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Getting ready, being ready, and having fun doing It (Proceedings)

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Apr 01, 2010

Introduction

From the very first time I was faced with the responsibility of possibly having to respond to an emergency when I was a young boy scout (at age 11) to just yesterday when I was an emergency clinician at the Pet Emergency Clinic, the immediate goal was "to make everything ready". A pioneer in emergency care that coined the term "the Golden Hour" Dr. RA Cowley, was emphatic on the carrying out of this goal. Because time is one of the things that can be manipulated and saved when faced with emergencies. It is a savings of time that can make a difference between life and death. The information presented here on practical readiness is provided to help each clinician and staff the ability to to manage patients and the most efficient way possible. Some of the recommendations comes from my experience and training as a surgeon and emergency and critical care specialist as well as a fireman and medic on the front lines...being the one to have to provide the initial care to critical patients whether 2 or 4 legged.

Readiness is also centered on being ready to perform those techniques that must be done immediately when critical patients are first seen.

Readiness also involves the need to perform emergency procedures that one might not do very often when the crisis even occurs. The crisis can occur even during during "routine procedures" such as the adverse drug reaction leading to anaphylactic shock in which a tracheostomy may have to be performed prevent airway obstruction from the edema produced , to a rapid thoracotomy, aortic cross clamping , and cardiac massage, for the patient experiencing a sudden cardiac arrest secondary to a vasovagal response from moving the patient while under anesthesia. So the bottom line is that we must all be ready for critical life-and-death emergencies, all the time, even during a "routine" day .

Readiness involves being ready within the facility regarding equipment and supplies/drugs as well as knowing how to perform emergency procedures, operative techniques, and having the memorized knowledge of protocols that will need to be followed for the successful management of common emergency conditions.

These include: patients presented with difficult breathing, collapse, severe hemorrhage, an acute abdomen, parvovirus like syndrome with diarrhea and dehydration/vomiting, gastric dilation-volvulus, acute poisoning, snake bite and spider bite-toxic envenomation, seizures, heat stroke, severe hypothermia or hyperthermia, severe sepsis, severe burns, acute paraparesis – paralysis, anaphylactic shock, aortic thromboembolism, severe hemorrhage, severe pancreatitis, peritonitis, severe wounds and fractures, and urethral obstrction, severe arrhythmias, head and spinal cord trauma, cardiac or near cardiac arrest from many causes and many others that may occur as a "routine" case in general practice and the procedures necessary to prevent a catastrophic even from occuring.

Prevention steps

Those steps neccessary in the anticipation that something could go wrong are also imprtant to do in readiness. An example is the older patient with dental disease that has renal and cardiac compromise that requires anesthesia for dental prophylaxis and the removal of a suspected tooth root abscess. The placement of an intravenous catheter while the patient is receiving blow-by oxyge anf the injection of a "chemical courage" drug cocktail of ketamine, butorphenol and acepromazine are performed. These steps help preoxygenate the patient and decrease the patient's stress levels and provides a gentle and cardiovascular and renal protective strategy as a preanesthesia and the patient will accept, stress free, a mask for the delivery of 100% oxygen and assist ventilation with the BM (bag-valve) and reservoir attached.

Isoflurane is then added for induction after continuous arterial blood flow Doppler monitoring is added. This is accomplished by clipping the hair over the palmar arterial arch and adding ultrasonic jelly onto the ultrasound flat probe and the probe fixed in place tightly with adhesive tape on the central portion of the metacarpal skin above the metacarpal pad. This may sound complicated but is very easy to achieve.

Since blood flow is the most important to monitor, much more than arterial blood pressure or pulse oximetry, the continuous flow Doppler monitoring provides a key to the knowledge of the patient's cardiovascular status on anesthesia depth and influence on the patient's heart and kidneys.

Now with the addition of local anesthesia in the mouth where the tooth abscess is, with a combination of lidocaine, bupivicaine and the addition of diluted sodium bicarbonate to keep the injection for stinging, the pain that will caused by the tooth extraction and abscess debridement, is able to be managed before it starts. Techniques like this have saved many patient's lives and have "made my day" as one veterinarian said it. Yes many agree; doing a service like this for clients and their pets; being able to managed animal's medical conditions effectively, economically, and with safely make many a health professional team members day. Anticipating and being ready are KEY.