Hello, I'm gonna talk to you about setting up your own dermatology clinic. So how do you start your dermatology clinic? The first thing you're gonna need to do is get some training.
And there's an awful lot out there. What I highly recommend is the veterinary nurse dermatology group. They've got a Facebook online that you can join, and it's really, really helpful.
People post pictures and say, what do you think this is? How can I treat this? What should I do?
So it's a community of veterinary dermatology nurses. It's really supportive. Really helpful.
If you go to their website, they can give you information like histories that you can take. They have an excellent history form that you can download, and you can even go and see a YouTube clip of how to take a dermatology history. So, absolutely, that would be your first step is join the VNDG.
You can contact companies and ask for resources, and then the companies selling dermatology products are very helpful. They're really happy to send you information about their products. Some of them will also send you free samples, they'll send you charts, they'll send you books, and they are very, very supportive.
A lot of them also have little training courses that you can do online at no cost. So that's another place to look. You can contact them online or you can call up your rep, probably post COVID, you would need to call up your rep and it's all there for you.
There are other courses. The one that I can recommend because it's based on the course that I did many years ago, is the BSAVA Merit Award in dermatology. It's an excellent course with really good resources.
Breaks things down, educates you step by step, and will, it is fantastic. But there are other courses that I can't comment on because I haven't done them, but the merit award is based on the diploma that I did about 20 years ago. So I know that was a good course.
I learned a lot. Another thing, another step, tell your vet you're interested or your vets. They will be thrilled that you're gonna help them out with dermatology cause dermatology takes so much time and vets in general practise seem to have no time whatsoever.
So tell them that you want to get involved. Some of them may be interested in dermatology themselves and they can help educate you, or maybe they want to learn with you. I'm very lucky at the moment that there's someone at our practise that has a derm certificate and we back ideas around and look at slides together, and it, it's fantastic.
But you might have someone doing a medical diploma at your practise, and there is a derm component in that, and they would be very happy to work with you as well. The next step is you got to find a room and a time slot. If you've already got nurse clinics set up in your practise, this is gonna be a lot easier.
If you haven't got nurse clinics set up in your practise, it's time to do that. You need to, you know, be used to your full extent. This is one thing that nurses can really, really give to a practise, so get those nurse clinics up and going.
The way that you can motivate your practise to get your nurse clinics going and your derma clinics going is do a business plan. I know this sounds a little bit daunting, but if you work out 30% of your cases that walk in the door are derm cases. If you see them before the vet for a 50 pound appointment for an hour, get all the information for the That do the tests, charge for the tests, sell the over the counter products and food, you're gonna bring a lot of money into the practise.
Say you did one a week, you're still gonna probably bring in 100 pounds a week into the practise and That's pretty good going for a nurse clinic. So go ahead and do a business plan and, and that should get them motivated to start, start supporting your dermatology clinic. You need to create your toolbox.
If you want, you can contact the VNDG that nursing dermatology group and buy a toolbox from them. They've got a brilliant one, or you can make your own. I'll go over that in more detail later.
You need to advertise, you know, online, in the waiting room. And a really important thing you can do is get the receptionists on board. They see everything.
They see it first. They're the ones who chat with the clients. If you get them on board, you're going to have tonnes of people coming into your clinic.
You might need to buy them a few biscuits, in some cases a bottle of wine, but if you get them on board, you will have major advertisements. Create information sheets. Now, this is one of the ways I started with, I also do clinics and physiotherapy.
So I started just handing out information dates for dogs with arthritis, or post orthopaedic surgery, and then they had my name and email, and they could contact me and I knew that I had an interest in this area and I could support them in that area. So creating information sheets can be a good way of subtly advertising. And again, vets are happy if you're handing out information about how to do air cleaning, how to bath a dog, side effects of perdicina and stuff like that.
You can even grab clients in the waiting room if you look on the appointment list and go, oh, that dog's coming in because it's been chewing on its feet. Could you go and just have a little chat with them and introduce yourself. You obviously, you're not gonna steal the vet's appointment, but just let them know you're there and, you know, if they want to have a little chat afterwards, you can be a support system to them.
Right, training. So I'm just gonna go into a little bit more detail here with that. That is the website for the veterinary nursing dermatology group.
Definitely check it out. Lots and lots of interesting material. Companies that sell skin products, I can't really say names, but you know what they are.
Just look at the skin products that are on your shelf or the next time we actually have a real life congress, you will see them. And you can get lots of information support there and training, courses, do your research and make sure it's what you need. So if you're Really happy with sampling and lab work.
Maybe you don't need a hands-on course. And maybe you need a more theoretical course. If you're happy learning the theory from a book, but want some hand holding with your sampling and your lab work, then go for that.
So definitely do your research. There are a lot of courses out there, again. I'm, I'm really happy to recommend the BSABA course.
I haven't done this merit award. I've done the merit Award in physiotherapy, and it was fantastic. I learned so much.
So definitely those are worth the while. They aren't free, but they are reasonably priced. Books, and here is the Amazon link, not that I'm trying to support Amazon, but it's an easy way to get books.
There's a link for my textbook on the bottom. I think that's, I should know, but I believe that was 2002. So obviously the one on top, the small animal dermatology, from 2019 is more up to date.
But mine's quite easy to understand and it's a bit humorous, so you might like mine better. So advertising in your practise, put A little poster up in reception. This is just an idea of one that I, I, put up there.
I put the chewing its feet all night cause a lot of people complain about that. They say, I can't sleep. I just hear that horrible all night long, and it is pretty hideous.
If you've ever had a dog that does that, it, it really does drive you crazy. So that is a good way to attract people. Put a cute picture on there.
Cute pictures are always good. That's Toby. He's one of my California patients, who, sends me lots of pictures and asks me lots of questions.
And, you know, say my appointments are every Wednesday afternoon. Don't put the price on your poster, let them ask about that later. Definitely use social media.
I mean, everybody's on social media, God help us. Your practise website, you could put a little advert on there. You can actually write a little article about Basic dermatology problems like I used to write like an article about fleas, and then you can do a little article about allergies, that sort of thing, and that's a really good place to advertise and your name's there and at the bottom, come see so and so for dermatology clinics on Wednesdays.
That's great. Practise Facebook, before and after pictures are fantastic, to put on there, or just, you know, this little doggie came in today, isn't he cute? This cat came in and, you know, we're working on this condition here.
And, and I know she's gonna get better, that sort of thing. Instagram, obviously, if your local community has a Facebook, I, I know ours does, you have to ask if it's OK to post something, but, they might be happy to do it. Community, little news.
Books that they have around, you know, the free ones that come through your door. A lot of them will let you write a little article for them. I've done that.
And again, get your receptionists on board. They know what's going on in the practise. They know who's been back 10 times for a skin problem and is starting to call up and complain, and they would say, maybe you need to work with this client.
So definitely, you know, be friends with your receptionist. You should be friends with them anyway. Information sheets, good way to to support your clients, to make sure the animals getting proper care and support the vet and get your name out there.
So, I really like, Praddicinolone is a really useful drug, and we do need to use it from time to time, but it does have side effects. There is a BSABA handout that we are supposed to give out with all drugs, and definitely give that out. But it is quite wordy, and I think some People don't like reading that much.
So I've also made this little simple handout and it has a cute pictures with the BSA VA one doesn't have, so my handout is more interesting. You need to let people know that, Pred is going to make your, your pet drink more, and it's therefore going to. Pee more.
And some people, I mean, dogs get punished for this because they couldn't make it through the night. That's not fair. The drug made them do it.
So let people know it's not the dog's fault. He is gonna need to go out in the middle of the night. I'm really sorry.
I know it's a pain. But you might have to get out and let your dog out. It's only while he's on this particular dose and then we'll tighter it down and get you on a dose where you can make it through the night.
But we need to get your dog as comfortable as possible and not causing self trauma. So, You know, just be aware that there's gonna be more drinking, more urinating. It's the drug's fault, not the dog's.
And also they needing to eat more. I did not feed my dog M&Ms, by the way, that's just a photo, but dogs might start tipping the bin over, they might scavenge, they need to be aware of that. And if they're on a weight loss programme at the same time, you're gonna have to say they will beg more, but just be strong, play with them, groom them, whatever.
Same with cats, give them loads of attention, but don't give them food. Again, it's the drugs talking. OK, your toolbox.
So this is an example of a few of the simple things that you can have in your toolbox. It's not, the exhaustive photo, but it's some of the things. You need clear sellotape.
Clearer the better. If it's that yellowy stuff, you're not gonna be able to see your parasites very well. So make sure you get the clearest you can find.
There used to be a brand out there that all the dermatologists, bought, but you can't get a hold of it anymore, so you're gonna have to shop around and find the best kind. So definitely get your cello tape in there. Scissors for clipping away, a little bit of fur, so you have the fur for the sample or just so you can get to the lesion.
Artery forceps. Some people like tweezers, but I don't cause they have sharppi points and if I'm plucking around the eyes, I don't like sharp points. I'm much happier with artery forceps.
You can, you don't need brand new fancy ones. You can use some that have been tossed out of your surgical kits. They'll still do hair plugs.
Cotton buds, slides, lots and lots and lots of slides, and make sure you're checking your toolbox on a regular basis to make sure that your supplies are up to date because the slides tend to disappear really quickly. Cover slips, slide holders, so that when you're transferring from the exam room to the lab, you're not trying to carry around slides on your hands. They're in your holders a little bit safer.
Number 10 blades, number 10 is the best for skin scrapes. You can reuse the blade. It, it doesn't have to be super sharp for doing skin scrapes.
In fact, it's better if it's a little bit dull, but obviously clean it between patients. Liquid paraffin or a safe oil derivative. I know liquid paraffin is a bit difficult to get hold of, as long as it's an oil that you can use on your slides.
If you're gonna put it on the patient, make sure that it, it's safe to put on animal skin. Magnifying glass, some people like these, some people don't bother, but if you've got a parasite, a surface mite that, is supposedly visible with the naked eye. I wouldn't know.
I have really bad eyes, but apparently Kylo Tella and harvest mites are visible with the naked eye. You might want to look at them under a magnifying glass and a chi marker or I've used a Sharpie here. Sharpies tend to, if you get some Of the fixative stain on it, they tend to run into your slides, so they're not great.
A China marker is better if you can get a hold of one. The reason you need one is you've got to label your slides because you need to know this came from the leg, this came from the foot, this came from the ear. It's really, really important to know where the sample came from.
OK, your history. So, again, the link for the veterinary nurse dermatology group, they have a dermatology questionnaire that you can download for free. It is very good.
We use it in our practise, our certificate, dermatology certificate vet uses it, so it is a very decent, Piece of work and there is also the questionnaire walkthrough on YouTube that is really worth walking really worth walking through, really worth watching if you haven't done a history before. So your medical exam would be your first step. Just being aware that skin problems can be caused by autoimmune disease or endocrine disease.
So you need to know, is there an underlying medical reason that this animal has skin problems. Eye disease that can be secondary to scratching or it can be related to allergies. So maybe the animal's been seen for an ulcer and you realise, well, it's because it's got lesions around the eyes and it's been rubbing and scratching, and that's why it now has an eye ulcer.
GI abnormalities can indicate an adverse food reaction, poor husbandry. Maybe the animal just really needs to be demotted and bathed, or is on a really unhealthy diet. These are things that you can, I mean, you gotta be careful and diplomatic, but getting this information out to the owner, like, you might notice that the cat is very, very matted and go, oh, is it, does he let you groom him?
OK, so he doesn't let you groom him. Maybe we can clip some of these mats off, that sort of thing. Body condition score is really important.
Fat animals can't groom, particularly we see the problem with fat cats because cats need to groom very, very often, and if they get fat, they can't. Also, you're seeing skinfold dermatitis on overweight animals. Another thing that I haven't actually listed here that's quite important is arthritis.
Arthritic animals can't groom. And you will see that a lot in older cats, them getting quite matted around the back because they're, they've got arthritis in their spine and they can't get around and groom there. So you need to be aware, well, maybe we need to do some treatment for the arthritis as well.
The neuter status can affect skin condition, because, you know, those hormones, hormones are all out of control and weird. And any medications that the animal is on that's not particularly for skin disease, that would give you an indication of something else going on. Now you get to your dermatological history.
So why is the person there? Is the dog chewing on its feet? Does the cat have alopecia on its abdomen?
Is there a recurring ear infection? What is a presenting complaint? Your next question.
Are any other pets in the household or people affected? This is gonna give you loads of clues. So if they are, you're thinking parasites, fungals, something infectious, could even be Lamaniasis.
Hopefully it's not that infectious, but there are a few studies saying maybe it can be shared between dogs. I don't know, but that's something just to keep in the back of your mind. So definitely that's gonna be a great big clue for you if pets and other people are affected.
How old was the problem with the pet? How old was the pet when the problem started? Allergies manifest in young animals.
If this problem just started when the dog was 6 or 7 or the cat was 12, it's not an allergy, unless it was a very mild allergy that's become progressive over time. But generally speaking, allergies are going to occur between 1 and 3 years. If the problem started later, it could be infectious, it could be endocrine or some other underlying medical condition.
What did the skin condition look like at the beginning? Maybe it was just red at the beginning, but now you've got crusts and pustules because the animal has been ripping at it for a while. Maybe it's all dark and full of blackheads and You know, really thick skin, but at the beginning it was just a little bit of redness and a little bit of hair loss.
So this is gonna tell you about how the condition has progressed. Demodex is a great one. Started out with a little bit of hair loss around the eyes, and now the dog has no hair on its legs and abdomen and is bright red.
That's, you know, a big indication of what has happened and what kind of condition it can be. Where on the body did it start? Skin conditions like certain places, like flea allergy dermatitis really likes the dorsum base of the tail.
You often see it starting there. Adipe, feet, armpits, ventrum, those sorts of places, ear, food adverse reactions, face and ears. These are, it's not always that way because our pets don't read the textbooks, but those can be really big clues.
Has the skin problem become progressively worse? That could indicate an allergy or it could indicate the fact that the animal's immune system is not fighting off the parasites, in which case, Maybe we got to look at some sort of autoimmune problem. You'll find with adult onset demodex, it is something to do with the immune system.
Demodex and puppies is they grow grow out of it. Demodex is a commensal that just lives there, and puppies don't have a strong immune system, so you might see some demodiosis and they grow out of it. If you get demodiosis in an adult dog, there's something else going on.
So you need to know about that. Was the pet itchy at the beginning of the problem? Some problems, we think of all skin problems being pruritic, causing itchiness, but some aren't.
Ringworm is not itchy. It becomes pruritic if the lesion as the skin gets more deformed, and lesions develop, they can develop pruritus, but initially, it's not itchy. Pruritus is always prevalent in allergies.
It's always, it's itchy at the beginning, if it's an allergy, definitely. And on a scale of 1 to 5, how itchy is the pet? If it's a 5, it's sarcoptes.
If it's a 1, maybe it's ringworm. So this is something you need to know. More on skin history.
Does the skin condition get worse at certain times of the year? I need people to be really aware of that atopic disease has seasonal flares. They might be going along fine in the winter and then get really bad in the spring when the pollens come out.
They might be OK in the spring and summer and get really bad in the winter because they're in. Yours more and their problem is a dust mite allergy. So letting you know that it gets worse at certain times of the year would be indicative of an allergy, but you can't absolutely say for sure.
But again, more clues for your detective case. Has there been any hair loss? If so, where is the hair loss?
Again, sites in the body are gonna help you look towards certain diagnoses. What treatments have been used so far, and have any of them helped and be very open and non-judgmental and let them talk about using cod liver oil or evening primer oil or homoeopathy, because you need to know everything that's going into that animal. Who knows, they might be having an an allergic reaction to them, or, it might really be helping.
So be really aware of everything that's been used both. As a prescription medication and an over the counter treatment. What antiparasitic is used and how often?
So are they buying it from a vet? Are they using it every month? Are they using it correctly?
There are people. I have seen people use a spot on and just do two drops out of the tube, and it's like, no, you have to empty the whole tube. And they thought, oh well, I thought I needed to save some for the next month.
You're like, no, you use a whole new tube for the next month, or people using the sprays, the fipronil sprays, and they do 2 or 3 squirts, and it's like, no, it's 4 to 6 squirts per kilogramme, so you're gonna have to at least do 20 squirts on your cat. So, or maybe they can't do it, maybe they can't hold the animal still, maybe they can't hold part the animal's hair. Maybe they've got really severe arthritis and can't squeeze the, the spot on tubes.
Got to know that stuff. Is a home treated with a premise spray. I think everybody should do this.
I know it's horrible chemicals and it's bad for the environment and everything, but if you've got a parasite problem, you got to treat your house. It's not going to go away, otherwise. Remember, fleas only jump on for a meal and they spend the whole rest of their life wandering around in your carpet laying eggs.
So if you're not treating your house, you're not getting rid of the parasites. And that also goes for Kayla Tella and a few other parasites. Are any of these conditions present, and this is just you examining the skin.
Is it greasy? Is there scarf slash standard of erythema, redness? Hyperpigmentation is darkened skin.
Like he skin is really thick, leathery skin, papules are just like pimples, pustules or whiteheads. Epidermal colorettes, I love that word, are ruptured pustules, so it's a little ring of dry skin that you see in a circle. Some people think it's ring ringworm, it's just a ruptured pustule.
Alopecia is hair loss or obvious parasites. So go around and circle all of that that you see. This is a lesion map, really helpful.
It should be part of your dermatology history, and you can just circle the places where you see, lesions. I find it's a lot easier to work with a map than writing down, saw a lesion on the dorsal spine, just easier to circle and also you can say, you know, you can do a big circle or a little circle depending on how much of the area is affected. .
These are available from some skin companies. You can download them from the internet. If you buy a dermatology book, they're in every dermatology book and you can just take a picture of them.
I know that's well it actually that would be violating copyright, so don't take a picture of them. You can copy them, hand copy them yourself and make your own little designs. Hopefully you're a lot better at art than I am.
OK, gathering evidence. So once you have a history, you need to take your samples. This is a, coat brushing sample or the old wet paper towel test.
We don't do this that often anymore because fleas aren't as big a problem, but we used to have to do this all the time to prove to people that their pets had fleas. It's just a wet paper towel and you rub the coat and all the flea dirt drops into the paper towel, and then you see blood spreading over the paper towel and say, yeah, your dog has flea dirt, so it has fleas or your cat, it's usually their cat. They say, my cat doesn't have fleas because cats groom off the fleas and you never do see them, but you get all the flea dirt.
So, your dermatological testing is not invasive. You are not entering a body cavity. A nurse can do every dermatology test.
You are even legally allowed to do a biopsy because it's not entering a body cavity. Obviously, that has to be under the direction of a veterinary surgeon, generally because of anaesthesia, but, you are able to do all dermatological tests and you have learned how to do them when you were. A veterinary student nurse.
OK. And your samples need to be analysed. So you're gonna go into the lab and you're gonna look at your skin slides for your parasites, your yeast, your bacteria, and you're gonna look at tra trachography, which is I think spelled wrong on that slide, sorry.
Is looking at hair, just little bits of hair, I can tell you a lot. And you've learned how to pair these slides when you're a student nurse. You might need some revision on that, but you know how to do it.
So go ahead and do it. You can think about parasites. It's generally gonna be your scrapes, your plucks, your coat brushings.
Dropped onto a slide with a drop of oil, cover it with a With the cover slip and then pop them under the microscope on 4 or 10. I prefer times 10, just because I like to see detail, but a lot of people are happier under times 4, so easy, easy. Tape strips, again, just press your tape all over the, lesion.
And then just press it down your tape onto the slide, pop it under times 4 times 10, you can see your klatella, your harvest mite, any of your sur surface mites, you can catch that way. Tape strips are also good for identifying yeast and bacteria, but in those cases you would need to stain the slide or stain the, the tape and then press it down onto the slide and examine it under 100. Trichography is generally just gonna be hair plucks, but you can also do it with coat brushes.
You're looking at whether the hair is, what stages it's in. So you've got, antigen, catagegentiagen. If you've got loads of tielagen hair, it's old hair, and if you've got loads of old hair, you're thinking this dog's not growing new hair, there's something wrong.
So there is generally something wrong with the thyroid system if it's not growing new hair, so you're gonna look for hyperthyroidism. If you're seeing a lot of fractured split hairs that can tell you the animal's chewing a lot, because quite often owners would say, no, I don't never see them chewing, but they're doing it secretly at night, especially cats. They like to secretly chew at night, and you look at their hair under the microscope and go, yeah, he's chewing, he's chewing a lot because all these hairs are damaged.
Another thing looking at trachography is looking for follicular debris, which is just Loads of gunk around the hair shaft, and that can tell you, it, it's sometimes very strongly indicative of, of demodex mites, because they are down in the follicles, so they're chewing away deep in the follicles and then kicking out garbage through the hair follicle, and it, it collects around the hair shaft. So if you if you, if you haven't quite caught the Damodex mites, but clinically, it looks like Damodex and You've got lots and lots and lots of follicular debris, you might be motivated then to do a biopsy or maybe treat for Demodex, depending on the vet's advice, of course. But follicular debris can be strongly indicative of Demodex or a bad separa, other conditions, but it's not normal.
There shouldn't be a load of garbage wrapped around the hair shaft. So that tells you a lot. Just looking at hair, really easy.
Try it with your own, might scare you, though. . So, moving right along, choose your products.
I've put this old lady's hands here. They look a lot like mine, I'm afraid. As we get older, we get arthritis and our, wrists and, thumb joints start to swell, and it's really, really hard to get the top off things, really hard.
No point in giving people treatment, they can't even open up. Or press down on the spray. Some of the foams you have to press really hard.
And these child safe caps, I know they're legally required, but if you've dispensed something and the owner can't get it open. Kind of banging your head against the wall there. So you need to work with your client and say, OK, I'm gonna to dispense this.
Are you happy with this container? They say, no, please put it in an envelope. You have to say, can you make absolutely sure it's going to stay away from a child, you know, if it's an 80 year old lady living by herself, she can probably do that.
So, Definitely, definitely work with your client. Some people can't give their dog a bath. They can't lift it into the bathtub.
They don't have a bathtub. The dog goes bananas and bites them when they're trying to bathe it. A lot of people can't give the cat a bath.
A lot of vets and nurses can't give a cat a bath. So Maybe that's not the best product. You go away from the shampoo.
So think about, is a wipe gonna work better in this? Maybe shampoo is the very best gold standard for that case, but if nobody's going to do it, it's useless. So you've got to adapt to the client and to the pet.
So maybe a mousse or foam would work better, or even just a wipe. Certainly, if you've got lesions around the face, you gotta look at using wipes because that's gonna be the easiest, the less frightening to the animal, and you're not gonna be getting product in the eyes. Ointments can be really good, but not if the dog or cat licks them off.
If you want to use an ointment, you might need to also employ a buster collar. Is that gonna make the animal very unhappy? Is that gonna make the owner very unhappy?
Putting a buster collar on a Labrador, you have to just clear your house of everything, basically, all the furniture. Everything, because they're going to just walk around and bulldoze things and knock everything over. So you got to really think about that, because if I've done it myself, I've had Buster colours on my dog and gone, Oh God, I can't deal with this.
And I've taken it off. That's horrible. I mean, we yell at clients for doing it, but I'm You know, an educated veterinary nurse, I know how bad it is to take the buster collar off and I have done it.
So be aware that if you're setting up a situation where the client can't comply, the pet will not get the treatment. Other products like supplements, some of these can be really, really helpful. We are looking at essential fatty acids.
They can reduce inflammation, and they can help with, just building up stronger skin, making the adhesion between the skin cells a bit stronger. Can the dog tolerate them? If it's got a history of pancreatitis, do you want to think about, is it safe to give it essential fatty acids?
It might be on a low dose, but that's something you want to chat about with the vet. Or the owner might just say, no, no, I'm so scared of it getting pancreatitis again. I'm, I, I just can't do it.
OK, then don't. And then the medications. A lot of people are afraid of pre, you talk them through the pros and cons, explain to them why it needs to be given, how you're going to lower the dose later, hopefully eliminate the need for it later, that sort of thing.
It's a lot easier to give it to cats. A lot of people are afraid, but cats tend to have less of side effects with pred. So talk through your meds, make sure the owner's happy with it.
Some people like to come in once a month for the injections, some people don't. They prefer giving tablets, some people can't give tablets, a lot of people can't give tablets to cats. So what are you gonna do about that?
Can you find a liquid form? Can you crush the tablet and mix it with water and syringe it down? Do you need to find a completely different alternative?
So don't just hand things out, make sure it is a give and take discussion with the client and with the pet. Teach your clients. Demonstrate how to clean an ear.
Cleaning an ear is not easy. Especially if the animal's afraid of having its ears touched. If it's not on a special diet, use treats.
Use cheese. I like that cheese in the tube that you can squeeze out a little bit at the time cause the animal's licking it and licking is a self, calming measure in dogs, so they can be lick, lick, lick, you know, going away at the cheese while someone else is cleaning the air. So you gotta say, is there someone else that can help you.
Flood the ear, loads and loads and loads of cleaner, rub for a really long time, wipe out with cotton wool. Don't let the owner ever, ever use cotton buds. Make sure they know that.
Never stick anything in the ear, smaller than your elbow, is that the rule? Yeah. So go ahead and really show them, make them.
You back. Because people, yeah, yeah, yeah, I know what to do. Make them show you back.
Just like when you're teaching student nurses, demonstrate the skill, have the skill demonstrated back. Do it with clients. You don't need to be condescending about it.
You need to say, OK, your turn, you have to go, that sort of thing. They've got to show you back to make sure that they really got it on board. And if they can't do it, then you know, OK, they can't do this.
I'm gonna have to do a mobile nurse clinic and go around, or they're gonna have to come in more often and get the air cleaned. I mean, I, I have had clients come in every other day for air cleaning. If that's what needs to be done, that's what needs to be done.
It's better than getting a tikka later on down the line. Always give a step by step leaflet. I've said here on bathing.
You can give a step by step leaflet on anything on bathing, on ear cleaning, on giving tablets, on how to apply spot-ons. If it's going to help, do it, use pictures, bullet points, use as little verbiage as possible. A lot of people don't like reading.
I love reading, so I don't understand why people don't like it. A lot of people hate reading. There may even be clients have trouble reading.
When I did work at a certain clinic, I had several clients go, Don't bother giving me that, honey, I can't read a word of it. So, make sure you have pictures that illustrate. There's also people with language problems, you know, maybe they don't speak English that well.
So have illustrative pictures. You can use your own animals, just be nice to them. And definitely give tips on travelling cats, definitely.
I know there's some YouTube clips on it, so you can always direct people to that. People love YouTube, but you can do step by step pictures yourself. Follow up.
Go to follow up. You gotta make sure that your treatment programme is actually working. If it's not, you gotta make changes.
You might need to increase doses, you might need to You know, double check your diagnosis. Maybe it was wrong. Maybe you and the vet need to have another little chat and think about what's going on.
So you follow up, look at the condition of the coat and skin. If you're smart, you would have taken pictures the first time and then you can compare. Just keep them on your computer at work or, you know, on your phone, whatever works for you, and then you can compare, oh, that lesion is getting smaller.
It's not quite as red as it was, or, oh, this looks worse. What are we doing now? Note down your lesions in your location.
Again, you're using your lesion ma map, so, you know, write those down. You know, are there less lesions? OK, this time, I've only got 3 lesions.
Last time I had 8. OK, we're getting there. .
Your level of progress. Have has the patient regressed? Could be having a flare.
Oh, it's that time of year. If things stayed the same, well, that's not good enough. I want it to get better, or have they improved.
You also have to be aware that If you're treating skin problems, they're never gonna 100% go away unless it's something like a parasite infestation that you can eliminate. But something like an allergy, it's never gonna 100% go away. There is still gonna be some scratching and chewing and That's gonna have to be acceptable on some level, but you don't want it to be to the point where it affects the animal's quality of life.
Do you need to do more investigations? OK. Well, quite often for mites, you're gonna scrape again just to make sure that you're mite free.
That that's just standard protocol. You're gonna keep scraping until you don't find any mites. .
For allergies maybe. OK. It was doing fine, but now it's got a little bit better.
I'm gonna do a tape strip. Ah, OK, we've got a little yeast infestation going on here. Let's do some wipes or moose that are gonna eliminate these yeast.
They hadn't been there before, but they're there now, so let's sort them out. Revise your treatment plan. And give your advice to the owner and make another appointment.
Especially with chronic conditions like allergy, you're gonna need to keep following up. If they're coming in for their monthly injections, that's great, you're doing it then. Otherwise, maybe every 6 weeks, maybe every 2 months.
If you're doing nurse appointments, they're gonna be less expensive than the back appointments, so you can have the people coming back a little bit more often. If they're coming back more often, it's gonna still add up to what a vet appointment was. So maybe they see you every month for 15 minutes, you're charging £15 and they see the vet every 6 months.
You'll have gained enough revenue to make, say it's, it's worthwhile to keep seeing you, to take the time out of the practise schedule. So it, it's gonna be in the animal's best interests, it's gonna help with client compliance, and it will be supportive of the vet if you're seeing them on a regular basis. Make sure you charge You are not free.
You are a good trained nurse. You know what you're doing, you've done your extra studying, you're qualified charge. If your initial appointment is an hour long, charge a lot.
What would be, I mean, some nurse clinics, I say the average between 12 and 15 pounds. So if you're doing an hour, that's for nurse appointments, 60 pounds. Your follow-up appointments, depends on how long they need to be.
Maybe your initial one is gonna be 30 minutes, so charge £30 and then follow up after that. Telephone support, you have to decide if you're going to charge for that or not. I think it depends.
If they're sending you photos and you're having a long discussion, charge the same as you would for a nurse appointment. If it's just, hi, how's it going, you're sticking to the diet, great, fantastic. You're not gonna charge for that.
You need to charge for your diagnostic tests. These take time, not a lot of time, but they still take time, and you're also using your expertise. They're paying for your expertise.
You know how to take the samples, you know how to look at them. You know, someone off the street cannot look at cytology. So you are trained, they're paying for your training and your experience.
So definitely they should be charged for these, scrapes, tape strips, hair plucks, coat brushings, even all of that, they should be charged for. I don't know, each clinic might charge a different amount depending on the test. That's up to your clinic, but definitely should be charging and serology, if you're taking blood and sending it off, there is a charge for that.
Your charges for all of your products if it's going on a food trial. You're gonna bring revenue with selling the hypoallergenic food. If it maybe needs to be on a dermatology support diet, it doesn't need to be on a food trial, but just a diet maybe with added essential fatty acids or something.
You're gonna make revenue selling that, your shampoos, mousse, wipes, supplements, parasite treatment, all of that is revenue coming into the practise. It's money you're earning for the practise. It, and it's making it more worthwhile to support your role as a dermatology nurse.
