Reducing stress and managing fear aggression in veterinary clinics

Chapter 23 Reducing stress and managing fear aggression in veterinary clinics



Chapter contents



INTRODUCTION: THE PROBLEM WITH THE STATUS QUO


THE SOLUTION: SET UP THE HOSPITAL AND HANDLING TO HELP THE PATIENT FEEL COMFORTABLE AND SAFE


STEP 1: BEFORE THE PATIENT COMES IN: WHAT THE OWNER CAN DO AT HOME


Counterconditioning and desensitization to crates and car rides

STEP 2: PREPARING THE HOSPITAL


The entry area and waiting room

The exam room

Treatment areas and kennels

STEP 3: GREETING THE PET APPROPRIATELY


Why do friendly people look scary?

Applying greeting principles to getting pets out of cages

STEP 4: HANDLING THE PET IN A CALM, SKILLED MANNER


STEP 5: DESENSITIZATION AND COUNTERCONDITIONING THE FEARFUL PET


STEP 6: SCHEDULING DS/CC TECHNICIAN SESSIONS AS AN ADDED-VALUE SERVICE


Managing fearful and aggressive pets

Pharmacologic management of fearful and aggressive pets

CONCLUSION


REFERENCES


RECOMMENDED READING



Introduction: the problem with the status quo


Imagine this. You’re grabbed out of your home, stuffed into a box, thrown in a car, and driven to a location where you’re left in a strange room. It’s a room with alien smells, screams that sporadically pierce through the walls, and eerie figures wandering about. You don’t know why the human you once trusted brought you here, but you’re not sure you should trust her to help you now.


Every day, pets are brought to our hospitals in this state of confusion and fear and we expect them to remain calm and cooperate for procedures. We poke them and prod them and carelessly flop them into various positions when they have no clue what we want. Then, in the name of speed, we react to the struggling pet by imposing some type of “death grip” hold instead of taking a step back and evaluating whether a more thoughtful approach might work better.


Many participants in this typical scenario might ask, “What’s the harm? It’s what we’ve always done.” Well, the harm is threefold. First, dog and cat bites as well as cat scratches are often the top causes of veterinary hospital staff injuries. Force-based techniques and crude handling skills undoubtedly play a significant role in these statistics. Second, for those of us who vowed to first “do no harm” as a veterinarian, every time we force pets in this manner or even handle pets in a rushed, careless way, we risk breaking this promise. We may send the patients home medically better, but they may also be leaving with a “behavioral injury.” That’s because, with each bad experience, difficult behavior and fear can worsen until they are no longer treatable. Even more ominous is the fact that a bad experience at the veterinary hospital can cause some pets to be worse with people overall. For an animal that comes in and is already slightly fearful of unfamiliar people or who has a genetic predisposition toward this trait, one bad experience can exacerbate the situation, from a pet that’s just fearful of some people occasionally to one who has a generalized and pronounced fear and suspicion of anyone new. Or worse, one that becomes fear-aggressive. The veterinary staff could, potentially, be the inciting factor that triggers this dramatic turn for the worse, which ultimately can contribute to the decision to euthanize (Figures 23.1 and 23.2).


image image

Figures 23.1 and 23.2 Unskilled handling can result in bites and scratches, a pet that is behaviorally more fearful and aggressive at future visits, and a loss in credibility for the hospital staff. The cat in this photo is acting aggressively because it is being “scruffed” – a common procedure to which many cats react adversely. This same cat does much better when a towel wrap is applied. It remained calm for a cystocentesis later while in its towel.


(Courtesy of Dr. Sophia Yin.)


A third harmful sequel is to the credibility of the hospital staff and the perception of how caring they are. Imagine if you took your child to a dentist. Which would you choose — the one who was in a rush and strapped your screaming child down in order to get the job done, or the one who set up the hospital to look inviting and knew just the right words to say to put your child at ease? The first dentist would be seen as cold and concerned most about money. The second would be seen as caring, more skilled at handling children, and more credible. Now imagine what’s going on in the child’s mind. The restrained child is likely to have a lifelong fear of seeing a dentist and as an adult may no longer seek dental care. The parents would also be less apt to bring the child back for regular appointments because they, too, dread the process due to its effect on the child and the embarrassment of having others see their child’s difficult behavior. On the other hand, the child that went to the child-friendly dentist would become increasingly easier to treat and her parents more likely to keep up the regular visits.



The solution: set up the hospital and handling to help the patient feel comfortable and safe


One might think that switching from the status quo of powering through procedures to a low-stress handling and hospital environment would take an impractical amount of effort and waste precious time. In reality, many of the changes are a matter of setting up a more inviting hospital; others are a matter of approaching animals correctly and learning to handle them or support them in ways in which they feel comfortable and safe. As a result, the changes often don’t take more time, they just require more skill. For cases where more time is needed to train pets that the procedures and environment are safe, this time can be turned into a value-added service that is carried out by paraprofessional staff and assigned an appropriate fee. It’s something that does not have to be sold to the client, just offered as part of the best practice, just like preanesthetic blood work or parasite screening. Owners can be informed of their options and the potential consequences.


This chapter provides a six-step approach to setting your hospital up to help reduce stress while increasing hospital efficiency. The predominant idea is that if we provide an environment where the animal feels comfortable and safe while also providing clear guidance regarding what we want the animal to do, the pet will be less fearful and more cooperative which in turn will help us get through the procedures more quickly both now and on future visits. This chapter represents an overview of each principle. For a more detailed description and techniques refer to the book and DVD set: Low Stress Handling, Restraint and Behavior Modification of Dogs & Cats (CattleDog Publishing, www.lowstresshandling.com). The six steps are as follows:



1. preparing the patient (what owners can do at home)


2. preparing the hospital


3. greeting the pet appropriately


4. handling the pet in a calm, skilled manner


5. desensitizing/counterconditioning (DS/CC) the fearful pet


6. scheduling paraprofessional sessions as an added-value service.



Step 1: before the patient comes in: what the owner can do at home


Patients are often anxious even before entering the hospital and by the time they’re in the exam room, they may be ready to attack. This may be because the pet was chased around the home to catch it and force it into the carrier or because the pet has never been habituated to car rides.


For all new clients as well as puppies and kittens the standard response from the receptionist making the appointment should be, “Is your pet comfortable riding in the car and if she’s transported in a carrier, does she view the carrier as a safe place? We’re asking because we want your pet to have the most pleasant experience possible and this is most likely to happen if she’s relaxed on her way over and enters the hospital in a calm, relaxed state.” If their answer is no or they are unsure, the next step is to send them to your website to download a handout or provide verbal instructions on training their pet to love their carrier and to love car rides.



Counterconditioning and desensitization to crates and car rides


The basics of teaching pets to view being in their carrier or car ride as a positive event is to pair each one with something they already enjoy, such as food. When we make this pairing, we are using a technique called counterconditioning (CC), so called because we are countering a previous association – that of fear or dislike – with the car or crate. Generally we also need to add in desensitization (DS). That is, we can’t just put the animal in the crate, shut the door and offer food, because the animal may be too scared or distressed to eat the food. So we often have to start with the stimulus (the car or crate) at a level that the animal can tolerate and when it shows no fear to that stimulus at that level we can increase the intensity systematically.


A common misconception is that DS/CC takes a long time. When done systematically it can go quickly, sometimes in less than a week. The standard procedure for teaching pets to go into their crate willingly is just to feed their regular meal in the crate. To make the cage more inviting and comfortable, add a blanket, towel, or perhaps Feliway or Adaptil spray. If they won’t immediately go in, then start with the food outside the crate. Once they readily go near, you can start placing the meal inside the crate. First place the bowl near the entrance so the pet only has to place its head and shoulders in, and then when it’s comfortable, move the bowl further in. The objective is to only move the food further in once the pet readily goes into the crate to the current distance of the food bowl. Once it is comfortable entering, occasionally sprinkle treats inside the crate for the pet to find throughout the day. With some cats it is even simpler since they may voluntarily enter and explore any new crate or box, which can then be rewarded with food. When the pet has a well-established positive association it will go in and lie in the crate on its own with the door open. The behavior can be put on cue by saying “kennel” or pointing at the kennel as the pet enters, and then tossing in a treat.



Car rides


A similar procedure can be used during which the pet is first put in an unmoving car and given treats. Once it’s readily eating (a good indicator of comfort level), take short trips that end in locations the pet likes. Cats should be secured in a carrier and dogs either tethered to a seat belt or in a carrier. Once they are in, give treats frequently enough to keep them in a positive emotional state.


For some pets, additional techniques may help. Placing a Calming Cap (thundershirt.com) that covers the eyes, hindering vision, can help the pet feel calmer or more relaxed. For dogs that get car sick, consider using maropitant citrate (Cerenia, Pfizer Animal Health). Maropitant citrate should be given 2 hours prior to travel and after food has been withheld for 1 hour. The treatment lasts for 24 hours so can be given the night before, at least 1 hour after dinner. Some nervous dogs also do better if they wear an Anxiety Wrap (Animals Plus), Thundershirt (Thundershirt), or tight-fitting T-shirt. Such products work based on the idea that the tightness of the fit provides comfort and has a positive effect on the dog. Another option is using Adaptil or Feliway (Ceva Animal Health) for cats. These pheromones have marked calming effects on some dogs and cats. And of course, careful driving is a must since a bumpy ride can provide pets with a bad experience.


For those people who are traveling alone and the pet will take treats, treats can be placed in a Kong toy (canned food, cheese or peanut butter works best). Alternately a Manner’s Minder (www.mannersminder.net)can be used to dispense treats by remote control or automatically at regular intervals.



Step 2: preparing the hospital


Once the clients have done their part to help their pets, there are many ways we can help them too. Begin with setting up the hospital environment so that it appears inviting and safe from the pet’s point of view. When the animal enters your hospital, what is the first thing it sees? Is it quiet and calm or full of barking dogs and hissing cats? Remember that the environment the pet enters sets the tone for the appointment and the mood for its entire stay. This environment includes all rooms of the hospital, not just the first room it sees.



The entry area and waiting room


The entry area and the waiting room may be the most important rooms in the hospital, in that they determine the pet’s first impression. If a cat’s first experience is a dog nose at its carrier you may be hard-pressed to convince the cat that your hospital is a safe place. In general it’s a good rule for all pets to be in carriers or otherwise controlled. So the first sign the clients should see is one thanking them for controlling the pet in a crate or on a leash.


Ideally a hospital should have a separate cat area and dog area and additional visual dividers within each section. That way, those pets who are afraid of other animals can feel somewhat safe. If your hospital has not been built with separate areas already, inexpensive portable dividers can be strategically placed. Within those species-specific areas, further divide the space by using half-walls, information displays, screens, planters, fish tanks, and partitions so pets can avoid direct eye contact with other pets. Alternately you might schedule separate times for dogs and cats. Pheromone diffusers in the waiting room may also help calm pets (see Chapter 9).



Scale


One predictable stress that routinely awaits dogs is the step-on scale. Many dogs balk at the sight of this uncertain item, and are then forced on. If a towel or rug with a nonslip liner is placed underneath, many dogs will be more comfortable stepping on. And if tasty treats are strategically placed by so that owners can use the treats to lure the pet on, the weigh-in can actually be a positive experience instead of a scary one.



The exam room


Most exam rooms are designed to be clean and sterile, and because of this they are also cold and uninviting. A few simple changes can turn the room into a comfortable, safe place that both humans and pets enjoy. Placing a washable throw rug or fleece pad on the floor will go a long way to making pets feel at home. You’ll see the difference almost immediately since a majority of pets will choose to station themselves on the rug. Similarly, for animals placed on the exam table, simply having a nonslip covering or warm padding can turn a quivering, cowering pet into a more relaxed one. A towel can also be placed on the cat scale because cats frequently choose to sit on these due to the raised sides which provide them some security.


Layout and type of furniture are also important. Avoid chairs and objects that pets can hide under, making it difficult to get them out. Fearful animals can be more aggressive once they have stationed themselves in a defensible space. The desire to remain in their safe spot, combined with our need to reach for them, can lead to defensive aggression. An exam table that folds up or moves out of the way provides more floor space for you to move around and adjust your height and body position to appear less threatening. It’s also useful because some pets do much better when examined on the floor.


Rooms should be stocked with tasty treats, preferably semimoist treats or freeze-dried liver or chicken, and a canned spray cheese which you can spread on a wooden spoon or tongue depressor. Some veterinarians are concerned that treats may cause lipemia, altering blood results. Postprandial triglycerides peak 2–6 hours after a meal, which is generally well after the blood draw. Always check with pet owners and the medical history to ensure that there are no medical (e.g., diabetes mellitus, hyperlipidemia, food intolerance), genetic (liver treats are typically not given to Dalmatians on purine-restricted diets), or cultural (pet maintained on a vegetarian, kosher, or halal diet) reason for not offering specific treats to pets. Having a few rubber or vinyl squeaky toys available can be a huge benefit for dogs that love toys, or can’t consume the treats you have available. Some who are tentative when offered treats will suddenly relax when they see a toy. For cats the favorite treats tend to be tuna, baby food, canned food, soft cheese, and Greenies, as well as both some moist and dry cat treats to account for individual preferences. In hospitals designed for comfort and safety, the overwhelming majority of dogs, and many cats, will accept treats. Clients can be asked to bring their pets in hungry by skipping the previous meal and also to bring their pet’s favorite treats.


Rooms should have a handy supply of towels, especially when dealing with cats. One of the best techniques for putting fearful cats (and some small dogs) at ease is providing a way for them to hide. Often when allowed to hide under a towel, an entire examination can be done on an otherwise untreatable cat (Figure 23.3).


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Figure 23.3 One of the best ways to keep the environment low-stress for cats is to let fearful cats hide. An entire exam can often be accomplished with the cat hidden under a towel.


(Photo courtesy of Dr. Sophia Yin. From Low Stress Handling, Restraint and Behavior Modification of Dogs & Cats by Sophia Yin, DVM, MS, Cattle Dog Publishing, 2009. www.lowstresshandling.com.)

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Jul 24, 2016 | Posted by in SMALL ANIMAL | Comments Off on Reducing stress and managing fear aggression in veterinary clinics

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