Hello, guys. Welcome to today. We're going to look at opportunities and challenges in ECC patient assessment.

So, my name is Jackie Seymour. I'm an RCBS advanced practitioner in ECC and currently work as a district vet in vets now. So for a little bit of background, then, I graduated in 2011 from Cambridge.

I initially entered a very busy mixed general practise, doing our own out of hours, and found very quickly that I liked the ECC cases so much that I moved into. That's now on their recent graduate programme back in 2012. Since then, I've worked in several of their clinics, taken part in various projects and training sessions, and that's let me progress up through the ranks to principal vet and then to district vet.

And having got the advanced practitioner status in 2018, then I now spend my time leading the seven clinics around the Peak District and try to get out into the Peak District as much as possible when time permits. So for the slightly less exciting conflict of interest statements then the organisations I'm affiliated with are vets now obviously for working with them, but also the regional division of the BVA with the North East Veterinary Association. Our aim for today.

So today, we're gonna look at the opportunities and challenges of ECC patient assessment, and they have a fair few opportunities and challenges. Now, whether we work in emergency medicine purely or whether we work in general practise, love them or hate them, chances are we're all going to see emergencies. And there's several key concepts that can make it much easier to approach them effectively and ensure best patient outcome and team-client experience.

These cases are often exciting or stressful or both, depending how you look at them. Often unstable and quite often we end up as a result of this with a limited history and limited planning time for interventions. So, we need to understand from hopefully at the end of this session that our ECC patients are often not suitable for the standard diagnostic paths, GA X-rays.

We need to weigh up what our benefits and what our risks are in these patient categories. We need to approach each parameter assessed for maximum benefit. So actually, basic clinical exam can provide a really good indication of shock type and narrow down our differential options.

We want to look at the value of minimally invasive diagnostics, like we say, clinical exam, but also multi-parameter monitors, point of care ultrasound techniques can be really useful in this category. And we want to recognise the importance of repeat assessments and serial trends. Things can change very quickly.

Actually repeating your clinical exam, repeating tests such as lactate, can really make a difference in letting you see the picture of how things are progressing and what impact your interventions are making. And finally, we want to identify the impact common factors such as pain, low blood pressure, can have unresolves and why we want to correct these alongside any diagnostic test, which essentially in its simplest form, can come down to us not killing a patient for poor pain control. So the first thing at this point that I'd like to ask you to do is to think about how you differ in your approach to ECC.

We're gonna start considering the differences in ECC cases versus normal. We need to understand what, what is different and, and what we currently do, what our current understanding is. So, if you've got a moment to press pause, get a pen, paper, or your tablet, and just jot down some words and phrases.

And essentially thinking about what aspects do you enjoy most in ECC. What's the biggest fear point in ECC? What worries you about these cases?

Are you actively aware of having a different approach with the sickest pets? And is there a different approach to clients? And if you are taking a different approach with these, if there is a different approach to your client communications.

Just take a moment and think about how these differ. And think about with the team as well, what matters to them. So if you are listening to this together, then pause and have a chat, particularly if you have different roles within the team.

Because recognising if you actively alter your behaviour in an ECC setting and how is really helpful to understanding your own treatment aims and priorities, but also your own resilience under pressure. So what do you then notice? The key differences often found in ECC are I absolutely love being able to make the difference, and quite often in these cases, your interventions are the difference between life and death.

Time pressure factors are often one of the biggest stressors because decisions, communication can need to be much more rapid in these cases. Attention to detail is one which when I first went into ECC. I was a little bit puzzled by on the grounds that Shirley detail in ECC.

Actually you're, you know, it's, it's going for it, you know, this, this is the action movie of veterinary medicine. And actually, it's a weird mix. So I've got a little link there to the differences in human between ICU and EAS is.

It's, it's a bit satirical, but it does kind of highlight that ECC is a really weird mix as a discipline, because the emergency aspect is much more in the heat of the moment, what you're going to do, how are you going to do it. The critical care aspect can sometimes be titrating small differences, looking for small changes, especially with neurological cases over a period of days if not weeks. So from that side of things.

Actually, it's really, really essential to realise that even in the emergency setting, the small changes can make big differences between the patient decompensation between any changes in terms of how they're progressing. And the outcomes and resilience with these cases, if they're sicker patients, sometimes we will have a higher loss rate with them. Sometimes we will end up, obviously, with much higher own emotions, and it can impact on our resilience.

So it's absolutely a heal the healer situation where we do need to look after ourselves as well in these and be aware that that's actually the one of the key differences that we will find. So communication. Before proceeding with any case, including the opportunities and challenges of the actual treatment options and diagnosis methods, we need to consider that communication is absolutely massive.

And it's probably the biggest opportunity in ECC, it's also probably the biggest challenge. So before proceeding with any emergency case, you want to pause, breathe and compose yourself, and bear in mind that the next client doesn't know what else has been in that day. Their priority is always gonna be their patient, and they expect it to be yours.

You know you're looking at a lot of other patients, but if you initially can set the seeing that even if it's very busy, their patient is a priority to you, it just might not be the immediate priority, then that'll stand you in great stead. Keep the essential niceties in the heat of the moment, the RTA cat, the temptation sometimes is to skip the social niceties. But for the client, they still need to know who you are.

They still need to see you show some sympathy for that pet, and they still want to know what's happening. And taking a moment to utter those three sentences sets the scene really nicely for what's then going on and how you're going to do it and handle it, and builds that rapport and trust from the start. Accept the loss of detail.

Clients will often be stressed. They'll often be upset. They may feel guilty depending on what's happened to their pet, the dog that slipped his lead and ran into the road.

And this can impede their own recall of what's happened, what medications, what he's done since, how long the fit was. And you may need to act fast, so you might well need to actually just skip those bits, take a capsule history. And then very clearly signpost to them.

Again, it's hard for them to process when they're stressed and upset. So making sure that they know what are you going to do. Where is that pet going if you're taking them through to the treatment room?

When will you be back? What should they do now? Should they follow you?

Should they stay? And this is where using your other team members. So my receptionists are absolutely worth the waiting gold for the ability to sit, calm down, and owner, and provide listening your cup of tea and obtain a supplemental history and extra details while myself and the nurse are getting our patients stabilised in the bag.

And closed loop communication is always a great thing, that what we're wanting to do with them is be able to say, Hi. So we're gonna do this, we're gonna do that. And in the same way that we'll get that repeating back with our team of, OK, I'm giving, can you give 2 mLs of adrenaline, I'm giving 2 mLs of adrenaline, 2 mLs of adrenaline given.

We also want to do the same with our clients and check that they do understand it, get them to repeat back to us, repeat back to them what they're saying, so that we've got that communication clear when people aren't processing as well as they would usually. And ultimately being kind to ourselves and being kind to them to realise that emergency and critical care, it's never a good visit to end up in the emergency room. It's either going to be more expensive than usual.

It's going to be a situation where the client is worried about their pet. It may be a situation where their pet is critically ill and isn't gonna come back out. So, from that side of things, clients often aren't delighted to be in.

And we need to recognise that and work with that. One of the best articles I've ever read was the Bateman 2007 on this topic, which was communication in the veterinary emergency setting. So I've got the reference just there.

I would strongly recommend having a little look at that because that's got some really, really good information on it. So We've got the communication, we've got our patient, and we now need to approach them in a sensible fashion as well. So, we need to understand firstly that ECC patients are often not suitable for the standard diagnostic paths.

They're often unstable in the major body systems, which we take to be cardiovascular, respiratory, and neurological. So based on that, then they may not cope with standard sedation and GA protocols without effective stabilisation first, we might need to modify what we use or whether we use it at all. So meatomidine may have an impact.

And prolonged GA's even if we're using. A medication and a protocol that might be safe and stable, we want to keep things. Within a sensible time period, so the orthopaedic stabilisation procedure for the fracture may need to be postponed for 24, 48 hours, maybe even up to a week, depending what's going on in terms of the pulmonary contusions and an RTA.

We need to realise that we may not obtain results before our treatment planning. Sometimes we're trying to work to stabilise these guys before we get the results in as to what's wrong with them. So we're having to go on first principles.

Particularly things like external labs results. Again, we may not have access to that. We may not be able to perform the X-rays, like we were talking before, if the patient's not stable enough to actually put them under the anaesthetic.

So we can end up needing to look at other options. And we need to be aware that even fairly benign tests that we do a lot can be higher risk in these patients. So, a general anaesthetic.

Can be higher risk, but so can the actual procedure, so obtaining. A venttra dorsal X-ray view in a dissonate patient tipping them on their back and straining them. Absolutely, can be something that can seriously decompensate them and then they actually lose your patient.

So we need to be aware and consider those approaches. What can we do? We need to look at good initial stabilisation.

So can we make them more stable? Might be things like fluid bonuses. Adequate analgesia, anxiolytics in a stressed dynamic patient.

We need to consider the general anaesthetic benefit, and sometimes to turn it on its head a little bit, talking about whether we want to go for a heavy anaesthetic in the previous slide. Sometimes we absolutely do. Sometimes that lighter sedation with something like midazolamketamine is great and much safer.

But sometimes, again, coming back to a dysphic patient at risk of respiratory arrest, actually obtaining a full general anaesthetic. Knockout and full airway control with an ET tube may actually be of benefit for resuscitation, for improving the oxygen and carbon dioxide balance, the ventilation. So we need to consider what we're aiming to do.

In clinic testing is absolutely worth its weight in gold. For myself and the work that I do. I wouldn't be able to do the level of care if I didn't have the facilities that I have.

So, a good ultrasound, on-site electrolytes, COAGs, lactate, having a microscope that I can take samples, I can look at them because at 2 in the morning on a Saturday night, I don't have access to the IDEX sample reports. They aren't going to send me the urinalysis until later down the line, in which case, I need to know, I want to be able to look at these things now. And prioritising the least invasive.

And the most useful. So, essentially. I don't want to do harm, but I do want to obtain results that are gonna help me in my treatment planning.

I want to be able to approach each parameter assessed for maximum benefit in a similar line. So I want as full a clinical exam as possible. I say as possible because there might be limitations, again, pinning a disate cat to the table to get a temperature.

It is not going to be a great option. So sometimes we do what we call primary versus secondary surveys, where the primary survey focuses on the major body systems and gives us the information we immediately need to know for life-threatening changes. But then we'll come back and we'll reassess the patient in more detail after that initial stabilisation.

So we might end up needing to tap a pneumothorax and identify that as a problem. But what we then want to do is come back and check the patient for any evidence of fractures. Have they got normal neuron responses, etc.

What to sample and how much is another aspect, so. Again, it's, it's what you want to. Obtain what the benefits going to be?

Is it blood, is it urine, is it an effusion? How much do you need? Are you going to put a couple of drops on a microscope slide?

Do you need a mill to run in your machine? And how are you going to obtain that? So for a blocked cat, you might want to look at urine.

But rather than an initial cystocentesis to check the urine before unlocking it. You would unblock him and then usually take a sample at that stage and have a look at that. If you were going to do a system, you'd be looking at what the benefit of that was versus essentially unblocking him and getting the sample in one.

So, what I would say is looking at it for what is your essential question or concern. So, a dyspneic cat, you may not be looking, be nice to run bloods for general health profile, maybe, but actually a thoracic point of care ultrasound might be more useful in deciding if you've got wet lungs, dry lungs, any pleurals based disease. So that might be the intervention to do first.

And thinking what will that intervention achieve? Again, going back to a Disney account. If you've got pleural space disease, thorachocentesis may actually take off some of the fluids and pressure.

And improve the dysp, as well as giving you diagnosis, whereas the ultrasound would find it. And then you'd be looking at the tap. So which one do you use them?

Which ones do you do? Do you do both? Do you do one?

And how are you gonna prioritise that? And ultimately, if an intervention doesn't fit your current key question. I probably ask, should you do it?

Should you delay it, or should you ditch it? And sometimes we will end up thinking, yeah, we might do that, we'll do that later down the line, or we need to do that now, or actually, that's not gonna be a benefit in this scenario at this stage. And it's really important to just keep that focus.

Appreciating the value of minimally invasive diagnostics is another key opportunity in that your clinical examination, it's cheap, it's repeatable, it can be performed by different members of the team, and it gives you a lot of information. Ultrasound, really useful, especially for abdominal thoracic free fluid, picking up pericardial effusions, seeing some masses, some changes. Massively, massively helpful, and because it's minimally invasive, you often don't need a sedation for this.

You often can get the results in real time very quickly. And we have portable ultrasounds that I can take my ultrasound machine quite cheerfully around the kennels and do kennel side ultrasound. Serial trends, looking at what's changing and how.

So electrolytes, lactic, glucose, what difference are you making with them? Multi-parameter monitoring. We usually hook up all of our unstable patients.

We tolerate it onto ECG monitoring, blood pressure monitoring, that's so that we can actually see what's going on in a little bit more detail. And we don't just go on the numbers, we go on the clinical exam as well, but it gives us an extra port of information again, minimally invasive. And the blood work as well.

Bloods don't tell us everything, but they can sometimes tell us things that we need to know about in terms of what we're stabilising, in terms of what differentials are more likely. So even in a case where maybe imaging would be the preferred option for, say, an obstruction in a vomiting patient you're wanting to look at, actually your bloods will give you an idea of the stability for being able to take that patient to surgery. And I'll also give you a potentially a hint as to how likely it is that there's an obstruction to go alongside.

Your imaging for what are your electrolytes doing? What's your lacta doing, what's your glucose doing, how likely do you think this is to potentially have already ruptured and gone septic. So you can find quite a lot of detail from this.

We want to recognise the importance of repeat assessments and serial trends in an unstable patient as well. And this is something that. We talk a lot about, I've mentioned it a couple of times, and it is this concept that in ACC the patients are very, very dynamic often.

An unstable patient can change so quickly. Things like a head trauma with Cushing's reflex, they can deteriorate. Within the space of minutes.

Sometimes these changes can be life threatening. Cushing's reflex comes with the risk of herniation of the brain stem. Hypoglycemia can change very quickly and what starts as a change indentation.

Can very quickly go into a coma and seizures. Sometimes it can be a response to treatment or progression of the case, and this is something that obviously we want to keep on top of because especially if it's something we're doing, the classic one would be a fluid overload as a response to our bola strategy. We want to pick this up quickly, we want to know this before we end up with any heterogenic harm, because we might well need to tailor things down.

We might have a patient who actually. Yes, a septic. They need fluids, but actually they've also got an endocarditis, can they cope with that fluid load?

And picking it up early gives us a hint that we've actually got a multi-factorial problem here. Progression again. Things like Addison's or ethylene glycol, Addison's can start with.

A very vague history and a bit of vomiting, but progressed to be very serious. Ethylene glycol could start with the slightly vague lethargic. Woolly cat.

But obviously it progresses horribly in a short space of time. And the trends are very useful in prognosis for us sometimes as well, in that we can actually see the change for that individual patient. So there was the Zaka at our study back in 2010 and it was.

It was absolutely great and I remember it coming out and looking at it and it was the seeing that it wasn't just what the lactate was when the GDV came in. Oh, he's got a lactate of 12, that'll be worse than a lactate of 6. It was looking at it actually being.

The changes in the plasma concentration of the lactate as to how it changed during surgery. Did we end up with a patient that improved? And it was a case of actually, if you, the lactate is coming down, that's a better response than if the lactate was lower to start with, but now isn't shifting in response to your stabilisation and your fluid biolysis.

So it can be really helpful for us on that. And finally, the last point. We want to identify the impact common factors can have on results.

So these should be corrected alongside your diagnostic tests as you're processing it as you're working through it. So, this was a dog that was very, very collapsed, didn't want to move and was absolutely stank to the high heavens of cannabis. It was utterly gross.

He was absolutely stoned, bless him. And he didn't want to walk. But it was a case of actually, when we'd looked over the rest of him.

Then we found that he, in this case, he wasn't showing much pain response, but he wasn't able to walk because he actually had quite a significant injury that you can see in the picture there on one of his legs. And it was a case of when he was just lying down stoned, primarily, he looked like a cannabis toxicity, but we also had this going on as well. So, for the symptoms, we don't want to have a symptom.

Impacted like mobility. Pain can also have an impact on mentation, can also have an impact on obviously the patient welfare, things like heart rate as well, I don't want to be bolusing a patient, trying to get the heart rate down and risk overload because actually the heart rate is up primarily for pain or stress. My diagnosis can be influenced trying to do a clinical exam in a painful patient, they may not show us the same responses.

With ultrasound, they can often board the probe so that you don't get such a good contact when you're trying to take an abdominal ultrasound. Team safety obviously is a big one, we don't want anybody getting bitten in these situations. The patient welfare is, is massive, both in terms of their response to how they then respond to that treatment.

Things like toileting, things like mobility, things like ileus, can all be impacted by how comfortable they are, by whether they've got normal glucose, normal temperature, and especially as we're often working with prey species and frightened patients, then actually they may not always show us this. So we're often looking at Having to actively think, is this a problem? Is this something we're going with, what can we do with it?

And looking at it from that aspect of, OK, we, we want to find these things. We want to consider them. We're not just going to rely that the patient will tell us, because in a lot of cases, that's not the setup.

And we don't want to end up in a situation where we've had something potentially reversible, and we've missed it. Yeah, the classic one is. Little collapsed kitten, where actually he looks comatose.

There actually is hypoglycemia, and if we don't check for that. Then actually we're not going to get him round and he's not gonna come round and he will continue to look awful, whereas actually. A bit of glucose and he may well improve rapidly from that.

So, in conclusion. We want to understand that ECC patients are often not suitable for the standard diagnostic paths. We need to consider the pros and cons of each approach that we're going to do and what its benefits going to be for us.

And what the potential risks are. And that's where the minimally invasive diagnostics are likely to give us maximum information. Relative to the minimum risk, and that's what we want.

We want to first do no harm, and we also want to move forward in our understanding of the case. We want to recognise the importance of repeat assessments. Once you've got a set of information, because these guys can change quickly, we want to be doing it.

Again, and seeing what it's doing now, and test it again and see what it's doing now. And things like serial trends for lactate to see how your perfusion is improving as you're resuscitating them with the fluids is great. And we want to identify the impact common factors such as pain, low blood pressure can have on results.

And what those can mean for us in terms of our assessments if the patient's got poor mentation doesn't appear to be. Responsive and why we need to correct those alongside any diagnostic test. So in conclusion, in a time dependent high pressure setting, which ECC is, I think these aspects are really too important to miss.

And so I've found in the time in the emergency clinics that actually if I prioritise these. Then actually the next steps of a sensible approach will often suggest themselves because it'll give you the information and it'll give you the information in a way that you're also benefiting the patient and stabilising them. So I actually take it tonne cat with effusion.

If I'm trying to X-ray him, I might destabilise him. I might end up with less time, less answers. Non-diagnostic X-rays and a patient diving off the table in worse dysm than he started.

I might end up with a sedation or general anaesthetic that makes him sicker and leads me into a recess situation when I'd rather be stabilising him. We may well end up in a situation where actually for that dyspne cat, a quick ultrasound probe to just check, oh yes, there's fluid in there. Fracacentesis, we can actually get a sample of the fluid.

Great, I can crack on with looking at that a little bit more. I've taken off some of that fluids so that we've now got a patient who can breathe better, so he's more stable, I bought more time, and obviously that has benefits for all of us. And that's the key thing is that we're trying to buy ourselves with these cases.

One of the things we often don't have is time or information. But with these approaches, I think you'll actually buy yourself more time, give yourself more information at the point you need it most. So for the final aspect going forwards in terms of what you can do with this.

Session to actually Develop your own clinical practise. I would say, if you again, just take a moment, pen, paper, tablet. And think about an ECC case you've seen.

Using the learning outcomes inserted here, assess your case. Is there an aspect you're proud of? Is there an aspect that you would try differently with the next?

And if you want to do something different. What would you need to achieve that for the next patient? Was it further training?

Is it a difference in any equipment that you would need for it? And then look at sort of going forwards. Is that something that you can access?

Is that something that you can use to improve your practise? So I've put in a couple of pictures along the bottom here of some of my reflections that the two cases on the right are ones that I'm massively proud of. The one in the far right is with one of my nurses, Helen, and this little dog was absolutely petrified in the hospital.

I'm really proud of the fact that while he had to stay in with us, he, he wasn't the bravest little guy. And he got an awful lot of TLC, an awful lot of time spent with him, and it was those soft factors that made the difference for his care. The next one along is the owl, where this one was a collapsed comatose owl from a head trauma found on the side of the road.

And it was the first IV I put in a bid. And he had some hypertonic, along with some other fluids to resuscitate him. I actually, he did amazingly well and went from comatose to sitting up clicking at us within the space of about 5 minutes, which was absolutely brilliant.

The chinchilla. A collapsed chinchilla was certainly an aspect that actually if I had one of those, I would, I would need a little bit of extra training, I would need to contact somebody else because I recognise that that is an area that my chinchilla skills could definitely do with some improvement. And the one over on the left was a splenic mass where the owners didn't actually want to go for x-rays.

They didn't see the benefit in taking X-rays before surgery to look for meds. A week later when the patient developed other symptoms and deteriorated. They went ahead with the X-rays and they weren't very happy that there were gross metastases that were visible.

At the time, I had offered the X-rays and they had declined them. But from my learnings and my reflection. In subsequent years, I don't think I'd have had the same problem.

If my communication skills at that stage had been at the level they are now, because it, it was a case that I got. I think I would be able to explain the merits of taking those X-rays. In a way that actually the client would probably have gone along with it, whereas at the time, I was a little bit more hesitant.

And my communication, it came across to them that actually this was something that was an, an extra procedure rather than a necessary, and it did impact on the case, on the outcome, and what they felt they would have done differently at that stage. So, I think it's really important to reflect, look at your practise and Make sure that we are doing everything we can for not only the patient outcome, but also our own clinical satisfaction and our client experience. And that takes me to the end of our session today.

Thank you very much for listening to it. I've had fun discussing it and I hope it's provided you some new thoughts and helpful recaps in a short, sweet fashion. Thank you very much.

Bye, guys.