Thank you very much for joining us today. My name is Leon Levi Hesh. I'm one of the district senior vets for, Vets now.

Vets Now is an emergency out of hours service, a company that provides out of hours services to a range of clinics across the UK, and we are kind of specialising in, providing, Specifically, emergency care to our patients. And therefore, we, we have decided and thought it would be sensible to, to talk about the first kind of approach and the initial kind of, steps that you would take when you get an emergency vet cause I, I appreciate that during the, during the day, general practise, the majority of your case load would be a routine, routine cases and cases that would not necessarily be considered as an emergency. However, you do still see emergency cases during the day and I guess for you it would be sensible to maybe switch, the way you, switch your approach and change the way you, think when you, when you do get the emergency, case, these kind of genuine emergency cases.

So it's just a different approach and we thought it would be sensible to talk about that today and also to consider, Emergency diag diagnostics, sorry, so the, the, the emergency diagnostic, one drop of blood title is actually what it says, you know, we, we'll discuss today how much value, and, yeah, value that you get from just seriously just one drop or a couple of drops of, of blood. So in terms of what we are going to go through today, like I said, you know, we would like to improve the awareness of the initial approach to the emergency patient, that you would see maybe during the day that we see during overnight. It's just slightly different approach than daytime practise.

So, we thought it would be sensible to start with that. And then we'll talk in general about the emergency diagnostic tools that you guys will have available to use with your emergency patients. Specifically about the minimum database blood test, and, we talk about the components of the emergency minimum database blood test and also communication around the minimum database and hopefully by the end of this webinar, you will also be, be able to appreciate how valuable the information is that you get from a couple of blood, blood drops and And the emergency treat or life-threatening conditions that you might be able to identify and most likely be able to provide the best possible life saving treatment plan.

So I guess at vets now and I guess and it's, you know, any, any veterinary practise across the UK and across the world, it would we have a common goal or couple of common goals that we share and firstly it's to provide high and constantly developing clinical standards. We want to make sure that we provide the best clinical standards to our patients and also to provide at the same time excellent service to our clients and who are the pet owners and colleagues, our vet professionals, and ensure that communication around the reasons why we do what we do is, is it kind of high standards. And, and one of the most kind of important and key goals that we have is to never miss a treatable problem, and I guess the emphasis here is a treatable problem rather than a diagnosis.

I think hopefully everyone will appreciate that within a couple of hours or Within a very short time, a short, time frame, it would be very difficult at times to reach a definite diagnosis. However, this is not the aim of our approach. Our approach is to, to try and, identify any life, threatening conditions, any problem that we can help and stabilise the patient until we, maybe proceed.

Afterwards, we proceed with a further diagnostic to reach a final and definite definite diagnosis. So in terms of the approach to the emergency patients and just to discuss where the emergency diagnostics fit and, and this is where I guess our approach is slightly different than the approach to the stable daytime. Practise approach where you maybe have the time to have a chat with the owner, take a full history and perform a full clinical examination, a physical examination on your patient and then discuss the option and further diagnostic plans that you might want to offer to your to the pet owner, to your client.

So in emergency and, and genuine emergency situations, things obviously are quite stressful and Maybe some other things that you might consider in a stable patient not be appropriate. Therefore, the approach is really to focus on the patients, take maybe a quick capsule history and, and perform a triage and during the triage. Initially, obviously, if we have an unresponsive apnaic patient, it would be very sensible to start with the ABCs, the airways, breathing and circulation check to make sure and to identify if the patient is in need for CPR for resuscitation.

If the patient, has passed this stage and they are fine and they're not in it for resuscitation, we then focus on the major body systems and, which I will share with you in the next, slide. Following the quick check, which ideally should not really take longer than 235 minutes. To be honest, once you complete your major body system check, then you need to ask yourself a key question whether your patient is stable or not.

If the patient is unstable or critical, it would be very, very reasonable and sensible to provide any life saving therapy such as oxygen, fluids. Obviously, pain relief is not life saving, but we are talking about well-being and preventing suffering. So we would consider pain relief as part of the initial approach.

And only once we start stabilising the patients or if the patient is stable already, then and only then we would consider emergency diagnostics. So now in terms of triage plus or the triage process, on the right-hand side, you will see a triage sheet that we would use and we have decided on, kind of this format, the black and red rather than the traffic light, approach, just because we think it's a bit more, . It kind of makes more, more sense and quite easy to, to use.

And the major body systems that we are focusing is the res respiratory, cardiovascular and central nerves and the system and then if it's the nurse or the vet that's performed the triage. We, we can identify any life threatening conditions if one of the parameters fall within the red area of the, of the page. And when you work in a small team, you know, if the vet is busy, the nurse, ideally should be performing the nurse triage nurse triage.

And then alert the vet with any concern that they might have. If you have a bigger team and you have a few nurses working alongside you or a couple of vets working alongside you, it would be very sensible that as part of the And triage process, you will also place an IV line or an IV catheter only and maybe collect a couple of tubes of blood. This blood can, can be put aside and then the focus obviously should be on the patient and provide life life saving procedures.

However, then you are saving yourself quite a lot of time later on, . And sticking another kind of needle in your patient and maybe if the blood pressure is not great, you are saving yourself a lot of time later on. You have the tubes ready and you are then able to discuss with the owner which Tests you would like to run.

And as you can see, I know some of you will be a bit itchy about the second picture. It's a bit kind of messy, but it's just kind of to, to, to, demonstrate, what we would normally do, just place a catheter, take a couple of tubes of blood, all the colours that you might think of, and just put them aside and clean and bandage the leg, you know, in if the patient stays with you and it's further fluids or further blood test that can be used using this catheter and you know, if things turn up to be Not great for the patient and euthanasia is considered, obviously, you have an open vein and you have a access and that you can also euthanize your patients. And if the patient goes home and everything is absolutely fine, you can just remove the catheter and, and, and bandage the leg.

So quite sensible, if you have the right staffing level, part of the triage process. Of identifying any life-threatening conditions by using the triage, they might major body system approach to also if you have the staffing levels to, to place an IV line and to collect a couple of blood tubes. So in terms of The diagnostic tests that we use.

I thought it was, it would be sensible for us to just quickly go through the reason why our, our patients might suffer from a cardio pulmonary arrest. And hopefully you will then appreciate the reasons why we have decided and chosen to use these diagnostic tools and, and these diagnostic tools will allow us to also in congestion with our radiobody system tests and approach to also identify any life saving, any life threatening conditions and will allow us preventing. A pending hopefully arrest, and I think, you know, everyone appreciates that, you know, performing a CPR, a good quality CPR is, is great and you know, we are, in some cases might be successful, but This condition of arresting is better to be prevented rather than be treated.

So in terms of the groups that we have split and the reasons for a cardiac arrest, and we have three groups, groups that we consider. One is the cardiovascular, the second one is the metabolic reasons, and then the others because we didn't have a better name for it, I guess. The cardiovascular, .

Things that we need to, to monitor is hypoxia, hypercardia, hypertension, and very severe anaemia, and these four parameters, you know, are quite critical and might cause an arrest in your patients. And in terms of the metabolic group, we have all kinds of electrolytes, abnormalities quite extreme electrode abnormalities, and the potassium hypokalemia, hyponatremia, and hypoglycemia. Acidosis and hypoglycemia are are considered quite life-threatening as well.

We'll talk about them, at least hypoglycemia later. And then we have other groups or other, other conditions that might cause an arrest, with a very severe hypo hypothermia, increased vagal tone, you know, you have those At least I had a couple of cases that were were vomiting quite severely and following a very severe vomiting episode that just collapsed and arrested because of the increased vagal tone, a severe brain injury and quite a few toxins that are listed, are listed for you here, that might cause the heart to arrest. So hopefully now you can appreciate why we have chosen these diagnostic tools to allow us to identify those conditions and try to avoid them and stabilise the patient and focus on those conditions to prevent from our patients arresting while under our care.

So in terms of the diagnostic tools, To be that we have available. And we, we do, we do, we have decided to use the cage side approach and just to explain quickly about the cage side approach, because I don't know, you know, some people, depending where you are coming from and which clinic, what kind of size of clinic you work in. And depending on the staffing level, you might have many kind of people and nurses working with you, but we work overnight, we work in a very small team.

Most likely will be 11 nurse and one vet looking after the whole clinic and all the patients, including inpatient and incoming cases. So what we want to do is make sure that the guys and the team utilise the staffing that they have on shift and by Taking the cage side approach, we make sure that we bring everything to the patients rather than one of the members of the team will disappear into the lab or into the ultrasound, . A room to perform a diagnosis.

So we want all the diagnosis to be done next to the patient. We get the results there and then. We don't lose a valuable member of the team, going anywhere and staying alone next to the patient, which is obviously I think everyone would agree would be quite difficult to, to, to help a patient when you are alone.

And, and therefore, these are the tools that we have, we have decided to use and all the machines and all the equipment that we use is a hand or is, most of them are handheld devices that can be brought next to the patient and everything to be done just there and then in the treatment room. So in terms of the diagnostic tools that we've got, they are listed in front of you, we have, the minimum database of which that we will explore, in a moment, and I, but I just wanted to mention obviously the other diagnostics tools and just to show you that the minimum database is just one small part of the variety of tools that we've got, at the emergency, in the emergency setting. And that will allow us to identify any life threatening conditions and obviously we hope to avoid them.

So, we have the venous blood gases and the electrolytes, and we, what we would normally use, we would use an epoch machine which is a handheld device that can be run next to the patient. In terms of other blood tests, we have, again, a handheld device that help us understanding the coagulation profile of the patient. It gives us the PT and the APTT values.

Blood smears, so if the, if this, you know, the slides and everything we need is just there and then microscope can be placed in the treatment room as well and you can And look at the smears just right and, and sorry, just next to the patient. And in terms of other diagnostics, diagnostic tools, we have the ECG and blood pressure, of course, that are quite small machines that you can use and bring to the patient. And it would be quite sensible when you start your, at least when we start our night shift, we would bring the ultrasound machine from the ultrasound room from the imaging room where it lives normally, but we will bring the the ultrasound machine.

Next to us, we'll also have a multi-parameter monitor with us that will assist us with the with the ECG and the blood pressure, or a Doppler machine and all these tools will be just there and then with us next to the patients in the treatment room and we'll utilise them depending on the case on a case to case basis. So just to To show that, I mean, the minimum database approach or the, the tool that we are using as as a kind of very kind of first time emergency diagnostic tool that we use is not something that we invented, you know, it's a worldwide kind of approach. It has been, Discussed over many studies.

These are quite just a couple of studies that mentioned the minimum database and how a minimum database. Blood tests, a very simple blood test can actually save lives and change the outcome for our patients. So the minimum database components and on the right hand side, you will have a picture of my first ever minimum database box.

Honestly, it cost me about 1 pound, the box, not the content. But, you know, what I've done, I've just created the box, put all the equipment that I need there, to allow me to perform the test next to the patient. .

So we're talking about the minimum database. It depends where. I guess which study you read, and which, and where the study was performed, you will see that sometimes they refer to the minimum database as the big 4 or big 5.

It's quite common in America to be to be referring to the minimum database as the big 4 or big 5 depending on What kind of components they have in their minimum database? And but for us, what we, what we would normally refer to as a minimum database blood test is a manual PCV and a refractometric total solids will perform a blood glucose. Test via glucometer.

We have a semi-quantitative BUN6s that we, we use to utilise for to understand the BUN level and then we use the lactate, lactate metre machine to to identify and understand what the lactate is doing. That's now, we also decided because we feel And the value will be much, much bigger for, for our, our patients and for us to understand the the, the, the, the blood tests. We also added urine specific gravity and the urine dipstick which we feel.

Together with the other tests will give us much more kind of much better understanding of, of what's happening with our patients. And hopefully, so here, you, hopefully you can appreciate that, you know, these tests only a couple of blood drops are needed to get these tests, tests done and we'll discuss the value of these tests in a moment. Before we do, obviously, as I said before, communication is very, very good.

Sorry, good communication is very, very important, when you want to get the message across and you want to make sure that the patients are getting the best care that you want to give them. We need to make sure that the pet owner, the clients are on board and agree to what we are trying to do. So just for you again, you know, why, why, why and when you should consider the minimum database.

So for me, I would use the minimum database as a very kind of baseline initial screening tool, and, it can be done again during the or following a consultation or the triage and a major body system test. Once we stabilise the patient, I will run a quick minimum databases screening tool. To try and identify any life-threatening abnormalities it's very, very early stages rather than rather than later.

Definitely for me, any patients that requires anaesthesia or sedation for an emergency procedure, I would definitely consider as a minimum, a minimum database. I might want to extend the database and perform other diagnostic tests. However, the minimum database for me would be the very, very basic and minimum test I would do before I anaesthetize or sedate any patient for any procedure, especially when we're talking about an emergency situation.

And any patients that I would Admit to the hospital, I would also suggest and recommend a baseline minimum database because we know that in terms of interpreting the blood results, we prefer to interpret the trends rather than one specific and one of snapshot in time, . Blood result. And we know that The trends give us much more value rather than 11 snapshot in time blood test.

And of course, you know, any, any unstable or critical patient would definitely benefit from a minimum database if not an extended diagnostic test. So with stable patients, you know, even if you have a stable patient coming to you, especially when they come overnight, I think, you know, you know, and a very concerned owner that calls you, it's 2 a.m.

Saying that their dog or their cats or their rabbit are just not quite right, are not doing quite right. And they're not sure if something is right or wrong. They are fairly stable but something is not just not right.

it's absolutely sensible and reasonable to perform minimum database. Also, Obviously, if you want to reassure that we are not reassure ourselves and, and the owner that we are not missing any, any life-threatening condition, but also it's absolutely fine to get To get a good results, you know, to get results that are absolutely fine and it will be reassure reassurance for you and for your clients that That that the patient is fine. There's nothing to worry about and the patient can go, can go home and maybe visit you or their their daytime practise that the following day.

With unstable patients, of course, you know, we want to make sure that we are not missing any life threatening condition. We need to understand the problem clearly so we can provide the best stabilisation treatment plan for the patient. And, and then based on the minimum database.

And the other diagnostic tests, we can then decide what other walkup is needed, what treatment is the most appropriate, and we can also decide on a monitoring plan for the patient. If the patient stays with you, most likely they will. So just quickly to go through the components of the minimum database which hopefully will give you some better understanding on the reasons also why we have decided to use them as part of the minimum database blood test.

So the first one is PCV total solids, you know, as probably as everyone knows, you know, we, we, we would take A blood, a blood tests, you know, we use microhematocrit tubes. We will put them in the micro microhematocrit tubes and, and spin the, the sample down and then the, the, the sample will be separated to plasma, a small kind of very small white blood cell kind of area, the buffy coat, and the red cell, red blood cells. And then you can You can decide whether the red blood cell count is is sensible and within the reference range or not, if it's reduced or increased.

And again, we would use very simple tools. We will use the micromatore tubes and the ruler just to understand the level of PCV and then what we would normally do, we would break the tube around the buffy coat kind of area, maybe slightly higher than that. And take the plasma and look at the plasma under and the refractometer and on the left hand side, you can see what we can, what we can see on the left, left, on the left side of the the view that you see from the refractometer and this is what we would normally see and then you can decide whether the plasma levels, the total solids are increased, reduced or normal.

So this is something that for me, you know, is kind of representing the, the very kind of Basic understanding why we need to perform the PCV and total solids together. I know that many practises would normally run the PCV alone without running the total solids at the same time and hopefully you can appreciate from this table that running the PCV alone would not necessarily give us the, or would not be able to necessarily help us getting to the . The, to the outcome and to the diagnosis that we, we are hoping to get.

Cause as you can see, if we are just running the PCV on its own, we can very easily misinterpret the, the PCV and a normal PCV although might appear normal, it really depending on what the total total solids does, then we can maybe make a better decision and yeah, make better choices for our, our patient. So again, you know, we would consider running the PCB and its together and they will give us a better understanding of what's happening with the patient at early stages. For, for example, you know, if, you know, the, the most kind of most common case that we would, we would use it for is, is for bleeding patients and we want to understand if they are acutely bleeding or, or not.

And you can see that The first again, pathophysiology wise, you know, we know that the first component that is reducing because of the compensatory mechanism, the spleen the spleen contraction and the way the body responds to an insult. PCV might, might be, might appear normal initially with acute bleeding. It's, and it's the only total, only the total solids, will be reduced as the part of the initial kind of response to acute bleeding.

Later on, obviously the PCV will join and then both of them, both of them will be reduced and then we are talking about haemorrhage. But again, the initially very, very kind of initial. Responds to.

Bleeding, if it happens there and then in front of you. If you only check the PCV on its own, you might miss an acute bleeding. So therefore, just one example why we would consider doing both of them at the same time.

So the next component is glucose and glucose, I hope everyone can appreciate, you know, hypoglycemia can kill and that's why it's, you know, it's it's a genuine true emergency situation and that's why it's part of our minimum database and it's very, very easy to check. All you need to do is just to quickly take one blood drop, put it on . Your glucometer and within a few seconds, you get an answer and the treatment is very, very easy as well, right?

All you need to do is just to provide, glucose. So normally what I would do, I would, provide a bolus of between 0.25 to 0.5 mL per kilo of the 50% dextrose diluted 1 to 1.

With saline, so we're talking about 25% of glucose given as a bolus depending on the weight of the animal. And then depending on the condition, what you then further identify, it would be sensible to also consider to put the patient on CRI and we know that there is a list of differential diagnosis for hypoglycemia which I can share with you again, not just. For the sake of you remembering them, but just to show you it's not a very long list, you know, we can based on history and your physical examination, you can very quickly rule in or rule out.

Some of these conditions and really be left with some specific conditions, that will also help you identifying the problem and that actually a diagnosis for the patient. And then You know, with in cases the type of hyperglycemia such as, you know, DKA, hyperglycemia itself is not a life-threatening condition, but it would be nice to know about this problem and also, you know, diagnostically important if you want to continue and treat the patients correctly. So the next component is the sorry, the BUN sticks that we use and, like I said before, we decided to, to also add the, the dip stick and specific gravity or specific gravity and the main key question here that we're trying to understand initially is whether our patients are aotemic or not.

And for that, we have a semi-quantitative. Stick and stick that we use and within 90 seconds, you can get a result that will give you some reassurance whether your patience is absolutely fine or if something is wrong, and then you can continue and provide other treatment or, or, or consider other diagnostic tools and that will help you further identify what the problem is. And the second question that you will need to answer yourself whether the patient is suffering from prerenal renal or post-renal issue, and I hopefully these, 2 or 3 tests that we do here will also help you rule in and rule out 11 of those components.

So it's important to remember that an increase of BUN with or alongside hypostenoia or iso tenuria is or might be considered as a kidney injury. obviously, you know, this is one, this is the, the main reason why we are testing this check but also What and again very sensible to remember that there are other conditions that might appear in the same way such as hypercalcemia, hypo or hyper adrenal corticism or Cushing disease and Addison disease, and even just a UTI might appear or might have, might give you the same results. So I would not sign any of my patients off as a result of this very kind of initial screening tests.

For me, the way I interpret these results, for me is I don't understand if something is right or wrong. If something is right, I'm Happy. If something is wrong, I need to do more investigation.

It would be very sensible to put them on fluids and again, check the trends of what these tests are doing or consider further diagnostics. But again, I'm, I'm using this test as a screening test rather than to To decide prognostically what I'm going to do with these patients. So the last component of the database and that we would highly recommend, not many practises use this tool.

However, again, like I said, you know, I'm, I'm very passionate about Lactech. I, I love Lactate. I think it's an amazing tool and Hopefully you will feel the same in a couple of minutes.

And it really is a great tool and help us in answering the question whether your patients, our patient is in shocks or hyper perfusing or not. So we know that normally the during aerobic respiration, we know that the body utilises glucose as part of the crab cycle. However, with any insult to tissues where the body, the tissues are starving for oxygen and they don't have enough oxygen, the body is trying to kind of in its last kind of efforts, trying to utilise the glucose that it has and produce as much energy.

It's not as great as with oxygen, but try to produce oxygen as much as it can. And without oxygen, pyroate doesn't go into the crab cycle to the TCA cycle and is converted to lactate as a result or as part of the process of producing energy. And, and lactate is a very, very small diffused molecule that just diffused to the circulation very, very quickly and can be measured very quickly within seconds in the circulation.

Of in the area or just systemically of a body that is suffering from hypo perfusion. At the same time, When profusion is restored, lactate is metabolised very quickly in the liver within the Cori cycle as you can see in front of you and very, very, very quickly is being discharged from, from the circulation and, and therefore lactate provides a real-time marker for profusion status because it's been produced very quickly and being . Been metabolised and disappears very quickly.

So it's a real-time marker. So the, the, the, the, the, what I'm trying to kind of to show on this slide is, is firstly, just to remind you that one. One measurement of lactate should not really be, be used to prognostically and decide what you're doing with your patient.

You know, we know that we have many conditions that lactates. Will not necessarily one measurement or a lactate will not necessarily give you the answer that you want. You will need to to check the trends and lactres like I said before, and you want to make sure that you keep on monitoring lactate and understand what lactate is doing while you are providing the treatment that you.

That you think is, is most appropriate for your patient. And alongside your clinical examination, lactate can really give you an idea of the severity of, of the shock that you are dealing with. Because, you know, depending on your clinical examination, your body major body system examination, you can, based on that alone, decide whether you are, you, you think you're dealing with mild or moderate or severe shock when you check the lactate if the measurements fit.

With your clinical examination, you, you know, you, you, you, you have some reassurance that your, your clinical examination is It is appropriate. If there is any discrepancy, then you need to think, you know, what the reason is and, and we know for example in fitting patients, in patients that has, have Hi Muscle activity and oxygen demand, we know that the lactate might not, the lactate levels might not be As expected, as with kind of patients that don't have this condition, and they might be deceiving and might kind of not kind of give us the right answer that we want. So obviously, lactate needs to be Considered and interpreted in context with what your clinical examination gives you.

So when you should consider lactate, so any, any patients that come to you with mild to moderate tachycardia and you know, you have those, patients that might have suffered from an RTA, might been been involved in an RTA, you don't necessarily know if the Patient is painful, is tachycardic, sorry, because they are painful or because they are bleeding. Obvious pain relief should be prescribed, but at the same time, it would be very, very sensible for those patients to check lactate and understand what the lactate is doing and whether the tachycardia is due to pain or stress or genuine because the patient is now breathing internally and you can't see it still, and you might see it later and you do, you don't, you wouldn't want to miss that. Any critical, a critically ill patients obviously would benefit from lactate and Measurements of coactates and to understand the trends.

Like I said prior to GI and sedation, I would definitely want to know what the lactate does. I want to understand if the patient is hyper perfusing or not, and I would want to correct the lactate as much as I can before GI because we know that the GI sedation will drop the blood pressure even further. So ideally I would want to start in GA or a sedation in the best state of the animal.

So correct it with fluids, improve the profusion, and only then if the emergency surgery is absolutely necessary, then I will perform the surgery. To monitor intravenous fluid treatment, also again, you know, very, very nice kind of tool to monitor fluids. You check the lactate before you start fluid therapy.

If the patient is in shock, then you provide a bolus treatment and then check the lactate again and it's very nice to see how the lactate. Improves. Obviously, if it's not, then you need to consider maybe other reasons, but it's very nice to, to see how the patient how the lactate improves as a result of your fluid therapy and then you can decide whether you want to stop, increase, decrease, make any changes with your fluid therapy, .

And alongside, you know, the, the, the, the, the blood results that you get from the lactate. And again, you know, any metabolic acidosis, that would be a very nice tool kind of to give you again some reassurance, that the patient is suffering or not from acidosis which will dictate how you treat the patient later on. So I just wanted to finish off with a couple of examples just to convince you if I haven't so far, where minimum database would be appropriate.

So that was a seven year old dog that came to one of the clinics out of hours was just not ain't doing right, that's ADR. I forgot to mention that before, so ain't doing right. It was quite, it wasn't quite right.

I mean, you can from the physical examination that things are not that bad or at least don't appear to be that bad and there obviously were quite, quite a few options given to the owner. It was decided, had been decided that only pain relief and monitoring at home would be appropriate for the patient. However, unfortunately, this patient returned the morning later with acute.

Bleeding, hemo abdomen and was operated that morning and unfortunately, was, was euthanized due to a splenic mass, on the day. So I guess if, looking at the case retrospectively and trying to kind of reflect on what could have been done differently in this case. I guess for this type of breed, 120 heart rate for me would be a clue maybe that something is maybe not quite right.

So I would consider a minimum database for this dog and potentially what we could have seen, we would have seen maybe slightly drop in total solids if not a drop in PCV as well, and a lactate might, might have given us some clue that something is going on and Probably following that, I would consider abdominal scan and to do a point of care ultrasound scanning. And maybe this patient would have could have been identified with the hemo abdomen area stage and the outcome could have been a bit different. The other example is another case, and again I, I think everyone can probably appreciate that this kind of this, these kind of cases you see almost on a daily basis, you know, these kind of young, young.

Male kind of dogs coming, has been vomiting for three days, just a bit . A bit sad, but otherwise, his, clinical examination was largely unremarkable. And you would, you would think, you know, you, you could have just kind of treated symptomatically with Marroritan you know serenia subcot and send it home for monitoring.

However, in this case, the vet, . Felt that something was not quite right. They decided to do a minimum database with the minimum database test.

The only test that was not quite right was the BUN. The BUN was quite, quite kind of markedly elevated, that had triggered the VET team to perform more diagnostic tests. This patient, .

Eventually was diagnosed with acute kidney injury was then Transferred to another centre and had a hemodialysis done and actually survived the the acute kidney injury. We don't know what the reason was, what the, or the underlying cause for the reason, suspect intoxication of some sort. But again, just to show you how a very simple minimum database blood test with just a BN stick have identified this life-threatening condition that could have resulted in the patient developing acute renal failure at home and might have died because of that and again something that has or had been avoided thanks to the minimum minimum database blood test.

So in summary, again, the tests are very, very simple to, to, to run, and very quick to run. You get the answers within seconds, if not minutes. We talked about the cage side approach.

We are using equipment that can be brought to the patient rather than to rather than taking the blood or the patients to the another room or to the lab. They are very, very cheap, relatively inexpensive, but holds very, very good value for, for the, for your client's money and we know that, you know, cost is important and it's important to communicate and Justify the test that you do and people want to make sure that they could, they get good value for money rather than necessarily kind of spend a lot of money on, on, on their patient and you know, money is not necessarily an issue if they feel that they good good value for your money and this test is definitely not very expensive and And, and hold very good value. Like I said before, these tests require a small volume of blood.

They are repeatable and comparable. We can, what, what we would normally do, we would advise to do, to run a minimum minimum database on admission and then run a more minimum database and blood tests every. A few hours or depending on the case, it can be a few minutes, but we can repeat them, they are comparable.

We're using the same machine, so statistically, you know, we know that we can compare the results and at times, you know, it allows us also to have a diagnosis and provide the best treatment and monitoring plan for our patient. Again, so just a reminder, we have many diagnostic tools at the emergency setting. Minimum database is one of them, and today we discussed the approach to the emergency patients, and the emergency diagnostic tools that we haven't specifically the minimum database which can allow us, .

To identify any life-threatening conditions, which will then, as a result will allow us to provide the best possible life saving treatment plan for our patients and give them the best care that they need. And the bottom line is that we save lives and, and hopefully by using this approach and using these diagnos diagnostic tools that you can introduce to your clinic if you don't have one, you will be able to do the same. So thank you very much.

Thank you for listening to, to me today. I would like to obviously thank to to thank to Amanda Bogue, our clinical director who helped with building this presentation and and to thank you for listening to us as well. Thank you very much.