dog that located people buried in the rubble of earthquakes and tornadoes. She developed a complete heart block and needed a pacemaker. After treatment, she returned to seeking out the injured in catastrophic events. We affectionately dubbed her “Unsinkable Molly.”

dvm360: Did you ever think about veterinary school, or is there something about veterinary technology that drew you to this role?

Durham: I did consider going to veterinary school but chose not to. I realized early on that we have lots of great vets-what we need are more great nurses. I charted a course for myself that would allow me to be a “mover and shaker” of the veterinary technology profession.

I thought I should go to vet school and become a dog heart surgeon. Not a terribly practical choice, I found out. Open heart surgery is a very limited field in veterinary medicine.

To that end, I worked with other veterinary technicians to create an academy for those who want to specialize in internal medicine. My section was cardiology, of course. I served as director-at-large for the Academy of Internal Medicine for Veterinary Technicians (AIMVT) for 12 years. We wrote the examination for the Veterinary Technician Specialist (VTS) certification in cardiology. From there, we realized there was a dearth of textbooks for veterinary technicians who wanted to study cardiology. Cardiology for Veterinary Technicians and Nurses attempts to solve that problem. The contributors are all either boarded cardiologists or charter members of the AIMVT and hold a VTS in cardiology. My ultimate goal is to become a professor at a veterinary technical college.

dvm360: What took you to RUSVM, and how long have you been in the Caribbean?

Durham: I moved to St. Kitts in November 2015. The anesthesia department at RUSVM had an opening, and I felt cardiology was important enough to anesthesia that I could still use it. The challenge of learning a new discipline closely related to cardiology and getting to live in the Caribbean were irresistible. St. Kitts is a beautiful island with the most delightful people. Living in a place in which I can swim in the ocean before work is a dream come true for me.

During my years at Missouri, I worked mostly with senior-level students in their last year of study. At RUSVM, the students are just at the stage of leaving the classroom and starting with more hands-on skills. This shift from written to oral examination can be difficult for many students at first, but with careful guidance they're able to make the paradigm shift. The school has put me in a place where I can have a huge positive impact on these students.

dvm360: Is there anything that's harder or easier about veterinary medicine on St. Kitts compared to the States?

Durham: St. Kitts and Nevis is a smaller island, and pets are not as common as they are in the U.S. Many of the animals are farm animals (mostly livestock) or strays. In most cases, pet care on the island is general practice, with specialty and advanced surgeries referred to the school.

RUSVM gives students an opportunity to gain hands-on experience researching tropical diseases, see what veterinary medicine has to offer outside of the U.S., and prepare to meet global health needs. These students are exposed to practicing veterinary medicine without all the advanced technology. They see how their skills will not just create a better life for pets, but in developing countries how veterinarians are integral to the food chain and the income of families.

(Photo courtesy of Ed Durham)dvm360: What's changed the most in veterinary cardiology as you look back? What hasn't?

Durham: The most significant change in cardiology has been the advent of new medications like pimobendan, which has significantly improved treatment of congestive heart failure. We even have evidence now that early use of pimobendan can increase the sign-free period in many dogs with heart disease. This data was just released in June of 2017.

The other change I'm excited about is the advancement of pacemaker technology. At the beginning of my career, we couldn't do physiological pacing, and we were relegated to simply maintaining a dog at a fixed heart rate all day and all night long. Today, the most modern pacemakers developed by the manufacturers do a better job of mimicking the patient's normal function by providing heart rate variability that will actually change with the patient's activity minute to minute.

The most significant change in cardiology has been the advent of new medications like pimobendan.

One area that has changed little is electrocardiography. The technology for identifying and characterizing an arrhythmia as an electrocardiogram was invented in the late 19th century, and it's an extremely valuable diagnostic I feel is underused by most veterinarians. It's not as difficult as many believe!

2 things vet techs could do more often

It's no surprise, but cardiology veterinary technician Ed Durham thinks listening to the heart and reading the heart can and should be part of veterinary technicians' toolboxes. Durham says he knows both skills take time to learn, but they're invaluable to the veterinary technicians, their patients and the grateful doctors who partner up with more capable vet techs.

Much ado about murmurs: Durham really, really wants veterinary technicians to take the time to learn to do a good physical exam that includes auscultation. “That's something well within the reach of any veterinary technician,” he says. Some veterinary technicians are told all they need to do is listen for a heart rate, and that's disappointing, Durham says.

“[With auscultation,] the cardiologists would use me as a backup for subtle murmurs. [If] there were three people in the room, I would help with the decision,” he says. “Murmurs and other heart sounds like gallops can be very transient-one person might hear it, a second person can't, then [back in] radiology the murmur's back again.”

Don't tell yourself, “Oh, I don't need to hear a murmur because I'm not going to do anything about it.” Veterinarians who know their technicians are good at auscultation and physical exams can respond faster and better to patient signs sooner, Durham says: “If a technician comes into the room and [gives the doctor] heart rate, respiration and says, ‘I heard a grade III left basilar systolic murmur,' then the veterinarian can go in and immediately be more attentive to what's going on.”

Excelling with ECGs: Coming in a close second on Durham's most-wanted skills for technicians working with patients in practice is reading ECGs. This is already happening more and more, Durham says: The veterinary technician is already the one monitoring anesthesia and doing most of the monitoring in the intensive care unit. And it's not impossible to learn, he says. “Veterinary technicians should be given a little time to learn it,” he says. “We need to be able to right away recognize arrhythmias under anesthesia.”

Today's veterinary technician is not the passive patient holder or instrument passer in Durham's world.

“There was a time when a veterinary technician would ask, ‘Can you explain to me why this is?' [And the doctor would say,] ‘It's not important for you to know, just know that's abnormal,'” he says. “The veterinarians who've graduated in the last 10 to 15 years, they've learned from technicians in vet school how skilled we can be. They're leaving school and want their technicians to advance.”

dvm360: What key things in your new book Cardiology for Veterinary Technicians and Nurses do you think are absolute musts for all technicians?

Durham: I find the echocardiography, interventional procedures and congenital heart disease chapters very interesting, but knowing how the heart works and how to detect abnormalities is an important skill for veterinary technicians. For example, some murmurs and gallop sounds are labile and may be not apparent to the DVM, but they might be heard by a skilled veterinary technician during the initial TPR exam. If the DVM respects the veterinary technician's opinion, serious disease may be identified early and appropriately treated.

dvm360: Where do you think cardiology needs to go next?

Durham: I've been working on an idea to create a new position for veterinary technicians who want something bigger, better and more lucrative than the standard position. I'd like to see cardiology technicians take more of a role in performing echocardiograms. In human medicine, an echosonographer performs the echocardiogram, and then a cardiologist interprets it. In veterinary medicine, veterinary cardiologists perform their own echocardiograms.

I want cardiology veterinary technicians to perform the bulk of echocardiograms, with cardiologists visiting the lab at the end of the study to take the probe and review the heart without spending valuable time collecting the standard image planes. Qualified cardiology veterinary technicians can also perform the measurements, freeing up the cardiologist to spend more time with clients and patients that require their attention.

This role is similar to what we see in anesthesia. The boarded anesthesiologist rarely “sits” a case but directs the actions of the qualified veterinary technicians.

dvm360: Our data shows that vet techs think they don't get enough training in cardiology during school. Do you agree? What would you consider adding to the curriculum?

Durham: Many veterinary technicians tell me they find cardiology intimidating or confusing. They're exposed to some concepts in school, but perhaps not enough to make a difference in how they perform their jobs. Schools could benefit from a cardiology veterinary technician specialist teaching cardiology.