Олеся Болтенкова / stock.adobe.com

Whether it’s human medicine or veterinary medicine, emergency cases are usually unexpected. Because of its unpredictably, emergency cases also create unexpected costs for owners. Elizabeth Rozanski, DVM, DACVIM (SAIM), DACVECC, associate professor at Tufts University in Medford, Massachusetts, explained that there are options to help owners afford the cost of emergency medicine. In her session at the 2024 Midwest Veterinary Conference, Rozanski discussed the common challenges in emergency medicine and how to best approach cases when clients cannot afford a wide expanse of diagnostics and treatments.

Frustrations for emergency care team members

Clients who can’t afford diagnostics or treatments can impede on potential solutions

“What’s our solution? It’s coming up with options that we can work with. And that’s spectrum of care. That’s emergency medicine—how we can help these people [and their pets],” Rozanski said.

Charlie is a 9-month-old mixed breed dog who came to see Rozanski after owners noticed black bruising on his neck and reported signs of lethargy over the previous 3 days. The owners had to wait a few days before coming into the emergency department (ED) because they couldn’t find a ride to the hospital and the area lacked convenient public transportation. “They couldn’t get to see us, there was no [ED] that they could get to. They knew he had been sick for a couple of days, now he shows up and he’s bruised…What do you think is wrong with him?” Rozanski asked attendees. “Rat bait. Yeah, he ate rat bait.”

Rozanski and her emergency team noticed Charlie’s prothrombin time (PT) was out of range high which is a common effect of rat poison toxicity. Rozanski explained that a case like Charlie’s can be frustrating for veterinary professionals because it could have been preventable and could have been taken care of sooner. If Charlie was brought to the ED a few days ago, he could have easily been treated with vitamin K for a low cost. However now his case is more dire, and treatment becomes more costly because he may need a transfusion and he is at risk of euthanasia.

Yet, if we take a spectrum of care approach and take into account the owner’s limitations, we can reevaluate the situation. Rozanski explained that a lot of time with rat poison ingestion, owners don’t know if they should call the veterinary clinic. They sometimes compare it to ant bait, which is harmless, and most of the time, dogs appear to be fine shortly after ingesting rat poison. Rozanski also mentioned that some clients don’t have easy access to their primary care veterinary clinic, so it’s harder for them to decide calling the emergency clinic when they are unsure of their pet’s condition. Keeping these circumstances in mind can help reduce frustration for veterinary professionals and help support the client.

Rozanski assured attendees that, in this particular case, Charlie did recover.

Rozanski shared the following things to keep in mind when approaching a client’s unique situation with access to veterinary care:

Veterinary practice type (primary, emergency, specialty, membership-only)

Community (where are you located and what is the average income?)

Presentation style (how are you presenting your veterinary care options to clients?)

Credit options (payment plans, CareCredit, discounts, etc.)

Treatment plans (keep the owner’s budget in mind with how aggressive treatment is)

“At the end of the day, if someone tells you ‘I don’t have the money for that’ then they don’t have the money for that. And then it becomes our job and our opportunity to help them figure that out. So what do you do with that? Is there a better way to pay? Do you need to be paid today or can you be paid over time? Can you make it cost less—not by not charging [for services], but by doing appropriately less tests. [For example], do you need a CBC chemistry before a spay in a cat? No, you don’t need that,” Rozanski said. Of course, doing a complete blood count doesn’t hurt and can be helpful, but this example is more for clients who specifically need to cut costs as much as possible.

Rozanski recommended being direct with clients and ask them what they are comfortable spending before starting your veterinary care. This can help everyone stay on the same page and allows you to clearly explain all their options within their limits. This also allows the client to be more prepared to pay for all the services needed at the end of the emergency visit.

As veterinary professionals, you can also give your personal recommendation to clients for what treatment you think would be best for the pet to let the client know what 

 be needed to properly treat a disease/condition. This way, clients are still aware of options that can offer their pet a full recovery if they have the ability to spend a little more above their budget.

However, Rozanski reminded attendees that catering to a client’s financial needs shouldn’t come at the cost of the hospital’s business and revenue. “You can do a good job and still make money…This is a business; we want to make sure we do OK. So, you have to make more money than you spend,” Rozanski said.

The end goal of better spectrum of care in emergency medicine is to reduce the amount of financial euthanasias that come from preventable or treatable cases. Rozanski stated that there is nothing more upsetting about having to euthanize an animal that could have been easily saved.

Rozanski E. Spectrum of care in emergencies. Presented at: Midwest Veterinary Conference; February 20-22, 2024.

Articles

What can you do to give clients more options in critical care cases?

Bringing a spectrum of care to emergency medicine

Antimicrobial resistance is growing, which leads to less effective antibiotic treatments. More resistant bacteria create a problem for human and animal health. Adam Christman, DVM, MBA, of 

, spoke with Andrew Rosenberg, DVM, DACVD, about the antimicrobial stewardship approach, which utilizes antimicrobial agents in a way that preserves their efficacy, as a potential solution for veterinarians.


What does it mean to use antimicrobial stewardship? How does this understanding lead us to be more prudent?

 Antimicrobial stewardship is responsibly using antimicrobials to decrease the risk of resistance occurring, and as a result allowing us to maximize our treatment. As resistance is growing we want to ask ourselves, why are these kinds of bacteria becoming more common? Sometimes, bacteria can transfer genetic mutations to other bacteria.

One of the hottest topics we’ve ever seen around antimicrobial resistance is biofilm. Biofilms are when groups of bacteria or yeast conglomerate together on the surface of the skin or even inside the ear, and they embed themselves in a slime layer. When embedded in said slime layer, they are resistant to lots of different antibiotics, physical stresses, and chemical stresses. You want to use products that can disrupt these biofilms and make it easier to kill microorganisms.

How do you approach the decision-making process for selecting an antimicrobial agent, taking into consideration factors such as culture and sensitivity testing as well as PCR (polymerase chain reaction) testing?

 I would start with topical antimicrobials that don’t have antibiotics, but rather antiseptic ingredients. These do not encourage resistance mechanisms to develop in the first place. Some products contain chlorhexidine. Newer products contain things like microionized silver, which can kill bacteria, yeast, and viruses, and disrupt biofilms.

When choosing an antibiotic, cultures and sensitivity testing can help us. There have been some studies on PCR cultures, some of which are not so favorable. I think it is good technology, but more advancements are needed before we use those on a regular basis.

Christman: Talk to us about some of the topical modalities that are available now.

 BioHex is a line of products that kill microorganisms in a multimodal fashion. It is a combination of chlorhexidine and miconazole—2% and 2% each—that has been shown to be a superior ratio for these two ingredients.It also has microionized silver and ceramides. Ceramides are important moisturizers for the skin that help increase skin barrier function. In most allergic dogs, they have a defective skin barrier, which can allow for more bacteria and yeast to get into that defective skin and create infection. Ceramides help prevent that.


How do we teach our clients about antimicrobial stewardship from our perspective?

 When educating my clients on what topical products to use, I say this isn’t just to treat infections; it is also to prevent new infections from occurring. I give them a reason why, not just tell them what to do. I will also say if we can use topical products in a good way, and we’re diligent about bathing their pet, we can decrease the need for antibiotics, even the heavy-duty ones.

How can a One Health approach enhance antimicrobial stewardship in veterinary dermatology

 Antimicrobial resistance is growing everywhere—on the human and veterinary side. If we can limit the use of antibiotics in veterinary medicine using increased topicals, then that benefits everybody.

Are there specific guidelines or resources for generalists when it comes to antimicrobial stewardship?

 There are 2 great resources out there. The World Association for Veterinary Dermatology has consensus guidelines for the treatment of methicillin-resistant 

. It is an open-source article that can be accessed without a subscription. Another resource is the Antimicrobials Working Group. They have robust guidelines on how superficial bacterial folliculitis should be treated in our companion animals.

Spearheading the path for antimicrobial stewardship 

Less is more

Learning Pathways empowers you to achieve learning milestones toward your specialty CE certification. Subscribe today and earn RACE®-approved CE.

A collection of multi-specialty simulive conference CE sessions available via subscription.

Introducing Inside The Clinic™--our new CE webcasts featuring clinical case videos in real-time action from practices across the nation. Chief Veterinary Officer, Dr. Adam Christman, tours veterinary clinics to capture what's trending in veterinary medicine. Learn what's happening now from the experts point of view, real time from inside-the-clinic! Sharpen critical thinking skills, boost your confidence, and advance your expertise for practical application, Plus earn RACE®- approved CE credit. Available exclusively on dvm360 Flex.

: Make Vetscan Imagyst A Hospital Superhero–Part 1 

: Make Vetscan Imagyst A Hospital Superhero–Part 2 

r: Your Analysis Requires Urinalysis: What AI Has to Offer 

Speaker: Dennis J. Chew, DVM, DACVIM (SAIM) 

: Beyond the Rainbow: Creating Safe Spaces for Authenticity in Veterinary Medicine 

: Ophytrium® in Dermatology: When, Where and Whys of Using Douxo® S3 Topical Therapies 

: Test & Treat: The Future of Allergy Testing Technology 

Speaker: Ashley Bourgeois, DVM, DIP ACVD 

: Don’t Fear the Blood Smear! Learn How Technology Can Help Interpret It for You 

Speaker: Emily A. Graves, VMD, MS, DIPL. ACVIM, Global Diagnostics, Medical Platform Lead – Hematology 

: Maximizing the Minimum Database: Diagnostics with a Twist in the Tail 

r: Getting Toxins Tox-Out! Decontamination in Veterinary Medicine 

Speaker: Mariana Pardo, MV, BVSc, DACVECC, and Erik Zager, DVM, DACVECC 

: Into the Weeds: Understanding and Treating Marijuana Toxicosis in Veterinary Medicine 

: Successfully Managing Cats with Chronic Kidney Disease: Managing the Two A’s 

Speaker: Natalie L. Marks, DVM, CVJ, FFCP-ELITE 

: Panoquell-CA1 and its Role in the Management of Acute Pancreatitis 

Speaker: Harry Cridge, MVB, MS, PG Cert VET ED, DACVIM (SAIM), DECVIM-CA, FHEA, MRCVS 

: Identification of Osteoarthritis in Dogs and Regenerative Therapy Options 

Speaker: Michael Jaffe, DVM, MS, CCRP, DACVS  

: Mobility Matters: Keeping Pets with Joint Disease Moving 

Speaker: Kara M. Burns, MS, MED, LVT, VTS (Nutrition) 

Check out these continuing education opportunities now available

Flex Forecast: March 2024 

Specialty care

Sounds like it's wonderful Dr. Penn that, you know, we have these offerings to hospitals, especially in areas where access to care is a really big concern. So, it's equally important to provide customization to our clients as well. So how has that landscape provided an opportunity for greater client communication and patient outcomes?

Yeah, I think...thank you for the question, Dr. Christman. I think when we think about this, and we think about the Zoetis virtual laboratory, we have really as an organization said, "Hey, here's the challenges that veterinarians face every day, and really try to alleviate some of those challenges or help with workflow efficiency, consistency, those types of things. So, there's always a virtual laboratory as an umbrella, has the, the VetScan Imagyst, has our point of care diagnostic analyzers, has our ZoetisDx platform, which includes trending those results and, you know, access to clinical specialists for a complimentary consultation. And we really, when we think about the VetScan Imagyst, the VetScan Imagyst is sitting right there, it's a scanner that has the...it's really your window to artificial intelligence, which is kind of a buzzword right now. But you can do fecal analysis, you can do AI dermatology, cytology, skin impression smears, ear swabs, skin swabs, you can do AI blood smear to add that qualitative information to that quantitative information. And that's that kind of expert level AI that is there to provide those results that are comparable to results that a clinical pathologist would provide. But in addition to that, it's always backed up. That whole slide image is always able to be evaluated by an expert by a clinical pathologist, by a parasitologist, if you wish to add on that expert review, or if you've got some sort of sample, like a fine needle aspirate, a lymph node aspirate that you would like to send into it to a clinical pathologist, you can do that. So not only do you have the artificial intelligence, which provides you results for certain types of tests in 10 minutes, it's always backed up by the expert, you have the ability to send that whole slide image of really any tissue, any fluid, you can put on a slide from any veterinary species, send that to a clinical pathologist, and have those results back within hours. So, it really is just absolutely amazing. And it all feeds in, you know, we know that the presentation of this information is not only important for us to be able to trend those results, but also for our clients to be able to really say to that pet owner, here's exactly what we tested today. Here's what we saw on that on that microscopic slide. And here's kind of our plan moving forward. So, we get that presentation that we can provide that value to be able to communicate, to be able to educate to help with compliance. And that next step, if we say, hey, we want to have access to a specialist, the Zoetis virtual lab and can take care of that.

Yeah, so our consultation service, we have also taken the approach of really wanting it to be personalized, so the veterinarians that are using our service have access in a way that's convenient for them. So, we do offer both email consults, as well as Zoom consults that can be done via phone; they can phone into that. So that really can be about their time, that's so valuable, that they can really individualize. You know how that consult happens, so that it's convenient for them. But they're still getting that access to quality, additional resources. And then beyond just them having more control about the form of the consult, the timing of the consult, also providing reports so that they have that physical evidence to provide to the pet owner, so that that everyone is aware or a part of kind of understanding the next possible steps that can be involved. And so that really is a complimentary service that we are really trying to provide to our customers. So, they have that extra support in their busy practices.

Videos

Discover how the Zoetis Virtual Laboratory offers a full suite of diagnostic products and services

Zoetis Virtual Laboratory:  AI results backed up by the experts

And I want to talk more a little bit about the virtual lab Dr. Hann. So, the virtual lab has many offerings to it too. And they play a vital role in the way in which we practice medicine today. So, we know that adjusting to technologies such as AI can be scary. You think of AI for some reason we get scared of it too, and it's overwhelming, but you embrace it. So how helpful has this been for, you know, what your experience has been like? And how has this been for, you know, what you're seeing out there today?

The artificial intelligence is great, and definitely gives us additional diagnostics and quick access to certain answers. But it's a piece of the puzzle. There's a stepwise process that we go through for kind of each case of, you know, getting from "Okay, this is how they're presenting to this is the diagnosis," And then that after that the treatment process, the prognosis, the follow up care. And so, we can utilize specialists. So, we have our consultation service that can work hand in hand with a lot of these diagnostic tools to provide kind of more individualized care. And we're trying to do a couple things differently with our consultation service, so that we can provide very individualized personalized experience for our customers, which includes having the ability to consult with us in different ways, the ways that work best for their practice. So, email consults, Zoom consults, and then having access to different specialties. And then beyond just having the consult, we do consistently provide a written report, which is not always the case with consultation services. So that really allows them to tie in with the pet owner of they can provide that report. And so they know that they've had a specialist involved with the case, because I don't know that pet owners are always aware of what that there are specialists available in veterinary medicine or what that provides beyond the general practitioner. And so knowing that, that added value of kind of that relationship, and how we're all working together for that pet to get the best care possible.

Yeah. And just what you're both talking about, there's a global network of specialists, right? I mean, just to digest that for a moment, that's pretty impressive, knowing that you can have access to someone around the world. And I'm curious to get your thoughts on that. Dr. Wolfe. What has that experience been like for you?

I had specialists from multiple other countries. It's provided accessibility and under two hours, and it's been very...I've been able to understand, despite our time differences and language barriers, it's been very understandable and very, very informative.

Things that I've liked about it in veteranary medicine, in vet schools, you're talking if you do CBC profile, urinalysis, blah, blah, blah...you're gonna get the diagnostic. You're going to have a black and white diagnosis. You're gonna know what it is. And what my young veterinarians, most of them come like "Well I was taught that if I did this, I would know what the problem is." That don't happen that often. If it is, it's almost always a bad guy. But if you don't have that, if you've got all this information from you, but you're not sure how to put it together, and you talk to a specialist, sometimes they can help clear my mind and say, "This is where you need to be looking." You may you gotta have some differential diagnosis, but at least you've kind of helped. You can sleep at night knowing you've done the best for that pet that you can. And that's a big deal too as a veterinarian. You know, I think that's one of the biggest problems we have is this ambiguity of what what's wrong with that pet? Because we were taught if we did XYZ, we know what the answer is. And that's not the case.

Yeah, it really is about interpretation of diagnostics. It's not just a result. There are certain diseases that you may get a very clear answer. But there are a lot of times where a diagnostic tool is only as good as the interpretation of it. And so we, as specialists can help in that process, put that puzzle together.

And sometimes it's only a CBC. You don't need...we made it to present the whole case to them, but you could present only a urinalysis finding. I have a protein losing nephropathy I'm working on and so we're just looking at that focused as well.

Yeah, I love that we're providing access to care not only to our clients, but to us, the veterinarian. So that's fantastic.

The one thing you haven't mentioned that's really important is if I was watching the show, okay, how much is it? How much is it?

Yeah, it's complimentary. Having access to the specialist is complimentary. I almost think of it like, if you use the Zoetis diagnostic offering, it's kind of like going back to veterinary school where you can get access to experts, not only fromclinical pathology where you can go down and knock on clin path's door. But if you get a result and you say, "Okay, well now I want to kind of know what I want to do next steps. "I can go talk to an internal medicine specialis.t I can go knock on an oncologist's door and I can get an individualized complimentary plan to move forward with the case.

Amazing. It really is. Well, great, thank you so much doctors. This is wonderful.

Find out how Zoetis’ complimentary consultation service puts the puzzle pieces together

A diagnostic tool is only as good as its interpretation

The Veterinary Emergency Team is shown during preparations for deployment to the Texas panhandle, where wildfires are burning. (Photos: Rachel Knight/Texas A&M University)

An emergency response team from Texas A&M University School of Veterinary Medicine and Biomedical Sciences (VMBS) has been deployed to the Texas panhandle, where a cluster of wildfires are affecting animals. The largest of 5 fires in the region, the Smokehouse Creek Fire, was spread over 850,000 acres on Wednesday, according to VMBS; and 60 Texas counties were placed under a disaster declaration by Gov. Greg Abbott earlier this week.

“Fires are unpredictable and often enter a community without warning; when this happens, more people and animals are likely to be affected,” Deb Zoran, DVM, PhD, DACVIM, Veterinary Emergency Team director, said in a news release.

 “In these situations, it’s critical that we begin helping to take care of affected animals and support the local veterinary community as quickly as possible.”

Natural disasters like wildfires can cause animals to become displaced, injured, or in need of temporary care with shelter and food. In the Texas panhandle, government agencies and other entities are assisting animals in need through a variety of ways. Animal supply points are receiving and distributing items, a hay hotline has been established by the Texas Department of Agriculture, and the Texas Animal Health Commission (TAHC) is working to reunite found livestock and stray cattle with their owners.

VET members load a trailer in preparation for deployment. 

The Texas A&M Veterinary Emergency Team (VET) aims to provide resident animals and search and rescue dogs with veterinary medical care, and support local animal shelters. Nine individuals, including 5 students, were deployed to the Texas panhandle on Wednesday. Additional members of the team—comprised of VMBS faculty, staff, and students, as well as other volunteers—are expected to join the deployed group today.

Among the working canines are a dozen dogs deployed with the Texas A&M Texas Task Force 1. “Working dogs are critical to the success of search and rescue efforts, and our role is to make sure they have the nutrition, post-work rehabilitation, and veterinary care they need to continue providing hope and answers to loved ones of those in the affected area,” Zoran said in the release.

For all species, the TAHC is urging the public to monitor their animals and consult with a veterinarian if signs of fire-related injury are presented. These signs may include distress, fatigue, lesions, and exertion.

Animal owners can also be advised about caring for their pets and livestock in areas where smoke caused by wildfires may affect their health. American Humane and the American Veterinary Medical Association recommend owners take precautions as follows:

Limit the time dogs and cats spent outdoors.

Keep birds indoors at all times when smoke or particulate matter is present.

Avoid strenuous activity and exercise for all animals. This includes playing fetch, going for a jog, or taking a long walk.

Take your pet outside for short bathroom breaks and come immediately back inside.

Bring outdoor water bowls inside so it doesn’t collect airborne particles associated with the smoke.

If pets have to be outside, mornings are preferred, as the weather is cooler.

Livestock need a 4-to-6-week period to recuperate after the air quality returns to normal is needed. Attempting to handle, move, or transport livestock may delay healing and compromise these animals’ performance.

Through social media, the TAHC is also advising livestock owners to allow their animals to have movement. In a post on X (formerly Twitter), the agency suggested opening gates, cutting fences and herding livestock to help ensure the safety of these animals. 

Students deployed with the VET team are receiving real-world, hands-on experience in providing emergency care to animals and managing their safety during a crisis event. Funded largely by donations,

 this Texas A&M team is part of the VMBS emergency preparedness rotation that draws students from around the world. The rotation educates students about basic preparedness and threat analysis and includes a visit to a Texas county, where students conduct a risk assessment and collaborate with regional leadership to develop a disaster plan.

The VET team was previously deployed in Texas 19 times—and 26 times overall—responding to wildfires, hurricanes and tornadoes. In addition to working throughout Texas, the team's deployments have sent volunteers to California and Florida.

 According to Zoran, although no 2 deployments are the same, the team’s responses share similarities.

“When we deploy in response to wildfires, we know we’re going to see burn victims, we know we’re going to have to work hard to keep the search and rescue dogs safe, and we know that the hope we provide by supporting the search teams,” Zoran said, in the release. “Helping reunite a family with a beloved pet is invaluable and more than worth the hard work that goes into disaster response efforts.”

Knight R. Texas A&M veterinary emergency team deploys to Texas panhandle in response to wildfire. News release. Texas A&M University. February 28, 2024. 

Natural disaster: animal preparation and response. Texas Animal Health Commission. Accessed February 29, 2024. 

https://www.tahc.texas.gov/emergency/naturaldisaster.html

Knight R. Texas A&M Veterinary Emergency Team shapes how future Aggie veterinarians prepare to respond to disasters. News release. February 7, 2024. Accessed February 29, 2024. 

https://vetmed.tamu.edu/news/press-releases/vet-clinical-rotation/

. June 8, 2023. Accessed February 29, 2024. 

https://www.dvm360.com/view/keeping-pets-safe-from-wildfire-smoke

An emergency response unit has been deployed to the Texas panhandle to care for animals in crisis and support local shelters