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Technicians can be a huge asset when emergent patients are brought into a veterinary hospital, as this case report illustrates.
When a trauma patient presents to a veterinary hospital, many things must be done immediately to stabilize the animal, determine the primary problems, and figure out how to correct them. Practices that utilize their credentialed veterinary technicians to the fullest extent possible will run much more smoothly during emergency (and many other) situations. Trauma can be daunting due to the dynamic and potentially critical nature of the patient, but with our thorough knowledge of emergency medicine, technicians can help navigate these cases efficiently and effectively.
The following case highlights the cruciality and extent of a technician’s involvement in trauma cases. One day, a 10-year-old spayed toy poodle named Ellie was presented to the Veterinary Emergency Group in White Plains, New York after being attacked by another dog.
Technicians should be performing physical examinations on patients presenting for emergency care. Because we are the team members primarily responsible for monitoring the patient, it is crucial for us to obtain baseline parameters. Although technicians may not be able to grade a heart murmur, we should know what one sounds like so we can monitor for any changes. Our assessment during triage also helps us determine whether the patient is critical and needs immediate attention or is stable enough that it can wait to see a doctor.
On presentation, Ellie was laterally recumbent, obtunded, and wrapped in a blood-soaked towel. She was in late, decompensated, hypovolemic shock. The dog had pale mucous membranes, with a capillary refill time of less than 2 seconds, and was hypothermic (body temperature 97 °F), tachycardic (heart rate 180 bpm), and hypotensive (blood pressure 43 mm Hg). She had a grade IV/VI heart murmur and was having increased respiratory effort. Upon further evaluation, the triage team found loops of exposed intestines jutting from an abdominal wound.
When a critical patient arrives, the veterinarian must evaluate the animal and then communicate with the owner. Depending on the severity of the case, the doctor may assist in stabilizing the patient. If the situation is not immediately critical, the doctor may give the technician a list of tasks to complete while they speak with the owner.
In Ellie’s case, as the doctor spoke with her owner, I began to stabilize the dog. I placed an intravenous (IV) catheter, started isotonic crystalloids, obtained serial blood pressure measurements, and administered flow-by oxygen via face mask. I also started the dog on a constant-rate infusion (CRI) of pain medications (ketamine, lidocaine, and fentanyl) and antibiotics (ampicillin/sulbactam and enrofloxacin), as ordered. Some tasks, such as setting up for wound management, were delegated to assistants.
The veterinarian lavaged the exposed organs copiously, electing to place the intestines into the abdominal cavity temporarily until the full extent of the trauma could be determined. The doctor then packed the wound with sterile lap sponges and applied a bandage around the dog’s abdomen; technicians checked the wound frequently overnight for strikethrough of blood.
Due to the tachycardia, hypotension, and significant blood loss, Ellie received a packed red blood cell transfusion, after which she was more alert and could sit upright, her heart rate decreased to 120 bpm, and her blood pressure improved to 80 mm Hg. She became stable enough for anesthesia, and full surgical correction was planned for the following morning.
It is also important for technicians to have some understanding of pharmacology in emergency situations. When we understand how medications work and what receptors they work on, we can anticipate changes in the patient’s status based on the medication administered. Knowing a patient is on certain medications can also help us anticipate associated adverse effects and adjust our monitoring of parameters accordingly.
Technicians should also be experts in medication administration, including calculating doses, knowing when medications require dilution, and being aware of any special considerations. Doctors will inform us of the doses, but they also trust that we understand how these medications work and the potential adverse effects they may cause.
In Ellie’s case, as noted above, pain medications were administered via CRI. On her second night in the hospital, the CRI dose was decreased in an effort to help increase the dog’s blood pressure. However, Ellie became vocal and tachycardic once the pain medications were decreased, so they were increased again.
Most technicians can set up and administer IV fluids, but we must also have a full understanding of how those fluids can affect the patient. Ellie had a grade IV/VI heart murmur, which means her heart was not pumping properly and she was at risk for fluid overload. Technicians must know how to determine whether a patient is becoming fluid overloaded.
It can become easy for technicians to fall into a role where we only complete tasks when asked, but there are many things we can do independently during emergency situations. In addition to performing a physical exam, we can provide supplemental oxygen, apply pressure to sites of active hemorrhage, and obtain many diagnostic measurements (eg, blood pressure, electrocardiogram [ECG], blood oxygen saturation [SpO2] level). Additionally, we can place an IV catheter when we know a patient is going to be hospitalized or euthanized.
Ellie’s packed cell volume (PCV) was 53% on presentation, but this was presumed to be due to her shock state and was expected to decrease following reperfusion. Her lactate level was elevated at 13.3 mg/dL but improved following the administration of IV fluids. In addition to sinus tachycardia, her SpO2 was 98%. I obtained thoracic and abdominal radiographs, which showed that Ellie had a large amount of gas along the left lateral abdominal wall consistent with her wounds.
A PCV of 53% may not seem concerning, but a knowledgeable technician understands that 53% means there are additional considerations for the patient. Critical thinking skills help us see the bigger picture and, in Ellie’s case, plan for increased PCV monitoring and prepare for a blood transfusion due to significant blood loss.
Anesthetizing a critically ill patient can be unnerving, so it is crucial that technicians understand how the anesthesia will affect our patients. In critical patients under anesthesia, ECG, SpO2, capnography, blood pressure, and temperature measurements should be obtained regularly. Technicians should also be evaluating anesthetic depth manually by assessing reflexes, pupil size and position, and muscle tone. The heart and lungs should be auscultated manually.
A fellow technician anesthetized Ellie for surgery, and the dog remained stable throughout exploratory laparotomy and wound repair.
Hospitalization and nursing care are where technicians can really make a difference for patients. Because the technician is the primary person monitoring the patient, we are usually the first to notice changes. This is especially true for patients that are hospitalized for several days. Ellie remained at our hospital for 3 days, during which she was monitored by 3 to 4 experienced technicians.
Ellie had continuous ECG monitoring throughout her hospitalization. She had sustained sinus tachycardia and remained hypotensive despite aggressive fluid therapy and pain medication. Manual auscultation was used to monitor for worsening of Ellie’s heart murmur, which did not occur.
Following surgery, Ellie received a fresh-frozen plasma transfusion to provide clotting factors and proteins. A recheck of her PCV after surgery showed a 15% decrease, likely due to further blood loss and hemodilution resulting from IV fluid administration. A second packed red cell transfusion was administered following the fresh-frozen plasma transfusion.
On Ellie’s second night of hospitalization, she began regurgitating and was treated with anti-nausea medication. She became hypoglycemic (74 mg/dL) and was started on a 5% dextrose CRI in her IV fluids. On day 3, she was transported to a 24-hour critical care facility, but her overall status declined and she was euthanized owing to the poor prognosis.
Veterinary technicians are skilled and knowledgeable. We are nurses, phlebotomists, anesthesiologists, and patient care advocates. When used to the greatest extent possible, we can take on a wide variety of roles in the practice, and pet owners expect us to be the best we can be. In Ellie’s case, I came to understand that adequate patient care in emergency situations cannot be achieved without technician involvement. We performed a large part of her care, while also attending to several other hospitalized patients.
Veterinarians should never underestimate the significant role veterinary technicians play in patient care. And we technicians should always strive to educate ourselves and fulfill our potential.
Marlaina Hrosch is a technician training manager atVeterinary Emergency Group in White Plains, New York. Her areas of interest include trauma and toxins. Marlaina is focused on training technicians in emergency veterinary medicine. She is sitting for her veterinary technician specialty exam in emergency and critical care this month.