Hello. It's Anthony Chandler from the Webinar vet welcoming you to another episode of vet Chat. The U K's number one Veterinary podcast really, really pleased to have Nicola Reed on today.
Who is a veterinary nurse? Basically, at the RVC specialising in oncology. Nicola did a PG cert PGC Sorry.
In in oncology and then a masters in oncology, both at Harper Adams. She's been at the RVC since, 2002 and, really looking forward to chatting to you. But perhaps for those people who don't know you, Nicola, you could give a little bit of an introduction about yourself.
Hello. Thank you for inviting me, Anthony. Yeah.
So I am a traditionally qualified nurse. I did the old fashioned apprenticeship route, so qualified in 2000 in a north London practise, which was great fun. It was a family led business.
So it's a very, very nice setting in order to be able to learn the disciplines of, all the different skills required of nursing and then, wanted to do more, and specialise in particular in medicine nursing. So moved to the Royal Veterinary College in 2002 where I was a medicine nurse. So, then did my diploma in Advanced Veterinary Nursing, which was organised with the BBN at the time, which was fantastic and then went on to be the head medicine nurse in I think, around 2007, I want to say something along those lines.
And then, on medicine just grew and grew and grew, and we ended up with a specialist oncologist at the RVC. And I got the, very, very privileged decision whether or not I stayed with medicine or, went and worked more, specifically with the oncologist. And so together we set up an oncology service here at the RVC.
So And that's where I've remained looking after patients with oncology, oncological disease, working with a team of specialists, vets and nurses. So I feel very privileged to be in the job that I do because it's one that I absolutely adore. Yeah, and I would imagine 2000.
I remember those green books and having to sign, you know, multiple times that you've done things and things. So it wasn't a bad system, and then I remember doing D 32 D 33. Which was hard work, but, yeah, it's, it's great to see the way that veterinary nursing is developed, you know, with specialist diplomas with masters PG, CS, et cetera.
It's it must be a lot different than when you first started in, you know, at the turn of the century. Gosh, you make me sound really old. It was actually.
And I think, I don't believe at the time there was any sort of, like, academic route. It was very sort of like based on trade and profession. Obviously, we now know that veterinary nurses, have a protected title as registered veterinary nurses.
So all of this, the whole, the profession has evolved. We're recognised, like alongside our veterinary colleagues as well. And it's just a fantastic place to be in.
I was really, really lucky to have been given the opportunities that I were, in order to get on to the postgraduate certificate because I wasn't a degree nurse, and normally that's the pathway to to have. So I had to do some bridging learning about how to critique things and understand how to write things very differently to how I have been educated before. But it's something I absolutely like.
Really, really do enjoy. And research is a big a big thing, with regards to sort of the opportunities that we have as veterinary nurses and especially in the institution where I work as well. Yeah, we love veterinary nurses at the webinar, but I think, vets and nurses working together is so critical, isn't it?
And I think also with the webinar vet training, a lot of training can be quite basic. Whereas learning, you know, some of the GP stuff. Anaesthesia, obviously radiography, et cetera, behaviour.
Nutrition nurses can really, go to another level. And that really supports the the vets we we do, you know, I'm I'm hopeful of obviously, I've not been in practise, but nurses cleaning kennels out all day is is not best use of their time and resources. When you are, as you know, qualified as you and and many of you of your colleagues are as well.
Yeah. I mean, I still clean kennels, definitely part of my daily job. And I think the thing is is that it's a collaborative approach, isn't it?
I'm still I'm lucky enough that we will have, patient care assistants that work here. We have, undergraduate, veterinary nurses and veterinary students as well. And, we all, like, literally collaboratively get the job done.
Obviously, there's very distinctive roles that we all have in which is part of our responsibilities and our professional obligations. But, I absolutely agree with you being able to use nurses now for their specialist, techniques and their abilities is certainly something which is progressing. And, very encouraging to hear as well, so talk to me a little bit about your role as an oncology nurse.
And how do you work with the oncologist at the R BC? OK, where do I start? So what about my average day?
Should I do something like that? Yeah, my average day. So I have very, very good point.
But I will try to make it as as consistent as possible. So we have We have two different days at the moment in which we run. So we have days where we have new cases and patients coming in for rest staging.
So that's quite exciting. Have a lesser number of cases on those days because these clients come in and they need a lot of time spending with them with regards to their, educating them and helping them understand all the different processes that can be involved with regards to, forming a diagnosis and making sure that we can determine their extent of disease. So, we have AC T scanner here.
We've got digital radiography. We can do synth grey here, and we've got an MRI scanner as well. And then we've also got fantastic, radiologists and radiographers who help us with regards to very specific sampling when needed.
So those patients take a lot of time as, they're worked up. We instrument them. By that I mean, we put catheters in to them, get them ready for their sedation, things like that.
And then we follow them down to down to imaging. Help them with regards to their their sampling as well. So we might be there sort of smearing slides, or going down to the lab and just checking to make sure that they're of good diagnostic quality because the last thing you want to have happen is that the animal is woken up and the sample is not a good enough one.
So we want to make sure that what we send off to our pathologist is perfect, and at least good enough to make a diagnosis. And then obviously we recover these patients and, send them home to be waiting their results. So that's kind of one kind of day that we'll have.
And we'll also have the patients that come in for restaging, which means, measuring their disease against their last lot of imaging to see whether or not the treatments we're giving them is having a positive effect. So and then normally reported as being in complete remission or partial remission, Sometimes they have stable disease, so we give them treatments and their cancer is not progressing, which also isn't a bad thing. So as long as they've got good quality of life, then that's fantastic.
Well, sadly, sometimes we see these cases come in, and despite the treatment interventions, they've got progressive disease. So it's about sort of coaching the client through those stages as to what happens next. And we're there as nurses to help support the clinicians and the vets, and the residents and our rotating interns to help do that.
So, yeah, that's one kind of day, and then the other day is we have our chemotherapy days. So for two solid days of the week, we have a number of patients that come in for different types of chemotherapy that might be oral treatments or infusions or bolus treatments. And we have a real, real, real emphasis on the patient's experience.
So making sure that they come in it's as calm as quiet as, individualised for them as well. So we make sure we try to work out very early on in these treatment protocols what they prefer. Some of these patients, or quite a large number of them, are, geriatric.
So they've got comorbidity. So we need to make sure they get comfortable if they've got to sit for, say, a 20 minute infusion. We use a lot of emler and topical, local anaesthetic aids so that they are they're having as least invasive experience and all these negative things that we associate with, these treatments being done so we'll have sort of 1012 of these patients coming in, and being treated throughout the day.
So and then they all get lots of love. Lots of attention. They all get fed and exercised and cuddled and things like that as well.
And then we discharge them back to their owners with instructions on how to look after them post treatment. So whether it's the right at the beginning of the treatment and we need to spend a lot of time educating the client at all the different signs they could be looking out for, or whether or not it's routine. And it's a case of just touching base with the owners and listening about all the nice bucket list things they've done, that week, which is fantastic to hear.
Yeah, yeah, and And do we do you leave catheters in if they're in weekly, or do you need to remove them and just redo them each week? Yeah, it's a really good question. It's very different in animal medicine than it is in human medicine.
In the sense, when a human is undergoing a treatment protocol for chemotherapy, they have these like they call them pick lines. So periphery placed intravenous catheters. Sadly, we can't leave them in our animal patients because of the risk of them pulling them out.
Risk of them getting infected. Or there's a sort of patient interference. But there are a small cohort of patients which we place, ports in so vascular access ports, which are really super cool.
If we're able to be proactive with regards to what kind of like cancer we're dealing with. So osteosarcoma so tumours of the bone or hemangiosarcoma, which are of like, nasty vascular tumours. We can put a port in at the time of the surgery to either do their limb amputation or a splenectomy, for example.
And that port sits, within the jugular vein. But it's implanted either on the back of the neck or in the femoral vein. And, it's not then on their hip, and it's just almost like a subcut injection in order.
Just one inject one literally, and it enters the pore underneath the skin, which is amazing. So again, focusing all the time on the patient experience and the innovation is great, isn't it? To see things you know, how can we all the time, make this better?
You know, what things can we do to improve health? And I know, I I'm not sure if you're known by your friends as this, but you are to me, the nausea nurse, because obviously that's what you did your, your masters in So tell tell me. I mean, how common is nausea in the patients that you're treating, or are you treating preventatively to, you know, prevent nausea in the first place?
So how is that developed over time? I think it's a really, really interesting thing. And nausea for me is, a very so there's no way of quantifying nausea.
There's no, nausea scale. And it's something I really, really want to collaborate with people on and be able to do something like that. Like what we have similar to pain scales.
I think nausea is completely and utterly underestimated in these patients. Nausea for me will be very different to nausea for you in regards to how you describe it or how it sort of manifests itself. And I think that must happen in the same way that it does in animals.
And because we assume so, we're looking for vomiting. Aren't we signs of, like, gagging and hypersalivation things like that. But the actual end product is the vomit, which then makes us give them antiemetic medications.
And so I think a big thing is to be able to, educate our owners so that they understand the difference of, like, presentations of what nausea might look like for their animals and be able to nip that in the bud much earlier. So yeah, I think it's I think it's an area which we can definitely develop on and do better with, all of us. Really?
So are they? Would you say there's particular treatments that are much more likely to cause nausea? And so, therefore, do you use, you know, pharmaceutical products preventatively?
Or do you always wait until there's a problem before you begin treatment? So there are some, chemotherapy drugs in particular, which are known to be very emetic. So drugs like doxorubicin carboplatin, for example, are reportedly known to be through studies and through, various reports in the cases that these patients really do need to have these treatments so we'll often give them antiemetics prior to giving them their chemotherapy.
And then we'll give them. We, like, almost give them, like, little first aid boxes, so to speak, so that they go home with, treatment to be given at home for a number of days, usually about three days for specific treatments for them to sort of, like, get over that period of the initial feeling sick, so to speak. Because we want these patients to be having good days like there the majority of the week and bad days, because sometimes they're coming back on a weekly basis.
So they're feeling sick and off their food for sort of 23 days, which is quite common, that that's the sort of acute chemotherapy post treatment phase that they could feel unwell for. You know, that's quite a majority of a week, isn't it? So, yeah, we do give them preempted treatments, sort of like almost premedications of antiemetics.
And then they go home with post treatment, antiemetics as well. And what sort of products are they going home with or being used here? So the right answer is always to be that we have to use products which, form part of the cascade.
So, anti nausea medications, is, the first go to is always going to be met. So and the reason being is mero is, produced as a multimodal antiemetic drug because it affects the different types of triggers within the brain and the gut as well. With regards to treating and, inhibiting that effect, there is, a condition known as breakthrough nausea.
So or, breakthrough emesis. So essentially, you give them their antiemetic medication, and then they break through that, and they're still feeling sick. And then usually the next go to medication is on dansetron.
And interestingly, ondansetron the drug which works on the chemo receptors within the brain. Which is your main, sort of like brain trigger for causing sickness, and ironically, is called your chemo receptors, which is kind of cool, but essentially it detects any kind of sort of toxin within the body. And that's what then, initiates this nausea pathway, so if they do still feel unwell or they're not eating, or, we feel that they've got signs of nausea.
Then we'll add in on dansetron as well. Usually. But there's other products which can be trialled as well.
Like, Mito, for example. Yeah, my old favourite before all these other drugs came along me And so I think, yeah, meta was was very popular at the time. So I been superseded by Miro, which I think is, works very well, doesn't it?
Most of the time it does. It does, and a lot of work. And obviously a lot of money and research went into developing Miro as well.
And specifically, Miro was used and tested in, so in a research setting specifically on chemotherapy drugs so you know that it's sort of like substantiates that evidence with regards to that. That's what we need to be using first line. But there are a number of patients where it doesn't always work on, and that's what we just because we gave them the anti me.
It doesn't mean to say that they're still not having that experience, and that's what's really important that we do monitor them for as well, you know, cancer and oncology is it's such an emotive subject, both for humans and for animals, obviously with animals, it's the client that you know is most likely to get upset. There is a feeling that we're now on this cancer journey, obviously, sometimes with full cure and remission. But other times, you know, there is a slow decline.
How do you cope with that one? As, as a nurse, you know that the presumably, there are successes. But there are also times when you know you have to make the big decisions.
At the end, how how do you cope with that? Individually, But also, portray that then out to the clients that you're you're dealing with you. I suppose.
I'm asking. Are you a hopeful person? Can you, encourage and cheer up people when they have a diagnosis like this?
They Presumably the diagnosis is kind of being considered because that's why they're being referred across. But then you're often the ones who can give the definitive news, aren't you? Yeah.
I mean, as you say, we're on this cancer journey with them. And I suppose it's almost a double edged sword. Professionally, I'm always, very optimistic, and very hopeful.
And I'm there to do the very best for that patient. Personally, glass is always half half full, and I'm always catastrophizing. But I can't let the clients know that.
But I do feel it's a huge honour actually to work with these animals And these clients. Cancer treatment, actually. The majority of the time works really, really well, we don't use the same kind of doses that we do with people, so the animals don't have anywhere near the side effects that people do because we're not aiming to cure most of the time.
Cancer treatment in animals is, palliative for want of a better word. But we don't use that word. We just want their clinical signs to go away.
So actually, after the first treatment, sometimes like a couple of treatments, these animals are like back to their Selves. And they're feeling better reportedly by most of our owners that they're better than what they've been in the past year, because understandably, they've had a slow decline, with regards to their disease. So it's like I say it's a huge honour to be able to work with such cases clients, and, these animals have like a new lease of life.
They also respect the time that they have together. And I think a lot of investment does need to go in at the beginning to educate the owner with regards to the expectations and the likely progressiveness of the disease. So as long as they're getting these rewarding days, their days at the beach, their sort of their days out and all the things which these animals and these owners enjoy, it's a really amazing part thing to be part of, and whilst that's happening, it's great.
The patients come in like you'll call someone from the waiting room and the dogs running at you, dragging the client behind you because they want to come in and they want to sit down on the scales and get their tree, and they, you know they want to sort of like run in. We have some dogs who lift their head up for their drug in the blood samples because they know what's going to happen and they're going to get a treat and they're wagging their tail the whole time. That's a really nice thing to be part of But then, at the end, it's not so enjoyable, as you can imagine.
But again, it's a huge honour to be able to see these animals through all the way and part of their end time that they have is just as important as all those good times, because these are the where that these are the core parts that the owners are going to remember as well. So being able to be there and make the the end points of their end of life care as comforting for them and their owners is really, really important. So the whole when when there's no more treatment options for these patients and we have to look at hospice care and things like that, it's It's about working with the client and making sure that all of those end points in which these animals are getting to are palliated as much as possible.
And the owners are able to look after them and enjoy them and say their final goodbyes. And that's hard. And I I as we said, I I'm slightly of the older and traditional age, and I.
I have got to point sometimes where I just feel really, really upset. And we're a very close knit team. There's sometimes where there's days where I'm like.
Can I tag out of this one? Because I'm just not able to do it. And I'm lucky enough to be able to do that.
But there are times where you just have to put on your big girl pants and go in there and do it and make sure that it's the best. The best thing for everybody. And we you know, we we look after these animals in their aftercare, like post euthanasia as if they were our own.
They're carefully wrapped and prepared, and we put them into cardboard coffins rather than into bags and things like that as well. So yeah, it's a It's a big thing for us as well. The end as much as the duration.
Yeah, I think it is. You know, you you said it right. I always felt those euthanasia consults were so important that they were done.
Well, you know, privilege often Certainly in my situation. You know, I knew the clients very well. I knew the pet very well.
We've been on a journey. Might have known these animals since they were puppies. Obviously a bit different, you know, with the referral situation.
But nevertheless, even with the referral situation, you're seeing these dogs regularly. So you develop all cats. You develop a relationship, don't you?
Yeah, absolutely. It's the same as, like, absolutely is in first opinion. A lot of veterinarians and veterinary nurses.
They're core parts of the community, aren't they? So you see people when you are out and about, and you see their animals as well and you want to do the very best. And despite that, sometimes there's the joys that you have of them being pups and kittens as they turn up into practise or a new a new rehomed animal.
It's fantastic, but then equally at the end you're there and you're relied upon and in order to do the very best for that pet and their family. Yeah, it it's It's difficult, I suppose. Sometimes there is also the involvement of the referring practise, because that may happen at the referring practise.
But quite often it also happens at the R PC does it the the final stages. Yeah, it does. I mean, we have a very wide catchment area so to speak of, almost from because we're just north of Hertfordshire and north of the M 25.
So there are other, referral centres for oncology quite close to us as well. But it tends to be quite a wide area that we do look after these patients from had two this week come up from Brighton, for example. And so we don't want them travelling, Do we at, in these last sort of, like, hours or days?
And so we do rely very heavily on our first opinion referral practises who sent, like who obviously refer them into us. And it's about having that good relationship with that team as well, in order to inform them and help them with all of our clinical notes as to what point we're at all the things that we've tried. And now what the goals are when it comes to hospice care or palliative care in the home, so that the owners feel as well supported as possible and also try to make a plan together.
So the owners and the first opinion practise, or whether or not it's us as well, so that you've got as much of an organiser. So things are organised as much as possible. Whether you're talking like fur clippings, nose prints.
You know, all those Mementos which the owners want to want and want to remember. Some don't. Some don't want to do anything at all, but some want a lot.
They might be very spiritual, and have prayers or a ceremony, and it's important that we help coordinate that where where we can, and obviously with, like with the first opinion vets, they're extremely busy. They don't have an hour for a consult. Like what we do in referral practise.
I remember when I was working all those years ago, in in, north London. There were five minute appointments, and there would be 10 minutes, 15 tops for a euthanasia in the middle of like the the consult list. So I'm sure there's still practises that still have to work that way.
And so it's Yeah, it's a It's a hard thing to do for everybody, and I completely appreciate that. So we're here to try and help coordinate and introduce as well to There are hospice, hospice providers as well popping up, where because there's a lot of vets that aren't able to provide euthanasia or visits anymore because they're also short staffed at this time. So it's just trying to find the right balance with every family.
I think, you know, listening and chatting to you. It's clear you're a really good communicator. And I think communication is is key to all of this because this is when things go wrong.
If if things aren't communicated well or if things aren't explained well, yeah. You have to have a collaborative sort of approach, don't you? You've got to be open and transparent.
Make sure that the clients know everyone's got to have a common goal, haven't they? We can't want to do one thing, and the owner wants to do something else, and it's about trying to do the very best for the animal. Because that's what we're here for.
That's what our oath is for, isn't it? But obviously this animal is attached to the owner, and the owner sometimes has enhanced wishes. Whatever they might be.
And, it's about working together in order to meet everybody's expectations for the end goal for the animal to, be as most comfortable and have the best quality of life possible for whatever finite time they've got. I always used to say to clients, You know, there's three people in the room, there's me, there's you and there's the dog or the cat. And actually, as long as we remember that the the cat or the dog is the most important and we make the right decision and we don't leave it too late, I'd rather leave do it two weeks too early than two weeks too late because, you know, we all know the cats that come in that look kelita when they come in.
The client says I didn't bring it in any sooner because I knew you wouldn't be able to. You put it to sleep and you go, Well, you haven't given me a lot of choice. So I think that's really crucial, isn't it, that we're always having the the pet at the centre of the, the discussions?
Absolutely. And I think a key thing to pick up from what you just said there was is that that animal didn't come to you two weeks before because they were worried that you're going to put it to sleep, but actually there that that two week could have still probably happened with your intervention to make that animal much more comfortable whilst everybody then was a little bit more prepared. Because there's there's, you know, all the standard medications which are provided in practise from antiemetics to, steroids to, you know, your tradition, all of your pain relief can be given at home.
And so these kind of things of a paramount to also the owner being on board for the end decision if we're if they're too scared to come to us to talk about these things because they think that we're just going to put them to sleep, then the animal is gonna be suffering. In that meantime, is it? Aren't they?
So yeah, that working together, Nicola, I've really enjoyed my time chatting to you. I was at the RVC last week. It's an amazing facility that you have there as well.
And, not only do you have the facilities, it obvious it's obvious from speaking to you that there's a lot of love and care going on as well. So Thank you for all that you do for the, for the pets. Bless you.
Thank you. Thank you so much for the invitation. I've really enjoyed speaking to you today.
Great to speak to you as well. Nicola. Thanks everyone for listening.
This has been vet chat. Hope to see you on a podcast or a webinar very soon. Take care.
