25 Sept 2017

Benefits of peer-to-peer vet learning

Emily Simcock ponders when we ever formally reflect on our technical or communication skills with another veterinary colleague after graduation?

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Emily Simcock

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Benefits of peer-to-peer vet learning

“What is the best farm vet you have ever worked with?” was a question posed to me by a veterinary colleague. After some thought, I couldn’t answer.

The problem is, we rarely see other vets in action on farm. Sometimes we have informal discussions or may see follow-ups of individual cases and herd health management. Occasionally, jobs may be done together for teaching or unusual surgeries, too. But, on the whole, practical farm work and consultancy go unwitnessed.

Clinical protocols can, hopefully, help guide work methods within a practice towards an approach based on evidence, and documented case reviews contribute to clinical governance. However, when do we ever formally reflect on our technical or communication skills with another veterinary colleague after graduation?

Open to change

I have witnessed fantastic analytical work from production vets who can drag important trends from records. I am in awe of those who come up with comprehensive differential lists and work through the possibilities in a systematic way.

Some vets are heroes of surgery, but I don’t think I know how most people approach a basic clinical exam on a cow. I had a colleague employed largely for TB testing seeing some clinical practice with me several years ago.

We saw an adult dairy cow with a fractured, dislocated fetlock. Perhaps because my era of time seeing farm practice coincided with the slaughter certificate, aka “a ticket”, my advice was emergency slaughter.

Figure 1. The heifer mid-surgery with the author‘s colleague starting to exteriorise the uterus.
Figure 1. The heifer mid-surgery with the author‘s colleague starting to exteriorise the uterus.

My colleague had a background where individual cows had much greater value and was keen to intervene. The cow was sedated, the dislocation reduced and a cast applied.

For several years afterwards I saw this cow with no residual lameness calve and contribute to the herd. She provided me with a reminder that value might exist in attempting treatment, and also be open to reviewing our entrenched ways.

In addition to formal CPD, I am sure immense value exists in seeing peers at work. It would take trust and respect for me to have my methods, adopted mainly through years of anecdotal experience, come under scrutiny – but, undoubtedly, it is a process we should be open to.

I hope being part of a group of veterinary practices will create more opportunities for experienced vets and graduates to appraise their clinical practice.

No cow, no fee

Opportunities for surgical intervention beyond caesareans and abomasal surgery are uncommon, and I have often made a judgement that the prognosis doesn’t warrant the economic cost of attempting surgery.

The problem with this approach is we may not gain the surgical skills to improve the prognosis of similar cases or never confirm a diagnosis.

An experience from a postmortem of a Highland calf that presented with recurrent bloat and inappetence has motivated me to attempt surgery more frequently. On that occasion, a large trichobezoar was found obstructing the pylorus and it seemed likely a rumenotomy may have resolved the problem, had it been attempted.

Where the farmer doesn’t want to risk the cost of surgery for a poor or unknown prognosis, I sometimes offer a no cow, no fee option. This is where the farmer pays for drugs only if euthanasia is required or the surgery performed is unsuccessful.

The full fee is paid if the surgery is successful – although the definition of success needs to be clear in advance. It may be undervaluing our skills and time, but it is often the only way to get more experience opening cases up.

Tried and tested

CPD that focuses on practical techniques given by someone who has tried and tested what he or she is teaching is just brilliant for me. I was really fortunate to listen to a talk by Eoin Ryan, from University College Dublin, on large animal anaesthesia techniques.

Two of the many nuggets of greatness in this lecture particularly stuck with me. One was the addition of xylazine into epidurals for mild sedation for obstetrics without noticeable effects on the calf. I am a big fan of making beef caesareans safer and this is now my standard anaesthesia technique.

The second gem was a description of a technique for caesarean section of a fetid fetus by making a large J-shaped incision following the costal arch in a recumbent cow with uterine exteriorisation. Success rates of 80% were reported.

I supported an inexperienced colleague called to such a case: a big beef heifer having shown no distinct signs of calving had a large, fetid calf inside. The cervix was contracting and severe tendon flexure was preventing the calf’s forelimbs engaging in the pelvic canal. Embryotomy was attempted unsuccessfully due to limited access and increasing vaginal oedema. The presence of two vets, a need for my colleague to gain more experience and my keenness to attempt the method described prompted a no cow, no fee offer.

Figure 2. The same heifer pictured in Figure 1 two weeks later at stitches out, with both her and her adopted calf doing well.
Figure 2. The same heifer pictured in Figure 1 two weeks later at stitches out, with both her and her adopted calf doing well.

I can’t say my method exactly matched the one described, but we heavily sedated the cow and got her down on her side. We had a strop on the left hindlimb because she kicked relentlessly, despite the anaesthesia and analgesia. A combination of inverted L block and local infusion for the ventral part of the incision was used.

I can only feel embarrassment at my attempts to drape this heifer. She had to be the one who lies out of a cubicle and was caked, but my efforts were unhelpful at best. Using large adhesive drapes or many more towel clips are clear improvements needed for next time.

The shape and length of the incision allowed near complete exteriorisation of the uterus. We removed the fetus with minimal abdominal contamination, and lavaged the wound edges and uterus with copious volumes of potable tap water (a big, non-sterile bucket full, in honesty).

Kits were changed and I scrubbed up again for suturing, with sterile saline used to lavage the sutured uterus and wound edges.

Perioperative IM antibiosis was used (penicillin and streptomycin), but I did also add in the possibly more traditional method of emptying the rest of the bottle into the abdomen and over the incised muscles – evidence base unknown.

Aside from the kicking (with associated swearing) and time for suturing, this, technically, was one of the easiest caesareans I’ve done this season, with abdominal access and competent help making a huge difference. Carrying out many postmortems has also improved my surgical skills.

Figure 1 shows the heifer mid-surgery, with my colleague starting to exteriorise the uterus. Figure 2 is the heifer two weeks later at stitches out, with both her and her adopted calf doing well. She recovered unremarkably.

It was a much better outcome for the farmer than a knackery yard bill, and fantastic experience for my colleague and me. We had a good conversation about how we approached this calving and any ways to do things better.

I’ll definitely use this technique again, too, but only with enough kit and suitable help. After all, postponing for a few hours is unlikely to affect the outcome.

My thanks go to Eoin Ryan for his excellent CPD presentation. You are right up there on the “best farm vets” list, should anyone ask me again.