Tag Archives: clinical

Time to Catch Up

Okay, I admit it…. part of the reason that I have been “off the grid”, in a blog writing capacity at least, is that I have been having fun. Lots of fun. In fact so much fun that you’ll probably want to hate me for it. But I’m cool with that. Seriously though, I just realised that it’s been over a month since my last post and I honestly had no idea such is the pace with which my time here in the UAE is hurtling past.

Much has happened since my last installment, from some interesting clinical cases and happenings at work through to some awesome social, sporting and, well, just fun endeavours.

In terms of the clinical, the main changes since my last post appear to be (in no particular order):

Down a Vet

The loss of one of our vets meaning that there have been some changes to the weekends that I now get to enjoy. Unfortunately one of our more recent vets just wasn’t getting on well and was, as far as I could tell, also quite unhappy. It was pretty darn clear even from the moment I started that there was a major mismatch between her style of consulting and flexibility to new ideas and ability to cope with the challenges of this particularly busy clinic with exceptionally high standards. It was telling that she seemed to spend rather a lot of time being corrected or otherwise having meetings with the bosses in the office, on a number of occasions preventing me from getting my stuff and getting home! In the end it was no surprise to discover that she was asked to part way with the clinic, a decision which was clearly inevitable. As I mentioned, it did mean that instead of my usual Friday to Saturday weekends, I was switched to working Saturdays and so generally get my weekends on Thursday and Friday, or occasionally Wednesday and Friday.

As mentioned above, I am now working regularly on Saturdays with the change in staffing, meaning that my working week technically starts on a weekend. This was initially at the main hospital all day, which tends to be crazily busy all day, although since we opened our branch in Mirdif, a part of town out near the airport, on Saturday mornings, I start there and then head back over to the hospital in the afternoon. Most Saturdays I arrive to find the clinic as busy as it often is on weekends, with people waiting to be seen and my colleagues all dealing with additional in-patients. There seems to be this annoying feature of veterinary life that dictates that there is never just a happy medium to anyones’ day. It’s either full on, crazy mental, oh-my-God-I-haven’t-even-got-time-to-think-let-alone-eat-or-go-to-the-toilet, with consults booked solid, walk-ins galore and extras just pitching up expecting to be seen (and doing so because we’re just nice like that), or nothing at all with plenty of time to thumb-twiddle, although there is obviously always plenty that can be done to fill the time. Busy is good: I would rather have stuff to do, especially as the day does progress much more smoothly and at pace than if you’re simply thumb twiddling. What I don’t like, however, is the frantic nature of those insane days, when everyone is just rushing around not quite sure if it’s all going to go to shit at any moment. What I have found some weeks is that by the end of the working week there is the danger that people start to get a little snippy with one another, meaning that there is sometimes some definite tension in the air, something that I find very uncomfortable. I like the people I work with – they’re great and I think we have a great team. I don’t like to see them stressed to the point where peoples’ tempers or nerves are getting stretched, which is what I have felt happening some weeks. The notion that it’s “just part of the job” is also something I don’t subscribe to, in much the same way as I view the concepts of “lunch is a luxury in veterinary” and “animal bites are part of being a vet or nurse” as the big crocks of shite that these viewpoints clearly are. It should always be possible to organise things in such a manner that people are busy and able, if necessary to work at 100% capacity when called upon to do so, but not to expect that level of intensity all of the time. The irony, of course, is that we will then get days where there are virtually no appointments – one of the twisted facts of life in veterinary!

Passed With Flying Colours

After a month of waiting, and a few days of hasty revision using my geekily created “Dubai Exam PDF”, I was once again back at the municipality to sit my exam for real this time. It was just little old me this time and I was led up to an office where I sat as if working for the ministry and completed my exam, with “colleagues” around me at their desks discussing various matters in Arabic. The exam itself was a fairly straightforward affair, following the formula that seemed to be firmly established by past papers: three questions on matters related to ministry rules and regulations, such as the duties and responsibilities of a vet and what is supposed to happen in the event a sole vet is absent from the clinic for more than 60 days; then some short clinical questions, including being asked for TPR ranges (temperature, pulse and respiration) for cows and camels – yes, there was a camel question! Most of the clinical questions are geared towards notifiable diseases and public health, so there were ones on everything from leptospirosis to rabies. The last part of the exam was three longer “essay” style questions on, if my memory serves me well, tuberculosis, distemper, and strangles (I think). I didn’t come out of that exam feeling like I’d nailed it and was actually rather apprehensive about what the pass mark might have been. However, this apprehension was misplaced as I discovered a couple of weeks later that I had in fact passed and so am now fully registered.

So, what does being “registered” actually mean? Well, it simply means that I am legally permitted to work in a solo capacity as a vet, such as I now do at our Mirdif branch, and not a great deal more. I have been led to believe that there are many vets operating in Dubai that are not fully registered and it seems they are still able to go about their business. Monique and Malcolm, however, choose to do things properly, which as grating as I am sure it must be to know others are blatantly flouting the rules, is the correct approach to take and one for which I applaud them.

Clinical cases…

Its been busy so that must mean some interesting cases, right? Exactly. There have been some great cases to deal with, as well as some just comical or downright bizarre experiences within the clinic, such as the situation I found myself in last week when a rather attractive client came in with her dog, very professionally and elegantly dressed, and then promptly farted in front of me. Not once, however, but twice! My initial reaction was to think it was the dog but it was quite clearly not and so I did the gentlemanly thing by simply ignoring what had just happened, even when it occurred twice! The bizarre thing was that she didn’t even seem fazed by it and I suspect just considered it a perfectly normal and reasonable thing to do in front of the vet. Bizarre indeed.

We see a lot of skin cases in Dubai, with ringworm top of the list when it comes to dermatological issues. Having never seen a case of ringworm in practice in the UK, with my only experience of it being getting it myself as a young vet student working on a dairy farm (I thought it was just a really nasty rash from rolling out the straw each day – it wasn’t), I now provisionally diagnose and start treatment for it on an almost daily basis. In fact I use the UV Wood’s Lamp so frequently that it occasionally feels like I’m running a tanning salon 🙂

Ear mites are another dermatological scourge oft seen and it seems the ones here tend to be bruisers compared to their whimpy European cousins, as you can easily see the little rascals scampering around down the lugholes of lots of the pets we get in.

When it comes to parasites, ticks are the big problem here whereas we see very few, if any, fleas. In fact I think I may have seen a single flea here since arriving, which is in complete contrast to my experience of working as a vet in the UK for the past five years. As I say, ticks are the big issue here, and unfortunately it’s a fact that they carry some pretty nasty diseases, especially ehrlichia, which I have diagnosed several times. I had a dog presented to me at the end of last week which had been missing from home for several days. When it returned it was found to be absolutely infested with ticks. Our nurses alone removed over 30 from the poor dog! Although the dog wasn’t displaying any overt clinical signs of ehrlichia, we routinely test where appropriate and so a blood test was run, rather unsurprisingly proving positive. Ideally in such cases a full blood count (CBC) would be run to assess the nature and extent of any haematological abnormalities but the owners were not keen to spend the money and so after checking a PCV (normal, thankfully), the dog was started on a 30 day course of doxycycline at 10mg/kg once daily and started on Frontline, to kill any remaining ticks and provide protection against potential further bites. Instructions were given to the owners to a) bring their other dog in for a check and testing – he also proved positive and so treatment was started – and to thoroughly spray the house against ticks, as ehrlichia is a known zoonosis, and a potentially very nasty one at that. Definitely not something that any person wants to end up contracting.

On the theme of ticks, we see a large number of “yellow” cats here, with Bartonella felis, from ticks bites, being the usual culprit. There was one case in particular that came in one day with a history of just being very quiet, flat and “just not right.” Upon examination it was clear that the cat would probably have glowed in the dark, such was the vividness and intensity of the yellow discolouration that it was showing. As with ehrlichia cases, a full blood count is performed, in addition to biochemistry, and the cat was found to have a severe anaemia, as a result of immune-mediated haemolytic anaemia, and so aggressive treatment was started, with doxycycline and steroids at immunosuppressive doses so as to halt the ongoing destruction red cells that the cat’s own immune system was undertaking. After several days in hospital the cat did make a good recovery and the last time I saw it for a check-up, it was a much more normal colour and a tad more feisty – always an encouraging sign!

Fun and Socials…

I always thought I had a lot going on in my life when in the UK but since moving over here it seems that the options for ways in which to spend any spare time you get are numerous, and at times it is difficult to know which options to choose and which to pass by. Since my last post I have been up to the following shenanigans:

Kitesurfing. After taking a few lessons, more as a refresher following the course I undertook in Wales last August, I took the plunge and invested in my own kite, and other gear, so that I am able to get out and put my new skills to use whenever it is windy and I am free. The past few weeks have been somewhat devoid of wind – good for a skydiver – and so I have only really been able to make it out onto the water properly twice. The first outing was fun but rather expectedly frustrating at times, as I spent the time getting used to the kite and board, never really getting up properly or in control, and crashing the kite on more than one occasion, at one point rather alarmingly near a group of sun bathers – quite why they choose to sit on a beach where there are loads of very large kites flying around is beyond me, but there you go, they exist and so it is generally regarded as polite to avoid thwacking them on the head with a large kite if at all possible. Friday, however, was completely different and in spite of the beach being packed, I had a blast, getting straight up on the board and actually kitesurfing for real for the very first time! The feeling of being in the water and then with a simple movement of the kite and a powerful pull from the wind, finding yourself skipping across the waves is indescribably awesome and it is instantly easy to see why people get hooked on the sport. You feel as though you’re actually flying across the surface of the water, which is an amazing feeling indeed. Although I had to ‘bail’ from the board a few times, I found it very simple to control my kite and steer back to my board, and didn’t crash the kite once during my session, which constitutes a major achievement in my opinion. I actually cannot wait until the next windy day when I am off and already find myself doing the kitesurfer thing of constantly assessing whether the wind is strong enough, even whilst walking across the street to get lunch and back. I am addicted it seems but as far as vices go, playing with kites seems a harmless one.

Skydiving. My other passion which, rather ironically, also relies heavily upon the wind, or preferably on very little wind being present, is jumping from perfectly good aeroplanes in the name of sport. Since arriving here in Dubai I have taken advantage of the fact that one of the best dropzones in the world is on my doorstep by jumping at Skydive Dubai several times. Unfortunately I have not yet reached 500 jumps and so am unable to jump at the jewel in the skydiving crown, The Palm, which is really the ultimate aim owing to it’s absolutely stunning location and views. I have, instead, been doing my jumps out at SD2, the desert dropzone, located on the main road between Dubai and Al Ain, and past both the Sevens rugby stadium and the main camel racing track. Getting out there is so easy given how good the roads are here, meaning I can, in theory, leave my villa in the Springs and be in a plane within the hour. As it’s generally hot and sunny all of the time, it is very rare that we get weather delays, although it does get really hot by about mid-morning, meaning that being packed into a small plane for the climb up to jump altitude can be a bit uncomfortable. Its so worth it though as that door opens and you get to leap out into the vast UAE sky.

I am currently working towards my USPA B-license, having logged over 50 jumps. Part of the requirements is to complete a canopy course, which basically teaches you how to fly (and land) your parachute better (in other words, more safely). The first day was sadly too windy and was cancelled but day two was on and so I spent the day learning the theory of more effective canopy flight, including such principles as stalling (not for the faint-hearted, as it basically involves pushing your parachute to the point where it collapses) and finding the flare “sweet spot,” before going up and out to put into practice what we were learning. As it is just the part of the skydive under canopy that we were concerned with there was no need to go to full altitude, meaning that those of us on the course were the first out of the plane at 5000 feet and literally pulled our chutes a few seconds after exiting the plane – Hop & Pop. Although jumping at 12,000 feet is exhilarating enough, the fact is that 5,000 feels so much closer to terra firma (because it is) meaning that the thought of impacting it seems to be much more prominent in the mind. My first exit wasn’t the most stable and it would be easy to just get into a panic and deploy before being in a stable freefall position, all of which increases the chances of there being a deployment issue and ultimately having to cut away. As such, it is vitally important to remain calm, remember the training, breathe and relax – the key to skydiving. After correcting my body position on exit, the next four jumps went very well and I finished the day with a series of pretty good landings, meaning that I have been able to ‘graduate’, as it were, onto a slightly smaller canopy. In practice, what that means is that I fly under canopy much faster, all increasing the importance of having good control so as to lead to a safe and stable landing, which is the number one priority with this sport.

My parents came over to visit. I have had my first set of visitors as my parents headed over for a week in April, arriving on the day of the World Cup horse races, which we attended. Although I had to leave them to entertain themselves for most of the week, owing to the need to work, the three days we did manage to spend together were action packed and a great deal of fun. There is something about having guests that ensures you remember to do all the touristy stuff that as a resident you’d probably not actually ever get round to doing normally. For example, we headed up the Burj Khalifa – a Dubai must – and had breakfast at the Burj al Arab – again, another must see and do in my opinion. One of the highlights of their trip was a desert ride, although it was not without it’s helping of initial drama, more of which I shall delve into.

So, all in all its been a busy few weeks since I last posted and although I have only actually been here for about nine weeks I do feel as if its been significantly longer, which can never be a bad sign. The next significant challenge, however, is going to be the summer, which I have been led to believe by many, many people is brutal. I guess I shall be catching up on a lot more DVDs then 🙂

Technology Advances & Its Impact on Veterinary Practices

Technology advances and its impact on veterinary practices – including e-CPD and e-learning options

(as printed in the Vet Nursing Times – see links to PDF versions at bottom of post)

The word technology means different things to different people. Many of us think of smartphones or sophisticated computers as cutting-edge technology and perhaps don’t imagine that there is much in the way of technological advancement occurring in everyday clinical practice.  The truth is that there is a lot of advancement in a variety of technologies taking place in veterinary practice, and it is some of these that I aim to share with you today.

Technology is, for me, anything that helps us to do our jobs better, whether it be enabling us to perform tasks faster, more effectively, or to enable us to achieve a better outcome for our patients and clients. In essence, technological advances should, and usually do, enhance both our personal and working lives. There are three areas in which we see advances in technology in practice. The first is clinical technology; the classic ‘vetty’ gadgets, gizmos and systems that make the process of diagnosing, treating and managing our patients easier and more effective. Secondly, there are the advances in practice management and client communication technologies, an area which in my opinion has probably seen the biggest changes and which offer the biggest opportunities for really impacting on our clinics’ bottom lines. The third area for focus is the use of technology in education and CPD, important in ensuring our personal and professional growth and where technology is certainly having a big impact.

 

Clinical Tech

Although our focus is on first opinion practice, it is worth noting the fact that as general practitioners we have ready access to the very latest clinical technology and cutting-edge diagnostics and treatments through our ability to refer to our specialist colleagues. We are, as vets, able to pretty much do anything that is clinically possible and this is, in large part due to the huge advances in knowledge, expertise and technology at our disposal within the specialist fields.

Imaging is probably one of the main areas in which technology is at it’s most obvious. Gone are the days, for many of us, of long periods stuck in a dark, hot, generally uncomfortable radiography suite taking multiple radiographs and getting more and more frustrated at how long it can take just to get a simple series of images. It was a revelation when I moved to my second job and discovered the joys of digitial radiography. No need to fumble in the dark with open cassettes and film or handle noxious chemicals, and the images were pretty much instantaneously available. The system I first encountered was CR-tech, or Computed Radiography technology, involving the exposure of a plate, as per traditional methods, and then the processing of these films by way of a digital system. Since then there have been further advancements with the emergence of DDR-tech (Direct Digital Radiography), in which the plate is exposed and an image almost instantaneously appears on screen without the need to manually place the plate into a processing unit. This is possible due to the use of a syntillated plate, or direct digital panel (DDP), which effectively replaces the plethora of film cassettes that we’re used to using at present. Never has the phrase “take a quick X-ray” been so accurate!

In parallel to advances in the technological hardware itself comes developments in software, meaning that the process of taking, processing and working with radiographic images is much more user friendly and clinically helpful. There are, for example, bespoke software packages that will guide the vet through the correct measurements required for planning a tibial plateau levelling procedure, for example. The reduction in the sheer size and amount of necessary hardware, coupled with the options of cloud storage, where digital files are stored on a remote server away from the clinic (think Facebook, whereby your profile is actually hosted on a server in the US, or elsewhere, and not all on your desktop) has meant that even the smallest of clinics can boast an impressively powerful and versatile radiography capability, with none of the hassle associated with the secure storage, organisation and retrieval of hundreds of radiographs. Much simpler and much more elegant.

portable ultrasound scannerUltrasound technology is another area where we have seen impressive changes in practice. From super-powerful, all singing, all dancing set-ups, such as the Logiq S7 Expert, which makes use of new matrix probes and B-flow technology, useful for assessing vascularisation in tumours, for example, to the miniaturisation of the scanners, allowing us to both reduce the amount of space taken up in our clinics and ‘take the scan to the patient,’ whether in a hospital or out on calls, the changes have been staggering. To have the kind of imaging power that we have in a device no bigger than a laptop computer is a sure sign of the advances in technology that we are enjoying as vets.

vgel endotracheal tubeOne of the key attributes of a true technical advancement is one which takes an established way of doing something and completely rethinks it, or revolutionises it. One such example of new technology that does just that is the v-gel, a new airway system for ventilating anaesthetised patients. The point to note is that it isn’t an endotracheal tube – that’s the revolutionary thing about it. Instead of inserting into the trachea, through the larynx, the v-gel creates an effective seal around the pharyngeal, laryngeal and upper airway tissues, thus positioning a large diameter opening directly over the larynx to permit normal gas exchange with no trauma to, or even contact with, the larynx. One of the key advantages of this new system is that rather than needing a tube that is in effect smaller in diameter than the trachea, the v-gel allows the tube to be larger in diameter than the patient’s trachea thus maximising air flow and exchange. The soft rubber tip, that atraumatically ‘plugs’ the oesophagus, also serves as a good counter to the risk from regurgitation under anaesthetic. Currently available for both rabbits and cats, with dog versions in development, these new tubes represent a fantastic example of a smart, cleverly designed advancement of an existing technology.

 

Client Engagement

MailChimp screenshotWe’re all aware of the need to better engage with and market to our clients, both current and prospective, with the level of competition between practices apparently increasing all of the time. The methods for doing so these days have never been so plentiful nor powerful, yet many of us are still failing to maximise on the potential returns that doing so could bring. One of the simplest ways of better engaging with our clients, and those who show an interest in our services, is through email and the careful but MailChimp email marketingeffective management of email lists. Email management services such as MailChimp, which enable even the most technophobic of users to set-up a mailing list, design a web form to be posted on a website, social media, or even accessed via a link which can be emailed, and then organise, manage and communicate effectively with the people on that list, are brilliant and it is amazing how useful they can be for practices. Imagine, for example, how impressed your clients would be to receive an email on their pet’s birthday wishing them many happy returns. Combining such a thoughtful gesture with a suggestion of a senior health check if the pet has just turned seven, for instance, could be an easy yet effective way of driving more business through your doors. Through careful segmentation of lists, such as having a list containing only those clients who own cats under 7 years of age, for example, it becomes much easier to provide them with relevant information that they will find interesting and useful, with the result being a much greater level of trust in and bonding with you and your practice. How many of us actively ask our clients or new prospects, for their email address? My guess is very few. The truth is that these days people almost expect to be asked for it and we should be making a greater effort to make use of the advances in email and online marketing, much of which is available either free or very low cost, especially when compared to other marketing media such as print. Done well, email could be the best use of technology you have in your practice at present.

Social media is another potentially powerful way to engage with our clients and to help make us stand out from the crowd. People are interested in what we do as vets and what can often seem like the most run of the mill, mundane, day to day event in our clinics may form the basis for a fantastic Tweet or Facebook post, which can encourage a conversation between people and raise the prominence of us and our clinics in a good way. Obviously care has to be exercised, like with anything, but Social Media is one surefire example of a recent technology that veterinary practices have a lot to potentially gain from. Some clinics have embraced this aspect of marketing, using it to converse with clients and to provide updates, information and education through the use of videos, for example. Engaging clients in such a manner is a great way of strengthening the bond they have with your practice.

vet using ipadSome clinics have embraced technology more than others with some even rewriting the rule books on how we can manage our practices. Vets Klinic in Swindon have just one desktop computer in their practice, with each vet and nurse issued their own, personal iPad on which the clinic’s bespoke practice management system is accessed, meaning that patients’ records are readily accessible no matter where you are in the clinic and making the consulting rooms, and other areas feel clutter free. Use of tablets also enables patients’ time within the clinic to be recorded, and photos and notes about their stay easily uploaded to their clinical ‘timeline.’ Owners can access their pet’s timeline and see in realtime how their pet is getting on. Clients are actively encouraged to register and book everything from appointments to surgery online, with an airline style booking system showing prices and times of appointments with each vet, with real-time variable pricing a feature and a discount on offer for clients who prepay in advance of their appointment.. Tablet computers do appear to be excellent devices for use in a busy hospital environment, with the ability to readily access a patient’s notes wherever you, as the vet or nurse, happen to be within the clinic.

 

Electronic Learning

nerdy vet with laptopThe internet has quite simply revolutionised the way in which we access and consume CPD, with webinars and online learning resources becoming ever more commonly used, and available across virtually every platform, from smartphones to tablets and the trusty desktop computer. The advantages are clear: access to reliable, interesting CPD without the need and expense of taking time out of our busy clinical lives or the hassle of travel to attend lectures. With a plethora of providers, including many of the drug companies, learning online can be achieved at little to no cost and represents a very cost effective way of ensuring we keep our CPD current and maximising our CPD budgets. The only limitation that I could see from my experience of ‘attending’ a webinar was the fact that as the event was taking place on my computer and in the comfort of my own home, unless the speaker was particularly engaging, it was very easy to get distracted with other activities whilst convincing myself that I was still learning as I had the lecture playing. This coupled with the knowledge that I could always go back to the lecture and view it again at another time only acted to fuel my distraction. Somehow there just seems less risk of this happening when you’re physically present with the lecturer and other CPD attendees present in the same room. But then, maybe that’s just me and everyone else is a consumate good student at home. With so many other distractions constantly vying for our valuable attention the challenge, as I can see it, is for e-CPD providers to ensure that their content is as engaging and interesting as possible, including the use of mixed media, from standard lecture-style presentation slides and speech, to clever use of graphics, video and animations to really bring subject matter to life and inspire people. After all, the last thing any vet wants after a long, hard day in the clinic is to sit through a dull lecture, even if they do have the option of switching over, as it were.

One of the exciting challenges for the future will be in seeing how e-CPD can deliver more practical training, with a physical presence still very much required at present for practical CPD courses. Maybe a stepping stone will be the provision of ‘learning kits’, complete with necessary equipment and materials which the student can make use of whilst receiving remote instruction via a webinar or other means of e-learning. Although e-learning is delivering a wider and more accessible range of CPD to the profession, available at any time, anywhere and in any format, it is unlikely that it will completely usurp the strong desire we have as humans to actually congregate in the same space to receive educational instruction and socialise, as is clearly demonstrated by the continuing popularity of congresses, such as the London Vet Show.

Whether we realise it or not, technology and advances in it are all around us in practice. From the scanners we use to make diagnoses to the equipment we employ to safely manage our ill patients, or the plethora software tools, both bespoke and consumer options, technology is pervasive and empowering. It has changed the way we engage with clients, market our services, and continue our professional development, and all pointers are in the direction of yet more innovation and technological advancement, I for one watch on excitedly.

Links to the PDF versions of the original article, as printed in the Vet Nursing Times:

VNT Tech Article Feb2013_p1

VNT Tech Article Feb2013_p2