Pain Control and Analgesia

Pain has an element of blank:
It cannot recollect
When it began, or if there were
A day when it was not

It has no future but itself,
Its infinite realms contain
Its past, enlightened to perceive
New periods of pain

- -Emily Dickinson                                               

Emily Dickinson's stark description of pain is especially true for animals and for infants, for whom the pain they are in must seem to them like all they have ever known, and worse, all they ever will know. How agonizing is the thought of this!

The recognition and treatment of pain in both human and veterinary medicine is undergoing a revolution of sorts. Old ways of thinking are being replaced by new, and at TotalBond Veterinary Hospitals we have made it a passionate point to stay on the cusp of pain relief and prevention. Aside from the latest research, medications, and modalities (including but not limited to drugs, acupuncture, laser surgery) that are used to address pain, we are talking here simply attitude and philosophy.

We find it simply unacceptable that an animal would be in unnecessary pain. That is as plain and simple as it gets.

Therefore we do not wait to see if a patient necessarily "appears" to be in pain (research clearly shows that because of adaptive behaviors in animals, even a well-trained human observer cannot reliably identify which pets are "in pain" and which are not). If logic would dictate that a procedure (e.g. surgery) or a condition (e.g. arthritis) activates nerve endings and would result in pain, then that patient will get medication for pain as a routine part of the procedure or condition. Period, paragraph.  For chronic pain, we are also committed to offering novel interventions drawn from the most recent experiences and evidence in human and veterinary medicine.

Philosophically we cannot accept the notion that your pet sits in pain, and as a result (research also tells us) recovers more slowly and with higher risk for complications from the stress that inevitably results.

An animal is just as vulnerable and no more understanding of the fear and pain involved in illness, injury, or surgery (even if elective) than is 4 month-old baby undergoing the same. We would no sooner withhold pain medication from one of our patients than you would if you had a child that got sick, hurt, or needed surgery.

To be truthful, the changes in veterinary medicine regarding control of pain are not yet universally accepted or implemented. TotalBond Veterinary Hospitals progressive thinking regarding analgesia is mirrored by some but not all practices. You may find that our philosophy here is something that separates us from the rest of the field. Dr. Epstein’s leadership activities in the International Veterinary Academy of Pain Management is a reflection of TBVH’s passionate commitment to pain control in animals.

Vaccination and Preventive Pet Health Care

Superior Preventive Pet Health Care with Fewer Vaccinations

When it comes to vaccinations of pets, I don’t think Bob Dylan would mind us borrowing "The times, they are a-changin’."

In fact, it is fair to say that they have already changed.

To be sure, aggressive, annual vaccination and re-vaccination of dogs and cats for the past 4 decades have taken infectious disease that once scourged the pet population and placed them far into the background: distemper, hepatitis, and others.

But what was once considered so regular, so routine, so seemingly necessary is now completely reconsidered, and well, different.

There is new information on both the safety and efficacy of vaccinations in pets that has driven these changes.

While the vaccinations we give are by any standard not only safe but very safe, they are not without the possibility of adverse effects. Certainly some animals can and do have allergic reactions to their immunization. There are some growing concerns about the role that over-vaccination may play a role in the development of hyper-active immune conditions. And the granddaddy of them all: the infrequent but confirmed cause-and-effect relationship between vaccinations and the formation of sarcomas (malignant tumors) in cats has been established for more than 10 years.

Thus the practice of indiscriminate vaccination, or of vaccinating annually merely because we have always done so, must be abandoned.

And it begs the question of whether it is even necessary to vaccinate so often in order to maintain protection against the diseases we are targeting. The answer is: almost certainly not. Advances in vaccine technology and enhanced understanding of the immune system have allowed leading authorities in veterinary medicine to argue convincingly that a protective immune response will persist for years following certain vaccinations. A growing body of data supports administering core vaccinations (distemper, hepatitis, and parvovirus in dogs; distemper, herpes, and calicivirus in cats) at 3-year and possibly even longer intervals in our household companions.

In fact: after years of objective consideration, the American Association of Feline Practitioners established such 3-year core vaccination guidelines for cats in 2000, and theAmerican Animal Hospital Association did so for dogs in 2003.

This has challenged and changed the veterinary profession. TotalBond Veterinary Hospitals has embraced the new protocols from their inception; many other veterinarians have not, and continue to re-vaccinate annually with little scientific reason for doing so. In fact some practices rely heavily on such outdated vaccination protocols. Moreover, many pet owners, so used to the annual protocols they had been recommended for years, continue to unnecessarily seek out vaccinations their pet may not need. This has the unfortunate effect of adding needless dollars and safety risks to the health care of those pets.

The new paradigm is: superior preventive health care with fewer vaccinations for your pet. At TotalBond, our vaccination protocol for pets looks something like this: no set protocol at all. We will still plan to see your pet once (or in later years, twice) yearly for a thorough medical exam, an interview with you, and some routine lab analysis…and then we will conduct a risk-assessment and make a recommendation for core and non-core vaccinations customized for your pet. You can be sure that the tendency will be that as your pet ages, we will be recommending fewer and less-frequent vaccinations.

We invite you to research this area on your own. Many websites will address the changes described, but you might consult www.aahanet.org and www.aafponline.comfor the some of the most comprehensive discussions. Please feel free to ask our doctors questions on this important matter, we are always at your disposal. Thank you!

Euthanasia – TBVH

Philosophy & Policy

          Whereas our patients lack the ability to understand their discomforts and fears, and moreover if persisting they perceive no end to them at all, we have an ethical obligation to provide a means by which pets may avoid needless pain, fear, anxiety, and suffering.  Euthanasia (“good death”) provides for such a peaceful, dignified ending and is a gift when properly applied and in an appropriate time and manner.

                Each pet’s end of life issues will be particular to him or her alone, and the owner and doctor will consider carefully the decision.  When the pet owner and the doctor agree that the time and the decision is right, then all of the doctor's skill and compassion will be called forth, along with that of our staff and hospital systems, to assist the client with the difficult emotional process to follow.  Done well, euthanasia can be a releasing, even beautiful experience, and this can be of great assistance to our clients working through the normal grieving process.

                It is this practice's view that such a gift is to be reserved for only those pets whose owners have exhausted reasonable options that might reasonably improve the pet’s quality of life, and who have consulted with the doctor, and whereupon the doctor’s professional and medical opinion rests in agreement with the owner’s.

                Further, it is this practice’s position that we will politely, gently, and without judgement decline to perform what we will call euthanasia of convenience.  “Euthanasia of convenience” can be defined as the request by a pet owner to conduct a life-terminating procedure on a pet deemed essentially healthy and free of serious behavioral problems, for reasons that may or may not be made known to the doctors or hospital staff but most often include a perceived negative impact on the owner’s personal lifestyle.

                We will instead kindly offer a number of other alternatives aimed at addressing the owner’s original concerns which has led to the request.  The compassion displayed toward the owner in these difficult situations is what can most often save the life of a pet that has come to the hospital for the sole purpose of being put to death. 

Our position takes no moral high ground and it is patently not permitted to judge the client or their reason for making a request which we have subsequently declined (which is almost always most difficult for them).  Instead, it merely speaks to a belief system wherein our advocacy for the pet may, at these rare times, override the immediate lifestyle needs of the pet owner.  At these times, we choose to use our skills and resources in creative ways that can address the owner’s needs without taking the irreversible step of ending a life than could otherwise continue to and receive love and unconditional affection for some time to come.

  Each request for euthanasia will be met with immediate attention, compassion, and empathy…as if it is the only time we or the pet owner will have to encounter it.  Given the emotional and permanent nature of euthanasia, such requests will be processed only through a compassionate and serious discussion with the doctor in the privacy of an Exam or Comfort Room.  Said more directly, as a strict policy we do not allow “drop-off euthanasia,” whereby the pet is presented for an end-of-life procedure without the owner and the pet spending some time with the doctor.

These consultations allow us to explore with the owner all their options, and the support available to them, much of which the pet owner is likely to be unaware.  We will describe the procedure in great detail, including the efforts made on their pet’s behalf that allow it to be peaceful and painless…this will be of great comfort to the owner.  Such appointments are best made, whenever possible, in slightly off-hours in order that we may spend the proper amount of time and provide some additional privacy.   We will offer to perform this service in the comfort of client's homes, or if in our hospital, in a Comfort Room, with helping words, a comforting touch, literature, websites, connecting items, follow-up contact, and the ability to further honor the memory of their pet.    Fees will be charged for the Consult & Support Services, the preparation of the patient, the euthanasia solution itself, and all appropriate memorialization services…which permits us to provide this kind of care at such a high level.

We pledge ourselves to making a pet’s end-of-life experience uniquely superior to the expectations of any pet owner.  For ourselves, we allow each other to freely and openly express feelings and emotions in the moment, and thereafter...whenever they might be there.  It is healthy and normal that our doctors and staff experience individual and a cumulative sense of loss, and we pledge our support to one another in addition to our clientele.

TBVH Code of Ethics

• TotalBond Veterinary Hospitals’ directors and staff will be honest and ethical in all words, deeds, and actions. 
• We will uphold quality of veterinary care and ongoing education to assure the most progressive and scientifically sound medical and surgical procedures, and humane, compassionate patient care.
• We will maintain and protect our practices’ reputation for honesty, fairness, respect, responsibility, integrity, trust, and sound judgment.  Our ethical performance equates to the sum total of each and every employee’s ethical principles.

Feline Onchyectomy (declawing);

            The controversy surrounding this procedure is well-understood.  TBVH’s position is that the procedure may be necessary for select cats in select households to remain indoor and bonded to their owner. 

• In kitten visits, doctors and staff should make the effort to education clients about proper training and tools with regards to scratch posts/pads etc.
• Doctors and staff will make no overt recommendation to the client for their cat’s declaw
• In the event the client complains about destructive behavior or inflicting wounds on other family members, behavior modification counseling and/or the recommendation for Soft-Paws is then undertaken
• In the event behavior modification or SoftPaws is unsuccessful at resolving the destructive and/or injurious behavior, OR the client at any time asks for information about declawing, we will educate the client with regards to onchyectomy at our practice, which includes the following principles
• • We are uncompromising about the steps taken to maximize safety and comfort
  • Only the front feet will be done; the rare exception may be made for homes where a family member lives who is intolerant of even the most minor wounds that might be inflicted by the rear claws e.g. when jumping off the lap i.e. diabetics, immunosuppressed individuals (HIV, chemo, steroids)
  • The fee is a turnkey fee which includes the following, and no component may be eliminated to reduce the fee:
  • • Pre-op lab work
    • EMLA/catheter/IV fluid support
    • Multi-modal perioperative pain management which includes but is not limited to:  pre-anesthetic opioid +/- NSAID, intra-operative ketamine CRI, ring block of the feet, procedure performed via laser dissection of P3 only; post-op medetomidine prn, post-op opioid +/- NSAID, +/- spinal cord modulator e.g. gabapentin, home w/ Yesterday’s News litter.

 Ear Trim, Tail Docks:

• TBVH will make no recommendation for either of these procedures to be done
• For the client that requests it, we will educate as to its strictly cosmetic yet painful nature, with no medical or health benefit to the pet, and not a procedure we recommend
• For the client that insists they will have the procedure done, we can quote them our fees which include an uncompromising stance on multi-modal peri-operative pain management, the timing, and the doctor to perform it.  The logic employed is that our pain management protocols are likely to be far superior to other practices where ear trim procedures are performed, and the patient ought to have the opportunity to have the procedure done with that level of attention to pain control, rather than being condemned to having it done with minimal pain control.  It is axiomatic that the procedure is likely to be more expensive at our practice then it might be elsewhere, but then it is the client’s responsibility to choose what they wish for their pet.  Hopefully the emphasis that we place on pain management (and its attendant expenses) may have the effect of casting doubt in the owner’s mind about the wisdom of proceeding with the procedure altogether, whether with us or elsewhere.

  Devocalization/Debarking

• TBVH will decline under all circumstances to perform this procedure
• Alternatives for incessant barking include a variety of behavioral modification techniques, citronella bark collars, and if necessary pharmacologic interventions to help deal with anxiety issues.

TBVH GOOD SAMARITAN PHILOSOPHY

The phrase and concept of “Good Samaritan” is nearly universally known by people of all faiths and religious persuasions.   Its meaning is generally taken to describe the person who helps during a crisis, without any expectation of remuneration, or sometimes, even thanks.  In today's society, we have come to expect the problem to then be handled by others e.g. police, EMT’s or the hospital, social services, or in the case of animals, welfare groups, the municipality (Animal Control), and private veterinary hospitals. This “Good Samaritan” help is certainly necessary and commendable, yet the responsibility sometimes appears to end there.

However, even in the original parable (it can be found in Luke 10:25-37), the individual did not merely help a man who had been beaten and robbed by treating his wounds and taking him to a nearby inn to recover…he also paid the innkeeper for the man’s room and board.  In other words, this good Samaritan did not rescue and then expect someone else to make the man well and bear all the expenses; he saw that his obligation continued, at least in a collaborative effort with others.

Veterinary hospitals, including ours, are regularly brought “strays” or “rescues” by folks that are generously and genuinely termed “Good Samaritans,” and indeed the trouble that such individuals have gone through is admirable and we are glad that they have given us the opportunity to help as well.  In fact, we started our non-profit “B.E.A.M” (Because Every Animal Matters) with such situations in mind and we can dedicate some resources to these animals. On the other hand as a practical matter tens of millions of unwanted animals are destroyed every year, and the point of that shocking statistic is that any given animal hospital can not solely bear the financial responsibility for every inured, sick, or even just merely stray animal in our communities.   Thus we consider doing the good work of providing for the under-served animals in our midst a partnership between ourselves, Good Samaritan citizens, humane organizations, and the municipal authorities, where all share in the financial and supportive roles.  And in response to this need  we have developed a Good Samaritan Policy with which to guide the decision-making process when presented with this type of situation, so that we can maximize the use of our resources to the widest, longest, and best possible use for animals who need every best of help that we can render them.