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How can I be a Patient Advocate in Pain Management for Exotics and Zoo Animals?
Mary Ellen Goldberg BS, LVT, CVT, SRA, CCRVN, CVPP, VTS-lab animal medicine (research anesthesia),
VTS – physical rehabilitation
mewhitester@gmail.com Vetscope 2019

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Where can I learn about Veterinary Pain Management?

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The First Patient Advocate
Florence Nightingale

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How do Human Nurses define Advocacy?
-The American Nurses Association (ANA) publication Nursing: Scope and Standards of Practice identifies advocacy for safe, effective practice environments as a responsibility of the professional nurse1,2
-Nurses can fulfill the role of patient advocate by determining the best interests of their patients and using their own voices to promote those interests.1
- Can we do this for our veterinary patients?

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The Veterinary Technician’s Oath The Florence Nightingale Pledge
-"I solemnly pledge myself before God and presence of this assembly;
-To pass my life in purity and to practice my profession faithfully.
- I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug.
-I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling.
-With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care."

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Veterinary Technicians and Nurses
Margo Monti
Stephen Cital

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Veterinary Technicians and Nurses as Advocates
-Veterinary Practice Pain Management Quality = Vet Tech Nurses
-Quality of patient care without the freedom to prescribe or initiate therapy.
-Knowledge of the physiology of pain and pharmacology of analgesics is essential.
-The skilled technician is a source of vital information required to choose and administer appropriate analgesics.

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Communication is Vital!
-Vet Nurses use critical thinking, observation, and interpretation skills to make important pain management recommendations.
-Based on his or her interaction with patients, the technician may offer suggestions for adjustments in analgesic regimens, changes or additions to drug protocols, or the possible addition of sedatives, if needed.
-Must accurately assess how painful the patient is.
-Plus why or why not additional analgesics could be beneficial.

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Palpation is a skill

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Allowing the Technician or Nurse Additional Freedoms
- Giving technicians greater choice and control over pain management involves trusting their judgment and experience.
- After standing orders are established, the success of pain management relies on giving skilled technicians the freedom to:
1. give analgesics as needed
2. to adjust dosages when required
3. to administer adjunctive medications
4. to potentially reverse drugs when severe adverse reactions occur

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Trust Must Be Established
-Creates a positive team environment in which their thoughts and skills are valued.
-Patients ultimately receive better care
-Nurses are doing everything they can to ensure the well-being of patients in their charge.

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How Stress and Pain Intersect
Comfort represents a state of well-being, where the animal is contented and relaxed.

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How Stress and Pain Intersect
Stressors acting upon the animal in increasing severity cause the animal to progressively become uncomfortable (Discomfort), then stressed (Stress), and finally distressed (Distress).

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How Stress and Pain Intersect
The animal may adapt successfully to a stress (Adaptive Behaviors) or it may become distressed in a way that threatens its well-being or health (Maladaptive Behaviors).

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Maladaptive Behaviors Include:
-Abnormal feeding
-Absence or decreased grooming
-Changes in social interaction (aggression, withdrawal)

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Signs of Pain and Distress
-Changes in temperament or attitude; a friendly, docile animal becomes aggressive or unresponsive
-Restlessness; pacing, changing position frequently
-Decreased activity; reluctance to move, does not respond normally when approached
-Isolation; stays in the corner of the cage, does not interact with cage mates
-Change in posture; hunching, huddling, crouching, stiff movement, head down
-Protecting a part of the body; growls or attempts to bite when that body part is approached or touched

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Porphyrin Staining in Rats

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Signs of Pain and Distress
-Abnormal vocalization, especially when a painful area is touched; whimpering, hissing, squealing, squeaking
-Change in appetite and water consumption leading to weight loss and dehydration (in small rodents, dehydration causes rapid weight loss)
-Self-mutilation, excessive licking of the area, biting, scratching, rolling, kicking
-Changes in hair coat appearance; decreased grooming leading to rough- looking coat, greasy appearance, piloerection (hair erect), loss of hair (baldness, hair shafts broken)
-Changes in facial expression; sleepy appearance, avoidance of light

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Self Mutilation
-Very common in certain bird species

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Signs of Pain and Distress
-Discharge from eyes (tears, pus, blood) or nose (runny)
-Changes in bowel movement or urination; diarrhea with soiling around the anus, or lack of bowel movements (constipation)
-Sores, reddened areas on the skin, open wounds
-Increased body temperature
-Changes in respiration rate or character; rapid, shallow breathing

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Stereotypic Behavior that could lead to Distress

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Non-Human Primates
-Osteoarthritis
-Kyphotic Spine in Geriatric Primates
-Key Signs: hunched position, failure to groom, refusal of food or water, dejected appearance

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Zachary
-Zach dislocated elbow, tried to fuse but was unsuccessful. On gabapentin for pain and walks upright.

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Scientific Poster Session IAVRPT

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This is your patient’s Intelligence

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Mice
-Key Signs: withdrawal, biting response, piloerection, hunched back, sunken eyes and abdomen, dehydration, weight loss.

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Mouse Grimace Scale
-The Mouse Grimace Scale is taken from the paper, Langford DJ et al. Coding facial expressions of pain in the laboratory mouse. Nature Methods June 2010 7(6) pg 448. In the MGS, intensity of each feature is coded on a three-point scale. For each of the five features, images of mice exhibiting behavior corresponding to the three values are shown

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Rats
The Rat Grimace Face is taken from Sotocinal SG et. al. The Rat Grimace Scale: A partially automated method for quantifying pain in the laboratory rat via facial expressions. Molecular Pain 2011, 7:55
-Key Signs: vocalization, struggling, licking/guarding, weight loss, piloerection, hunched position, hypothermia.

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GUINEA PIGS
-Key Signs: withdrawal, vocalization, failure to resist restraint, staring coat, unresponsive.
hunched posture: “tucked-up” abdomen, scruffy coat, weight loss, and general ill appearance.

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Mongolian Gerbils
-Key Signs: hunched appearance, weight loss, shock syndrome.

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SYRIAN (GOLDEN) HAMSTERS
-Key Signs: weight loss, hunched appearance, increased aggression or depression, extended sleep periods

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Rabbits
-Key Signs: reduced eating and drinking, faces towards back of cage, limited movement, and apparent photosensitivity.

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Rabbit will Freeze if Anyone in room

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Rabbit Grimace Scale, Keating et al, 2012.

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Epiphora and a depressed attitude may be associated with pain in rabbits

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Ferrets
-Key Signs: Stiff posture, demented behavior, lack of grooming, hunched head and neck, and inappetence

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Ferrets in pain or sickness
-Sleepy look
-Not grooming
-Anorexic and not drinking
-Not active

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Ferret Grimace Scale

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Birds
Birds 30 year old penguin at Buffalo with OA.
-Key Signs: Escape reactions, atonic immobility, inappetence, and avoidance of use of pain site

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Painful Birds

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Reptiles
-Key Signs: flinching and muscle contractions, weight loss, anorexia.

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Lizard with light Burn

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Tortoise HBC and Boa with Rat Bites

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Shell Trauma
Lance had his shell healed using a vacuum (VAC) system. Dr. Elizabeth Hammond ACZM at Lion Country Safari 100+ years Aldabra Tortoise

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Egg Bound
-This tortoise has a large bladder stone that acts as a ball valve in the pelvis, blocking the passage of eggs.

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Amphibians
-Key Signs: Muscular movements, closed eyes, color changes, rapid respirations, immobility, and anorexia.

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Red Leg in Frogs
-Bacterial dermatosepticemia, is one of the most common clinical conditions of captive frogs.

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Fish
-Abnormal swimming behavior, attempting to jump out of water, rapid opercular movements, clamped fins, pale or darkened color, and hiding. Anorexia is the first sign.

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Swim Bladder Disorder refers to issues affecting the swim bladder, rather than a single disease. Although most commonly seen in Goldfish and Bettas, it can strike virtually any species of fish. In this disorder, the swim bladder does not function normally due to disease, physical defects, or mechanical/environmental factors. Affected fish will exhibit problems with buoyancy. Interestingly enough, not all fish possess a swim bladder, most notably sharks and rays. Swim Bladder Disorder is usually caused by compression of the swim bladder. The most common cause of swim bladder compression is a distended stomach from rapidly eating, overeating or gulping air. Eating freeze-dried or dry flake food that expands when it becomes wet often leads to an enlarged stomach or intestine. Do not feed for 3 days, then feed skinned peas Increase water temp to 80 Lower the water level to make it easier to reach the surface Hand feed during treatment, if needed Use broad spectrum antibiotic if indicated
Physical Rehabilitation for fish

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Invertebrates
-Protozoa grouping (like of convenience) the worms, an arbitrary
-Sponges (Porifera)
-Stinging jellyfish and corals (Cnidaria)
-Comb jellies (Ctenophora)
-Flatworms (Platyhelminthes)
-Round- or threadworms (Nematoda)
-segmented worms (Annelida)
-Insects, spiders, crabs and their kin (Arthropoda)
-Cuttlefish,snails, mussels and their kin (Mollusca)
-Starfish,sea-cucumbers and their kin (Echinodermata)
-Key Signs:
Invertebrates: Rapid withdrawal.

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Cephlapods

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Zoo Animals
-Behavioral changes, appetite changes, animal isolation from their group or pack, aggression, lameness, unkempt appearance, or lowered head.

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Llama
Eye ulcers (corneal abscess) common from scratching against posts/trauma. Treat with atropine, Triple Abx, Banamine (NSAID with good eye perfusion, SSD)

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Waterbuck
-Interdigital lesions and heel bulb sores
-Teeth issues manifest as loss of body condition.
-One male has a “knocked up” hoof from overextension of the flexors.

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Lion - Panthera leo
-Tsavo and his Pride
-Safina recovering from surgery
-Pyometra

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Siberian tiger (Panthera tigris altaica) Must be treated same as other feline species

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Watusi Cattle

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Zebra

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Indian Elephant
-This female Asian elephant is showing disengaged behavior after being struck by her mahout multiple times. Notice the lax trunk, partially closed eyes, and ears lying flat to the body. Source: Courtesy of Stephen Cital.

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Giraffe
Mary Ellen Goldberg

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Mouflon
Necrotic horns that break off

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White rhinoceros

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African Elephant and White Rhino

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Chimpanzee and White Gibbon

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Marine Mammals
Dr. Tonya Clauss and Snooty

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Flamingoes and Stork

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Sarus Crane Chick and ME

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Winston at San Diego Zoo

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Giraffe and Chris White

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Thank you