In this VETgirl online veterinary continuing education blog, Dr. Justine Lee, DACVECC, DABT reviews the top 5 things you must have at a veterinary clinic before you say yes to that veterinary job. If you’re job hunting right now as a new graduate, pay heed. These are the MINIMUM requirements I think that a vet clinic should have before you say yes, so you know you can practice the best quality of care, even with limited finances.
By Dr. Justine Lee, DACVECC, DABT
Director of Medicine / CEO, VETgirl
5 Things You Must Have at a Veterinary Clinic Before You Take That Job
The Ability to do Minimum Bloodwork
I wrote about this in a previous VETgirl blog, but to me, the BIG 4 (or PCV/TS/BG/AZO) give you a wealth of information. If you send out blood work and get it the next day, no prob for the majority of your cases. But, once in a while, you’ll get burnt and have to call the owner back, telling them their 2-year old cat that vomited twice as a creatinine of 22 mg/dL, and needs to be seen and hospitalized ASAP. 90% of the time, sending out blood work is totally fine. 90% of the blood work is non-urgent. But, in the emergent or critically ill patient, you may need that blood work sooner. In my opinion, in the least, you need the ability to do a BIG 4. Because you can learn A LOT from your BIG 4 within a few seconds, for really $5-10 worth of blood work and supplies! You can find out if your patient is anemic or has a severe hemoconcentration from dehydration. You may be able to pick up on acute blood loss with a profoundly low hypoproteinemia in the face of clinical signs of hemorrhagic shock. You can tell if your patient has a life-threatening hypoglycemia causing the seizures secondary to an insulinoma, or if it’s a newly diagnosed DKA patient. All that for $5. So, in the least, work in a veterinary clinic that has a point-of-care, handheld glucometer, centrifuge, and ability to read a PCV/TS. If the boss isn’t willing to splurge on that, he or she won’t be willing to splurge on more important things that you’ll need!
Now, don’t get me wrong – do you need a BIG 5? (Add in a lactate). If you’re a general practice, no you don’t. How many GDV’s are you going to test for gastric necrosis or perfusion parameters with that hand-held lactate meter? Hardly any. But a BIG 4? A must.
A Doppler Blood Pressure Monitor
If you only have two pieces of monitoring equipment in the veterinary clinic, it’s going to be a Doppler blood pressure monitor and a pulse oximeter. I’m assuming that you already have an ECG, or you fail the clinic test from several decades ago. As a criticalist, a blood pressure monitor is a MUST. Not only do you need this for your anesthetized patients, but you better have it near your treatment table for readily available use. If you’re not using your Doppler on at least 20% of your veterinary patients a week, you’re doing something wrong. OK, in truth, I randomly made up that 20%, but in general, one out of 5 of your patients is likely geriatric and older than 7 (dog) or 13 (cat). And you should be doing an annual blood pressure on all your geriatric patients or those with co-morbidities affecting blood pressure (e.g., IMHA, heart disease, hyperthyroidism, chronic kidney disease, diabetes, do I need to go on?!). And at least some of your patient load every day is being anesthetized for procedures. So, 20% is a MINIMUM!
And, if your boss is only going to buy ONE blood pressure monitor, please let it be the Doppler. The doppler technique uses a crystal to detect flow instead of a stethoscope. Using this technique, ultrasound gel is placed on the crystal surface. The gel and crystal are then placed distal to the cuff over the artery, and the crystal coverts the flow signal to an audible (well, mostly audible) sound via the Doppler speaker. A blood pressure cuff is used to occlude the artery, with the assistance of a sphygmomanometer. The pressure cuff is inflated to a pressure greater than that of the blood pressure, at which time the audible sound of the pulsitile flow is lost. The pressure in the cuff is then slowly released. The pressure at which the audilble flow signal returns is considered the systolic blood pressure.
A doppler blood pressure is obtained with the use of a crystal, placed over the artery distal to the cuff. The reading at which the pulse is again audible is considered the systolic blood pressure. (For you cat vet peeps, Doppler values obtained may be closer to the mean arterial pressure (MAP) based on more recent literature.).
Yes, all that sounds high maintenance. But please know that short of having a catheter in the artery of your patient, the Doppler is THE MOST ACCURATE way of detecting blood pressure versus oscillometry. Trust me, I know it’s way easier to slap a blood pressure cuff and just press a button for these automatic cuff devices. But oscillometry blood pressure reading isn’t as accurate and it DEFINITELY isn’t accurate when the heart rate doesn’t match the machine and patient! So, if you’re only going to buy one blood pressure device, please stick with the higher-maintenance-harder-to-use-but-more-accurate Doppler. You can also check out our videos on how to measure blood pressure here.
A Pulse Oximeter
Pulse oximetry is a diagnostic tool used to estimate hemoglobin saturation. Pulse oximeters use light-emitting diodes (LED) to transmit 2 wavelengths of light, a red and infrared band. Oxygenated hemoglobin absorbs less red light and more infrared light than desaturated hemoglobin. The amount of light absorbed, red vs infrared light, is calculated by the pulse oximeter and the per cent of saturated hemoglobin is displayed numerically as the SpO2. To use the device, a probe is placed on hairless areas of the body with little to no pigment, common sites including the tongue, lip, ear, toe, prepuce, vulva, digits and tail. When obtaining a SpO2 reading, the probe should be in place for at least 30 seconds with consistent oxygenation levels (rather than variable, fluctuating readings) as well as a displayed pulse rate equaling the palpable pulse rate.
The pulse oximeter is a non-negotiable for me – all anesthetized or sedated patients should have a minimum of an oxygen source, ECG, and pulse ox monitoring. This is ensure that appropriate oxygenation is occurring. It’s not just the beep to tell you that your patient is alive (although that helps), but it is imperative that your pulse ox be reading at > 95%, especially while on oxygen supplementation.
A common misconception is that just because the reading is acceptable (96% or greater on room air), this means there is good tissue perfusion, cardiac output, or oxygen delivery. This is unfortunately not true. Pulse oximetry does not measure tissue perfusion, cardiac output, or oxygen delivery. More importantly, the calculation is based on the oxyhemoglobin dissociation curve, which describes the non-linear relationship between PaO2 and SpO2. Since the oxyhemoglobin dissociation curve is sigmoid shaped, it is important to understand even small changes in SpO2 can indicate large changes in PaO2. While a 90% or 92% on a veterinary school examination is pretty good…pulse oximetery readings below 94-95% are concerning, best emphasized when there is a SpO2 reading less than 90%, which corresponds with a PaO2 less than 60mmHg.
Now, some people get frustrated with the pulse ox, thinking it doesn’t work well. A lot is user error! Please note there are some limitations of the pulse oximetry include possible erroneous results with abnormal tissue perfusion (poor cardiac output, vasoconstriction, decreased body temperature), pigmentation such as icterus, excessive skin thickness, dry mucous membranes, patient movement, and ambient light. Most importantly, make sure to read and use your pulse ox appropriately – again, this is a MUST for the anesthetized patient!
Continuing Education Money for You and Your Team
OK, shameless plug here for VETgirl TEAM memberships. That’s because we know most veterinary technicians, tech assistants (TAs) and CSR don’t get ENOUGH CE allowance! I mean, $200 bucks a year? What does that cover (Well, a VETgirl ELITE membership, with our we-love-vet-tech 30% discount). Seriously, don’t you want to elevate the quality of care in ALL your staff? More than just your veterinarians deserve – and NEED – CE. So make sure you’re providing it for ALL your team members. With our VETgirl TEAM memberships, it works out to be about $1/CE hour. For real. After all, they are your right (and sometimes left) hand.
A Decent Library
I’ll all about investing in people. With that, you need to put some money behind that investment to grow and improve the quality in your veterinary clinic. This is especially important if you’re a young, new veterinary grad, as you’ll want (HINT: need) more resources in the beginning. From having an updated library of veterinary books. Having had to do my very first emergency tracheostomy at Angell Animal Medical Center in Boston, MA back in the late 90’s, I’m painful aware of this. My non-sterile internmate was flipping the pages of the Slatter surgical textbook as I was looking at pictures on how to do a tracheostomy. So, yes, you need an updated, decent library. Make sure your boss is supportive of you purchasing a few books (on the clinic’s credit card) to buy a few updated books a year for learnings sake.