Hello, everybody. My name is Hayley Walters, and I am a British registered veterinary nurse. I qualified back in 1999.

I spent, many happy years in mixed veterinary practise in Buxton in Derbyshire, before moving to China to work with bears rescued from. The bile farming industry, working with those bears and rehabilitating them into semi-natural enclosures. I then did a bit of teaching in Paris, teaching of English, and then I worked for the University of Edinburgh.

For the Jean Marchique International centre for Animal Welfare Education, where I still work for them remotely. And this involved travelling and teaching in low to middle income countries in vet schools. So working with the lecturers and, and the vet students in those vet schools.

And I worked in, in many different countries there and saw many different practises and, and teaching techniques. I've also worked in first opinion and also in referral, so I have, hopefully a wide range of experiences, that help me to, be a better veterinary nurse, and, will hopefully give me some information that I can share with you today if any of you are thinking about working overseas in low to middle income countries. Your learning objectives of today, for today are to understand what the ethical and animal welfare challenges are when working within the veterinary profession in low to middle income countries.

So we used to call . Not so long ago, we called low to middle income countries developing countries, and prior to that we would call them third world countries, but now it is, it is more correct to say low or middle income country. Your other learning objective will be to be knowledgeable as to why these challenges exist in these countries and to identify what you can practically do to improve animal welfare whilst working in these countries.

So I'd just like to give a warning before I start this, this, presentation. Some of the images that you are going to see will be upsetting. I would like you to know that I did take all the photos opportunistically, nothing was staged and where possible, I did help the animal as much as I could after I'd taken the photo or taken the little video.

So please be aware, this, this lecture can be a bit heavy going and some of the pictures will certainly be upsetting for some people. OK, so working in low middle income countries can be extremely rewarding. And, it can be life changing.

It certainly was for me when I first took, took my first trip to China. This is a bear that I worked with in China. Her name was Caesar.

She'd lived her whole life in, a cage, roughly the same size as her own body, wearing a full metal jacket and having her bile, consciously extracted from her, gallbladder every day to use in traditional medicine. And for me it was life changing and I, I really wanted to feel like I was making a difference in using my veterinary my veterinary nursing qualification to its full extent. So you do feel like you're doing something worthy with your qualification.

But the experience isn't always positive. I'm sure for any of you listening to this, if you have worked in low to middle low to middle income countries, you'll have seen things that. Really saddened you or that you felt actually quite comfortable with either seeing or being a part of.

And as with any clinic in any country, there will be challenges, and those challenges will be based on that organisation's geographical location. Their culture, the resources that they have available, and the knowledge of animal welfare. So working in low income countries can be a life changing experience, but it is also very possible to feel compassion fatigue.

I suffered from it, or frustration that you're not making a difference whilst you were there. This was a little bear that, came from a bile farm and just arrived with us too late. He was so broken, .

And this bear was actually euthanized, and that's really depressing cos this little bear had come so close to being saved and living in an amazing sanctuary, but we just got him too late. So challenges are aplenty sometimes. OK, this lecture is a general overview of the most common challenges seen and why they occur when you're working in different low to middle income countries.

It's not an exhaustive list, and it does not apply to every single practise or project. Each country, in each country, there will be practises and projects that are extremely well funded and are doing a really great job, but there will be others that have very limited funding and staffing and resources. So I, I would like everyone to be aware that this is not a presentation, based on attacking low to middle income countries, and sweeping negative, racist comments about other countries are really unfair, extremely unprofessional, and really unhelpful when you're thinking about working in those countries or actually working in those countries.

So please be aware this is a general overview of the most common challenges seen. And it really is not specific to any country or practise or charity. So as I said, this is, there are issues in every country and the UK is no exception at all.

But one of the biggest issues that you can, and challenges that you might find when working in low to middle income countries is the veterinary surgeons, may be lacking in many skills, so practical skills, may not be what we're used to dealing with. The surgical technique. Might be different.

It might be a bit rough and ready in some places, or, or not as skilled as, other vets that we've worked with. Anaesthesia, the knowledge and in anaesthesia, might be, might be very different to ours. I've certainly seen cases of poorly anaesthetized animals or animals anaesthetized only, with ketamine, which is obviously not ideal.

Aseptic technique, this, this picture is a great example of a lack of aseptic technique, . Might be, that knowledge might be impaired. Pain recognition, actually detecting, spotting when an animal is in pain and then knowing how to treat that pain, is, often a problem.

The handling of animals, for many, many reasons might be very different to what we're used to experiencing. And then performing euthanasia on the sickest and most broken of animals might be something that the vets aren't trained in or even have the, accessibility to, to the drugs that need to be used. So the vets may be lacking in these skills, not all are.

Some, some vets are extremely skilled, but as I say, this is a very general overview of what you may see, and as I also said, every country has its issue and the UK is no exception. Right. Why do veterinary surgeon related issues occur?

Well, it's really interesting when you start to to dig down as to as to why these problems exist. And education and training techniques differ in different countries, so many vet schools will still use live animals. These pictures are of of live animals that are being used to teach students.

Now many of the students are opposed to using the live animals, but they are offered, no alternative. Two live animals. So in order to qualify they have to perform.

Really harmful and unnecessary procedures on live animals and the and the animals that are used are dogs, rabbits, chickens, water buffalo, goats, and in one vet school I I went to, we were taught, And that the students, around 6 to 10 students would share one dog over a period of several months. And at fortnightly intervals, the dog would be sedated with xylazine and receive a vocal cordectomy. And then 2 weeks later, a lateral wall resection, and 2 weeks after that entropy and surgery that was not needed.

Then gastrootomy, enterotomy, cystoomy, and before finally having its leg deliberately broken for fracture fixation practise. Obviously this is really hard for any person who loves animals to deal with, and, but also being trained in this way may limit future empathetic responses, and it creates a culture for some that some animals are worth more or less than others. And if you look at this photo.

You can see, . You can see that these empathetic responses might be, might be lessened as time goes on. These dogs and goats and water buffalo are used to purely teach surgery, and they're being kept in conditions that do not even begin to meet the welfare needs of a sentient being which suitable environment, suitable diet, exhibit normal behaviour patterns, be housed with or apart from other animals, be protected from pain, suffering, injury and disease.

None of these needs are being met, and this is how the veterinary surgeons of the future are being taught. Look at all those lab coats, those are the students, and this is, this is what they're being exposed to as normal or acceptable way to treat an animal. Cultural and religious influences will also affect how animals are treated.

Different species are treated. Various religions and cultural practises, will affect the attitudes like the attitudes towards different procedures like neutering or limb amputation and euthanasia, as I mentioned earlier. For example, in India, the cow is sacred and it's never eaten by Hindus.

Cow sanctuaries exist, and euthanasia of even very sick or disabled cows is rarely performed. And in other countries, eating dogs, but keeping goats as pets is not considered unusual, but that would be considered unusual in the UK. And for some, even pet ownership and therefore veterinary treatment available is still in its very early stages, that's due to a long history of pet ownership being considered bourgeois and not fitting the communist ideal.

The role of vet in society, the role of the vet in society differs from country to country, and in some countries, sadly, working with animals is seen as dirty work and a very lowly profession, and the veterinary surgeons often will not enjoy the same respect that a UK vet receives despite being excellent at their jobs as this vet is in this picture, working for a charity or an NGO, so non-government organisation. Doing trapne to return work of, of street dogs, this, this vet and all his colleagues and all his assistants were excellent at their work, but just not well respected in society. Assigned university courses, this is really interesting when you start to, to find out about this stuff.

In many countries, many of the students did not want to become vets. The course was assigned to them because they failed to get the grades needed to become a human doctor or a dentist, which are extremely well respected professions. Some of the students, don't like animals, and some are even scared of them.

And I remember once in a classroom of 90 final year veterinary students in India. I asked for a show of hands who actually wanted to study veterinary medicine, and you won't believe how many put their hands up. It was just 4 students.

It's a very different situation to the, to the UK degree. And some people even refer to the veterinary degree as the dropout degree, although I did meet one student in Sri Lanka who had failed her exams on purpose so that she couldn't study human medicine and had to study veterinary medicine instead. So a very brave girl there.

But I've also had students graduate from, from Edinburgh vet school, from the University of Edinburgh. And one of the most prestigious universities in the UK and then be asked when are you going to become a real doctor? So different attitudes vary from country to country, but we're not that different actually in the UK when you think about it.

And just as an aside, if this is the attitude towards veterinary surgeons, can you even begin to imagine what it's like for, for a veterinary nurse like myself in these countries? I've been classed as a failed vet so many times. OK, keeping on why veterinary surgery related issues occur, well, there's a lack of EMS or practical experience.

So our UK vet students have to complete hundreds of hours of EMS, which stands for Extramural studies. Mural is Latin for wall, so extra mural is just a posh way of saying outside the wall. And during EMS under supervision, these vet students gain a lot of practical experience in clinical and surgical skills.

But for a lot of students in low to middle income countries, being able to perform a necessary procedure on a genuine patient is completely forbidden. Some vet schools will provide models and mannequins for the students to practise on, which is extremely beneficial and gets them, used to handling instruments and that dexterity that they need and and where to position their hands when taking blood samples or placing IVs or or suturing or, or using a scalpel blade for the first time. But many other vet schools don't provide models and mannequins and live teaching animals are used and sometimes they're referred to as the experiment animals.

And usually these students are under a lot of pressure as they practise, as the other students are watching them. And I remember giving a lecture on clinical skills to a lecture theatre, must have been about 200 students in there. And we talked about using models and mannequins, and we displayed how to use them.

And er a female student came down at the end and she said that was really, really interesting. She said, I'm off to cut my first cow and suture it. This was the first time she was ever going to perform surgery, and the cow would be, it was a water buffalo, sorry, the cow, the water buffalo would be restrained.

It would have a local block, and then she would have to cut through the skin and then suture it with all of her class watching her and cow skin is tough. And she'd never even held the instruments before, and she was so worried about doing this, and this, but this was her only opportunity, and we said, would you like to practise? And she picked up the instruments and we showed her how to hold them.

We let her practise on our suture pads, and after 30 minutes, her, her skill had gone from rock bottom to, to much, much better. And she went off to cut her first cow, and I'd like to think that she and that water buffalo, had a better experience just for 30 minutes of practising on suture pads like our UK students have to. OK, here's a nice picture to look at for a second.

This is one of the bears that did make it, and lived a very long and happy and relaxed and enriched life in the sanctuary in China. So let's just, all focus on that picture, because now we are going to move on and look at other issues that may be encountered when working in low to middle income countries. We've looked thoroughly at why veterinary surgeons may be lacking in certain skills, but there are many other challenges that can be faced.

So, deep breath, we'll move on. Drug availability and costs in many countries, access to drugs that we have readily available to us in the UK are difficult to purchase, and they have to be imported, and whether that's imported legally or illegally, remains to be seen with each, with each different practise that you're in, but that is a real issue, just getting your hands on the drugs that that you know are going to work so well for those patients. So because of this need to import the drugs or the drugs being limited, it, these drugs can be extremely expensive for that country, and if that.

Practise that you're working for is an NGO, so non-government organisation or a charity, this can be very prohibitive for them to be able to use these drugs. Import licences have to be obtained to purchase many of the drugs and therefore, the clinics or the non-government organisations, the NGOs will have to have to have access to a supplier of those drugs. It's, it's just not nearly as easy as the UK.

Now government approved vets or veterinary establishments like vet schools. Have easier access to drugs than non-government approved practises such as NGOs, and I suspect most of you, if you're working overseas, you would be working for NGOs so would fall into the category of limited drug availability. Each country is different and it's beyond the scope of this lecture to look at each individual country, but please remember that every country has different rules regarding drugs that vets can and cannot obtain for use in veterinary medicine.

And the table I'm about to show you shows a general overview of anaesthetic and analgesic drug availability in several different low to middle income countries. So if we take a look. Excuse me, across the top here we have 4 of the countries that I've lived and worked in, and down the side we have the anaesthetic and sedative drugs that we're very used to or familiar.

With and enjoy using in the UK, perhaps not so not so much I I Xylazine or halothane anymore, however, these are all the drugs that I did some research on to find out if access to them was available or not. So, as I said, there'll be less problems with drug choice if you're working for a government organisation, but the majority of vets and nurses that work overseas are working in low to middle income countries tend to be based with NGOs, they have less drugs available to them. So as you can see, ketamine is usually readily available, but not available in China.

And Meatomidine, so our dormitor, is also very difficult to obtain. And you'll see on the next page that I'm about to show you that butorphannil, sotubbogesic, is also unavailable. So for a go to sedation like Dom Taub or mediomidine butauphinnil, you're actually quite stuck already.

And if any of you are really old school, like me, you will have used Xylazine, and it's a decent drug, to use in small animals, but we, we progressed to Medoomidine and Dexedatomidine, but look at that, it is available, so you could have a go at using that, . It may as well that you would have to use ketamine and diazepine as your anaesthetic. So interestingly, isofluorra is readily available, but I'll talk to you about the difficulties of using isoflurane in a moment.

This slide shows the same countries across the top again and the analgesic drug availability in those different countries. And as you can see, opioids are very difficult to come by. Morphine was available for that Indian NGO but I suspect it was referring to the availability for human use only, and the the vet school in Sri Lanka.

Was using tramadol and pet pethidine, but they are government approved establishments, so they will have greater access to those drugs, but I was an NGO that I surveyed and as you can see, they had no access to to pethidine, buprenorphine, burophenol, morphine, methadone. Fentanyl, ah, so, but meloxicam was available, so as you can see, very, very challenging if you're going to be working in those countries to provide good analgesia, let alone multimodal analgesia. Support staff.

So very often you'll find that there are no veterinary nurses, which leads to multiple challenges. The veterinary profession is evolving to include more small animal based training, as historically it has primarily focused on livestock, training the vets of the future to to treat livestock, and small animal training is, is catching up. So the booming pet population in many of these countries means that the education has had to evolve, but sadly, veterinary nursing is still a bit behind schedule in being recognised by some.

As a necessity for improving patient care. And this is also despite many people wanting to become a veterinary nurse. And when I'm talking about patient care, as I'm sure all of you will know, I'm talking about recognising and treating pain, feeding and walking these patients, turning the recumbent ones, medicating physio, just monitoring them, bandaging, taking them out to the toilet, intravenous fluid therapy, feeding.

The list is so long for what patient care involves, and in terms of what nurses do regarding hygiene, sterilising everything, and the cleanliness, that's all the job of the veterinary nurse. So in terms of veterinary time. They have nobody to delegate to, and this can lead to the vets obviously being very stressed.

If they want to specialise in any research, that can't be done. If they want to specialise, that's also challenged because there is nobody to delegate these, these tasks to, like bandaging or blood sampling, IVs or X-rays. Veterinary nurses are such an essential pair of hands.

Can you imagine your practise with no vet nurses working in it? Now, there is a profession called livestock inspectors. Excuse me, and they are trained to do some of the large animal work, but they've had a different, a difficult relationship with vets, as they often perform many of the roles only a vet should after only 11 to 12 months of training.

However, there is a huge shortage of vets, especially in India and Sri Lanka, so livestock inspectors are filling a gap. The veterinary nursing profession is now viewed with suspicion because of this, as there is a fear that vet nurses will behave in the same way that the livestock inspectors do. There are veterinary assistants in some countries, but they are trained to a lower level than vet nurses, and they won't have many of the clinical skills that vet nurses have, and their training is usually on the job with no classroom time.

I also met some veterinary assistants who were failed failed vets, vets who hadn't qualified, but were trying again to resit their exams. So their training was, was just not specific in nursing. Inpatient care, they might experience unsuitable areas or cages, if they're an inpatient, and there may be certainly cases of, of benign neglect.

Why does this happen? Well, there's often limited spaces in clinics. This picture on the left is actually a vet school, surgical recovery area on the left.

This is, it's a room, and the patients are tied to the table legs. So there's no kennels for these dogs, there's no cages. They regularly were getting twisted up in the table legs.

They're lying on cold hard concrete floors, often they can't reach the food bowl, . As you can see they're wearing buckets on their heads for Buster collars, and they're obviously licking their wounds because they're very painful cos analgesia is not available. So really, really not ideal situation.

This is, this is the surgical recovery area for these patients after having major surgery. So space can be very, very limited, and there's a lack of staff to look after these patients as well. Resources are often not available, like beds, for example, but then even if they were, were to have beds, there's no washing facilities available in in many places.

And then a lack of knowledge and a lack of time to individually care for each of these individual patients. So if you look at our dog on the right here, I placed that dog on on that drip, as you can see it's on a wire bottom cage. No comfort for that dog.

There's no, you know, food or water there, even if this dog could lift its head to eat or drink, it, it doesn't have the option to. And if you look closely to its leg that has the IV cannula in, you'll see a little blue and white capsule. And then just beside that, a yellow one.

This was the medication that someone had placed in the cage for the dog. They, they popped it in the dog's on the dog's lips and it just fallen through the bars of the cage. So even though it was being medicated, there was, it wasn't being.

Efficiently medicated. So, really, really tough situations. Euthanasia is often not performed in low to middle income countries, and this is very, very often due to religious reasons.

So cases that that really struggle to cope will not be euthanized, and vets are often criticised by the public if they do perform euthanasia because they've got to be seen to be saving animals and not killing animals. Some vets really do want to perform euthanasia and understand the importance of euthanasia and how it is a useful welfare tool to end suffering, but they know that they have to be seen to try first, and they have to try every option available. And then once they've done that, they can legitimise a euthanasia.

And very often the public will go to the press if they've found out that a vet has euthanized an animal that they took in, perhaps a stray dog, to be, to be rescued. And so vets fear for their reputation as well. And very often a good euthanasia is not witnessed by vets and certainly not by veterinary students.

Pentobarbital is not available. So the euthanasia that they see using potassium chloride in some places are very painful, very distressing, and so they are completely avoided. This was a dog with end stage distemper.

This dog is alive in this picture. This dog was not euthanized, it was left. To die it's own quotation marks, natural death.

This is a bird of prey that had been brought in by a member of the public, could not be fixed, so could not fly, and it was living out the rest of its life in this bathroom in this corner of a veterinary hospital. And this was a deer that could not be released back into the wild. And was living out the rest of its day in a, a disused operating theatre.

So really tough situations often to, to be dealt with. Equipment may be challenging. So for example, anaesthetic machines, you, there might not be anaesthetic machines, and if they do have them, they might be broken or leaking.

There's no scavenging, which you can see in this picture with the red arrow there. That is an anaesthetic machine that is being used, and scavenging is just non-existent, so that all that . Used isofluorine has just been pumped out into the room.

There's no servicing often available and no repairs available, and it's expensive. There's no repair or servicing companies in those countries, and sometimes there's a lack of knowledge in using anaesthetic machines. As I said, isoflurane is readily available, but very often teva is what's taught at vet schools.

So total intravenous, total intravenous anaesthesia, which is a totally acceptable way of anaesthetizing an animal and, and can be extremely well done. But the animal must be. So if you're going to a place where they're doing teva, the animal should still be intubated so that you have a protected airway and access should you need it.

So that can be challenging when you go to a, you go to work overseas and there's no anaesthetic machine and you're, you're using tea, but there's the reasons why you might, experience that. An aesthetic monitors might not be available. Again, they're expensive, no repair or servicing company.

I mean they're expensive in the UK. They're prohibitively expensive in low to middle income countries, and very often they're not deemed necessary by the by the vets, and there's no support staff anyway to monitor or record anaesthetics, so, so why bother? However, this was a vet school that I did visit and they did have an anaesthetic monitoring equipment and you'll see here that the SPO2.

And that it is 100. But for those of you that use and are familiar with catnography, you'll have spotted that the fraction inspired CO2 is 30. And nobody was, concerned about this, or, or, or tried to rectify that the, the inspired CO2 was, was at 30 that this animal was re-breathing.

And if you looked at the, the last photo, you'll have seen that it was a ban breathing system being used. This is the same from the same picture. And that banin breathing system was being used on a 35 kilogramme German Shepherd, and the fresh gas flow was just 1.5 litres.

So this rebreathing could have been very, very easily fixed, but due to a lack of a lack of training and understanding, this dog was rebreathing for the whole surgery. So yeah, lack of knowledge in using them. Right, intravenous access.

IV cannulas are often not used. They are, of vets may not be trained in using, IV cannulas and and not know how to place them. It is definitely a tricky old skill, learning how to use an IV cannula, not something that, you can teach yourself to do if you're not taught in vet school.

They're also extremely expensive, prohibitively expensive for many vets, clinics. So butterfly needles, may be more readily available. However, they may be reused, so they might be dirty or blunt.

Why does this happen? Because it's to save money, it's limited resources. I worked in one place where the butterfly needles were used, and then when they had finished using them, they took them out of the animal.

I gave them a rinse and then popped them into a big polystyrene block. So, and that was how they were stored, and then they were removed from the polystyrene block, in the and then used on the next animal as well, so not ideal in terms of bluntness or sterility either. Fluid therapy, intravenous fluid therapy might not be readily used because there is sometimes a suspicion with leaving animals unattended on intravenous fluid therapies, on fluid therapies.

So bandaging materials, unbelievably, you can't imagine that some of these problems exist because of other reasons, but bandaging material is expensive and it's also very limited. So very often what will happen. Is that the dog will be restrained, the dog or the cat will be restrained, or held either by veterinary students, if it's a vet school, very often by owners.

Owners will sit for whole days with their patients whilst they receive, either drip drip rate of fluid or a bolus of fluid. So that's much more common. But that comes with its challenges because then the animal is removed from its cage that it's resting in, and hopefully, Being allowed to rest, and then it's removed from its cage and then it's held down and given a bolus of fluids and obviously those veins are being repeatedly stabbed often with dirty or blunt butterfly needles.

The animal is stressed, the, the veins are, are a mess. The animal is. Not obviously enjoying that situation very much, so they may be tied to a table and left on fluids there.

All sorts of things occur. And I remember being given this quote, by a, a vet, I think it was an Indian vet, who said, our dogs are different. Your British dogs are trained to tolerate intravenous fluid therapy, which is obviously not the case.

Asepsis, might see a poor aseptic technique. Antibiotics are very heavily relied upon, in some countries, so a poor aseptic technique will often be treated with, a heavy use of antibiotics. And why is there a poor aseptic technique?

Well, it's often not properly taught in vet schools. I think in the UK it is hammered into us how important it is. And as you can see in this picture, The vets are gowned and masked and hats on, which is absolutely brilliant.

They've got their sterile gloves on and they are being passed all of the sterile instruments by someone who is, is not gloved and not sterile. There is, there can be a lack of understanding and knowledge in the importance of asepsis, and I've witnessed this a lot, a belief that gloves are mistaken as protective if you, if you've got your gloves on, you're sterile, but obviously whatever you touch that isn't sterile renders your gloves pointless. Often there's no autoclaves as well, so that can be a real problem in trying to do nice sterile surgery when, when the kits are simply dunked in dilute hevidine or just rinsed over with, with spirit.

An aesthetic depth. OK, this, this video is a little bit upsetting, but. Very often In surgeries you might see movement or vocalisation under anaesthesia, and this is because they're often aren't staff to monitor the anaesthetics.

And So therefore, the animals are moving and the vet may have to unscrub to . Give more anaesthesia, but if there's no IV access, then they're giving an IM injection. So it takes, it takes a bit longer for that animal to, become unconscious again.

And often, this is the tail end of the surgery here. There is a desire for the animal to recover quickly or wake up quickly. So top-ups aren't always, given because they, they've got a lot of surgeries to get through.

So they want the animal to recover quickly, and therefore, if it does start moving a little bit, they just try and finish the surgery faster. This is not the case in every clinic or every practise, but this is something that may be seen. Wound and fracture management can be extremely challenging.

Road traffic accidents and injuries are extremely common, as many low and middle income countries have a huge free roaming dog population. So if you do go overseas, you may see a lot of wounds and fractures when you're working in the clinics there. And they may be inappropriately treated, and that's because of a lack of knowledge on treating options, on treatment options that they have available, and also the practical skills.

Maybe lacking as well. So white open weave is regularly used, and also gauze swabs, gauze swabs placed directly on wounds. Bandaging material, material, as I said earlier, is expensive.

Dressings are really limited. So, Very often the vets and the assistants are just doing what they can with their very challenging situation that they're in. There's also a problem with flies in many of the hotter countries, and so wounds that we may, we might leave open then become inappropriately bandaged, which has a knock-on effect and and more problems can develop from inappropriate bandaging.

If a wound is particularly awful, like the fracture on the bottom right here, there may be a reluctance to amputate. And so these wounds fester on and on, and, and the amputation again is just cultural, cultural reasons. They maybe a belief that three-legged dogs or three-legged cats don't do well, so leaving a non-functioning, deformed useless limb on is is preferable.

Dog in the top two pictures, an awful degloving injury, and when I removed the bandage, it cotton wool had been placed directly onto that wound, so it's a decent clean wound just was not going to heal with cotton wool placed directly on it. The picture in the bottom left, extremely unusual one, that's a drain of, of a bandage drain at the top of the leg. I, I, I haven't seen this one very regularly.

That, that wound was so swollen. Obviously, that drain at the top of the leg is not working and it's just wicking in bacteria. The picture on the right with the pink vet wrap, this is the problem when sometimes inexperienced people have access to bandaging materials without the training.

Vet wrap in the wrong hands or, or a cohesive bandage in the wrong hands is dangerous, and this bandage had been placed, and as you can see, those toes are so swollen. The bandage has been pulled out and then wrapped around rather than allowing it to relax in on itself before being placed, and the dog has, it's been too tight for the dog. The dog has chewed at the bandage, its toes are now exposed.

Blood flow is just appalling because of the restriction, and, and those toes are really, really swollen now. This cat, I think that was a cat by abscess. Again, just, no way, not been properly debrided or treated, just sprayed with the Terramycin spray.

So extremely painful for that cat, but debriding the wound hadn't been done. And then the fracture, this, this fracture had been, if you can see that picture. Closely, the bottom right one had been splinted.

The splint was below the the elbow of the dog's front leg, and the leg, you can see that that foot has rotated around the splint. Sorry if I said splinter splint, that leg has rotated around the splint. Ah, stands absolutely no chance of healing.

And with that picture, we did go on to, amputate that leg of that dog, and the students watched and we did a lovely anaesthetic, a teva anaesthetic, and then amputated that leg, and the dog did so much better after that. Handling techniques, if you're working in rescue shelters, you may see some really challenging conditions, and these are just a few of them. So the handling techniques, are often not ideal.

This is a net grasper being used in the left-hand picture. Minimal, if any training at all is given to staff, and the staff are overwhelmed with the number of dogs that they are dealing with. They're also very aware that these dogs may have rabies.

Very often the staff aren't vaccinated for rabies, so you can understand why these rather rough and ready handling techniques are used on the dogs. Sick dogs are often mixed with healthy ones. Look at the middle picture.

There's a lack of facilities or a recognition of the necessity of isolating the dogs before mixing them with the main population. Vaccinating and funding and veterinary treatment, veterinary treatment availability is often, is often extremely challenging in rescue shelters. And overcrowding, many shelters I've been to had.

Thousands of dogs. One of them, the biggest one I went to had 3000 dogs, and many shelters really do the very best that they can with the dogs that they have, that what they're doing comes from a place of love and, and care for the dogs, but simply overwhelmed with the numbers that they have. And very often no act of rehoming takes place.

As you can see, these are all mongrel dogs or mixed breed dogs. Pedigree dogs are much more re more desirable. And more easily rehomed, street dogs are not, and they're often just rounded up to be removed from the streets and taken to shelters, or they've been injured and then taken to shelters or they've been confiscated from trucks from the illegal dog meat trade and placed in these shelters.

And these dogs are really tricky to rehome, and it's really tricky to provide good quality of life in overcrowded, underfunded, under-resourced shelters. So you, you can imagine what life can be like for these dogs. Analgesia may not be given, even if it's written up on the hospital sheet to, to, to be given, it may not be given.

And this problem occurs in the UK as well, because people believe it's already had it in its pre-med and therefore it doesn't need any more analgesia. And there can be a lack of understanding of how analgesia works and the multimodal approach and the different drug classes and so very often. Dogs and cats can be left in in horrible painful situations, and you can, we can see clearly that these two dogs are painful, but very often it's recognising pain is not obvious to people who haven't been trained in how to recognise pain.

The drugs, as I said earlier, are expensive, although they're difficult to obtain, so they're saved for the more painful cases, perhaps the orthopaedic cases, and not the routine bitbas and dog castrates and deglovings. And then, yeah, a lack of knowledge of behavioural signs of pain. Pain assessment can be very tricky, when you're dealing with street dogs.

So the Glasgow short form composite pain scale, as we know, is validated in dogs, but there can be potential confusion between pain and anxiety in street dogs, and a study was done of CNR, so catch you to return, catching you to return dogs of street dogs in India. And what they found, they did a pre-surgical pain score, and those pain scores were actually higher. In those street dogs and the post-surgical pain scores, so what we would class as a sign of pain.

In a UK, a well handled UK dog, so, flinching when touched or reluctant to come out of its kennel, signs of pain in a UK dog, were actually just very, very worried, nervous street dogs who weren't used to being touched, weren't used to being on a lead, behaving in a normal way, but could be interpreted as pain. So the pre-surgical pain scores were higher than the post-surgical pain scores. So we can't really be assessing pain using the Glasgow pain scale.

Street dogs will often also mask behavioural signs of pain. They are more stoical. There's, there's no benefit to showing signs of pain, and it can put them at risk of being, of being picked on or picked off.

So minimal pain expression, minimal vocalisation, so that they sit there very quietly being all huddled and painful. And also evidence suggests that in, in the study that you can see below. Those that work regularly with street dogs aren't always great at recognising pain.

And it's not just street dogs. People that work in, in, in UK shelters aren't always great at working at recognising pain as well. So what can we do?

Well, research has been done and shown that very often posture and facial expressions are an extremely reliable way of assessing pain. So if you are going to go overseas, then I, I highly recommend, remembering these, the focal. Ization looking at the wound, the hunch tense body, the reluctance to move, the the head hanging below the shoulders, the facial grimacing, so the tightening of the eyes, the squinting, ears pulled back.

Learn all of these because these are all reliable indicators of acute pain and In dogs, street dogs. OK, let's just take a break. OK, there, there was a lot to digest there, and a lot of upsetting pictures and, and videos.

So we'll just have a, a little break and have a look at this cute kitten that belongs to my friend. And before we move on and have a look at what we can actually do when we encounter these, these challenges. Most importantly, we need to understand the challenge, so hopefully this, this presentation has gone some way into understanding why these challenges exist, and learn not to judge it.

Find out why is it the way it is. Identify the barriers. Is it a knowledge problem?

Is there a problem with with time, is it staff, resources, money, drug availability? And That often solutions can be found, but we need to communicate with the other members of staff, about what these potential solutions are. Do not just make take changes.

It is very tough to see a lot of this stuff, but there are often solutions that we can find. But we can't just make those changes. We must always be respectful if we are to be effective.

Can you imagine? If a nurse, or a vet from another country came to your practise, silently judged everything you did, and then just started to make changes without speaking to you first or explaining, explaining why those changes needed to be made or why they'd made them. The combi model can be used in in many situations in life, and it was designed by proposed by scientists, .

And it's called a behaviour system, the combi model stands for capability, opportunity, motivation, and when those three are in order, you get a behaviour. It's very similar to the US criminal law model. That the police use when they are solving a crime and they have a suspect, and but they need to ask themselves, did the suspect have the means, the motive, and the opportunity to commit the crime?

And we can use the comb model in a very similar way, but to establish behaviour change rather than to find a criminal, find a suspect. And the comb model suggests that 3 conditions are essential for a person to perform a specific behaviour. So for changes to happen, the people managing those animals need to change their behaviour.

We can go there and we can recognise what needs to be done, and we, we can make changes whilst they're there, but it's the people that are there long term looking after those animals whose behaviour needs to change for the animal welfare to improve. So for a person to improve a behaviour, they need to have the capability to do it. They are psychologically.

Able to recognise the welfare problem and physically able to resolve it. And they need to have the opportunity to do it. They're, they are in the right place at the right time with the right tools.

And they need to have the motivation to do it. And this can often be very, very challenging, as in that that person wants to resolve it. And once you have addressed all of these three areas, then the behaviour change should happen.

So First things first, when you are working in, in, in one of the countries and you spot the problem, identify what the welfare problem is. So for an example, a patient, the patient's in post-op pain, so we then set a desired goal, and the desired goal would be for patients not to be in pain post-op. Next we have to identify the barriers, including people's habits.

So it might be that they've always done it that way, or there's a lack of understanding about pain, or the drugs are not available. So those are your barriers. And then we want to identify solutions and change behaviour.

So you'll need to speak to the NGO, the other NGOs or the clinic director. And this is when you have to ensure that the people that are working there and you're working with have the capability to make the necessary changes, the opportunity and the motivation. So in terms of animals being in pain, we need to make sure that pain is understood.

There's a knowledge of which drugs to use, that they're physically able to give the drugs so that they've, they, they, they've got the skill to give IM or IV or subcut injections. The drug is available, they have needles and syringes. The drugs are sourced cheaply and locally.

And then when you look at the opportunity, you need to make sure that that the people there have the time and. The time to give those drugs access to the patient that the drugs are actually in stock. And when you look at motivation.

We need to find a way to make people care enough to do it. They may already intrinsically care enough. Peer pressure might need to be used to get people motivated to do something that certainly works well in the UK or it even becomes the clinic policy that this is done.

I don't care how people are motivated so long as they are motivated. And then hopefully those pain behaviours are not exhibited anymore. And once we've identified some solutions to change things, we can try a few things, we can try them out.

Often one solution may not get the results that we want, but we get partway to a goal, and this is good progress. But it might be that we need to put several solutions in place to address all the different barriers and get us as close as possible as we can to our goal of improving patient welfare. And then we'd check for progress.

So the progress would be patients aren't exhibiting pain anymore. Here's a real life example I'd like to give you. So first of all, we identified a welfare problem in a vet school in a low to middle income country, and the welfare problem was dogs were without water in, in a very hot and humid environment and water was only offered twice a day, so the bowl would be put in, the dog would drink and then the water would be taken away, and then there would be up to 8 to 10 hours before water was next offered, and the country was absolutely boiling hot.

So our desired goal would be access to water 24 hours a day. There's there's very, very few reasons why you would deny an animal access to water 24 hours a day. So our goal was to have everyone have access to water 24 hours a day.

So the barriers were dogs kept tipping the balls over, and that was, that was the reason. And then the kennels were getting wet. And if the animals had wounds or bandages, they were getting wet.

So their solution was to only offer the water and then take it away, to prevent these wet floors. They didn't have non tip bows available, finances were extremely limited. There was a lack of understanding as well with daily fluid requirements.

Solutions. Teach the benefits of hydrated dogs the importance of a minimum of 50 mL per kilogramme per day, and create a readily available non-tip bowl. So that was the, those were the solutions, and it would be less work for staff.

And then check for progress. The bowls, the non-tip bowls would be used, and they would be regularly topped up. That's the, that's also important that the bowls are then put in place, but they're also topped up as well.

This is a little video of the solution that we had. You'll see in this video that there are other problems, like the dog I give this, that we created this water bowl. This was just made out of, an old disinfectant bottle, and then we put wire on the side, so.

Could be hooked onto the side of the cage and then therefore suspended off the floor. And you'll see in the video that there are other problems, like, there's no bed, for the dog, there's no hospital sheets, on the kennel door, but we picked our most important battle first, and that was simply hydration. We made one of these water bowls for each of the kennels there, so it was easy to carry on.

So it was very easy for the staff to carry on giving all the dogs water once we had left, and it was far easier for them to top up these water bowls with a hosepipe than it was to physically go round twice a day offering water bowls and then clearing them away again. So the solutions that are offered need to be, the solutions that are offered need to be easier. Than what there is currently being done.

If you want to make changes, make the changes easy. So other potential solutions that we can look at, this, this is just a few and I'm about, I'm nearly finished, but just to end the presentation on a bit of a high that there are potential solutions, it really just involves thinking outside the box. So no gas anaesthesia.

Available, so what can we do about that? Well, we, before we go to that country, we can look at our teva doses, total intravenous anaesthesia for thiopentone, quite old school, but it is often available. Propofol as well, you can do tea with propofol.

You could sedate with ketamine and Xylazine and diazepam, it would just be a case of checking your doses before you leave for that country. Research the different drug cocktails depending on what is available in that country. OK, no opioids available.

Excuse me, huge problem. Perhaps a ketamine CRI would be a good idea. Again, check your doses before leaving.

If there's no ketamine, you could actually use a xylazine CRI. So this is, not something that is regularly done at all in the UK, but is a possibility for some of those patients. Lidocaine is readily available in all of the countries.

So you could do a lidocaine CRI or block it or do intradermal, injections at the incision site. All of these will help to improve patient welfare. And pain when opioids aren't available.

Paracetamols often usually available, obviously dogs only, that's a nice, addition to the meloxicam that is available in those countries. But again, human comfort, a comfortable bed, going home sooner to the owner who's able to offer love and support may also be options for many of the patients. No comfortable beds available, then, and there's no washing facilities either, then rubber mats can be bought.

There's hardware stores all over the place and rubber mats can be bought far more comfortable than the concrete floors. If they're too expensive, then we can use cardboard, newspaper, hay, grass, ask the owner to bring in bedding. It's usually a solution.

If the animals are getting cold under anaesthetic and there's no heated tables or heat mats or or bear huggers, then you can put cardboard underneath the patients, you can use gloves or bottles filled with hot water, you can place the animal in the sun to recover. No wound dressings available, or, or treatments available to, to deal with the many, many wounds that are seen. You can use panty liners or sanitary towels.

These are readily available in the country, have to obviously be a bit discreet, when you're using these. So just be aware of that. You can make your own salty water solution if, if saline, is unavailable or too expensive and you need to Flush a wound, honeys usually available and silver sulphur diazine cream, it will work well in the absence of, of everything else that we're so used to having available to us in the UK.

So there's some options. And with, with the panty liners and the sanitary towels, they are usually sterile and they're less adhesive than cotton wool or gauze, and they're malleable as well. So they are actually a really good solution.

And then if you've got somewhere, something like nowhere to hang a drip bag, a fluid bag, then you can string up a washing line, and in one case we did actually have to, use a plant pot. So look at what's available, locally around you and, and do your best to think outside the box. As a final word, and I am about to finish, if you're a vet student.

And you want to go overseas to practise your skills, then these animals are not for students to practise on. You can see many, many problems in this picture. This is a 3rd year vet student practising her veterinary skills on a street dog practising, space surgery.

And being involved with substandard elective procedures, it really is not to be encouraged. If you need to practise your surgical skills, these animals, they're not for practising on, they, they are sentient beings that deserve the same amount of expertise and respect as an owned pet, dog or cat in any country, and animal welfare aside. The emotional consequences of what you may do to those animals if you're practising on them or if you are unsupported and out of your depth and you can't stop a bleed due to unfamiliar blood parasites, those emotional consequences are long lasting.

If you do want to improve your surgical skills in low to middle income countries, please research your NGO or your clinic really, really well. Their standards must be acceptable. So by acceptable standards, I'm talking about a drape, adequate depth of anaesthesia, sterile instruments, aseptic technique, and analgesia.

These are not luxuries. They are necessities. If the NGO or the clinic cannot provide the basics for elective procedures, they should not be doing them, no matter how well-meaning they are.

And then as a, as a, a final note, these are some of the problems that I have seen and I've been involved in, and they're just questions that you might want to ask yourself if you're, if you would be ready to meet these challenges if you were working in any of these situations. I won't pause on this slide for too long because I have now finished, and I'd like to just thank you for your time. And, I hope you learned something from this presentation.

Thank you very much.