Life-saving strategies: Important considerations in emergency medicine
DVM: Tell us about your experience in emergency medicine and critical care.
DVM: How would you describe your work as an emergency-medicine practitioner?Barnes: My work is challenging and exciting. There's never a dull moment, with always one more or multiple things to do. It can be emotionally draining, though very rewarding.
DVM: As the immediate past president of the Veterinary Emergency and Critical Care Society [VECCS], tell us how it can help veterinarians?
DVM: How has your work changed in recent years with, say, new technologies or practices?
Barnes: There has been quite an evolution over the years, all for the good. First, there's been a rise in 24-hour emergency facilities. Previously, we would save lives and then transfer patients elsewhere and never know what happened to them. Now we can see the continuum of care — how the animal is trending — which is very important for patient care. Long ago, I recognized, as did many others, a great need for 24-hour intensive care, and I'm happy to see that need has largely been fulfilled.
Second, there's been the development of the Veterinary Technician Specialist [VTS] groups, such as the Academy of Veterinary Emergency & Critical Care Technicians. We have two full-time and two part-time VTSs certified in emergency and critical care who are terrific, very knowledgeable and experts in our field. They've made my job so much easier. They improve patient care and allow me more time to speak with families and clients. They ask questions and provoke thoughts and have raised the level of patient care.
Third, the availability of advanced imaging equipment has changed our capabilities and work. Now I can expedite the conclusion of a diagnosis and counsel the client on life-saving strategies and maneuvers that improve outcomes and quality of life. With these technologies, we quickly learn more about the patient's status. Also, the availability of technology to help with critical-care ventilation has helped. This technology can sustain life while we do our jobs.
Finally, there's the improvement in transfusion products. Previously, we had to go through the time and trouble to find a donor. New transfusion products and typing and crossmatching techniques have helped with patients that have, for example, massive blood loss through trauma or other clotting disorders.
DVM: What are the most significant advances for this specialty during the past five years?
Barnes: Significant advances include digital radiography that allows us, in a timely fashion, to diagnose accurately. It's especially helpful in interpreting simple cases. Also, the increased availability of ultrasonography has helped us more accurately treat shock patients. For example, we can see if there is free fluid in the abdomen or chest. With point-of-care testing we can act on information in a real-time manner. And improved availability of the intravenous infusion pumps enables improved accuracy of intravenous continuous infusion monitoring and identifying trends.
DVM: Timing is everything, especially in responding to trauma. Can you offer advice to a primary care practitioner when it comes to stabilizing an animal after it has suffered a traumatic event, such as a car accident?
Barnes: Be prepared for basic resuscitation. Indecisiveness can result in delay of care and loss of life. The best way to help a trauma victim is with what I call the 3Ps: pain management, perfusion and pulmonary care. Patients should be treated for shock and pain.
DVM: What about the role of pain management when faced with a traumatic case? When do you treat?
Barnes: Always. Pain should always be treated. A patient should never have to endure pain.
DVM: Why should primary care practitioners consider referring their clients, when possible, to emergency clinics rather than trying to deal with critical cases themselves?
Barnes: Primary care veterinarians do a great job of delivering preventive healthcare. But they should refer to emergency clinics when rapid decision-making will save lives. The primary care veterinarian can stabilize the animal that is, say, arresting, and then transfer the animal to the closest emergency clinic where there are people with the necessary experience, resources and 24-hour care. Often, those patients have the best outcomes.
DVM: When it comes to emergency medicine, can you bust a myth or two in terms of treatment?
Barnes: Oh, yes, there are many myths I can bust:
1. It used to be said not to treat for pain because it would mask the signs or would prevent detection of worsening signs. That is totally untrue. Pain should always be treated.
2. In past years, it's been as the pendulum swings with use of corticosteroids and glucocorticoids. At present, these should not be used to treat shock, snake envenomations or intervertebral disk disease. Rather, they are used at varying doses to treat inflammation and for immunosuppression. Physiologic doses are administered to supplement adrenal gland or cortisol deficiencies.
3. Any patient with pericardial effusion is not stable, nor is any patient that has a diaphragmatic hernia.
DVM: What advice would you give primary care practitioners about effective emergency medicine — that is, what should they know about basic emergency veterinary medicine?
Barnes: The importance of preparedness. Use the 3Ps I noted earlier.
In addition to joining and using the Veterinary Emergency and Critical Care Society as a resource, refer early to critical care and emergency specialists, and don't be shy about asking for advice before transporting a patient for intensive 24/7 care. A primary care practitioner can perform life-saving care, as can the closest emergency clinic, followed by transfer to an emergency specialty facility that you trust to carry through any resuscitative effort begun. A primary care practitioner should be confident that any 24-hour practice in his or her area has the resources and will be available, so the best care possible is provided to the patient. This will allow the patients to return to their primary care practice, hopefully, for many healthy years to come.