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ISSUE 11 | OCTOBER 2021
CONTENTS OCTOBER 2021
®
®
ARTICLES
04 Adverse Food Reaction:
When Diet is the Problem—and the Solution
20 Do You See What I See? Ophthalmic Exam Basics 22 On Simone Biles, Emotional Agility, and Leading with Mental Health 07 Management of Cats with Adult Heartworm Infections 10 Monitoring the Anesthetized Patient - Part 1 14 Goodbye Toxic Team
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SPONSORED ARTICLE
Adverse Food Reaction: When Diet is the Problem—and the Solution
ALISON MANCHESTER , DVM, DACVIM (SAIM) Veterinary Specialist and One Health Fellow Colorado State University College of Veterinary Medicine
How often do we experience gastrointestinal (GI) upset and say to ourselves, “It must have been the burrito/ice cream/ sausage pizza/bean dip I ate.”? If we’re sensible, we avoid consuming the offending food until at least the next time our cravings overcome our common sense.
Unfortunately, dogs can’t perform this kind of self-regulation, even though their kibble may be the culprit behind their chronic diarrhea, vomiting, flatulence and/or poor appetite. As veterinarians, we often overlook diet as a potential instigator of GI distress and instead jump to the assumption that a patient with GI issues must be suffering from a parasitic or bacterial infection. As a GI-obsessed internist, it’s disappointing to walk into a consultation and learn a dog has been struggling with GI distress for months or years, undergoing treatment with metronidazole, tylosin, dewormers, and holistic supplements, with only a passing reference to dietary investigation. In many cases, a simpler, safer option might have been to first consider changing the dog’s diet. The term “adverse food reaction” is broad. It encompasses everything from a true food allergy to food toxicity to intolerances of proteins, fiber sources or fats underpinning a host of chronic enteropathies . The good news is that approximately two-thirds of dogs with adverse food reaction can experience marked clinical improvement, if not full clinical remission, when we feed them the right diet.1 ASK QUESTIONS—AND LISTEN We can’t ask our canine patients how they’re feeling, but we can get a lot of information from the owner. The catch is that owners don’t always know what’s normal and what’s not. Ask a client if their dog is experiencing “diarrhea”, and you may miss something simply because the client doesn’t realize that their dog’s bowel habits actually might indicate GI dysfunction. A thorough nutritional history is also vital. Unless you probe deeper, the client may tell you their dog is eating a prescription hydrolyzed diet, but neglect to mention that the dog also gets the milk at the end of the cereal bowl, three rawhide chews a day and “a bite” of whatever the owner eats for dinner.
RUN THE RIGHT TESTS After you take a diet history, the next step should be to ask yourself, “Is this animal sick or well?” If the dog has a good appetite and normal body condition, a conservative approach, such as switching the dog to a different over-the-counter food or to a therapeutic GI diet, may be appropriate. If the animal is not well, with a decreased body condition, loss of muscle mass and/or a poor appetite, a more thorough investigation is warranted. I start with a minimum database of a CBC, chemistry panel and urinalysis. These tests can help rule out renal or liver disease, leukogram abnormalities, nonregenerative anemia, and hypercalcemia. These results might alter your differential list and workup. While veterinarians may be tempted to confine testing to a GI panel because of cost concerns, evaluating B-vitamin levels and pancreatic enzymes will provide little information beyond ruling out conditions such as exocrine pancreatic insufficiency. The minimum database gives the clinician a much better overall assessment of the dog’s health. SEPARATE FOOD INTOLERANCE FROM FOOD ALLERGY Does this scenario sound familiar? The patient in your exam room is a two-year-old dog suffering from chronic small bowel diarrhea and nonseasonal pruritus with chronic otitis externa. Such signs could be due to an adverse food reaction or perhaps a true food allergy. An elimination diet trial is needed at this point to diagnose the condition. While the idea of a strict elimination diet may be daunting to some clients, the good news is that such a trial will not necessarily be a two-month ordeal. In fact, if the dog improves within a couple of weeks, a nonimmunologic food intolerance should be suspected versus a food allergy. Furthermore, many
ELEMENTAL DIETS—ARE THERE OTHER APPLICATIONS? Elemental diets have been used with great success in human patients with conditions such as pediatric Crohn’s disease. Not only can patients achieve clinical remission, but they experience mucosal healing as well—without the use of medications (e.g. oral glucocorticoids) that can cause serious side effects. Beyond their lack of immune stimulation, elemental diets are thought to benefit patients because the calories are readily assimilated and digested. This helps address the malnutrition component, that can be a significant component of people and dogs with chronic intestinal disease. The veterinary profession is still learning about potential applications for elemental diets, but the potential to help dogs with chronic enteropathies or to diagnose food-allergic dogs that react to novel protein and hydrolyzed elimination diets is exciting. Adverse food reactions are a common cause of GI upset in dogs. Thanks to the wide range of therapeutic GI diets—from hydrolyzed diets to low-fat, high-fiber and elemental diets, veterinarians have the means to help patients in ways that do no harm—but can do much good. REFERENCES 1. Allenspach K, et al. Long-term outcome in dogs with c hronic enteropathies: 203 cases. Vet Rec 2016;178:368. 2. Allenspach K, et al. Chronic Enteropathies in Dogs: Evaluation of Risk Factors for Negative Outcome. J Vet Intern Med 2007;21:700-708. 3. Walker D, Knuchel-Takano A, McCutchan A, et al. A Comprehensive Pathological Survey of Duodenal Biopsies from Dogs with Diet- Responsive Chronic Enteropathy. J Vet Intern Med 2013;27:862–874.
dogs with food intolerance vs. food allergy may eventually be able to resume eating their former diet.2 This supports the theory that nutritional therapy can allow the gut to heal.3 When clinical signs—including both GI and dermatological— recur with deviations from the prescribed diet (including attempts to transition back to the original diet), the presence of true food allergy becomes a lot more likely. In my practice, many owners are averse to rechallenging with a previous diet, and that is fair. One instance where I would not advocate for a deviation from a beneficial diet would be in protein- losing enteropathy dogs responding to an ultra-lowfat diet. That suggests the presence of lymphangiectasia, and fat restriction should be life-long. SELECT THE DIET FOR THE ELIMINATION DIET TRIAL For dogs with suspected food intolerance or allergy, a dedicated feeding trial with an elimination diet is a must. For most cases, a hydrolyzed diet that is highly digestible fits the bill. Hydrolyzed diets are formulated by taking a native protein such as soy or chicken and using enzymes or heat to break the proteins into tiny pieces that can go unrecognized by the immune system. However, a small number of patients will react to hydrolyzed proteins as well as intact proteins. A new dietary option for elimination diet trials is an elemental diet for dogs. An elemental diet sources individual amino acids and combines them with a carbohydrate and fat source to make a complete and balanced diet. Because the immune system cannot detect individual amino acids, this type of diet is effectively the gold standard for hypoallergenic diets.
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SPONSORED ARTICLE
BUTTERNUT SQUASH CROCK POT SOUP
Management of Cats with Adult Heartworm Infections
Recipe Submitted by Katie Engel
A PERFECT FALL FAVORITE
MARISA AMES , DVM, DACVIM (CARDIOLOGY) Associate Professor of Cardiology | UC Davis School of Veterinary Medicine
Cats with adult heartworm infection present a unique challenge for veterinarians. Cats are both susceptible to heartworms and more resistant to adult worm infections than dogs, typically harboring six adult heartworms or fewer when they are infected. Infections with just one or two worms are considered common in cats and one-third of these infections are single-sex. The catch is that even one or two adult worms in a cat can constitute a serious, and even life-threatening, situation. There is limited prevalence data on heartworm infection in cats. While canine patients are routinely screened for heartworm infection via antigen tests during annual veterinary visits, cats tend to be tested only when the cat is symptomatic and heartworm infection is suspected. Of 157 feline practitioners who completed a 2020 survey conducted by the American Association of Feline Practitioners (AAFP) on behalf of the American Heartworm Society, 85 percent indicated they believe feline heartworm is underdiagnosed. Antigen tests also have the limitation of only detecting live adult female infections and dying male and female worms, which means that immature and male-only infections can be missed. Nevertheless, a positive result on a heartworm antigen test is a definitive indication that a cat has an adult infection. With this question answered, however, another quickly takes its place: given that melarsomine use is contraindicated in cats, how should an adult heartworm infection be treated? While no official guidelines definitively answer this question, there are steps practitioners can take to support these patients. • Ensure the cat is on a heartworm preventive. While heartworm preventives cannot be expected to kill adult heartworms, they can prevent new heartworm infections from developing. Macrocyclic lactones are generally safe to administer to cats with adult heartworm infection. As noted above, a cat typically has a low adult worm burden and does not have circulating microfilaria, thanks to an immune system that almost always destroys them. This
largely eliminates the concern that a hypersensitivity reaction could develop as a result of microfilaria death.
Client compliance in administering heartworm preventives is paramount, so veterinarians should be sure to recommend a preventive the client is comfortable giving. Multiple options are available, including topical and oral products that are given monthly or bi- monthly. A bonus to administering feline heartworm preventives is that they can eliminate or manage other parasites besides heartworms. Depending on the product, preventives may be effective against intestinal parasites, such as roundworms and hookworms, and external parasites, such as fleas and mites. Meanwhile, preventives containing ivermectin and moxidectin are slowly adulticidal in dogs and this is likely also true for cats. • Eliminate Wolbachia to weaken the adult worms. Heartworm treatment protocols in dogs include the administration of doxycycline for 4 weeks to kill the Wolbachia bacteria that contribute to the inflammatory reaction associated with heartworm infection. The same principle applies in cats; by killing the Wolbachia, heartworms are weakened at all life stages and are possibly rendered less antigenic to the host. The downside to administering doxycycline to cats is the association of this antibiotic with gastrointestinal side effects. Reducing the dose to 5 mg/kg BID or 10 mg/kg SID may help reduce nausea, vomiting and inappetence, while administering doxycycline in a liquid formulation may minimize the risk of esophageal injury. • Consider steroid therapy and other medications to manage clinical signs. If the cat is demonstrating signs such as cough, the cat should be treated for presumed heartworm associated respiratory disease (HARD). HARD essentially is treated like feline asthma, using oral ± inhaled steroids. Inhaled albuterol can be dispensed for
INGREDIENTS • 1 butternut squash, seeded and chopped (leave skin on) • 1 head cauliflower, roughly chopped • 4 carrots, peeled and chopped • 4 stalks of celery, chopped • ½ onion, chopped • 4 cups vegetable stock • ½ teaspoon salt • 1½ teaspoons ground ginger • 2 teaspoons dried rosemary • 1 can (15 oz.) coconut milk • sour cream/plain yogurt, if desired • paprika, if desired
DIRECTIONS 1. Add squash, cauliflower, carrots, celery, and onion to slow cooker. 2. Add vegetable stock. Add water so that crock pot is about ⅔ full of liquid. Add salt, ginger, and rosemary. 3. Cook on LOW for 8-10 hours. 4. Add can of coconut milk. Blend with immersion blender or carefully blend by batch in a blender. 5. Serve with swirl of sour cream or plain yogurt and dash of paprika.
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acute attacks related to bronchial reactivity. It should be noted that low-dose steroids are beneficial for asthmatic-like clinical signs but will not prevent the ARDS-like reaction that can occur with the death of an adult worm in the cat. Cats that present in acute, severe respiratory distress may require higher dosages of injectable steroids and oxygen therapy for stabilization. Some clinicians send owners home with an emergency dose of injectable dexamethasone to administer to the cat if needed. Finally, there is anecdotal evidence that supports the use of the antileukotriene montelukast (2mg total dose PO SID). This drug reduces the release of inflammatory leukotrienes from cells that mediate immediate hypersensitivity reactions or allergic inflammation (e.g. mast cells and eosinophils). This drug is administered chronically to heartworm infected cats. • Remove the worms. A final treatment option for cats that are heavily infected and/or in critical condition is removal of right atrial/ventricular worms. An echocardiogram allows the clinician to confirm the presence of intracardiac worms. Worms within the right atrium or right ventricle can be retrieved using a small Amplatz gooseneck snare introduced through a jugular venotomy. Risks with this procedure include hemorrhage from the venotomy site, tearing/breaking the worms and anaphylaxis (which can be fatal), and damage to the tricuspid valve. This procedure is ideally performed with the aid of fluoroscopy or transthoracic echocardiography.
the likelihood of permanent pulmonary damage. In subclinical cases, radiographs and echocardiography are still useful for a baseline comparison if cardio- respiratory signs develop. Cats should be monitored with thoracic radiography every 6 to 12 months as radiographic signs can wax and wane. Repeat
antibody and antigen testing is also recommended. A regression of radiographic signs of pulmonary vascular/interstitial disease and seroconversion of the cat’s antigen status from positive to negative may be indications that the risk of acute disease has passed; however, an ARDS-like reaction is still possible if the cat has harbored an adult male worm that ultimately dies. Much remains to be learned about the pathophysiology and treatment of heartworm disease in cats. Given the serious consequences of adult heartworm infection in cats and the safety and efficacy of heartworm preventive medications, the American Heartworm Society recommends that heartworm prevention be administered to cat in areas where heartworm disease is endemic in dogs.
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WEBINAR HIGHLIGHTS
JANE QUANDT , DVM, MS, DACVA, DACVECC Professor, University of Georgia VETgirl, Forum Consultant/Contributor Monitoring the Anesthetized Patient - Part 1
In this 2-part series webinar entitled “Monitoring: What monitors tell you & what is considered standard of care” Dr. Quandt reviews the physical exam parameters used for monitoring the anesthetized patient as well as endotracheal tube (ETT) mishaps and post-op emesis and regurgitation. Please check back in Q4 e-newsletter, where Dr. Quandt will review monitoring devices and parameters for monitoring the anesthetized patient.
Auscultation of the chest is a greatly underutilized method of assessing patients. Any patient that has a history of chest trauma, cardiac or pulmonary disease, or being mechanically ventilated should be ausculted both pre/post-operatively. Often, it is much easier to auscult an animal after intubation since upper respiratory sounds are minimized when a patient is correctly intubated. The best way to ensure correct intubation is direct visualization of the glottis and the presence of end-tidal CO2. Endotracheal tube mishaps: An over-inflated cuff on the ETT can cause tracheal irritation and possible necrosis and could lead to a tracheal tear. Tracheal tear is most commonly seen in cats following anesthesia for a dental. The cat presents with subcutaneous emphysema. Possible causes may include- overinflation of the ETT cuff, changes in body position without disconnections from the y-piece resulting in twisting of the tube within the trachea, traumatic intubation, and removal of the tube with the cuff still inflated. The overinflated cuff is the most important cause. Only inflate the cuff so there is no leak of air when the re-breathing bag is squeezed to a pressure of 15 to 20 cm H20. Endobronchial intubation is placement of the ETT down one bronchus and only ventilates one lung which can lead to hypoxemia. The ETT should be past the larynx and not further than the thoracic inlet. The ETT against the tracheal wall can impede ventilation, therefore it is preferred to have ETTs with a Murphy eye which is a second opening to prevent possible ventilation impairment. Post anesthetic blindness can occur in cats most commonly following dentals but can occur after endoscopy. The spring-held mouth gag seems to increase the risk. Hypotension may compound the risk. The blood supply to the feline brain is primarily via the maxillary artery. It is possible that the use of the mouth gag reduces blood flow to the brain through the maxillary artery by stretching of the vasculature and/or adjacent muscles with resulting vascular compromise. Some cats will regain vision but
The pulse pressure , or difference between the systolic and diastolic blood pressures, is responsible for the strength of the palpated pulse and is an estimate of stroke volume. A decrease in strength of the palpated pulse indicates a decrease in pulse pressure. • Weak pulses indicate decreased left ventricular stroke volume or poor ventricular filling, as seen with hypovolemia, ventricular failure, severe arrhythmias, pericardial disease and/or effusion, and subaortic stenosis (SAS). • Bounding pulses are seen with increased systolic pressure +/- decreased diastolic pressure such as with patent ductus arteriosus (PDA), aortic insufficiency, generalized or excessive vasodilation, and anemia (high output circulation). Heart rate should be counted when checking pulse quality. Normal heart rates vary with species. • Tachycardia can decrease the ventricular filling and coronary perfusion because the heart doesn’t have time to fill normally. It can occur with inadequate anesthetic depth and/ or pain, anesthetic drugs (thiobarbiturates, dissociatives, anticholinergics, catecholamines), hypotension, hypoxia, hypercarbia, anemia, and fever. • Bradycardia can cause decreased cardiac output and hypotension. It can be seen with increased vagal tone or vagal reflexes, excessive anesthetic depth, anesthetic drugs (opioids, alpha 2 agonists), hypertension (reflex bradycardia), hypoxia, hypothermia, increased intracranial pressure, and hyperkalemia. D. Respiratory System Ventilation is often decreased by anesthetic drugs via direct depression of CNS respiratory drive and relaxation of the respiratory muscles (intercostals and diaphragm). Ventilatory rate, effort and pattern (thoracic, abdominal or diaphragmatic) should be monitored and assisted if necessary. Assessment of ventilation may include, visualization of chest excursions under drapes, condensation inside the ETT at exhalation, monitoring the reservoir bag, listening for breath sounds via esophageal stethoscope and the presence of end- tidal CO2, but can be difficult in some patients.
Monitoring the anesthetized patient is the most important job during anesthesia. Thorough monitoring is the best way to assess the condition of your patient and avert disasters before they occur. Waiting for difficulties to arise not only delays solving the underlying problem(s) but also delays treatment of the obvious abnormalities. Monitoring basic parameters will draw attention to involved body systems. Although the sheet upon which we record information is divided into five-minute increments, monitoring should be constant from the time pre-medications are given until the patient returns to consciousness and is extubated. Trends, as well as absolute values, are important, and the periods before, during, and after anesthesia are included. A thorough preoperative physical exam and ASA status assignment are important in order to ascertain the beginning condition of the patient. Monitoring equipment is important for patient assessment, but NEVER lose sight of the patient. Physical monitoring is the easiest, cheapest, and best way to monitor your patient. A. Mucous Membranes Normal mucous membranes (mm) are pink, in most species. Pigmentation, especially in dark colored dogs and cats, can interfere with the interpretation of mm color. If the tongue and/or gums are dark, check the vulva/prepuce, toe webs or nail beds for a less pigmented area. Changes in mucous membrane color warrant attention. • Pink mm generally indicates acceptable oxygenation. Anemic or vasoconstricted animals may be difficult to assess. • Pale mm indicate hypotension and/or vasoconstriction as can be seen with blood loss, hypovolemia, hypothermia, decreased cardiac output (CO = HR x SV) related to anesthetic drugs, shock, patients with cardiac disease and bradycardic cases.
• Grey (ashen) mm indicates poor perfusion and are often seen with hypothermia or patients in shock. • Blue (cyanosis) mm indicates SEVERE hypoxemia and occurs when >5% of the hemoglobin (>5g Hgb/100 ml of blood) is desaturated. Severely anemic animals are difficult to assess because > 5g/dl of hemoglobin must be present in order to visualize cyanosis. Anemic patients with a PCV of 15% have a Hgb of 5 g/dl, which means all of the hemoglobin would need to be desaturated before cyanosis would be noticeable, and by this time the patient would be dead. B. Capillary Refill Time (CRT) Refill, return of color, after blanching the area with digital pressure, gives a subjective indication of tissue perfusion and vasomotor tone (e.g., vasoconstriction, vasodilation). • <1 second is normal in awake, healthy animals. • 1-2 seconds may be acceptable, but NOT necessarily normal, in anesthetized patients, especially if they are cold, hypotensive or vasodilated. • 2-3 seconds is prolonged, characteristic of increased sympathetic tone, vasoconstriction, hypotension, poor perfusion, or hypothermia. • >3 seconds is markedly prolonged, indicating severe decompensation. C. Heart Rate / Pulse Quality Rate, rhythm and strength of pulses give a subjective assessment of the cardiovascular system, contractility, blood volume and stroke volume; relative changes should be recorded and trends noted. Normal pulses are strong and regular, within the normal number of beats per minute (BPM) limits of the species. Pulses can be easily detected at the following arteries, lingual on the tongue of dogs, cats, metacarpal, brachial on the front leg of dogs, cats, horses, ruminants and wing of birds, metatarsal (dorsal pedal), femoral on the hind limb of most species and auricular in horses, ruminants, swine and floppy eared dogs, the artery runs down the middle of the ear.
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WEBINAR HIGHLIGHTS
SAFE FOR USE AROUND PEOPLE, PETS, WILDLIFE & LIVESTOCK SAFE FOR USE AROUND PEOPLE, PETS, WILDLIFE & LIVESTOCK
SAFE FOR USE AROUND PEOPLE, PETS, WILDLIFE & LIVESTOCK
JANE QUANDT , DVM, MS, DACVA, DACVECC Professor, University of Georgia VETgirl, Forum Consultant/Contributor Monitoring the Anesthetized Patient - Part 1
Cont’d. from page 11
These patients may be extubated with the endotracheal cuff partially inflated to prevent any material from leaking past the cuff and entering the lungs. Regardless of the visible presence of regurgitation, patients can experience “silent” reflux into the esophagus. Monogastric patients (dogs, cats) may represent for esophageal irritation (esophagitis) or stricture weeks to months after being anesthetized. The cause of this problem is currently unknown but is thought to be related to prolonged fasting periods. Therefore, it might be suggested that dogs and cats should be fasted for NO LONGER than 6-12 hours prior to anesthesia (in contrast to the traditional >24 hour fasting recommended in the past). Metoclopramide may decrease the potential for regurgitation in dogs. The loading dose is 1 mg/kg IV followed by a CRI of 1 mg/kg/hr IV. This has been used prophylactically in brachycephalic dogs, dogs undergoing laryngeal paralysis surgery and HBC dogs that have may have full stomachs. Maropitant at 1mg/kg IV to prevent vomiting is also used in the premedication period for these dogs along with the metoclopramide. Make sue to tune in for Part 2 of Monitoring the Anesthetized Patient in our next issue! “You don’t have to provide monitoring for every patient…only those you can’t afford to lose” - Anonymous
some may not. A small mouth gag can be fashioned by cutting a tuberculin syringe barrel and placing it on opposing canine teeth and thus avoid overstretching the mouth. E. Reflexes and Muscle tone Ocular reflexes include eye position, pupillary, palpebral, corneal and nystagmus. Withdrawal or pedal reflexes (toe pinch) include patellar reflex, anal reflex, jaw tone and muscle relaxation or response to stimulation. F. Blood Loss The surgical site and the surgeon are a great wealth of information. • One blood saturated 4”x 4” gauze sponge holds about 10-15 mls of blood. • One 12”x12” lap sponge holds about 50-75 mls of blood. • Sponges can be weighed for a more accurate estimate (1 ml blood = 1 gm). • The suction containers are marked to estimate the amount of blood loss. G. Urine Output Urine output is a relatively noninvasive way of estimating cardiac output, (CO). If CO is sufficient to perfuse the kidneys and produce urine, then the CO is generally sufficient to perfuse other organs. Minimal acceptable urine output is 1-2 ml/kg/hr. Urine output is easily measured with a urinary catheter and a closed collection system. Alternatively, urine output can be measured in cats by weighing litter boxes before and after urination, and then calculating (subtracting) the difference (1 g = 1 ml urine). Lower output indicates inadequate cardiac output and subsequent poor renal perfusion. Higher output may occur with fluid diuresis, diabetes, or renal insufficiency. H. Postop emesis/regurgitation Patients may passively regurgitate stomach contents during anesthesia or recovery. This fluid and foreign material must be suctioned and the oropharyngeal area cleared before extubation.
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No one should be permitted to yell at each other. It simply should not be tolerated. Throwing of items or slamming things on tasks should be immediate reasons that an employee is written up. While at times it seems like a casual place of employment, it is a working hospital performing medicine. It is a professional environment that many times employees forget to be professional in. If there is a heated exchange of words or actions it should be immediately corrected once the individuals have had time to reflect on the inappropriate behavior. They need to apologize in order to mend the relationship they have as team members. And while they may not agree with each other, they need to agree that they are working towards the same common goal and will treat each other in a more respectful manner moving forward. Team members should not be permitted to curse frequently. There may be a rare instance where cursing happens. The team member who said the bad word, should apologize and make it known that it was inappropriate behavior but that they were reacting to the situation. Cursing directly at a team member is grounds for immediate action from a manager. Above all else, it is important to remember that every team member works in a professional environment. Maintaining professionalism and being polite and respectful is important to good team health. Own Your Mistakes & Be Honest This one always made the list because it was so important for people to work with an honest team member. Everyone makes mistakes. If they don’t trust each other, then they will struggle to work with each other. This trait is about team members being able to trust each other. One of the first things that we can do in a leadership role is to ensure that we cultivate a team where mistakes are not at the forefront. If we have our employees fearing they may get in trouble, then they are less likely to communicate an issue or be honest when it is necessary. Instead, we must praise those that are honest. We do need to correct mistakes, but those corrections should be few compared to the praise and admiration we provide to our teams. We often see a lack of communication between the doctor, veterinary technician, and front office. Many times, the front office and the veterinary technician are afraid of telling the doctor that a mistake was made. After all, they are the doctor. They don’t want to get yelled at, made to feel stupid, or have the doctor not trust them. We need to ensure that our teams know how to communicate between all areas of the hospital. We need to have a hospital where honesty is valued and praised. Be a Cheerleader Not every team member is going to be vocal and cheering everyone on all the time. That’s okay. However, whether you are an introvert or an extrovert, it’s important to give praise to your team members when they do a good job. Be genuine about your appreciation to the person. “Good job getting that catheter in,” or “Great job dealing with the difficult client,” is essential to maintaining the best team. So many times, I hear from teams, “Our manager doesn’t praise us at all. She doesn’t even know what we do.” They are right. The manager has no idea what they do. Most
VETgirl U HIGHLIGHTS
10 KEY TRAITS OF BEING A GREAT TEAM MEMBER
AMY NEWFIELD, MS, CVT, VTS (ECC) Veterinary Team Training Goodbye Toxic Team
1. Start the Day Off On a Good Foot 2. Be Kind, Respectful, & Polite to Each Other 3. Own Your Mistakes & Be Honest 4. Be a Cheerleader 5. Be Helpful 6. Be Engaged & Have a Good Work Ethic 7. Don’t Gossip & Assume Good Intention 8. Remember It’s ONE team 9. Create Moments of Laughter & Fun 10. End the Day With a Unicorn Flying By
In this VETgirl Technician Webinar, “Goodbye Toxic Team: Converting the Negativity to Positivity,” veterinary technician Amy Newfield reviews how to convert negativity to positivity in the veterinary clinic.
Working in veterinary medicine can be difficult because it involves working in a team. So many went into the industry thinking that they enjoyed animals more than people only to find out that they work with people the same amount, if not more. In hospital settings it is a matter of life and death on a daily basis for patients. In order to perform even the simplest task, like drawing blood, team members must work side-by- side with each other. This is unlike human medicine, where oftentimes the registered nurse performs phlebotomy solo. The stress of day-to-day experiences, coupled with having to work so very closely, if not on top of each other, can result in a stressful work environment. Being a great team member not only allows for better experience for everyone else but yourself as well. The Team Members People leave managers, not jobs. That saying is mostly true, but it can be argued that people also leave bad teams with bad morale. Usually, the teams that have bad morale and high turnover are the direct result of also bad managements. Rarely, but sometimes, a team member may leave a job simply because they want a challenge outside of what the company can offer. That said, I personally worked in a veterinary hospital where the management was terrible, but my team was amazing. I stayed because of the amazing team members that I had working alongside me. A team is made up of many individuals, all with different personalities. There are many personality testing software and theories out there that attempt to classify one’s personality. There is no exact or perfect testing method, but certainly having a good understanding of the different types of personalities out there allows any team member to interact with their coworker in a more productive manner.
personality types. It is based on the conceptual theory that was proposed by Carl Jung and created by Katharine Cook Briggs in the early 1900s. It is such a popular personality classification system that numerous websites, including www.16personalities.com, offer tests to classify you into one of the 16 different personality types. There are four main groupings of personalities with two choices in each group. • People tend to be either extroverted or introverted. - Extroverts tend to draw energy from action. They like crowds and they react first and think later. Solitude is stressful to them and takes more energy than interacting with people. Being with people recharges them. - Introverts tend to draw energy from inaction. They are thinkers first and react second. Crowds are stressful to them and take more energy than being alone. Being alone recharges them. • People tend to be either sensing or intuitive - Sensors tend to focus on real senses they can see, touch and feel. They trust the information that are tangible and that they can see. - Intuition individuals tend to focus on possibilities. They learn from larger experiences and can apply it to what could be in the future. • People are either thinkers or feelers - The thinkers tend to be overanalytical and they do not use feelings to place judgment on a decision - Feelers tend to look at the impact it would have on those around them and take into consideration others’ feelings - People are either judging or perceiving. Judging individuals like to live in a very organized manner. They feel satisfied when a plan comes to a closure. They like planning and organization. - Perceiving individuals like to keep options open. They are spontaneous and adaptable. While there are plenty of ways to categorize human behavior, the Myers-Briggs method is certainly one that many people enjoy and can relate to. There are certainly people who are
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very extroverted and people that are very much thinkers. There are also people who fall in the middle. Having the team take a Myers-Briggs test or other personality test will allow the members to understand how best to interact with each other. Starting the Day In veterinary medicine, all team members perform shiftwork. It might be an overnight shift or day shift, but team members are expected to arrive and end the shift at a certain time. In order to start the day off on a good foot (or perhaps it’s the night you are starting) you must arrive on time. This doesn’t mean just in the nick of time. You must arrive before your shift, put away your belongings, check your cell phone one last time, and be ready to work at the start of the shift. Say hello to your team members. Say something nice. The first words out of your mouth should not be complaining. Starting the day off with a complaint sets the tone for the rest of the day. No one wants to hear about how you’re tired and you didn’t want to come into work. Probably several other team members feel the same way. Complaining just breeds negativity. Don’t let it be the very first thing that exits your mouth when you walk into work. Instead, put in a few positive sentences before maybe adding in about how you are tired and would rather sleep in. Be Kind, Respectful & Polite To Each Other This seems to go without saying, but it is difficult to remember this when there is a patient who is not doing well or a client yelling at you. If the exam room appointments start getting backed up and a technician is taking longer than usual to read a blood smear or a few things get said that are not kind. One of the largest issues in veterinary medicine is that people forget to be polite, kind and respectful to each other.
One of the more popular methods is the Myers-Briggs personality test which categorizes people into 16 different
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/// QUARTERLY BEAT / OCTOBER 2021
QUARTERLY BEAT / OCTOBER 2021 ///
Be Engaged & Have a Good Work Ethic If you are not engaged in your job, then others will disengage from you. The minute we see disengagement, or we feel disengaged, we need to figure out why. Disengagement is the start of burnout. Maybe you know someone who is completely disconnected. Start a conversation with, “You don’t seem like yourself today,” or “What’s going on? You don’t seem to want to be here.” They may not want to talk, but they will realize you see a change, and you are concerned. They will know you care. There will be days that you are disengaged. It is important to let the team know that you are having an “off” day. It’s okay to tell your team, “I’m exhausted today because I didn’t get enough sleep. I’m sorry that I am dragging or cranky today.” If this behavior occurs every day, then it is usually a symptom of a more significant problem. Everybody wants to work with a teammate that works hard and does a good job. Remember back to the story where I said that I went through 100 job applications. I went through them to find if there were any commonalities in employees being unhappy at their previous place of employment. Gossip was written down the most as the one thing people did not enjoy about their previous job. The second thing that people wrote down under the question, “List something you did not enjoy about your last job,” was the “laziness of my coworkers.” When you are a hard-working employee and the rest of your coworkers are sitting around not doing anything, you are bound to get upset. No one wants to work with lazy people. Look and ask yourself, “Am I engaged?” If the answer is “no” every day, figure out why and work to resolve it. Don’t Gossip & Assume Good Intention Just don’t do it. When team members gossip it breeds distrust. The trust in a team comes from a respectful and healthy relationship. It’s okay to make mistakes. Everyone does. However, if people gossip about the person who made the mistake behind their back and that individual finds out it becomes a very bad team. Even if the person doesn’t find out, anyone who makes a future mistake will assume that they too will be the brunt of gossip. A good team is built on trust. Gossip is defined as talking about someone when they are not present. Gossiping makes people feel uncomfortable and they will shut down and become resentful. The person who is gossiping requires attention or acknowledgment of what they are saying. It is hard for those who are listening to the gossip to disagree with the gossiper. Disagreeing with someone who is gossiping creates conflict. No one likes conflict when they have to work in a team environment. So, even if individuals disagree with the gossip they are often times left with just agreeing to get through the situation. Gossiping makes everyone except for the person who is doing it uncomfortable. Since most gossip is about something that someone did wrong or how someone is bad or how something is annoying, the best rule of thumb is to “Assume Good Intention”. If all team members can assume good
intention from clients and each other, it will make for a better team environment. Assuming good intentions and not gossiping go hand-in-hand. Getting off the phone and complaining about a client who called in for a silly question about their cat’s medical health and about how much time they took out of your day is gossiping. It’s also not assuming good intention. The client had good intention. They were worried about their cat. You work in veterinary medicine. You share a same love of animals as that client. Their only intention is to do right by their cat. Maybe they don’t have all the answers or maybe they’re not going about it the right way but the end result is they are trying to have good intention for their cat. When you get off the phone and talk about how the client is “stupid” and “annoying” and “wasted 15 minutes of your day” that is the opposite of assuming good intention. It also is gossiping. It is unlikely that your coworkers want to hear you go on and on about the client on the phone. They have other things to worry about. The reason why you are upset and gossiping in a negative way about that client is because you did not assume good intention. Take a moment to have compassion for them and assume good intention. This same scenario can be used with your coworkers. The doctor wasn’t trying to make your life harder because they forgot to write a prescription that you asked them to do three times. They were busy and they had good intention doing other things. Maybe they simply forgot. It was not, however, their personal vendetta against you to not write the prescription. Don’t gossip about it. Assume good intention. Remember ONE Team You are part of ONE hospital team. Within the hospital team there may be smaller teams. There may be the front office team or the management team, but regardless you all work in the same hospital. You are all striving for the same goal. No team is better than the other so please, don’t start the team wars. If a team member is struggling in a different department or area of the hospital you don’t normally work, but you’re able to help them even if it’s not the best help, do so. They are your coworker. If you see the front office staff struggling to answer the phones, answer a phone. You may not know the answer to the client’s question, but that’s okay. You can put them on hold or explain to them that the front office is busy and you’re going to try to get the answer for them. It’s okay to say that you don’t normally work in a certain area of the hospital but you’re doing your best to help. Be respectful of the fact that that individual has to do their main job too. If the team member is constantly being pulled away from their main job then it will cause more stress within their team. It’s important to remember that each team member has a very specific job within the hospital in order for the hospital to function best. Most of that team member’s job must be dedicated to their original job description. It’s okay to ask for their help, but don’t be upset if they truly can’t because there is a more pressing issue in their team
VETgirl U HIGHLIGHTS
AMY NEWFIELD, MS, CVT, VTS (ECC) Veterinary Team Training Goodbye Toxic Team
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managers do not work directly on the floor with their teams every day. Ninety percent of the praise that a team should receive should be from the members themselves. Leadership might not have any idea that the team managed an exceedingly tricky surgery or dealt with a problematic client. The team needs to boost each other up. I often describe a bubble team, which is a team that lives in its own happy bubble. I see bubble teams when I go into largely dysfunctional hospitals. The leadership has issues and most of the team is at each other’s throats. The sky is falling, there’s a dumpster fire, and everyone is angry with each other, except the bubble team. The bubble team is super happy. Rainbows, unicorns, and cotton candy live in their bubble. When I ask the bubble team if they enjoy working at the hospital, they inform me they love working at the hospital. They tell me how amazing the team is that they work with. They cannot imagine working anywhere else. They are in their own happy, wonderful bubble. They don’t see the dumpster fire or the meteorite that’s about to hit the hospital. They are blind to all of it. How can a bubble team exist in such a terrible environment? Simple. They have managed to tune out all the negativity and infuse the team with positivity. They have spent their energy lifting each other up and promoting each other’s strengths. They have each other’s backs. As a result, they are super strong and committed to each other. And yes, they live in their own happy bubble. There is nothing wrong with it. The other teams within the hospital likely can learn a lesson from the bubble team. I am a big fan of bubble teams because they know how to be each other’s best cheerleaders. Be Helpful If you do not notice how your team members are doing, then you are not a good team member. Being a good teammate requires you to step up to the plate and be there for your team member when it’s necessary. You must be observant of how your team members are doing.
Having a helpful teammate was one of the most mentioned traits when I asked individuals. If you see somebody always grumbling about having to take care of the dog with bloody diarrhea or they talk about how they don’t want to handle the cat that is growling, ask if you can help. Take the initiative to help that team member because, at some point, you will need help yourself. If you think someone is suffering from compassion fatigue or burnout, talk to them or their manager. It is not your job to counsel them, but it is your job to ask them if they are okay. Check in with your teammates. If you notice that someone is struggling to reach something high and you know where there is a step stool, help them. If you see that someone is setting up for an intravenous catheter and looks like they are waiting for someone to help them, be the person to offer help. “Did you eat lunch?” is a simple check in with a team member and can mean so much. Observing if your teammate needs help, whether it be physical or emotional support, is important to being a good teammate. If you sense someone needs some type of help in doing a task, then help them. If you see someone who needs an emotional check in, ask, “You don’t seem like yourself. Is everything okay?” I developed an acronym to utilize with my teams. I wanted them to H.E.L.P. themselves and each other every day. Each one of these things means the difference between having a good day or a bad day. It’s so simple, but when you think about it, these are the fundamental basics that every employee needs so they can function to the best of their ability every day. If all employees can ensure that they stay hydrated, eat, laugh throughout the day, and they take care of their bladder (pee), it would be a much better day. Too often, our employees sacrifice these important things and end up becoming miserable because of it. Being helpful means checking in with your teammates on how they are doing. Are they H.E.L.P.ing themselves? Are you H.E.L.P.ing yourself throughout the day? I know that I am in the midst of a good team when I hear them checking in with each other regarding who still needs to eat lunch.
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