VETgirl Q2 2022 Beat e-Magazine

VETgirl Q2 2022 Beat e-Magazine

beat

ISSUE 13 | JULY 2022

Photo by Karina Vorozheeva on Unsplash

Celebrating Year One!tral Valve Disease? It’s hard to believe it’s been exactly one year since VETgirl joined the BluePearl/ MARS. While a few of you complained about this, we wanted to reflect back on this year about this collaboration. 1. WORK-LIFE BALANCE my idea of VETgirl. It’s hard to believe that we officially started our LLC at the Minnesota Secretary 10 years ago in 2012. It’s hard to believe that we built VETgirlontherun.com for one year, only to release it on July 1, 2013. To be honest, it’s been a lot of work. It’s been a lot of sleepless nights. It’s been a lot of time taken away from our spouses and children. It’s been a lot of late nights (Justine) or early mornings (Garret) on our laptop, when our household was asleep. It was trying to figure out QuickBooks. It was trying to grow social media without much paid advertising. It was begging our internmates and residentmates to help lecture for us at minimal wage rates. But grow it did. While Garret and I are still up for all the hard work, one of the reasons why we sold to Blue Pearl/Mars was to regain our work-life balance. After a decade of a lot of sweat equity, we needed some help. After all, it was yours truly (Garret and I) as the only W2 employees for the past 10 years, and we needed a lifeline. 2. RESOURCES And, thanks to resources, we were able to grow our team. 3. BUILDING OUR TEAM Through partnership with MARS, we were able to grow our full-time team from two W2 employees to 10. You can see our amazing VETgirl team HERE. We’ve been honored to have Tracy Covert, who was part of the WVC team for the previous 11 years, join us as our Director of Events/Marketing. We were honored to have amazing veterinary technician, Amy Johnson, join us as our Manager of Content. We finally had a full-time social media veterinary colleague, Rachel Feldman join us and long-time, first to help out, Corrie McClusky officially on board as member of the team. Being ECC biased, we grabbed the amazing vet tech (who’s VTS in ECC), Tiffany Gendron to help grow our medical content. We officially built out our IT crew with Stacy Calabretta and sales/marketing team and Melissa Mercado and Debbie Lynch. Why I’m happy? Because I don’t have to spend late nights on my laptop trying to figure out PNL’s, invoices, and QuickBooks, thanks to MARS! 4. ADDING MORE CE As board-certified veterinary specialists in emergency critical care, Garret and I are classic hyper-efficient, go-go-go, workaholics. It’s hard to believe that it was over 10 years ago that I first reached out to Garret (with NDA in hand!) about Which led us to teaming up with a strategic partner with MARS. We wanted to continue to grow VETgirl as we always boasted: clinically relevant, practical, unbiased continuing education (CE) that was going to help save a patient’s life. In 2013, we released VETgirl with 12 hours of CE a year. In 2014, we jumped to 20 hours. Each year since then, we’ve added anywhere between 20-40 additional hours of new, live CE a year. Through amazing resources, we were able to close out 2021 with 165 hours of live CE a year. And that’s not including the thousands of hours of CE on-demand in webinars, videos, Real-Life Rounds, blogs, podcasts and more! Thanks to resources from MARS, we were able to get a CMS to help make the user experience better for you. We were able to expand, after years of trying, to offer a free Spanish certificate track with 20 hours of free CE. 5. ADDING MORE LIVE EVENTS Back in 2018, we decided to go beyond the screen and offer our first ever LIVE event. We created VETgirl U and it was designed to be a boutique conference designed to help you learn clinically relevant, practical CE with TED-like talks. We wanted to reward our amazing VETgirl community – including non-throw away conference bags (e.g., North Face, anyone?) – after all, you guys deserve it after the past 2.5 years of COVID, curbside craziness! Thanks to strategic partnership with BluePearl and generous sponsorship with Royal Canin, we are able to offer our small group “Powerful Minds” women’s leadership retreat in November 2022. We’ve added our first ever wetlab to VETgirl U (eyeballs, anyone?!). And we’ll continue to grow it more in the future. It’s been an amazing ride. Thank you for sticking with us and trusting us with your veterinary learning. Our entire VETgirl team promises to continue to strive to make us the #1 online veterinary CE provider out there; after all, if you can walk away from our CE with 2-3 points to save that patient’s life or improve your quality of medicine, that’s why we’re here. While we always love seeing you “behind the screen,” we hope to see you in person at VETgirl U 2022 in a few weeks in Minneapolis.

CONTENTS JULY 2022

ARTICLES

18 5 Things You Must Have at a Veterinary Clinic Before You Take That Job 21 On Simone Biles, Emotional Agility, and Leading with Mental Health 04 Can Diet Reshape Early Intervention for Dogs with Myxomatous Mitral Valve Disease? 08 Kidney Disease in Horses 10 Creating Sticky Messages: Your Team Superpower

21 TECH TIP 22 UPCOMING WEBINARS WHAT’S NEW 23 PROVIDER SPOTLIGHT

Your truly,

Justine, Garret & the entire VETgirl team

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HELPING DOGS WITH MMVD THROUGH NUTRITIONAL MANAGEMENT Current ACVIM guidelines recommend mild sodium restriction beginning in stage B2 and modest sodium restriction beginning in Stage C for dogs with cardiac disease. 1 However, very low sodium diets can actually do more harm than good, stimulating the renin- angiotensin-aldosterone system (RAAS) and releasing aldosterone in high amounts that are detrimental to the heart. This worsens systolic function in the ventricles and causes cardiac fibrosis. 4 Today, we have new nutritional strategies to employ to help manage dogs in the very early stages of MMVD . This approach has the potential to help dogs earlier by supporting cardiac function, reducing left atrial enlargement, and stabilizing mitral regurgitation. CLINICAL STUDY SHOWS EFFICACY OF A CARDIAC-FOCUSED DIET Despite studies showing the benefits of many nutrients in promoting heart health, nutrition has often been overlooked in the management of pets with heart disease—particularly the notion of employing nutrition earlier in the disease process. For example, as noted above, current ACVIM guidelines recommend that nutritional management for dogs with mitral valve disease begin in stage B2, when there are no clinical signs of heart failure but when dogs do have a left apical systolic murmur—likely with an intensity of at least 3/6—and significant cardiac remodeling. Now, research from Purina indicates a proprietary blend of nutrients including amino acids, omega-3 fatty acids, magnesium, vitamin E and medium-chain triglycerides can be fed in stage B1, when dogs have a detectable heart murmur but no or limited evidence of cardiac remodeling. The goal in feeding this nutrient blend is to slow disease progression in dogs with early mitral valve disease. As a result of this research, Purina scientists developed the Cardiac Protection Blend (CPB)—a combination of nutrients found in Purina® Pro Plan® Veterinary Diets CC CardioCare™ Formula diets. Together, these nutrients could help make a positive difference in dogs in the early stages of the disease (see Figure 1). A six-month dietary study 5 demonstrated the effectiveness of a diet containing the CPB in: 1. Addressing the metabolic changes that occur in early mitral valve disease 6 2. Helping reduce left atrial enlargement 5 3. Helping stabilize mitral regurgitation 5 4. Slowing the progression of mitral valve disease in dogs at early stages 5 In the study, 19 dogs with stage B1 or B2 mitral valve disease, as established by ACVIM consensus guidelines, and 17 age-, sex-, body condition- and breed-matched healthy dogs were enrolled.

In each group, half the dogs were randomly designated as control diet dogs while the other half were fed the CPB diet for six months. Both diets were formulated to provide complete and balanced nutrition for adult dogs. The nutrient profiles were similar between the two diets, except for the addition of the Cardiac Protection Blend to the CPB diet. Key findings revealed: • Improved mitral regurgitation in 30% of CPB-fed dogs with early-stage mitral valve disease • Increased serum omega-3 and decreased omega-6 fatty acid concentration s to help nutritionally manage dogs with cardiac conditions • Increased serum arginine and citrulline (precursors of nitric oxide) to promote vasodilation • Improved energy use as signified by biomarkers of fatty acid oxidation FIGURE 1. CARDIAC PROTECTION BLEND COMPONENTS

SPONSORED ARTICLE

Can Diet Reshape Early Intervention for Dogs with Myxomatous Mitral Valve Disease?

SHERRY SANDERSON , BS, DVM, PHD, DIPL ACVIM (SAIM AND NUTRITION) University of Georgia College of Veterinary Medicine

In this VETgirl online veterinary continuing education feature article sponsored by Purina® Pro Plan® Veterinary Diets, Sherry Sanderson, BS, DVM, PhD, Dipl ACVIM (SAIM and Nutrition), discusses myxomatous mitral valve disease (MMVD) in canine patients. She also talks about new research from Purina that reveals early nutritional intervention may slow the progression of mitral valve disease in dogs at early stages.

Nutrient

Benefits

We’re all used to seeing dogs display boundless energy: jumping, running and fetching. It’s this unbridled enthusiasm for life that endears them to millions of people. Sadly, many dogs with advanced heart disease aren’t able to maintain this level of activity. Clinical signs for dogs with late stage myxomatous mitral valve disease (MMVD, or mitral valve disease) include exercise intolerance, increased respiratory rate and unproductive coughing, as well as non-specific signs like lethargy and inappetence. Heart disease is one of the most common disorders of dogs , affecting 1 in 10 canine patients seen in primary care practices. 1 Mitral valve disease is also the most common canine heart disease in many parts of the world, accounting for approximately 75% of heart disease cases seen in dogs by veterinary practices in North America , with the highest incidence noted in older, small- to medium-sized dogs weighing less than 20 kilograms. 1 In dogs with MMVD, the mitral valve progressively degenerates, leading to an enlarged left atrium and ventricle, a less-efficient heart and the risk of congestive heart failure (CHF). Although the majority of dogs with mitral valve disease are not—and never will be—in heart failure, about 30% go on to develop end-stage disease. 2 When we first hear a heart murmur in a dog with mitral valve disease, we typically note it, tell owners that it’s present and recommend diagnostics such as echocardiogram. If the disease progresses, we may add medications like pimobendan to help facilitate disease management. Historically, nutrition has received little attention in the management of canine cardiac

disease beyond a general recommendation that patients avoid high-sodium diets. MEETING THE HEART’S ENERGY NEEDS The hearts of healthy dogs derive the majority of their energy needs from long-chain fatty acids (LCFAs) in the diet. Carnitine is required to get fatty acids into the mitochondria inside the cell to generate energy. However, as mitral valve disease advances, mitochondria become less efficient at using LCFAs as a substrate. One way we can supplement this energy loss is to add medium-chain triglycerides (MCTs) in the C8 and C10 range into the diet. MCTs are a source of medium-chain fatty acids (MCFAs), which the heart can use for energy production. MCFAs do not require a carnitine transporter to get into the cardiomyocyte mitochondria and are easily oxidized to produce adenosine triphosphate (ATP). They can also be converted into ketones by the liver, which are used by the heart muscle as well. So MCTs serve as an alternate energy source for cardiomyocytes, which enhances mitochondrial function and reduces the risk for oxidative stress. Dogs with advanced heart disease can also develop cardiac cachexia and lose muscle mass. To help combat this, we need to ensure their diet has adequate levels of protein to help offset some of the catabolism of lean muscle mass. At least 25% of calories for healthy senior dogs should come from protein. 3 As heart disease advances, especially if dogs are on medications, it is not uncommon for them to sometimes feel unwell and to develop food aversion. This makes it imperative to feed them a highly digestible and palatable diet to help ensure adequate calorie intake.

Synthesized from the precursor amino acids lysine and methionine, carnitine is important for generating energy in the heart and transporting long-chain fatty acids into mitochondria. Taurine aids myocardial osmoregulation, calcium modulation, inactivation of free radicals, mitochondrial functional support and ATP production. It’s the most abundant free amino acid in the heart. EPA and DHA reduce inflammatory mediators, stabilize cardiac arrhythmias, reduce blood pressure and thrombosis, reduce cardiac remodeling in heart disease and reduce the risk of cardiac cachexia. Magnesium is a cofactor in many different enzymes in the body. It’s required for protein synthesis and energy production and reduces inflammation and oxidative stress. Dietary vitamin E is a potent antioxidant that scavenges free radicals and prevents them from contributing to oxidative damage. MCTs are a source of medium-chain fatty acids (MCFAs). MCFAs can be used by the heart for energy production. They do not require a carnitine transporter to get into the cardiomyocyte mitochondria and are easily oxidized to produce ATP. They can also be converted into ketones by the liver, which are used by the heart muscle as well. MCTs serve as an alternate energy source for cardiomyocytes, which enhances mitochondrial function and reduces risk for oxidative stress. Continued on page 6

Amino acids (lysine, methionine and taurine)

Omega-3 fatty acids (EPA and DHA)

Magnesium

Vitamin E

Medium-chain triglycerides (MCTs)

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THE ROLE OF CARDIAC NUTRITION IN MMVD MANAGEMENT, TOMORROW AND TODAY While recent research has uncovered what may be a powerful nutritional strategy in the management of canine MMVD, I would like to further build on this approach in the future. For example, I would like to see research on Cavalier King Charles Spaniels. Because the prevalence of MMVD in this breed is greater than 90% in animals older than 10 years of age, 2 it would be helpful to learn if it is beneficial to start feeding the CPB to these dogs at a young age without waiting until we first hear a murmur. I’d also like to see if a similar nutritional approach could be beneficial for cats, since we have limited options for feline patients with hypertrophic cardiomyopathy. To date, we’ve primarily focused on medications and reducing sodium to manage dogs with heart disease. Now, instead of the “watch and wait” approach we have historically employed, we have a nutritional tool in CardioCare that has been shown to slow the progression of mitral valve disease in early stages. Put nutrition high on your list of management options for dogs in the early stages of mitral valve disease. Keene BW, Atkins CE, Bonagura JD, et al. ACVIM consensus guidelines for the diagnosis and treatment of myxomatous mitral valve disease in dogs, 2019. J Vet Intern Med. 33(3),1127-1140. 2. Borgarelli M, Häggström J. Canine degenerative myxomatous mitral valve disease: natural history, clinical presentation and therapy. Vet Clin North Am Small Anim Pract. 2010;40:651–663. 3. Laflamme DP. Nutrition for aging cats and dogs and the importance of body condition. Vet Clin North Am Small Anim Pract. 2005 May;35(3):713- References: 1.

42. https://doi.org/10.1016/j.cvsm.2004.12.011. PMID: 15833567. 4. Ames MK, Atkins CE, Pitt B. The renin-angiotensin-aldosterone system and its suppression. J Vet Intern Med. 2019;33:363–382. https://doi. org/10.1111/jvim.15454 5. Li Q, Heaney A, Langenfeld-McCoy N, et al. Dietary intervention reduces left atrial enlargement in dogs with early stage myxomatous mitral valve disease: a blinded randomized controlled study in 36 dogs, 2019. BMC Vet Res. 15(1), 425. 6. Li Q, Laflamme DP, Bauer JE. Serum untargeted metabolomic changes in response to diet intervention in dogs with preclinical myxomatous mitral valve disease, 2020. PLoS ONE 15(6): e0234404. https://doi.org/10.1371/ journal.pone.0234404

YOU COULD SLOW THE PROGRESSION OF EARLY STAGE MITRAL VALVE DISEASE? WHAT IF…

CC CardioCare ™ is a revolutionary diet that helps protect a dog’s heart at the first signs of mitral valve disease.

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Helps reduce left atrial enlargement associated with early stage mitral valve disease

Sherry Sanderson, BS, DVM, PhD, Dipl ACVIM (SAIM and Nutrition), is an associate professor in the Department of Biomedical Sciences at the University of Georgia College of Veterinary Medicine.

*Li, Q., Heaney, A., Langenfeld-McCoy, N., Boler, B. V., & Laflamme, D. P. (2019). Dietary intervention reduces left atrial enlargement in dogs with early stage myxomatous mitral valve disease: a blinded randomized controlled study in 36 dogs. BMC Veterinary Research , 15(1), 425. Purina trademarks are owned by Société des Produits Nestlé S.A. LEARN MORE AT PURINAPROPLANVETS.COM/CARDIOCARE.

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hypersensitivity or anti-tubular basement membrane antibody. Prognosis usually grave, not commonly diagnosed, requires biopsy. Steroid responsive in people. Acute glomerular nephritis: Relatively rare in horses, manifested as nephrotic syndrome sometime with hematuria and oliguria. Group-C Streptococcal antigen, EIA Ag:Ab complexes along basement membrane or in mesangial area. Associated inflammation results in decreased GFR.

Diagnostics : Similar to that for ARF.

Treatment : All efforts are primarily palliative with the goal of preventing additional complications and minimizing weight loss.

WEBINAR HIGHLIGHTS

Prognosis for CRF : Grave.

PAMELA A. WILKINS, DVM, PHD, DACVIM-LA, DACVECC Equine Medicine and Surgery University of Illinois College of Veterinary Medicine Kidney Disease in Horses

URINARY TRACT INFECTIONS Clinical Signs: Lower urinary tract: Altered urine flow, urine scalding, dysuria, pollakiuria, gross hematuria, urinary calculi at end of urination Clinical signs : Upper urinary tract disease: Fever, weight loss, signs of lower tract disease combined with signs of systemic illness. Diagnostics : Urinalysis: More than 20 organisms/hpf, more than 10 WBC/hpf in a midstream catch sample or catheterized sample highly suggestive of infection, WBC casts, azotemia with pyuria, low SG with signs of upper urinary tract infection, ultrasound chemistry screen, hematology with fibrinogen. Pathogenesis : Neurologic disorders: EPM, EHV-1, Cauda equine neuritis, botulism, etc.), urolithiasis, foaling trauma, poor perineal conformation. Common organisms: E . coli, Proteus spp., Klebsiella spp., Pseudomonas spp. Treatment : Preferably based on sensitivity from positive culture. TMS, penicillin, ceftiofur commonly used with success.

Post-renal AKI: Increase in ureteral pressure for whatever reason decreases GFR and ultimately renal blood flow.

Treatment of Acute Kidney Injury: Initial: Focus on reversing the inciting or underlying causes and correcting any fluid and/or electrolyte imbalances. Prevention is most important in patients at risk of developing ARF: rapidly restore fluid volume, maintain intravascular fluid volume, maintain glomerular filtration, maintain urine production, monitor serum creatinine frequently, perform frequent UA. Once diuresis is achieved, maintain on intravenous fluids at ~40-80 mL/kg/day until creatinine decreases dramatically, then go to 10-20 mL/kg/day until creatinine is normal and/or patients is eating and drinking normally. Prognosis for AKI: Depends on underlying cause, how long present until treatment was initiated and development of complications including diarrhea, thrombophlebitis and laminitis. Severe ischemic failure and acute interstitial nephritis carry the worst prognosis. Postrenal ARF carries the best prognosis. Acute tubular necrosis carries a good prognosis if the basement membrane remained intact. Animals frequently recover, but may not fully regain the ability to concentrate urine. CHRONIC RENAL FAILURE (CRF) Infrequently recognized in horses. Considered a problem of older patients primarily, stallions may be at greater risk. As many as 1/3 of all horses have renal lesions microscopically at time of death. Lack of clinical signs of disease due to large renal reserve as clinical signs do not become apparent until ⅔ to ¾ of functional parenchyma has been lost. Underlying causes may be congenital or acquired. • Congenital causes: renal agenesis, renal hypoplasia, dysplasia, polycystic kidney disease • Acquired disease: ARF or consequent to renal tubular or glomerular injury.

In this VETgirl Large Animal Webinar, “Kidney Disease in Horses,” Dr. Pamela Wilkins, DVM, PhD, DACVIM-LA, DACVECC reviews some of the more common urinary problems of horses in a simple and approachable manner. Learn to understand and interpret the common causes, clinical signs and potential treatments of uremia and renal dysfunction in horses of all ages. These proceedings originally presented at the South African Equine Practitioners Congress.

ACUTE KIDNEY INJURY Usually secondary to some other disease process:

Radiography: Not useful in adults. Nuclear Scintigraphy: Useful in providing information about individual kidney function. Renal biopsy: Provides sometimes useful diagnostic and prognostic information regarding type of renal disease in horses with ARF (glomerulonephritis, interstitial nephritis, tubular necrosis) it is usually reserved for chronic renal failure cases. PATHOPHYSIOLOGY OF AKI Heterogeneity of renal blood flow makes the kidney susceptible to ischemic and toxic insults. Low medullary blood flow supports counter-current circulation generation of concentration gradient to allow concentration of urine. HOWEVER, this results in a large corticomedullary oxygen gradient creating a relatively hypoxic medulla normally. Renal cortex receives about 90% to total renal blood flow, making it particularly susceptible to toxins. Acute tubular necrosis: • Aminoglycoside toxicity: accumulation of drug within the renal cortex. Usually need some degree of decreased renal perfusion also. Mild cases usually associated with non- oliguric ARF and may go unrecognized. • Pigment nephropathy: arguable as to whether pigment (hemoglobin or myoglobin) is direct cause. Principal characteristics are tubule obstruction and reduced renal blood flow (loss of vasodilation tone due to pigment?). Acute interstitial nephritis: More likely to be associated with eosinophiluria and eosinophilia, more likely to be associated with red cells than acute tubular necrosis. Mechanism unclear, possibly associated with delayed cell-mediated

aminoglycoside antimicrobial therapy, NSAID toxicity, acute enterocolitis, exertional rhabdomyolysis or other myopathy, pleuropneumonia, DIC, purpura hemorrhagica, etc. Physical examination findings, clinical signs, complaints include weight loss, dullness, depression, odor, anorexia, polyuria, oliguria, pigmenturia, signs consistent with primary disease. If ARF secondary, pigmenturia: hemoglobin or myoglobin, secondary to intravascular hemolysis (red maple leaf toxicity, DMSO) or rhabdomyolysis. Distinguish from hematuria by centrifugation of urine. DIAGNOSTICS Urinalysis: ARF: renal tubular casts, moderate proteinuria, +/- hematuria, pigmenturia, increased white blood cells. Increased uGGT, increased uGGT:uCr, abnormal fractional electrolyte excretion, isosthenuria in animals not on IV fluids poor prognosis. Serum chemistry analysis: Azotemia: BUN> 20 mg/dl, creatinine > 2.0 mg/dl, Creatinine > 8 mg/dl poor prognosis. Electrolytes: Decreased sodium, decreased chloride in animals not on IV fluid supplementation, calcium can be >13 mg/dl, potassium can be increased. Fractional excretion of electrolytes: Sodium primarily. Need urinary and plasma sodium and creatinine values. Ultrasonography: In AKI kidneys may appear normal or slightly enlarged with little appreciable parenchymal abnormalities. When present, abnormalities include perirenal edema, widening of the renal cortex and loss of a distinct corticomedullary junction.

Parasitic infections: Strongylus vulgaris, Halicephalobus gingivalis (deletrix), Dioctophyma renale, Klossiella equi

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WEBINAR HIGHLIGHTS

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Creating Sticky Messages: Your Team Superpower

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BY DR. MARY ANN VANDE LINDE, DVM, Vande Linde & Associates, LLC, Brunswick, GA USA

In this VETgirl practice management webinar, “Creating Sticky Messages: Your Team Superpower,” Dr. Mary Ann Vande Linde, DVM discusses building the foundation of effective team communication. Learn techniques to build client trust with your veterinary health care team.

MORE LIVING

WHAT HASN’T CHANGED IN 2022? POWERING UP RECOMMENDATIONS Communication is the creation of shared understanding or meaning through interaction between two or more parties. Communication is the foundation of your practice. Through communication you relay the values and processes of the hospital to the health care team, your clients, and the community. Through communication you build trust which is the lynchpin of the success of your business. There are five components to trust building communication: 1. Consistency and predictability a. Dependability of events, responses, behaviors b. Congruity of verbal and non-verbal messages c. Avoid mixed messages d. Avoiding capriciousness or the appearance of favoritism e. The sense of familiarity, that people will be able to fairly accurately anticipate events, outcomes, responses

5. Examining mistakes - and problem-solving - as a team, not assigning blame Be aware that trust can be undermined quickly. Trust breakers include: • Failing to deliver on commitments • Gossiping or disregarding confidentiality • Ignoring problems when they occur • Not communicating clearly COMMUNICATION SKILLS The first communication with clients often starts on the phone. A well-trained front office team can enhance the success of your practice by using communication skills that attract new clients and bond them to your practice NON-VERBAL COMMUNICATION Non-verbal communication can be just as important, if not more powerful, then verbal communication. Regardless of what we say, our body language also tells a story. It’s imperative that team members be mindful of the message received by clients as a result of non-verbal communication. For example, folded arms, a frustrated sigh, or frowning may indicate impatience and frustration with the client or pet. On the other hand, smiling, nodding of the head, and leaning in toward the client demonstrate interest and patience when the client is talking. Eye-contact is one of the most significant non-verbal communications. Communication can become impersonal, and clients won’t think you’re very interested if you don’t make eye- contact with them. Be sure to establish eye-contact with clients when they arrive at the practice, when you ask them to follow you to exam rooms, when you greet them in exam rooms, when you ask clients questions and when you say good-bye.

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3. Respect for confidentiality 4. Commitment to shared cause, goals, and behaviors

a. Demonstrating concern for the needs of others and the shared cause b. Make sure the goals are clear to everyone. c. Check with people frequently to see if they have what they need to fulfill their commitments d. Strive to create an atmosphere where it is OK for people to ask for help e. Sharing the credit

Protection unites us.

References: 1. LaFleur RL, Dant JC, Wasmoen TL. Prevention of disease and mortality in vaccinated dogs following experimental challenge with virulent leptospira. J Vet Int Med . 2011;25:747.

Copyright © 2022 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved. US-NOV-220300020 537650

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Try to sit down next to clients during important discussions. This helps make clients feel like they are a partner in the care of their pets and facilitates easier dialogue without distractions. When you stand while clients sit, clients may feel intimidated and be less likely to ask questions. In addition, it is easier for team members to focus on the client when sitting down to talk. In addition to your own non-verbal communication, observe the non-verbal communication of clients which will give you clues about their feelings and what actions you may need to take to improve communication. For example, glancing at a cellphone or watch, pacing, folded-arms, hands on the hip, standing instead of sitting in the exam room, standing near the door, and frowning can all indicate the client is in a hurry or unhappy about the wait time. Clients who are afraid or uncomfortable for some reason may display nervous behaviors such as clutching their pet, looking down, reluctance to talk, or fidgeting in their chair. Once you become more observant of client’s non-verbal communication, you can take action to respond to their body language. OPEN ENDED QUESTIONS To determine what your client’s needs and wants are, ask questions. How does your client value their pet? Find out what activities they do together. What is the pet’s lifestyle: indoor, outdoor, hunting, community service? Questions can assist and guide the owner to see and understand the medical concerns. Through understanding the medical concerns, clients can better value the comfort and quality added to their pet’s life delivered by the treatment. By asking questions and listening to the client, a team earns the client’s trust and commitment. Then, the visit and the treatment become “the clients” idea and vision for a healthy pet, and the team, the partner that assists them. There are two types of questions that gain trust and valuable information so we may know our client’s expectations and create compliance. OPEN QUESTIONS The question process is like a funnel . The beginning of the process is very open and broad. It is here that we use questions beginning with How? What? Where? These are called open questions. They are designed to get opinions, attitudes, and beliefs about the pet and owner’s needs. Let’s look at examples of open questions about dentistry for Marty (the cat) and Ms. Vickers (his owner). They progress from general to more specific. 1. What type of food does Marty like to eat? 2. How would you describe Marty’s chewing and general grooming? 3. Have you noticed any changes to Marty’s movie star smile? 4. How are you currently caring for Marty’s Teeth? From asking open questions you tap into a client’s insights about the health of their pet. This allows the veterinarian to see gaps in the client’s understanding of a disease process, such

as dental disease, and the pet’s current health status. Or stated another way, where does the client see their pet’s health vs. where does the veterinarian see the pet’s health. By carefully listening to our clients, we can give pet owners information and ask questions to close gaps in health care understanding. CLOSED QUESTIONS How do we close these gaps? There are closed questions. These are yes or no questions that determine facts and specific information. Here are some examples of closed questions on dentistry for Marty and Ms. Vickers: 1. Have you noticed the brown discoloration on Marty’s teeth? If not show her. 2. What about Marty’s breath? Does Marty sleep with you? Does he have a different odor? 3. There is a chatter of pain when I touch this tooth. Have you seen this while he is eating? 4. Has anyone ever talked with you about cleaning Marty’s teeth? Closed questions following open questions allow the owner to track with the doctor step by step through the disease process. Some short explanations with the questions are helpful, however, explanations are best understood if accompanied by a visual (such as a cat dental model or a picture of the cat’s mouth before and after cleaning). The goal is a shared understanding of the disease with the client as well as a shared vision of their pet disease free. How much should the veterinarian be talking vs. the pet owner? The rule of thumb is 70% of the time, the client is the person talking and sharing. The remaining 30% of time are yours to question, explain and reinforce the health care vision. LISTENING Your secret communication weapon is listening. According to businessman Ken Johnson, who is quoted on the International Listening Association Web site, “The contrast between hearing and really listening can be as different as night and day. And in a business environment, not listening effectively to customers, employees, and peers can mean the difference between success and failure.” Most of us take good listening for granted and don’t work very hard at improving. But listening is a complex activity. Listening requires an active response, not a passive one. Effective listening doesn’t just happen; it takes thought—and thinking can be hard work. But there is no other way to become an effective listener. Think about the complexities of listening, and work to understand them. When the client responds to your questions, it is critical that you LISTEN to their words and to their non-verbal cues. The goal is to listen for understanding. The process is crucial for building the relationship that will grow the client’s confidence to trust and follow your recommendations for their pet. When you listen for understanding rather than listen reactively, you will gain a

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Indication: Zorbium is indicated for the control of postoperative pain associated with surgical procedures in cats. Important Safety Information: Before using ZORBIUM (buprenorphine transdermal solution), read the entire package insert including the Boxed Human Warning. ZORBIUM contains buprenorphine, an opioid that exposes humans to risks of misuse, abuse, and addiction, which can lead to overdose and death. Use of buprenorphine may lead to physical dependence. The risk of abuse by humans should be considered when storing, administering, and disposing of ZORBIUM. Serious, life- threatening, or fatal respiratory depression may occur with accidental exposure to or with misuse or abuse of ZORBIUM. ZORBIUM should only be administered by veterinarians or veterinary technicians who are trained in the handling of potent opioids. Accidental exposure to even one tube of ZORBIUM, especially in children, can result in a fatal overdose. ZORBIUM is for topical application in cats only. Following application to the cat, allow a minimum drying time of 30 minutes before direct contact with the application site. Do not administer to cats with a known hypersensitivity to buprenorphine hydrochloride, any inactive ingredients of ZORBIUM, or known intolerance to opioids. Most common adverse reactions during anesthesia were hypothermia, hypotension, and hypertension, and after anesthetic recovery were hypothermia, hyperthermia, and sedation. The safe use of ZORBIUM has not been evaluated in debilitated cats, those with renal, hepatic, cardiac or respiratory disease, pregnant lactating, breeding, in cats younger than four months old or 16.5 lbs. Please see accompanying brief summary for additional product safety information.

Zorbium, Elanco and the diagonal bar logo are trademarks of Elanco or its affiliates. ©2022 Elanco or its affiliates. PM-US-22-1256

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TEAM-BASED CLIENT EDUCATION Strive to define clear job roles and responsibilities for all team members to create the best client experience that will also result in pets getting the care they deserve. For this to happen, client engagement and education needs to occur before clients are given recommendations they aren’t prepared to accept. Consider that when you see the client, you are following a systematic approach to build trust and relationship. 1. Identify client concerns/preparation (this happens mostly before the client arrival): • Consider: how is this client different? What are the pet’s needs? • Think about how to develop rapport and personalize the visit for this client • Meet as a team to discuss the client and pet before the appointment, define each team member’s role • Color code charts, review medical records before appointment • Print a list of appointments for the day w/ notes • Here’s an example for new client program. A potential client calls the practice. The receptionist asks questions about the pet - age, breed, and needs. The receptionist integrates the benefits of the spell check program and the values of the hospital in the conversation, sets up the appointment, and sends a targeted mailer appointment reminder to the prospect (“We are looking forward to meeting you and Fluffy on the date.”) 2. Client engagement/Needs assessment (getting clients involved in process): • Consider the client vs. team member perception • Client engagement very important • Develop scripts for needs assessment process and visual tools to help client with descriptions of concerns or questions. • Continuing with our example, the client enters the practice; the receptionist reviews the client information, and in conversation asks other questions: family, hobbies, activities with pet, etc. A technician takes the client through a needs assessment of the pet. Then the client could be asked questions about diet, favorite foods, exercise, health, history, behavior, grooming, fleas, boarding, etc. 3. Solve problem/ Make recommendations / Client education (focus on what client needs and wants) • Gap analysis: ask open-ended questions, listen, solicit primary concerns at beginning of exam • Perform physical exam: determine what pet needs, assess clients’ understanding, what does client need to know to change behavior, use core communication skills. Ask questions when doing PE-have they noticed…. rather than beginning a lecture on findings • Don’t tell client before they are ready to hear information.

greater understanding of the client’s needs. Your active listening may encourage the client to “open up” and provide more complete information. Also, your willingness to take the time to listen and respond often results in improved client listening and ultimately in compliance. What does empathetic listening look like in the questioning process? The listener is focused on the words, inflection, facial expressions and body postures of the client. The listener gives verbal and non-verbal feedback to communicate understanding, clarify information, or to encourage the client to continue. Effective listening is challenging. There are many pitfalls poised to push you off track. Examples of obstacles to effective listening include: • Distractions from thoughts outside the exam room – to listen effectively and completely, you must put aside the other business of the day and focus on the here and now. • Preparing your response while the client is still talking – if you are busy formulating your answer or follow-up while the client is still talking, you are not fully listening. • Preconceived judgments of the client. • Noise, activity – acknowledge the disturbance and if possible, isolate your conversation from the commotion and invite the client to continue. EMPATHY STATEMENTS While veterinary teams generally do an excellent job of showing compassion to grieving clients and are routinely praised for being kind, many team members miss out on opportunities every day to convey empathy to pet owners. It isn’t that doctors and staff don’t want to let clients know they are empathetic; rather it is that teams often don’t know what to say and when to use empathy statements. Let’s begin by defining empathy statements. These statements convey to the client that you understand their perspective and feelings. Empathy statements are an acknowledgement of the client’s emotions or their position. Here are some examples of empathy statements: • “I can understand that this is a difficult time for you.” • “I appreciate that you were not expecting these expenses for Scooter’s care today.” • “I bet it was frustrating to go through that experience.” • “That must have been very upsetting. I know I would be scared too.” Empathy statements don’t have to be confined to discussions about the pet. You can express empathy about anything a client may tell you including family illness, job situations, personal problems, minor frustrations, etc. People appreciate affirmations and concern about what they are going through.

test when it is completed and the tonopen or Doppler. • Educate client using support materials, literature, models, computer educational programs and posters to illustrate and educate on the main points. Use visual aids or models to reinforce verbal messages when possible. For example, use the body conditioning score chart to let clients see why you want to talk about weight loss for their pet. If you don’t have client education brochures with pictures or anatomical drawings, look into obtaining these visual aids. • If information can be emailed to the client, this is even of greater benefit. • Provide the client a report card of findings • Present treatment plans: formulate plan with owner, partner with owner • Strive to build trust

• Focus exam on showing vs telling: • Doctors and staff members need to be sure all aspects of the physical exam and procedures are thoroughly explained. While conversing with the client is desirable and necessary, don’t make the mistake of having the pet owner completely miss out on the value of the exam because they didn’t even realize the pet was being examined. The client should be informed of normal and abnormal findings and the reason for each part of the exam. Make sure clients know you palpated for lymph nodes and what you can feel when you palpate the pet’s abdomen. • Sometimes veterinarians start making recommendations for services before the physical exam is completed. This is a common scenario with a head to tail process. Periodontal disease may be noted and immediately a discussion of dental recommendations starts. When this happens the pet owner doesn’t appreciate the rest of the physical exam which doctors often complete while talking about the dentistry procedures. Moreover, the client may feel like all you care about is scheduling a dental cleaning rather than discussing the overall health of their pet. • Even if you take the pet to the treatment room for procedures, take the opportunity to show clients some of the equipment used. For example, show clients the snap

Check for understanding/overcome objections: • Use communication skills, talk about money with confidence

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4. Commitment (want client to take action) and Satisfaction • The staff reinforces the DVMs recommendation, provides further information and support so client feels assured in the decision. • When the client commits to the recommendation, it is written down and prioritized and • The client is taught how to perform the treatment plan needed. 5. Reinforce messages/gain commitment (want client to take action): • Use consistent messages by team • Keep in touch with clients with progress phone calls • Schedule rechecks at time of first appointment • Give CE handouts • Take advantage of online resources and your website to give clients • In our example, the client receives a folder with Fluffy’s medical record in it. The folder has the practice name on the cover and has other pertinent information: emergency numbers, medical information, product coupons, etc. The receptionist makes the next appointment for vaccinations, dentistry, lab, etc. A summary of the finding is then sent to the client with a personalized thank you note attached. One to three days later, the client is called to see if they have any questions or concerns. Check your mindset - Stop selling and start educating If you want to increase service utilization and compliance for wellness care services at your practice, then start educating pet owners rather than just making recommendations or “selling”. Clients feel like you are selling if you immediately tell them what you recommend for their pet before even asking questions, taking a thorough history or performing a physical exam. Pet owners may feel like their pet is just a number to the practice and receives the same recommendations as every other pet that walks through the door. Here are some tips on how to take steps to educate pet owners and inform them about the value and benefits of services: • Don’t assume clients are knowledgeable. Ask if they have questions about heartworm disease and let them know which common parasites are being looked for when they bring in a stool sample. • Ask open-ended questions about pets and engage clients in a dialogue before immediately launching into what services you recommend. Ask questions such as “What problems is Sophie having?” or “Tell me what concerns you have today about Max?” • When team members make recommendations for wellness care prior to the veterinarian doing a physical exam and consultation, be sure to let clients know that the doctor will do a full evaluation of their pet’s health and answer any questions they may have.

• Give clients sufficient information. For example, after recommending wellness care such as diagnostic testing, give the client more detailed information about what tests are included and what they will reveal about the pet’s health. • Don’t just make recommendations - focus on need recognition and the value of the services. Tell the client why the pet needs the tests. Use phrases such as “the senior testing will determine if Jake is healthy or if he has any early indications of illness.” And finally, tell the client the value of the services by using phrases such as “We want to catch any abnormalities early so that we can help Jake live a long life” • To effectively communicate the value of a veterinary service or product to clients, make sure everyone on the team understands and agrees with the value of the hospital’s services and products. When gaps in knowledge are identified or employees demonstrate discomfort associated with certain client interactions, focus training in these areas. • Staff meetings are an excellent time to discuss the value of veterinary services. Train team members so they can easily describe services or products to clients in lay terms and convey to clients the benefits for each service. • Be sure to give clients consistent messages about the value of routine preventative healthcare services and products. • Remember to always highlight the benefits of services to clients even when the client has purchased similar services in the past. SUMMARY: MEASURING RESULTS, FOSTERING ON-GOING RELATIONSHIPS/CLIENT LOYALTY When the whole team focuses on enhancing client communications, you will improve client engagement and trust which leads to greater client loyalty and client compliance with treatment recommendations. Remember to select the core messages you want to communicate throughout your operation. Multiple communication channels can and should be widely used to reinforce and support your core messages. Develop highly visible scoreboards, bulletin boards, or announcements of progress toward team and organization goals and priorities. Establish an internal “best practices and good tries” communication system. A free flow of information and active communications is the lifeblood of a learning organization.

SAVED YOU A SEAT.

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OK, maybe there won’t be a cat in your chair. But you will get 20+ hours of RACE-approved CE in our TED-talk like, case-based program, with topics ranging from surgery to anesthesia to emergency to derm to ophtho! Plus you’ll be treated right. Awesome speakers, relaxing evening events, free daycare and free swag! AUG 25-28, 2022 | RADISSON BLU, MINNEAPOLIS, MN

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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 including 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! 4 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. 5 A DECENT LIBRARY I’m 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 painfully 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 learning’s sake.

returns 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 on 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. 3 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 percent 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 to 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 oximetry readings below 94-95% are concerning, best

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5 Things You Must Have at a Veterinary Clinic Before You Take That Job

JUSTINE LEE, DVM, DACVECC, DABT Director of Medicine / CEO, VETgirl

In this VETgirl online veterinary continuing education article, 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.

1 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 problem for the majority of your cases. 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, has 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.

2 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, 1 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 pulsatile flow is lost. The pressure in the cuff is then slowly released. The pressure at which the audible flow signal

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