Sedation & Fear Free techniques with Dr. Kelly
By Kelly Dunham
This week let’s talk about sedation and fear free techniques! We as a profession often want to get things done, to get the answers and get them now. I know I’ve said something along the lines of “do you think we can take x-rays on this pet real quick?” But the reality is there is nothing real quick about it. We are not cowboys and shouldn’t behave as such. Sometimes we have to slow down to speed up, and that includes using sedation and fear free techniques for fractious, scared, and painful pets, as well as hands-free protocols for radiographs.
It is ok to have a pet come back. I can’t even count how many times I’ve seen a fractious cat and said “you need some gabapentin”. Pushing through, getting something “real quick” is stressful and can be traumatizing to the pet, the staff and the client. Check out this article in dvm360 about fear free protocols we can all start to put in place.
Be an educator
Not all hospitals practice fear free techniques. This is a great opportunity for us to be educators. One of the many benefits of working in many different hospitals is that we can see different ways they operate and bring with us and share the best of it. It all comes down to having open communication with the client, and the hospital team. No one wants to wrestle that fractious cat. No one wants to hold down that painful dog to get blood or take a radiograph. That is why we have drugs, let’s use them (for our patients)! To learn more, check out this great article from Clinician’s Brief which overviews the top 5 short sedation protocols.
You may be asking yourself, what if the client doesn’t want to do injectable sedation? In those cases we can recommend things like Trazadone and/or Gabapentin to go home and be given prior to the next appointment. Most clients are willing to try this when it’s explained to them that this if for the benefit and health of their pet and will reduce stress and anxiety.
Of course, there are exceptions to the rule. In those instances, try starting with over-the-counter products like pheromones, thunder shirts, and last but not least, happy visits. It is always important to explain to the owner that there is no quick fix. Changing behavior takes times, and pushing forward too quickly or aggressively will cause set backs.
VCA has been in the process of transitioning to hands-free sedated radiographs over the last year. Their hospitals, like many other non-VCA hospitals are at various stages of transition, some only taking Sedated rads, while others are still taking non-sedated rads on a case by case basis.
How do we know what to do? Just ask! The techs and support staff are there to help and by opening that line of communication we came make sure we’re doing what’s best for the pet, the staff and the hospitals.
Now you may be asking, what if I do not have the staff available to sedate safely, or the time in a fully booked schedule, or I just don’t feel comfortable? First you can see if you are working with a surgical doctor, and if they are able to take the case over for sedation.
If you’re alone or the schedule will not allow it, ask yourself if this is something that can wait. Can the patient be started on supportive care and be scheduled to return for sedation in a day or two? Obviously, this would not be appropriate for the profusely vomiting dog, but for things like lameness starting anti-inflammatories and rest can help decreased pain and soft tissue swelling prior to coming back for radiographs. Use your best judgment here.
Many of our hospitals are Fear Free practices. Getting fear free certified is easy through an online CE course. You can learn more about this at https://fearfreepets.com/. This is a great way to get some additional CE from the safety of home.
Why is practicing fear free important? Well, I’m glad you asked. Practicing fear free helps to alleviate unnecessary stress, anxiety and fear in our patients creating a calmer, happier pet and visit. This allows us to complete a more thorough physical exam, catch changes/ problems sooner and build a stronger veterinary – client – pet relationship.
This first step is to set the patient up for success. When you have those new puppy/kitten visits, talk about behavior and conditioning. This allows us to get our patients started on the right paw. We can encourage our clients to start playing with their new pets ears and paws in positive ways, while providing praise, treats and love at home.
Have the owner bring the pets favorite treats to appointments. We can even encourage our clients to bring their pets in for “happy” treat and weight check visits. These can help to build up positive experiences for the patient so that they don’t have a fearful/ negative visit (vaccines, blood work or even temps) every time they come into the hospital.
Assessing the patients’ behavior/ attitude can help us to track subtle changes and intervene sooner if a shift in behavior/ attitude is appreciated. We’ve all had that happy go lucky patient that “suddenly” comes in fearful/anxious. It can be hard to pinpoint where or when things changed. Sometimes it is as simple as the build up of multiple negative experiences (ex: vaccines at every visit). Other times it may be related to the pet coming in for an illness/ injury in which they were scared or hurt and now associate that experience with the hospital/ team.
Fear free techniques start at home
The good news is that even when starting with a fearful patient there is still a lot we can do! Fear free techniques start at home. Once we figure out what is causing this shift or if there is a trigger, we need to educate the owner on what they can do starting at home to help reduce fear and anxiety.
If the pet fearful of having the ears touched, or is it just coming into the hospital? Having the owner work on training at home, with treats, praise and love is paired with gentle ear touches can start to build up positive experiences and decrease the fear response. This can progress to touching the opening on the ear canal and even to massaging the ear canal at home. Have the owner bring these favorite treats to the next appointment.
It is important to go slow. Do not expect that the next time the patient comes in you can jump right into exam. Getting down into a lower position, dropping treats and allowing for the patient to approach you can help reduce the patients fear and anxiety.
Don’t forget that for our fearful/anxious patients sedation/ fear free drugs can be used to help facilitate counterconditioning. However, it is important to remember that it does not stop at sedation. Sedation/ fear free drugs should be a tool to allow for reduced anxiety and the practice of additional fear free techniques. Use treats, move slowly but with purpose, and talk gently.
Fear Free with difficult pets
Many pets can be sensitive to touch. Maintaining continuous gentle touch of the patient can help to reduce stress and anxiety by eliminating the continuous shock of a new touch. Typically starting over the shoulders / back can reduce stress while allowing full exam by gently moving from one location to another.
Providing fear free care takes time. This can be challenging, particularly with the full/ busy schedules we are currently experiencing. Taking a couple minutes to slow down and use these fear free techniques can help up speed up going forward by alleviating stress and helping to prevent that reactive pet who can’t be touched, that we’ve all seen.
What do you do for those pets that can’t be touched? The first step is to start with fear free medications like gabapentin and trazodone at home. I will often recommend that the owners do a trial run at home as some pets are more sensitive than others. It is important to let them know that this may cause sedation and that’s ok. When the pet is at home and relaxed it is normal to become sedated from fear free drugs, however many pets can overcome that that once in a stressful situation or environment like coming into the hospital.
For the pets who are still very reactive injectable sedation should be considered as the next step. Given appropriate training, counter conditioning, and medication support we are able to see a real transformation with many previously anxious / fearful pets.
Kelly Dunham is Area Medical Director for the Greater NYC region.