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Veterinarian Technician June 2011 (Vol 32, No 6)

Inside Behavior: Ten Quick Ways to Improve Patient Handling

by Alicea Schaeffer, BS, RVT, VTS (Behavior), KPA-CTP, CPDT-KA

    “Primum non nocere” (first, do no harm) is the first rule of medicine. Veterinary professionals often hear this regarding topics such as elective surgery or pharmaceuticals, but not patient handling. I often hear that there is not enough time to desensitize fearful patients to veterinary procedures. However, with most patients, the principles of operant and classical conditioning can be applied as quickly as restraint. Every interaction with a patient is a training session for the patient, regardless of whether you intend it to be. Here are 10 quick ways to improve patient handling.

    Give Treats (if Possible)

    Food is the most basic reinforcer for animals, so giving treats is a quick way to countercondition patients in the examination room. If you give your patients treats, they may think something like the following: The examination room equals treats; therefore, I like the examination room. To incorporate treats in your patient care, ask clients not to feed their pets for a couple of hours before bringing them in and to bring some of their pets’ favorite treats. Every staff member who enters the examination room should give the patient a treat. If the patient readily takes treats from the hand, continue to give them that way. If the patient does not take treats from the hand, simply drop them on the floor or table near the patient. Keep plenty of different treats available. At my clinic, the examination rooms have small soft and hard treats in a jar on the counter so that they are easily accessible. My clinic also has peanut butter, liver paste, hot dogs, cheese, and cream cheese if highly valued treats are needed. To reduce the risk of vomiting and aspiration, treats should not be given before sedation or anesthesia. If treats cannot be given, plenty of verbal praise and petting should be used.

    Giving treats can provide useful information to patients and the veterinary staff. Providing a treat at the correct time tells a patient that you like a behavior, increasing the likelihood that the patient will perform it again. A patient that accepts treats has a stress level that is low enough to allow training. A canine patient that has not eaten for a couple of hours is most likely very scared if it will not eat a palatable treat such as peanut butter or a hot dog; in this case, stop what you are doing and find a less stressful starting point for the patient. 

    Use No-slip Mats

    No-slip mats can be a dog’s “best friend.” You have probably seen dogs on slippery examination tables: their eyes widen as their feet slip out from under them. When a patient begins to panic, it is hard to stop and can work against you. However, slipping and the panic it causes can easily be prevented. No-slip mats on examination tables, radiograph tables, scales, and slippery floors can decrease patient anxiety and discomfort, especially for arthritic patients.

    Use Low-stress Handling Techniques

    Veterinary visits can be very stressful for nervous or fearful cats and dogs. Patient stress can be reduced by leaving cats in their carriers for as long as possible and by not approaching fearful dogs. To enjoy petting, many animals need to have a history of trust and reinforcement. Staff members should avoid petting dogs and cats that indicate that they do not want to be touched. If a patient does not approach you willingly, do not force the issue. However, when it is time for the physical examination, be expedient without using quick movements that might scare the patient; if necessary, give the patient a break from physical contact. When examining cats and birds, perform as much of the examination as possible with your eyes before handling the patient. To decrease the amount of touching, try to limit the number of helpers.

    To weigh patients in a low-stress manner, weigh cats inside their carriers and use food to lure dogs onto the scale. When the doctor needs you to remove the cat from its carrier, weigh the carrier without the cat and subtract the carrier’s weight to obtain the cat’s weight. Ask the client if you can write the carrier’s weight on the carrier (or tape it to the carrier) so that the weight is visible for the next visit. If a client puts a towel or bedding in the carrier, it must either be removed before weighing the cat in the carrier or be weighed separately so that the result can be subtracted from the cat’s weight. If a cat is cowering at the back of its carrier, do not shake it out onto the table or grab it by the scruff to remove it. Instead, remove the top of the carrier, if possible. If the cat is stressed enough to react, lay a towel over the cat while it is still in the bottom portion of the carrier. Keep the towel on top of the cat as you remove it from the carrier, and leave the cat under the towel or let it hide its head in the crook of your arm.

    Reduce Environmental Stimuli

    Environmental stimuli should be reduced to help decrease patient stress. This is important for cats but can also help nervous dogs. For example, do not talk loudly while drawing blood. For nervous cats, lower the lights, turn off music, and use a small, quiet room instead of a busy room.

    Removing a cat from the examination room and walking it to the treatment room can elevate the cat’s stress level. At my clinic, all blood draws are performed in the examination room; clients who do not want to be present are welcome to go to the lobby for a cup of coffee. If you need to relocate a cat, wrap it in a towel and block its view of the hospital. Before you move the cat, ensure that the place you will be taking it does not have activity that will elevate the cat’s stress. Prepare anything you will need for the procedure so that you can begin immediately after the cat is moved. If a cat is nervous enough to be wrapped in a towel, take a few seconds to listen to the sounds in the hospital: What do you hear? Are dogs barking in the kennel? Is someone vacuuming? The more that environmental stimuli are reduced, the better your feline patients will do.

    Remove Leashes and Choke Collars

    Owners of overly friendly dogs may keep them on a tight leash, which can increase a dog’s anxiety and desire to jump. Clients are often embarrassed by their dogs’ “bad” behavior, so they may punish their pets with a yank on the leash or slap on the rump. However, it is important for the examination room to be free of punishment. This will help you gauge how comfortable the dog is with you.

    Leashes must be used in the waiting area but can be removed (from patients without a known history of aggression) once the patients are in a secure, closed examination room. For dogs without a history of aggression, being unrestrained can reduce frustration. At my clinic, the staff also removes choke and pinch collars in the examination room. Some dogs may pull on their leash to approach you, but they might not approach once the leash is removed. Conversely, some nervous dogs (especially farm dogs unaccustomed to leashes) are more comfortable without a leash and will approach. In addition, when a dog is not on a leash, you have the opportunity to lure the dog with treats. Leashes and collars must be used when patients are being walked from one area of the clinic to another.

    Use Food Smells and Pheromones

    Smells can be our best “friend” or worst “enemy.” Unfortunately, most veterinary hospitals, even the cleanest ones, may smell the same to pets. As soon as pets enter a veterinary hospital, they smell all the reminders, including disinfectant and fear pheromones, of previous aversive experiences at a hospital. You can increase good pheromones in your clinic in two ways. First, decrease the amount of stress in your patients: happy patients may produce “happy” pheromones. Second, use artificial pheromone analogues: plug in diffusers of these analogues in examination rooms and/or apply spray formulations of these analogues to towels used for restraining patients. In addition, the more that food reinforcement is used, the more examination rooms will smell like treats instead of alcohol.

    Understand Body Language

    It is important to understand what you are saying to patients through your body language and what patients are saying to you through theirs. Every time I give lectures on body language, I am amazed by the signals that veterinary professionals miss. We are savvy to aggression when it comes at our faces, but what about 3 minutes earlier? A bite rarely comes without warning. Learn how to read stress signals in your patients. When stress (also called conflict) behaviors occur, you should stop what you are doing. Common signs of stress in dogs include yawning, an averted gaze, “whale” eyes, scratching, “wet dog” shaking, paw lifting, low and stiff tail wagging, and lip licking. Once conflict behaviors appear, the patient is feeling conflicted and trying to decide what to do next. If the veterinary staff stops or slows down what it is doing to decrease conflict behaviors and increase positive reinforcement, the patient is less likely to display aggressive behaviors. Fortunately, giving treats usually decreases—and does not reinforce—fear. However, being “pushy” about presenting treats can heighten fear in patients, no matter how desirable the treat is. In addition, staff members should avoid looking dogs and cats in the eyes.

    Keep Large Dogs on the Floor

    Most large dogs are not used to being picked up, and they are much more comfortable on the floor instead of an examination table. Putting a large dog on a table can scare it into holding still, but the patient’s fear can have undesirable effects. When placed on a table, many large dogs stop accepting treats because their stress level is too high. In addition, large dogs can be difficult to restrain on a table. So keep large dogs on the floor, and get down to their level.

    Pick Your “Battles” With Your Patients

    You may not win every “battle” with your patients, but the outcome of the “war” is what counts. This is especially true for nervous or fearful patients, but it also applies to patients that seem happy to see you. Just because you can hold down a “happy” Labrador retriever to take its temperature and use a fecal loop does not mean that the patient should be held down. To avoid giving the patient an aversive experience, use as little restraint as possible.

    Unless you work in an emergency clinic, you will probably handle most patients again, so it is important that they have the best experience possible. If a patient’s stress level is increasing, stop what you are doing! Many examinations and procedures can wait. Give the client some home training tips or drugs to reduce the patient’s anxiety at the next visit. At my clinic, if a patient requires a muzzle or more than one person for restraint, the staff members stop what they are doing and talk to the client about a plan for the next visit. You need to be able to handle fractious patients at the next visit, so just because you can apply a muzzle does not mean that you should: how many veterinary professionals have been bitten trying to put a muzzle on a patient a second time?  Safety can be maximized and stress minimized in fear-biting dogs if clients get their dogs a correctly fitted, plastic basket muzzle. To accustom the dog to a muzzle at home, the client should regularly put the muzzle on the dog and give the dog treats before removing the muzzle. If this is done, the dog will associate the presence of the muzzle with pleasant experiences.

    Keep Your “Cool”

    Admit it … you have witnessed a staff member lose his or her temper with a patient, which can lead to overrestraint or rough handling. A patient that has had a bad experience at a veterinary visit may have learned that a good offense is the best defense. Most aggression toward veterinary staff is fear based and has a learned component. For example, two staff members who “sit” on a dog to perform a toenail trim will almost certainly increase the dog’s anxiety. If the dog wiggles free or bites someone, the toenail trim ends and the dog has learned how to stop it next time. My clinic is increasingly seeing aggressive dogs from other clinics that have used muzzling and forceful restraint, causing patients to become terrified of the examination room. After a few “happy” visits at my clinic, most of these dogs do not require muzzling or forceful restraint. Some of these patients are even excited to see us!

    Conclusion

    These tips can be implemented quickly and should be applied to every patient—not just fearful cats and dogs. Decreasing patient stress can decrease stress in clients and the veterinary staff. Changing the norms of any clinic can be a slow process, but if you implement these tips, other staff members who see the changes in your patients and clients are likely to ask for your advice.

    In the author's credentials, KPA-CTP stands for "Karen Pryor Academy certified training partner" and CPDT-KA stands for “certified professional dog trainer—knowledge assessed.”

    NEXT: Snake Envenomation

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