Tuesday, 18 April 2017

In memory of a Bearded Collie called Barocca

Do you still have cases that get to you?

I had one recently, 12 years I've been nursing now. I still get cases that affect me, this one particularly in fact went home and had a little cry after my shift.

The dog in question was in for a GA to examine a mass in its mouth. I know what you're all thinking, probably an oral mass this story is only going to go one way. Except it really didn't.

On admit the owners were so upset, obviously being prepped that it could be something nasty. The dog was 8 years old, the right age group for that kind of mass and generally didn't look as healthy as it could. 

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Example of Epilus in a dog. 
It was last on our list. Induction went smoothly, nothing unusual. I open the mouth for intubation and the vet has a quick examine, we tube and I get the dog connected up. I look at the vet and together we say 'this will be a quick GA' after we both spotted that the 'masses' were merely epuli. We knew that we could easily cauterise these lumps out and it should be pretty quick. However, on admit the owner did also say that the dog had been displaying some behavioural changes and itching a lot. I spotted some inflamed dry skin around the lumber spine. And the vet tracked this all down the animal's hind quarters. So could just be a skin condition, or is the animal painful somewhere? We decide to call the owners to ask permission to do some x-rays.

Meanwhile the dogs GA was smooth. HR fine, breathing fine.

We moved the dog through to x-ray, take three views. VD pelvis, Lateral lumbar and lateral thoracic spine. Easily seen was spondylosis.

We proceed to cauterise the epuli and then I proceed to turn off the gas and start the process of waking the dog up. The surgery had been a success and we couldn't wait to inform the owners of the diagnosis we had found due to the likelihood of anything being malignant quite low. The dog was recovering well, blink had returned well - normal recovery. So we turn off the oxygen and take the dog back to its kennel where the vet tells me its been a long surgery list and to go for my lunch whilst he takes over recovery. 

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On return from my 30-minute lunch, I find the vet still recovering the patient. ET tube still present, which is a little strange. However the dog still has a blink and it is 8 years old, so perhaps it will just take a little while.

Palpebral & corneal reflex video

Almost as I'm thinking this I notice the dog's tongue has gone a purple tone and I run for the oxygen. I put the dog on oxygen, take her temperature. Although not too low I still ask for heat pads and extra blankets. Also at around this time, I notice the dogs pupils are a little enlarge, but also not bilaterally, the right was slightly more constricted than the left. I check for other signs of life, but there was no deep pain (withdrawal reflex). There was anal tone still present. I then check for pupil light reflex but this wasn't present - not a good sign at this stage.

Pupil light response video

Over the next four hours, I sit with the dog, it's heart rate remains steady and its breathing is normal. We placed it on fluids and took bloods however it shows no further signs of waking up. It never gets its gag reflex back. Eventually, the owners come down. I am now breathing for the dog as she has ceased breathing for himself, I have been doing this for 30 mins. By this point, she has lost her blink reflex and her cornea is dry and tacky. Her colour, however, has remained pink throughout other than previous attempts to remove oxygen with the pulse oximeter attached. Every time this was attempted the dogs colour changed back to purple and the O2 levels lowered to around 76% before we replaced oxygen and continued the therapy. 

The dog never woke and was put to sleep with the owners present.

This case affected me hugely and I replayed the anaesthetic over and over to work out if anything had gone wrong. There was nothing I could pinpoint, had it been an 8-year-old dog under for a 4-hour dental I could perhaps understand it better. However, this was a 30 min event. Had the dog had a stroke or another brain event that we just didn't know about? Pre-GA bloods had been normal. I guess we just won't know, perhaps the behavioural changes were an indicator? This case has really got under my skin, and I miss that dog.

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Sunday, 9 April 2017

Challenging the RCVS - 1966 Act

Shouldn't we be challenging this? 

I think it's finally time to hop off that fence I've been sitting on whilst writing blogs. Ever increasingly and probably with age, I am forming opinions that I just cannot bite my tongue on any longer.

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One is the genuine need for the RCVS to amend and update the Veterinary Surgeons Act 1966. It is not only outdated but has had so many amendments made to it over the years that it needs a complete overhaul in my humble opinion.

In 2007, my class year became one of the first to automatically be entered into registered nurse status and in doing so we became a profession in our own right. I am aware in recent times we still have miles to travel with government recognising us officially as an entity of our own and protecting the title of RVN. However having our own nursing council and disciplinary committee means that we have com on leaps and bounds.

But come on guys seriously more needs to be done. Any nurse knows that we are best placed to be monitoring anaesthetics, speaking to many a vet student they inform me time and time again about the lack of training they receive is this field. Yet the 1966 act still states;

Maintenance and monitoring of anaesthesia

18.9  Veterinary nurses and student veterinary nurses may be directed to assist veterinary surgeons with the maintenance of anaesthesia and the monitoring of patients under anaesthesia. The following advice applies to these tasks:
  1. Inducing anaesthesia by administration of a specific quantity of medicine directed by a veterinary surgeon may be carried out by a veterinary nurse or, with supervision, a student veterinary nurse, but not any other person.
  2. Administering medicine incrementally or to effect, to induce and maintain anaesthesia may be carried out only by a veterinary surgeon.
  3. Maintaining anaesthesia is the responsibility of a veterinary surgeon, but a suitably trained person may assist by acting as the veterinary surgeon’s hands (to provide assistance which does not involve practising veterinary surgery), for example, by moving dials.
  4. Monitoring a patient during anaesthesia and the recovery period is the responsibility of the veterinary surgeon but may be carried out on his or her behalf by a suitably trained person.
  5. The most suitable person to assist a veterinary surgeon to monitor and maintain anaesthesia is a veterinary nurse or, under supervision, a student veterinary nurse.
So basically we can move some dials under the direction of a Veterinary Surgeon.....come on how belittling is that? This is our bread and butter!

Another area that really gets my goat is the subject of Dentals and the grey area of minor surgeries. Schedule 3 is defined as;

18.4  Under this Schedule 3 exemption, the privilege of giving any medical treatment or carrying out minor surgery, not involving entry into a body cavity, is given to:
  1. Registered veterinary nurses under the direction of their veterinary surgeon employer to animals under their employer's care. The directing veterinary surgeon must be satisfied that the veterinary nurse is qualified to carry out the medical treatment or minor surgery (see paragraph 18.5).
  2. Student veterinary nurses under the direction of their veterinary surgeon employer to animals under their employer's care. In addition, medical treatment or minor surgery must be supervised by a veterinary surgeon or registered veterinary nurse and, in the case of minor surgery, the supervision must be direct, continuous and personal. The medical treatment or minor surgery must be carried out in the course of the student veterinary nurse's training (see paragraph 18.5).

So reading this you think dentals, no body cavity. We can be best utilised to undertake these, for one no offence vets but we're a darn site less gun hoe than most. We have the time and can utilise our time and take the pressure of the veterinary surgeons by engaging in these tasks. And yet again the 1966 Act states;

Veterinary nurses and dentistry

18.13  Veterinary nurses and student veterinary nurses working under the direction of a veterinary surgeon may carry out routine dental hygiene work.
18.14  The extraction of teeth using instruments may readily become complicated and should only be carried out by veterinary surgeons. The RCVS considers that the extraction of teeth using instruments is not within the meaning of “minor surgery” in Schedule 3.
So wait, has it contradicted itself...I mean what is minor surgery? All this act does is throw up so many grey areas that are open to interpretation. It's not a body cavity, yet the use of instruments defines it as not minor surgery. Yet a stitch up is, so I can stitch up after a tooth extraction?
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Personally, I believe this act needs to be looked at and rewritten. Veterinary nurses are under appreciated as it is, the profession has cracks showing as many do but there's a lot the RCVS could do to further clarify. Other countries such as New Zealand and Australia look to us for guidance, Veterinary nursing is in its infancy in these countries and not even regulated at present (in NZ) so come on UK lets step it up! Rant over, but seriously where are our advocates of Veterinary Nursing in the UK?