Restraint

It is the duty of the team to prevent the veterinarian or veterinary technician from being bitten by the patient. Restraint is one of the most important tasks that must be learned and mastered. Patients can be wiggly and excited. All patients have their own emotions and deal with stress differently. They may be scared and may bite out of fear; others will bite because of pain or because they are aggressive. Every animal should be treated as if it could bite, puppies and kittens included. When doctors look into the patients’ eyes and ears, they may become scared and bite out of fear. Dogs and cats can bite the tip of the doctor’s nose when they are looking in a patient’s eyes. Cats are quick with their forefeet and will strike with no warning.

Time and experience will teach new team members the best way to restrain animals and how much restraint is needed for each individual. Some cats may react best with little restraint; when the scruff is grabbed for restraint, they begin to object.

All animals should be observed while being restrained. The patients should remain pink and able to breathe well. If the patient’s mucous membranes become blue (cyanotic) at any time, the animal should be given a break.

If a muzzle is needed at any time, team members should not hesitate to use it (Figure 23-1). Muzzles are made to protect team members from being bitten! Some owners may argue that their pet does not need a muzzle; however, for everyone’s safety, including the owner’s, muzzles should be used. Both dog and cat muzzles are available and come in a variety of sizes. Muzzles should fit snugly on a dog’s nose. If the dog can open its mouth, the muzzle is too large, and the purpose of the muzzle is defeated. Cat muzzles should fit snugly over the entire head. Cat bags and towels may also be helpful to prevent team members from becoming scratched (Figure 23-2). The full cat body is placed inside the bag with only the head exposed. Most bags have two small openings that will allow front legs to be pulled through if needed.

Common Diseases

Boxes 23-1 through 23-3 are not a complete list of diseases, but rather a summary of diseases for which there are vaccines. A brief description of the disease and symptoms is also included. Some tests are available for in-house diagnostics to determine if a pet has a disease, whereas other tests need to be submitted to an outside laboratory for diagnostics. Table 23-1 summarizes tests available for diagnostics.

Bloodwork

It is imperative for the veterinary assistant and technician to become familiar with general tests that are run in-house. Clients will ask what test correlates with what bodily system, and these questions must be answered clearly and confidently. Table 23-2 lists the names of common tests and the system with which the test correlates.

Cytology

Cytologies are prepared for a number of reasons; the most common of which is to look at cells under the microscope. Cytology preparation can depend on the sample, the doctor, and the stain that will be used.

Different cells take up stain differently, which helps in diagnosis. Many veterinarians and technicians become proficient at reading cytologies; however, a histopathologist that is employed by a laboratory can provide a more definitive diagnosis.

Urinalysis

Urine samples can provide a wealth of information for the veterinarian, and several tests can be performed on one sample. Most urine samples are obtained by free catch; either the owner has obtained a sample or an assistant has walked the dog and caught a midstream urine sample (Figures 23-4). Other methods of collection include cystocentesis or catheterization (Figure 23-5). If a urine sample will be sent to the laboratory for culture, a sample acquired by cystocentesis is highly recommended because it is a sterile sample that is obtained without any contamination. Cystocentesis is the process of inserting a needle into the bladder and withdrawing a sample.

The tests that can be completed on urine are numerous; the most common tests completed in the hospital include specific gravity, stick urinalysis, and sediment (Boxes 23-4 and 23-5). The specific gravity provides the concentration of the urine and is a key indicator of how well the kidneys can concentrate the urine. Certain disease processes can affect the concentration, including renal disease and diabetes.

A stick urinalysis is performed by dipping a urinalysis stick into the sample itself (if it is a sterile sample, the urine should be dropped onto each testing block) (Figure 23-6).

The sediment is essential to verify the information provided by the stick.

Fecal Analysis

Fecal analysis is extremely important in puppies and kittens and in pets with diarrhea. A fecal analysis can diagnose internal parasites such as Giardia, Coccidia, roundworms, hookworms, whipworms, or tapeworms. It can also indicate severe bacterial overgrowth and determine if a sample should be sent to the laboratory for further diagnosis.

Electrocardiogram

Electrocardiograms, often referred to as EKGs or ECGs, are recordings of the heart’s electrical activity. The recording traces the entire heartbeat process, through both the systolic and diastolic phases. Arrhythmias and conduction disturbances of the heart can be detected on ECGs, and an ECG is highly recommended before administering anesthesia to patients (Figure 23-7).

Blood Pressure

Measurement of blood pressure is an underutilized tool in veterinary medicine. Variations in blood pressure are characteristic of a number of diseases. By definition, blood pressure is the pressure exerted by the blood on the wall of the vessel. The systolic pressure is the maximal force caused by the contraction of the left ventricle of the heart. The diastolic pressure is the minimal force during the relaxation phrase, when the aortic and pulmonic valves are closed. The mean arterial pressure is the average pressure of both.

Safety

Care must be taken when taking radiographs. Safety cannot be emphasized enough. Studies indicate that excess radiation causes cancer, birth defects, a decreased life span, and fertility issues. Protection must be worn at all times while taking radiographs (Box 23-6 and Figure 23-8). Lead thyroid collars, gowns, and gloves are the absolute minimum that should be provided to all team members allowed to take radiographs. Eye goggles are also a good idea (eyes cannot be replaced!) to provide ultimate protection. Team members who are exposed to radiation on a daily basis have a higher incidence of reproductive, thyroid, and eye cancers.

Lead aprons, collars, and gloves should never be folded; any fold can crack the lead and allow radiation to penetrate the team member, decreasing safety (Figure 23-9). All apparel should be hung on a wall or laid flat on a table surface to prevent cracking. Aprons, collars, and gloves should be radiographed yearly to check for any cracks that may have appeared (Figure 23-10). Radiographs should be compared year to year, and safety equipment should be replaced as soon as visible cracks appear. Team member safety cannot be compromised.

Guidelines

Several regulations must be followed to comply with guidelines set for employee safety. All team members in the room during the radiograph process must be older than 18 years. Dosimetry badges must be worn at all times, and pregnant team members should especially avoid exposure to radiation. Personal protective equipment (PPE) must be worn. Employers must enforce the use of PPE, and employees must wear PPE. According to the Occupational Safety and Health Administration (OSHA), employers can be fined for not providing or enforcing the use of PPE, and employees can be fired for not wearing PPE. Excess radiation can have detrimental effects, and all protection must be used.

A dosimeter measures radiation exposure and should be worn on the collar at the thyroid gland level. The maximum permissible dose (MPD) is 5000 millirems per year (a millirem is 1/1000 rem), and should be monitored closely. The average exposure is 5 rem per year for a small or mixed practice. The United States Nuclear Regulatory Commission has determined that the MPD is a dose that is unlikely to harm a person over a lifetime of taking radiographs. Every precaution should be taken to keep radiation exposure low by wearing all protective gear. If a practice manager notices high levels of exposure on a dosimetry report, an investigation should be launched to determine the source of radiation. Machines may malfunction, and this may be the only way to detect the excess radiation being emitted.

All radiograph machines must be monitored and inspected by an Environmental Protection Agency (EPA) official yearly. The EPA certificate must be posted in the radiology room.

A radiology log can be helpful to team members when a digital system is not used. Figure 17-1 shows an example, listing the date, client and patient name, area being studied, position, and machine settings. This type of log allows team members to retrieve settings used in previous radiographs in case repeat or follow-up radiographs are required. To compare radiographs, the same setting should be used on both. Different settings may produce slight differences in quality of images, thereby making comparison difficult. Digital radiographs have setting information stored with the image, allowing exact settings to be used.

Films must be stored in a system that allows quick and easy retrieval. Digital radiographs are stored in the patient’s file, allowing quick access at all times. Regular films may be alphabetized by the client’s last name or patient name, or numerically by client ID number. Whichever system is used, it must be simple and prevent lost films. Lost films are the biggest hassle of film storage. Many clinics now use a scanner or digitizer to enter radiographs onto a CD for easy retrieval, freeing up storage space once taken by radiographs. This also eliminates lost radiographs.

Radiograph checkout logs should also be implemented when owners take x-rays for second opinions or when films are sent to a specialist. Figure 17-2 shows a log that allows radiographs to be traced if they have not been returned.

Digital Radiographs

With the technology available today, digital x-rays have begun to replace the standard x-ray system. With digital x-rays, the tube is coupled with a specialized receiver that changes x-rays into electrical signals. The image is digitized and displayed on a computer screen, then stored on a DVD, CD, or magnetic optical disk (MOD). The advantages of a digital system are numerous. The processing time is reduced to seconds because film does not have to be processed. Images can be viewed immediately and can be manipulated with software to lighten, darken, or magnify the image. If a film needs to be repeated for positioning only, it can be done in a shorter amount of time. Views are stored within the computer system and/or disk, so images are never lost. Images can also be sent to a specialist for a second opinion by phone, DSL, or T1 cable line.

Fluoroscopy

Fluoroscopy involves projecting a continuous x-ray beam onto an image intensifier. Fluoroscopic units are suited for the study of moving structures and can provide the maximum information regarding the processes of the moving structures. Fluoroscopic studies are usually limited to gastrointestinal studies, myelography, and heart and vascular studies. They are rarely used in veterinary medicine for economic reasons.

Ultrasound

The use of ultrasound is becoming popular within veterinary practices, especially as the price of units decreases. Ultrasound is noninvasive and well tolerated by patients. A major disadvantage is the learning curve associated with using the unit. It takes practice and patience to master ultrasound imaging; the diagnosis is only as good as the diagnostician.

Ultrasound uses sound technology. The frequency of sound is computed into an image with an equation that involves wavelength and frequency. Sound reflection forms the basis of an ultrasound image. The thicker the tissue, the less sound is reflected, creating a darker image on the screen. The thinner the tissue, the more sound is reflected, creating a lighter image of the organ.

Ultrasound can be useful in diagnosing and evaluating tendon injuries, tendon sheath infections, adhesions, or foreign bodies. Joints can be evaluated for injury, neoplasia, or osteomyelitis. Abdominal cavities can be evaluated for fluid, cancer, or congenital defects. The list of uses for ultrasound is endless, making it a useful diagnostic tool when evaluating pets for disease.

Computed Tomographic Scanning

Computed tomographic (CT) scanning is performed by passing a thin x-ray beam through the patient and measuring the x-ray attenuation at multiple sites within a thin slice of a patient’s anatomy. A computer then configures the data and provides a cross-sectional image on a video monitor. In veterinary medicine, a CT scan is generally used to diagnose neurologic disorders within the spinal column or brain. It can also be helpful to identify musculoskeletal, thoracic, and abdominal disorders.

Patients must be fully anesthetized to prevent movement within the machine. The patient is placed in a ventrodorsal position on a table that moves through the machine. As the table moves, the CT scanner obtains cross-sectional data. Two studies are generally performed: the first without any contrast media, the second after an intravenous injection of iodinated contrast. Contrast allows visualization of vascular structures.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is the newest imaging modality for veterinary medicine. MRI is similar to CT scanning in that it takes thin slices in cross-section and transfers the images to a video screen. MRI differs in that it does not use radiation to create the image; it uses radiowave signals in which hydrogen nuclei have been disturbed by a radiofrequency pulse. MRI produces superior results; clearer images and sensitivity to the composition of tissues are just two qualities worth mentioning. These qualities are excellent for diagnostics involving the brain and spinal cord.

Some veterinary teaching hospitals and veterinary specialty practices use MRIs; most animals are referred to a human hospital, imaging center, or a truck-based mobile MRI unit. Patients must be anesthetized for these centers; therefore the veterinarian must provide everything that would be needed for anesthesia, resuscitation (if needed), and recovery. The animal’s bowels and bladder should be empty, and it should be parasite free.

Because MRIs use a strong magnetic field, anything metal must be removed from the room. The magnetic field will forcefully pull any metal object into the magnet, injuring anything in its path. Therefore animals must be anesthetized with injectable anesthesia. This can be a disadvantage because it can be difficult to monitor patients while they are undergoing the procedure. MRIs generally take 45 to 60 minutes to complete. They can be done with and/or without contrast media.

Preanesthetic Documentation

Preanesthetic questions MUST be addressed and documented. It should be confirmed that patients have been held off food and water (NPO) per practice instructions. Owners must be given the option (if it is not hospital policy) to have preoperative tests performed on their pet before anesthesia.

If a patient is going to be spayed or neutered, it should be checked for testicles. Owners cannot always tell the correct gender of an animal; therefore it must be verified before surgery (it is frustrating and wasted time when a veterinarian cuts into the abdomen of a patient looking for a uterus to find out it is a male!). If a mass will be removed from the patient, the hair should be clipped (before the owner leaves) to verify the mass or masses that the owner has agreed to remove. If any other masses are found on physical exam, the owner should be called for permission to remove the additional masses.

Each patient should receive a physical exam at least 12 hours before anesthesia. The heart and lungs should be evaluated with both heart rate and respiratory rate noted. The mucous membranes should be pink, and the capillary refill time should be within 2 seconds. The pulse should be strong; any pulse deficits should be noted. The abdomen should feel normal to palpation, as should the lymph nodes. The pet should be well hydrated and have a normal temperature, and a weight should be taken for the current visit.

Anesthesia

Once all the parameters are evaluated and the patient is deemed healthy enough for surgery, an anesthetic protocol will be developed. Each patient is unique, and consideration should be given to each patient regarding the anesthesia protocol.

Anesthesia is the loss of sensation that can be induced by a number of drugs. Local anesthesia deadens sensory nerves; an injection of lidocaine is given at the site of the procedure. General anesthesia influences and desensitizes the central nervous system; it produces unconsciousness. Spinal anesthesia interrupts the function of nerves.