How low-stress handling changed one patient’s lifeMyla’s journey started with “just because” visits with no sedation or muzzle allowed April 6, 2018 By Phil Zeltzman, DVM, DACVS, CVJ, Fear Free CertifiedMyla, a 5-year-old pit bull, was deemed evil by her family veterinarian and his staff. Every time she came to the hospital, even for something as benign as a wellness visit, she had to be sedated at home. The owner had to muzzle her even before entering the building. Every visit was worse than the previous one. It was a never-ending vicious cycle. Visits were a mixture of growling, high anxiety, anal gland smell, pounding heart rates, and sheer terror on both ends of the leash. When Myla started to limp on the left back leg, the exam was even more traumatic. After being wrestled by several technicians, Myla was diagnosed with a torn ACL. Surgery was recommended, but Myla’s owner could not imagine how much stress leaving her dog at the practice would lead to. So as a result of this she postponed the surgery. For many more months. Meanwhile, Myla kept limping. She was in constant pain and lost muscle mass in the affected leg. When Myla’s owner reached out to me to discuss her dilemma, I referred her to a practice that embraces low stress handling—and incidentally, a clinic that has a nurse who thinks every pit bull, no matter how “aggressive,” is adorable and lovable. A plan was put in place. Myla’s journey started with “just because” visits. Her owner was advised to bring her through the back door. No sedation and no muzzle allowed. Most importantly, she had to arrive hungry. She was then immediately placed in an exam room that had been very thoroughly cleaned of all terrifying smells. A comfortable blanket was also sprayed with a canine-appeasing pheromone. She then was given 15 minutes to acclimate to the room before anybody entered the room to interact with her. The low-stress handling “queen” then entered slowly, without making eye contact, and allowed Myla to investigate her. She dropped treats on the floor in different locations. Then the nurse left the room. The visit was over. No restraint, no handling, no touching. This took place weekly until Myla was literally running to the back door to receive her treats. After a few visits, the nurse in question was petting and hugging Myla, who proved to be a perfectly nice and well-mannered dog. Her TPLO was scheduled, with an overnight stay. The entire process was uneventful—so much so that the owner scheduled a second TPLO after the right ACL tore one year later. That entire process was just as peaceful. What can we take away from Myla’s experience? Suggest “just because” visits Encourage as many people as possible to be part of “just because” visits. One condition: They all must be trained and comfortable with this situation. If a staff member is nervous, the patient will know immediately and will be on high alert. Learn the signs of fear, anxiety, and stress Memorize them and back off as soon as you notice them. The goal is to keep patients under their anxiety threshold. If you do this correctly, their threshold will increase. Offer rewards Find what stimulation or reward patients like best, whether it be food bribery or physical interaction. If you plan on doing something uncomfortable, the positive stimulation should start before the event and not be stopped until after it’s over. Myla was given treats before, during, and after a blood draw. When she had to be fasted for surgery, her favorite petting spot was used during catheter placement. Control pain Do not manipulate any body part (such as a drawer test) or even perform a physical exam if pain is present. Even the nicest patient can be difficult to handle when in pain. In Myla’s case, this meant starting her fentanyl CRI prior to the intake exam with the nurses she had been acclimated to. Use the catheter Catheter placement early on allows minimal handling by giving all medications and induction agents through an IV line without scary manipulation. Reduce E-collar scares Placing the E-collar before extubation can help reduce panic in some dogs. It can be terrifying to have a giant plastic cone shoved around your face while you’re dysphoric. Use pheromones Canine appeasing pheromones were used throughout Myla’s stay. Her cage was sprayed. Her blanket was sprayed. The scrubs of nurses who had to handle her were sprayed. Offer extra TLC Only half of the cage door was covered with a blanket in case Myla wanted to hide. Ironically, she preferred to watch the events in the treatment room. She also demanded to be hand fed by the technician she had spent the most time with. Go slow to save time Rushing is not welcome with a fearful patient. Prefer slow movements so you never startle your patient. Every gesture and every change is potentially scary and could be a trigger. Always proceed with caution. Reduce noise Minimize noise in the treatment room and the kennel. We may be used to it, or we may have learned to block off annoying sounds, but dogs hear all kinds of scary noises: IV pumps, monitors, other animals’ protests, laughing out loud, head-banging music, etc. The use of peaceful music or canine-specific sounds can be helpful to lessen the scare factor of strange noises. Discovering a practice that promotes low stress handling was a game changer for Myla and her owner. Your ability to handle challenging patients can be the difference between providing mediocre and excellent medical care. Keeping patients’ emotional well-being in mind is just as important as their medical care. We took an oath to protect animal health and welfare, and to prevent and relieve animal suffering. Let’s not break that promise. TELL-TALE SIGNS OF FEAR, ANXIETY, AND STRESS Diverting eye movement Licking lips Yawning Small posture Tail tucking Ears to the side Panting Pacing Dilated pupils Barking, growling Tachycardia Hiding Escaping Dr. Phil Zeltzman is a board-certified veterinary surgeon and author. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. For more information, visit his websites at DrPhilZeltzman.com and VeterinariansInParadise.com. AJ Debiasse, a technician in Stroudsburg, Pa., contributed to this article.