Surgery II Lab Practical

The scenarios won't fit the narrow width of this blog, so you can see the it in a document format at:
https://docs.google.com/etc

Abscesses:

• result from wounds sustained at least 3 days ago
• Step 1: surgical debridement
• don gloves and face mask
• surgically prep the puncture site
• use scalpel blade or hypodermic needle to lance abscess usually where original puncture was
• empty the abscess
• lavage with 1:40 dilution of Chlorhexidine
• remove necrotic tissues
• suture edges of wound if it's large
• create 2 new holes for Penrose drain to enter and exit, keep gravity in mind when choosing the location
• insert drain and suture on both ends
• clean drain site daily
• remove drain within 3 days
• remove drain as you would sutures so that nothing that's been outside the wound gets drug back through the wound upon removal
• Step 2: medical treatment
•  antibiotics

 Caution Numbers:

• HR: below 80Bpm
• RR: below 12 bpm
• CRT: under 1sec or over 2sec
• T: under 99F or more than a 2 degree drop
• Doppler, Systolic: below 100mmHg
• Doppler, Oscillometric: below 80mmHg
• CVP: 8cmH2O
• ET CO2: less than 25mmHg or over 45mmHg
• SpO2: 90%

 Cleaning/autoclaving:

• Autoclave 121C/250F 15 PSI 15min
• Flash Autoclave 133C/272F 35PSI 1min
• Detergents:
• Ethylene Oxide 1-18hrs + 24-48hrs to vent
• NOT inactivated by organic materials: Phenols (Pine-Sol), Biguanides (Chlor-Hex)
• Sporicidal:  Chlorine (Bleach), Aldehydes (Cidex)
• Scrubbing:
• fingernails
• wash w/ soap
• scrub fingertips, fingers, then hand  on hand  #1 (20 strokes on each surface)
• scrub fingertips, fingers, then hand on hand and wrist area of hand #2
• scrub wrist area of arms, then elbow area of arm #1
• scrub elbow area of arm #2

CPR:

• start in right lateral recumbency
• do compressions about where the elbow rests
• at costochondral junction
• compress no more than 30% to avoid cracking ribs
• thoracic pump: do compressions in time with breaths
• in dorsal recumbency, compressions are done on caudal end of sternum and at an angle down and cranial
• never stop for more than 10sec for any reason
• compressions contraindicated with:
• rib fracture
• pleural effusion
• pneumothorax
• cardiac tamponade

Drugs:

• Analgesics:
• Ketamine/Telazol
• A2A's
• Butorphanol
• Controlled:
• Diazepam
• Torbutrol
• Butorphanol
• Morphine and derivatives
• Fentanyl
• Ketamine

Equipment:

• Manometer max for giving breath: 20cmH20/14mmHg
• Manometer max for regular use: 4cmH20/2-3mmHg
• F-tubes: blue inner tube = inspiration, clear outside = exhalation
• Staining:
• Black/White spots = minerals in water
• Corrosion = wet, dry time cut short?
• Rust deposits = hard water, corrosion
• Blue/Grey = reverse metal plating, in cold sterile too long, chlorhex residue, exposure to saline?
• Brown/Orange w/o pitting = iron in water, high pH detergent
• Dark Brown = dried blood
• Multi-color = excessive heat exposure
• Read flow meter at center of ball, or at top of bobbin.  If there are 2 balls, there should be 2 scales, the top ball will read on the smaller scale, the bottom on the larger scale.
• APM, Audio Patient Monitor: esophageal stethoscope w/ speaker to amplify the sound.
• Direct BP monitor(MAP, Mean Arterial Pressure -most accurate) inside body (uncommon),atrial or CVP which must be measured on expiration.
• Indirect BP monitor = Doppler or Sphagnometer: hold the part with the reading at the animal's heart level; the 1st sound is systolic, 2nd is diastolic; not accurate, so take 5 readings, eliminate the highest and lowest, then average the other 3.
• Ocillometer -gives digital readout, measures size change.  Cuff size: width more important than circumference, width should be 40% of the circumference of the limb it will be used on.
• Laser: Think of the laser workpiece as looking like a mechanical pencil.  If you take the lead out, the "lead" is the tip and the empty pencil is the laser handpiece.

Math:

• # of L of O2 left in an H tank:  psi x 3.3
• # of L of O2 left in an E tank:  psi x 0.3
• Reservoir bag:  5-6 x tidal volume, always round up
• Tidal volume: 10ml/kg minimum
• 2.5% = 25mg/mL
• 1:1000 = 1g/L? = 1mg/mL?
• max lidocaine for cats= 4mg/kg (3 spots per paw)
• fluid deficits =  % lost x kg (10% of 20kg = 2kg = 2L lost)
• Fluid rates
• shock in dogs = 60-90ml/kg/hr
• shock in cats = up to 60ml/kg/hr
• maintenance = 40-60ml/kg/day
• surgery = 10ml/kg/hr
• drip rate: (calibration x volume)/time
• max potassium rate =0.5meq/kg/hr

Oxygen supplementation:

• flow-by
• face mask
• nasal prongs
• tube pointed at nose/mouth
• oxygen tent
• zip-lock bag
• e-collar
• oxygen cage
• nasal catheter -for longer term administration
• numb nostril
• measure tube from nose to medial canthus
• mark tube w/ tape
• lube tube
• insert tube when at leats 4min have passed since numbing
• suture a loop next to the nose
• suture tape on tube to suture loop through skin
• secure tube above forehead with tape?, glue? or more suture

 Suture Patterns:

• simple interrupted -J-J-J-
• uninterrupted/continuous -/-/-/-
• horizontal mattress = = =
• vertical mattress -| -| -|-
• cruciate/cross mattress  -X-X-X-

Triage:

• Airway
• make sure patent
• clear obstructions
• place ET tube
• Heimlich?
• tracheostomy?
• Breathing
• O2 supplementation
• manual ventillation?
• mouth to snout?
• Circulation
• IV catheter, fluids
• hemorrhage control
• CPR
• Drugs
• bolus IV drugs with 10-20cc saline
• dilute intratracheal drugs with 5-10cc sterile water
• Exam/Electrical Defibrillation
• defibrillation is only for v-fib or v-tach
• Follow-up

• Immediate:
• airway obstruction
• cardiac or respiratory arrest
• DOA
• Critical:
• respiratory or cardiac distress (pulmonary edema, arrhythmias)
• shock
• active bleeding (arterial or venous)
• active seizuring
• Serious:
• large wounds, compound fractures, traumatic injury
• bloat (GDV)
• toxin ingestion
• blocked male cats
• puppy and kitten sickness/weakness
• Less Serious:
• fractured tooth, toenail injury, URI, etc

 Misc:

• MAC:  high MAC = high safety = less potent = more required to maintain anesthesia
• Methoxyflurane is nephrotoxic
• Halothane is hepatotoxic
• Intubation:
• size according to width of space between nares
• ready one size smaller as well just in case
• check for leaks
• measure to thoracic inlet on the animal
• lube
• push epiglottis down with ET tube
• push down while inserting tube between arytenoid cartilage/vocal folds and into trachea
• tie in
• verify it's in place:
• watch for fogging INSIDE the tube
• palpate neck, if you feel 2 tubes, it's in the esophagus
• watch for bag movement during breathing
• listen to lung sounds on both sides
• Prep:
• cat spay:  midway between umbilicus and pubis bone
• dog spay: 1/4 to 1/3 down from umbilicus
• Review nerve block sites
• Monofilament:
• less traumatic to tissues
• does not wick
• Multifilament:
• greater strength
• holds knots better
• less memory (easier to work with)
• Storage times for packs:  4w muslin, 6m paper, double if double-wrapped
• Black handled instruments are "extra sharp", but dull more quickly.
• Gold handled instruments hold their edge longer  and have stronger gripping surfaces
• Osteotome has a point at it's center, slices bone.
• Bone chisel has it's point off-center and is used to chip away bone.
• O2 flow by: connect O2 to flow meter to outlet to patient (ET tube, mask, etc)
• ECG:
• measuring mv: 10cm = 1mv  (at standard calibration)
• if not standard, squared off wave = 1mv
• complexes are measured in height (mv) and width (sec)?
• intervals are measured in width (sec) only ?
• lead placement
• front: just proximal to elbow (on the caudal aspect)
• rear: just proximal to stifle (on cranial aspect)
• precordial clip goes on end of sternum
• Tourniquet placement:
• front: proximal to elbow, metal clasp over tricep (caudal aspect, not medial or lateral)
• rear: proximal to knee, metal clasp lateral or medial (check) 
• Landmarks for Ortolani's sign:  ischium and greater trocanter
  

Euthanasia as treatment for behavior issues in shelters

I tend to root for the underdog.  In a shelter situation, that's usually a dog with medical or behavior problems.  Having been an employee and (currently) a volunteer in a "no-kill" shelter, I've fallen for many animals who never made it out despite the "no kill" label.  Some succumbed to disease or illness, but at least an equal number were euthanized for behavior problems that could not (or would not) be solved.

This is an incredibly difficult thing to deal with.  I can't tell you the number of hours I've spent trying to rehabilitate and socialize animals with behavior issues only to see them either euthanized in the shelter or shortly after adoption.  The reasons given are liability and adoptability, but in many cases I have to say I believe the real issues is not having the resources to identify and deal with the problem early and on the organizational (rather than the individual) level.

Our shelter used to have a behaviorist that would come in an volunteer her time testing and giving tips on working with the animals that had issues.  But, her advice was given to one person who was tasked with spreading the word on the training plan.  There was no consensus.  There was no way of asking the trainer questions or otherwise allowing volunteers (some of whom think they qualify as a behaviorist themselves) to buy into the plan.  So, everyone did what they thought was best which meant the dogs were confused and the trainer was frustrated, so I assume she got tired of wasting her time and no longer comes to the shelter.

But, when an animal has a medical issue, even in a shelter environment, it's usually treated.  If behavior issues can be fatal, why aren't they treated the same as a medical issue?  With professional advice and a structure in place for implementing the recommended training, I think we'd see a lot more animals surviving the shelter environment and getting adopted.

Of course, that touches on two main issues that are probably the reasons this isn't done.  1.  There are too many pets out there anyway and some might say that the loss of a dog with a behavior issue likely saves a dog without one.  That may be true.  And 2, behavior issues aren't as easily solved as many medical issues are.  It's not as easy as one pill twice a day or some salve to put on a wound.  Instead it requires time, training, and liability.  ...and the outcome you hope for is adaptability, but given their history they will never be as adoptable as most other dogs and will likely take up space on the adoption floor for awhile before the right adopter comes along.

That brings me to another issue -the selectivity of potential adopters by shelters.  They often won't adopt to you if you'll be gone more than 8 hours, you don't have a fenced-in yard, you've never owned that breed before, you have kids, you have a roommate, you or your child have a disability, etc.  Anything that sets off alarms to the particular counselor you are talking to is grounds to deny you the adoption even if the next counselor would have said yes.  Why are we being so picky (and in some cases discriminating based on race, age, sexual orientation, and/or disability) if so many pets are dying?  How can they not think that the adopter they turned down is just going to the pet store down the street to buy a puppy mill dog?  Is that ever weighed into the decision at all?

And maybe if we didn't make people go through an interrogation to adopt a shelter animal adoptions would go up and puppy mills would loose business and profitability?  Maybe if people felt they could answer the adoption counselor's questions truthfully they'd get better advice and more adoptions would be successful.

Then again, maybe I'm just naive.  Or maybe there's a middle ground.  And maybe other shelters are run better (I hope they are!).  But, all of this has sparked something in me.  I look forward to being a Vet Tech with my hands in the poop and my eyes throbbing from looking into a microscope too long for as long as possible, but when I'm too old and can't do it anymore I would really love to start a shelter.  I understand that I'd have to be the one to make the call on euthanizing a dog for aggression, but at least when I made that decision I'd understand and agree with it.  I'd have the time, ability, and resources to look for other options before that needle hit the vein and it was too late.

I hate being the victim of someone else's decision.  I hate nodding my head "yes" when they tell me they've done everything they could while knowing there were options that were not explored.  But I do because at the time it doesn't matter.  The decision is made.  My friend is dead.  But I do hold some hope that one day I can make a difference in some of these dogs' lives.

RIP Vixey, Mike, Boris, and the many others.