005 Pain: Recognize and Advocate For Veterinary Patients

Our job as technicians is important. We are the voice of our patients. This week Yvonne and Jordan discuss how to recognize physiological and behavioral signs of pain in your patient and advocate for their needs while under your care.  

Show Notes:

Join Yvonne Brandenburg, RVT, VTS SAIM and Jordan Porter RVT, LVT, VTS SAIM as we talk about:

• Recognizing behavioral and physiological signs of pain in your veterinary patients, and how to advocate for your patient.
  
  
  
   Resources We Mentioned in the Show 
•    IMFPP Blog Post: 
  • https://www.internalmedicineforpetparents.com/blog/topic-of-the-week-pet-pain-education
•  CSU Pain Scale:
  • https://www.researchgate.net/figure/Colorado-State-University-Canine-Acute-Pain-Assessment-teaching-tool_fig1_49661913
  • http://csu-cvmbs.colostate.edu/Documents/anesthesia-pain-management-pain-score-feline.pdf
• American College of Veterinary Surgeons:
  •  https://www.acvs.org/small-animal/pain-management
• IMFPP Journal:
  •  www.imfpp.org/journalonemonth
• Small Animal Internal Medicine for Veterinary Technicians and Nurses by Linda Merrill
  •    www.imfpp.org/saimbook

Want all of the different handouts and forms we talk about on the show? Sign up for our mailing list at https://imfpp.org/joinus and get your password to access the site.

Thanks so much for tuning in. Join us again next week for another episode! 
 
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Thanks for listening! 
– Yvonne and Jordan 

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Transcripts of the Episode

005 Pain: Recognize and Advocate for Veterinary Patients transcript powered by Sonix—the best audio to text transcription service

005 Pain: Recognize and Advocate for Veterinary Patients was automatically transcribed by Sonix with the latest audio-to-text algorithms. This transcript may contain errors. Sonix is the best way to convert your audio to text in 2019.

Yvonne Brandenburg, RVT, VTS SAIM:
Welcome to the Internal Medicine For Vet Techs podcast. If you haven't joined us before, we're passionate about all things internal medicine that affects our pets. We'll be discussing crazy internal medicine diseases, how to work closely with pet parents, and how to be the best tech we possibly can. Let's start the show.

Yvonne Brandenburg, RVT, VTS SAIM:
Hey, everybody. Welcome back to the Internal Medicine For Vet Techs podcast. We're super excited that you are still with us. So, I am Yvonne. I am the host. And then I am today joined by Jordan.

Jordan Porter, RVT, LVT, VTS SAIM:
Hello again.

Yvonne Brandenburg, RVT, VTS SAIM:
Hey.

Jordan Porter, RVT, LVT, VTS SAIM:
Hi.

Yvonne Brandenburg, RVT, VTS SAIM:
So we are going to be talking about pain today and I'm gonna let Jordan take it away this time. So, girl, why are we talking about pain?

Jordan Porter, RVT, LVT, VTS SAIM:
Well, we like to discuss pain and how to manage it in our patients. I think a lot of people think in internal medicine, you don't really come across that. But in general practice, you do probably a little bit more just considering broken bones and surgeries and everything in between. So, we wanted to kind of bring the topic about different pain management methods, what to look for, how to tell if your patients in pain, and then client education, of course.

Yvonne Brandenburg, RVT, VTS SAIM:
Wait, I going to say something really quick, though? I see plenty of pets be painful and internal medicine. I think people forget that things like pancreatitis is really, really painful, or IBD, you know, if their guts are painful. So, just what I mean by that is, you know, when you're in your day to day life, don't assume a pet is not painful because you're like, "eh, that doesn't seem painful." Really take a moment, step back, and assess your patients and talk to your doctor, and talk to your co-workers and be like, "hey, what's going on?" And talk to your clients.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
And if they're quiet, but they're normally a crazy dog. But you've never seen them crazy, you may not realize that that's abnormal for them. So yeah, I had to throw that out there. So, sorry.

Jordan Porter, RVT, LVT, VTS SAIM:
No, I agree. I definitely agree. I just think in general practice, you assume that the painful things are surgery or broken bones. But yeah. So, we'll discuss like what to look for so when you do have that, abdominal pain patient, you can kind of assess what the signs that they're showing to show you that they're painful.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. Perfect.

Jordan Porter, RVT, LVT, VTS SAIM:
So, why is pain bad? Well, according to the American College of Veterinary Surgeons, again, doesn't always pertain to surgeries, but they just made an article about it. After being in pain for a set amount of time, stress hormones are released as the pain continues. And when the downside of pain starts to outweigh, you know, keeping them quiet, everybody says that you kind of want to pet to be a little, at least I've heard this in the past, you want to pet to be a little painful so they don't move around as much and injure themselves more. So, when the pain starts outweigh those quote unquote benefits that I don't necessarily agree with, then the effects of pain can include, you know, your pet might stop eating or drinking, especially while in the hospital. It can increase their stress levels. They have poor intestinal function and poor mobility. So, they do not have the nutrient uptake that they should, even if they are eating. And then, of course, there's other risks like infection, increased risk of infection, and delayed wound healing. I don't think people know that if your pet is painful after a surgery, it will take longer for that to heal.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, I think that's really interesting, because if you think about stress hormones, one of the biggest ones of that is cortisol, and cortisol is steroids. We all know that a patient that is on steroids, especially long term steroids, they're going to be more susceptible to infections and wounds are not going to heal the way that they should. So, I think, remembering physiology and anatomy and stuff like that I think will help, too. And not just, you know. And I agree with you, by the way, I have worked with some, I call them the cowboy vets, they're just, "oh, yeah. No, we don't give, we don't give pain medications because we want the dog to be quiet.".

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Great. They're quiet. But there's other ways to do that besides making them be painful. Because things happen like, if an incision is painful, you potentially can have that animal start chewing at the incision and then open it all up. Right. So.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So yeah, there's definitely that.

Jordan Porter, RVT, LVT, VTS SAIM:
Well not to mention when they go home, you're going to have the clients complain that they do seem painful, they're restless, they can't get comfortable, they can't sleep, they're not moving around a whole lot. So, then they're urinating on themselves. And then of course that increases your risks for other complications, or they become aggressive especially. I mean, I've been bitten by a dog with an osteosarcoma because it was so painful. And, you know, you can't fault the patient for that. He came in for the osteosarcoma. So, of course, we started pain medication after. But on initial exam. He was extremely painful.

Yvonne Brandenburg, RVT, VTS SAIM:
Right.

Jordan Porter, RVT, LVT, VTS SAIM:
You know, so just pain management in general to kind of combat some of those behaviors is necessary.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, 100 percent agree with that. And it's important to also let our clients know these things as well, because I think they don't understand what the, you know, behavioral slash attitude change with our patterns might mean. They're you know, they may associate it with like, oh, well, we moved their favorite toy. And so now they're just quieter than normal. Well, that is possible. But we need to make sure that there's not something else underlying it, too. So.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly. I mean, pets exhibit so many different behavioral symptoms. Just to kind of tell you that they're in pain. I mean, cats are probably the worst at telling people that there's something wrong. As we all know. But kind of before we dive into all that, like the process of pain is a sensory process. I always suck at saying this word, but nociception is what it's actually called.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, I was to say it's nociception. Yep, we got it. All right.

Yeah. It usually takes me a couple tries.

Yvonne Brandenburg, RVT, VTS SAIM:
Good job you got it on the first try.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah. But it involves a series of just electrical events obviously starting at the site of injury. So, your dog is walking and steps on, I'm going to say seashell because that's what happens around me, so they say they step on an oyster shell and it cuts their paw.

Yvonne Brandenburg, RVT, VTS SAIM:
I'm so jealous by the way, I was going to say nail. You're like, "a seashell because I'm by the shore." Whatever.

Jordan Porter, RVT, LVT, VTS SAIM:
Make it a little bit more pleasant. And then that pain of, you know, the shell slicing the paw pad is then conveyed by signals to a brain, resulting in a perception of the pain from the brain. And the brain's like, "hey, your foot hurts." And then they start limping.

Yvonne Brandenburg, RVT, VTS SAIM:
And the really important thing to remember about that is the pain pathway. Right? So, it goes from the foot, but then it goes to the spine. And the spine does have a little bit of a regulatory effect that says, "is this worth sending up to the brain or is it no big deal?" And so that's important when we're talking about perception of pain and local blocks and those kinds of things. So, just kind of keep that in mind, too, when we're talking about pain.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
This could very well be the difference between the little Chihuahua that you look at it funny and it feels painful.

Jordan Porter, RVT, LVT, VTS SAIM:
Right?

Yvonne Brandenburg, RVT, VTS SAIM:
Versus the giant, I gonna say pit bull, because pit bulls never feel any pain. But they probably do. It's just their pain pathway that's responding differently. So, we just because they're acting stoic, it doesn't mean that the pain's not there. So, that's also an important reminder.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes, exactly. So, then we get in to the talking about the different signs of pain. So, you have behavioral signs of pain and then physiological signs of pain. So, this is kind of where it gets into the nitty gritty details of like monitor your patient, get baseline vital signs, get baseline how their behavior is when they walk into the clinic. Obviously, it's gonna be a little skewed because they're coming into that clinic. They're comfortable. But there are signs that you can tell the owner to watch out for when they get home, too. So, physiological signs of pain are changes within the body. So increased heart rate, increased respiratory rate, increased blood pressure. So that's kind of goes to where like you want to monitor those baseline vital signs, temperatures of dogs or cats anywhere between 99.5 to 102.5 degrees Fahrenheit, or for our UK friends, 37.5 degrees Celsius to 39.1 degrees Celsius is normal. You have a dog that come in that comes in and is showing signs of pain and has a fever of 103.1. You're going to want to take that into account as you start pain management to see if you can get that temperature down. It doesn't always necessarily mean like an infection of some sort. It could mean pain.

Yvonne Brandenburg, RVT, VTS SAIM:
Mm hmm. That's I think that's a big thing to remember. I relate it to internal medicine because that's what I do. You know, we have pets that come in with like immune mediated poly-arthritis. And sometimes the first thing that you see is all of a sudden, their temperature goes up, right? They're a little bit stoic, like they're still walking kind of normally. But all of a sudden, you know, you've had normal temperatures of like 101.7. But they come in this time and they're not, you know, being crazy. So, you can associate it with that. They still look normal, but maybe their temperature is 103.1. And you're like, "wait a second. Why is the temperature up?" It can be pain. So, it's funny that we don't always think that. You know, we always go, "oh, it's everything else." And it's like, but it can also be pain.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly. And then kind of goes, too, towards those cats that we come in with fever of unknown origin. You know, you got a really kind of evaluate to see if there is a painful aspect to it, not just the fever of unknown origin. It's not just like cystitis. I mean, it could be and their bladder is extremely painful. Then, of course, you spoke about the stress hormone release, so cortisol. You're doing lab work and you notice that the cortisol is through the roof, just everything else is normal. But for some reason you're running cortisol to rule out other diseases and you see that the cortisol is falsely increased because of that stress.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And that's part of the reason why that test isn't you know, you may you may do that test, but it doesn't guarantee that it's an adrenal gland issue. Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
That's why there's other tests to rule that out. But it is a stress hormone and we need to be careful with that.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah. Yeah. So, and then, of course, I mean, panting is a sign. So normal respiratory rate in a dog is between 15 and 30 breaths per minute while for a kitty cat, it's between 20 and 30. So panting it's kind of hard to assess because usually they come in there like you're panting and cats panting is always bad. But if their respiratory rate when they're quote unquote, resting is, you know, forty eight, then you might know that something's up. And then same with heart rate. I mean small dogs and cats vary. So, small dogs are around 140 to 180 beats per minute, while medium to large dogs can be a lot lower at 60 to 90 beats per minute. And then even if you have a very athletic dog, they can be even slower. And then for a cat, it's between 140 to 220 beats per minute. So, there's a wide range there of what's normal versus what's abnormal. But if you've seen this dog in the past and you're taking vital signs of normal physical exams, you should kind of get a baseline if they're normal is around 86 beats per minute and then they come in one day not acting. Right, and they have a heart rate of 140. Then you might have a clue that something's going on.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And to go along with that, you know, I know in my practice I see medical records. Right? We request medical records from our primary vets. And there's been numerous times where we'll get records and a patient has come in and their vitals aren't recorded.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, this is definitely a tech tip. Right? Every single time you put your hands on a patient and it comes in, it needs vitals, and it needs to be recorded in the medical record. Because we don't see these patients on a regular basis until there's an issue. Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So knowing what the normal vitals are when they're relatively healthy or they are healthy is huge for us. So just make sure to keep your medical records the best that they can. Right? We're trying to elevate our profession. We need to be professional and keep good medical records.

Jordan Porter, RVT, LVT, VTS SAIM:
Exactly. Even if it's not required by your doctor. I've worked for those doctors. It's not required every general practice. But just do it because you know, it's the right thing to do. You can easily get a temperature, pulse and respiration and a weight within like three minutes. So, you know, there's those tips and tricks that you don't have to count a whole minute to get that pulse. You can count fifteen seconds and multiply it by four. I've just gotten so used to it over the years that now I count six seconds and multiply it by 10. You know, there's tips and tricks to make it go quicker. And yeah, it's not as accurate as if I were to put an EKG on the dog and get a heart rate that way. But you're still going to have a general sense of like, yeah, the heart rate I got is 140, EKG got 142.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And the other thing to go along with that is you should have a stethoscope.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
Please have a stethoscope. And listen to your pets, because the more you listen, the more you're going to start catching things that sound different. And you may not know what it is yet. But you know, if you start listening to what normal is, you're going to start picking up on abnormal. You might pick up on a heart murmur that nobody else has picked up before or you may pick up an arrhythmia that nobody's heard before. And then you can talk to your vet. And I still do that. I go, "hey, I think I hear a murmur." Which you know, you can't diagnose it, you know, whatever. But you talk to doctor and be like, "hey, I hear a heart murmur, or at least I think I hear a heart murmur. Can you please take a listen and just make sure that I'm not hearing something weird?" And that's huge when you can start noticing that, like I remember I celebrated when I heard my first heart murmur.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah, exactly. And it's nice to especially if you're a veterinarian willing to tell you. "Yeah. You know what? Good job. That's like a grade one", which is super difficult to hear or, "No, I don't hear it this time. But next time I hear one, I'll let you listen.".

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
So, definitely try to take advantage of that.

Yvonne Brandenburg, RVT, VTS SAIM:
The other thing too with clients is that they don't have stethoscopes at home. Right. But I've had clients do a couple of different things. They can either, you know, put their hands on their pet's chest, sometimes they can feel pulses, but not very often. I've had clients do the whole put their cat up to their ear and listen. Right? So, they can monitor vitals at home as well and we'll put a link in the show notes about this. We have a good blog post that talks about how to monitor vitals at home.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, definitely.

Yvonne Brandenburg, RVT, VTS SAIM:
And the other thing, too, when you're talking to clients, I don't know about you, but I get this all the time from clients, "How do you know if they're painful at home?".

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
And I tell them animals do commonly one of two things, right? If they're painful, they'll either lay on their bed and not want to move unless you really coax them because they're painful. Right? So, it's kind of like us when you have a really bad headache, you're either laying in bed and you don't want to move and you don't respond to things the way you normally would. Or if you, you know, hurt your back, you're shifting around, uncomfortable, moving, and you can't find that spot that's great. So, I usually tell clients that, you know, a lot of times that's what you're gonna look for is either they're not moving as much as they normally would or they're moving way more than they normally would. Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
And those are subtle things that they could be doing. That's something that they can look for as well.

Jordan Porter, RVT, LVT, VTS SAIM:
One that falls under those behavioral changes. So, you have those physiological changes of the vital signs. Then you have those behavioral changes that you really want to look out for as well. Again, skewed being in the clinic, but tell your clients to look out for them, or if the patient's in the hospital for a couple days and on pain management, you want to look for these vital signs, or these behavioral signs. So, restlessness, like you were saying, or inability to move or reluctance to move. Trembling, weakness, of course. And then you have the droopy ears, the droopy eyes, hiding, self-mutilation like you talked about licking at those incisions, or sometimes in kitties, they stop grooming.

Yvonne Brandenburg, RVT, VTS SAIM:
Or excessive grooming, right?

Jordan Porter, RVT, LVT, VTS SAIM:
Exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
We see those cats come in with gut disease where they've just,

Jordan Porter, RVT, LVT, VTS SAIM:
licked all the hair off their abdomen.

Yvonne Brandenburg, RVT, VTS SAIM:
They're naked. Like you don't even have to shave or an ultrasound. So those are those are things to be looking for as well.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. And then, of course, agitation. I mean, I don't know about you, but I say a lot of bad words when I hurt myself and am very grumpy.

Yvonne Brandenburg, RVT, VTS SAIM:
No, I'm perfect when I hurt myself.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, you're just like, "oh, ow." So, it's just those things that you kind of want to look for behavior wise and you can even separate on the chart. You can say behavioral changes I'm noticing and then physiological changes I'm noticing.

Yvonne Brandenburg, RVT, VTS SAIM:
And it's good to remember too: subjective versus objective. Right? Subjective is more behavioral things that you might be noticing. And it depends on how you word it. But objective is: "this is their heart rate, this is their respiration rate, this is what we're noticing." So, just keep that in the back of your mind to when you're recording those things or talking to clients.

Jordan Porter, RVT, LVT, VTS SAIM:
Well, you are in charge as a veterinary technician of your patients' pain. So, when you feel like your patient's painful or not being adequately managed with their pain medications, you want to bring it to the veterinarian attention. The more information you give your veterinarian, the better. So, you need that. You can't just say, "hey, I think Fluffy's painful", and not say why you want to say, you know, "hey, Fluffy's restless temperature of 102.7, not really willing to eat or drink and not moving around too much aside from like not being able to get comfortable. Things are changing. And I think we need to increase pain management". And bring that to the attention of your veterinarian and come up with a plan together. You are responsible for watching that patient.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And that goes a huge way with your doctors. If you can give them concrete information to say this is why I think they're painful, they're more likely to listen to you than if you're like: "I think Fluffy's painful." They'll be like, "great. I'm glad you think that". Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Hopefully they're not doing that. But I mean, in the back of their head, that's probably what they're doing they're like, "OK, well, give me reasons for it". or ask them.

Jordan Porter, RVT, LVT, VTS SAIM:
Ask them if you want them. If they want you to do something, you give them all the reasons why you think Fluffy's painful. And then you say, "would you like me to check a blood pressure, too?" If the blood pressure is high, then yeah, the pet might be painful.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
You know, so if they want more answers as to why you think that pet's painful, try to give them a step as to, you know, I can do this to kind of help prove it. So, I think that's key. Communication is key when talking to your veterinarian and kind of speaking up for your pet. They can't do that. So, you need to be the one that can say, "hey, we need to increase this, or decrease it". You know, you got to have that balance of: is this dysphoria or is this pain?

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, yes. We've had that numerous times where like our surgical patients, especially like TPLO's, I feel like in my clinic where, you know, they get a nerve block and then they have surgery, and they're maybe running on a fentanyl CRI. And, you know, they gave him carprofen post-op because they're being good and doing multi-modal. And we'll talk about a minute. But, you know, they've got all that. And then they put the fentanyl patch on them to get it to kick in because it takes 8-12 hours. And then all of a sudden, you know, they're flailing and you're like, "OK, wait, is this because they're painful or is it because we've just given them a boatload of pain medication?" So that is hard to figure out sometimes if it's dysphoria or if it's pain.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Well, especially with the like the not moving. I mean, you're going to have drunk patients who are reluctant to move because they're dizzy. So, observation before and after medications are given is definitely key.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
Monitor changes. And it is a very fine line to kind of tell if your pet's kind of howling because they're dysphoric or because they're painful.

Yvonne Brandenburg, RVT, VTS SAIM:
Yes, definitely. Yeah. And then another part to talk about is going to be the spontaneous versus iatrogenic pain. And does everybody remember what iatrogenic means?

Jordan Porter, RVT, LVT, VTS SAIM:
I gotta say, that was something I freshened up on when studying for my VTS.

Alright. So, just in case you can't remember, what is iatrogenic again?

Jordan Porter, RVT, LVT, VTS SAIM:
So, iatrogenic pain is pain that is caused by us. So, when we say that, we mean like surgical procedures, declawing. If people still do that, it's still out there. Spay's, neuters, surgical fixing CCL tears, abdominal explores. There's a range between mild, moderate and severe pain that you cause. Obviously if you are doing a TPLO, that's probably going to be more on the moderate to severe side. Chest tubes are painful. So, it's pain that we cause that we want to manage.

Yvonne Brandenburg, RVT, VTS SAIM:
And then spontaneous is the pet or the animal's body has kind of caused it. You know, it's whether that's wounds or, you know, a pet with osteoarthritis. You've got the disc disease, back disease. I would even say things like pancreatitis.

Jordan Porter, RVT, LVT, VTS SAIM:
I mean, pleural effusion gotta to be uncomfortable. Yeah, cancer. Cancer can definitely be painful.

Yvonne Brandenburg, RVT, VTS SAIM:
Cancer can to do whatever it wants. And even a bad infection. So, yeah, abscesses, kidney infections, bladder infections, those are all painful. Let's that's an example of like the spontaneous pain versus iatrogenic pain. They do have different levels of pain associated with that. So, those are things to just kind of keep in mind of painful, what can be painful.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. So, when either you're causing the pain or if your pet comes in painful, you've got to just determine what to do with your drugs to manage this pain as Yvonne said earlier multi-modal is best. So, what we mean by that is using, we'll go into more detail probably in a different episode, because you can talk forever on the multimodal pain, but using different types of pain management. So, you have your NSAIDs to relieve inflammation along with opioids, to relieve pain. So, that would be multimodal. I personally am a big fan of blocks along with pain medication. And then like I said, we'll definitely get into that a little bit more detailed. And then I love CRI's too, especially with severe pancreatitis cases. They're on a CRI of fentanyl. Sometimes we do torb, especially if we want to keep them quiet. And versus like bolus dose of medication, they wear off a lot faster versus a CRI. You can kind of taper to your liking. You can say, "hey, I think this pet's a little bit dysphoric. And let me wean back a little bit on this fentanyl CRI". To kind of manage that.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And one thing to remember too, the big difference between a bolus of it versus the CRI. A CRI, you know, you can use a smaller drug amount to get the same effect. Right? Because we're not having these giant peaks and valleys. The other issue is a bolus is each pet's metabolism is going to be a little different. That's why a lot of medications, it's like four to six hours because we don't know is there is their metabolism slowed. So, it's actually six to eight hours versus four hours. And that, if you remember from school, is pharmacokinetics and pharmacodynamic. Which I remember learning about, and being like, "why would I ever need to know this?" But that is one of the reasons to understand it is each metabolism is a little bit different. That's why, like your ED50, your effective dose is for 50 percent of the population. Some are going to need way less of it. Some are going to need way more to get the same effect. You know, the boluses you could be overmedicating them, but it's not lasting for long enough. And so now they're painful. And so then we you know, we give them another medication, but they've already ramped up their pain. And nerves are funny. You know, once they're stimulated, they like to be stimulated and keep responding. And sometimes they'll start over responding to the same stimulus that was just a little bit painful before. It's kind of like, I don't know about you, but if you've ever had a really bad headache, right? And you touch your skin and that hurts. It's because those pain receptors are firing and kind of over stimulated. So the CRI is great because now you've kind of cut that painful stimulus and they're not receiving more stimulus. So, sometimes we kind of say that if you get behind the eight ball on it, sometimes no matter what drugs you give, you're still not going to control the pain.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
But if you can get ahead of it and you keep it from firing those pain receptors, it's going to be easier for you guys to manage these patients.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Exactly. You don't want to let them become painful before their next dose of medications is due. You really want to try to stay on top of it.

Yvonne Brandenburg, RVT, VTS SAIM:
Jordan, at your clinic do you guys do CRI's in syringe pumps or do you do them in fluid bags or like a combination, like what are you guys doing?

Jordan Porter, RVT, LVT, VTS SAIM:
We do a combination. Like fentanyl will go in a fluid bag. But when we do the torb CRI's or something like that, we usually put that on a syringe pump. And I like the torb CRI's just because that's more for like mild pain. But I can do like minimal doses and it keeps my patients so quiet, especially if they're super anxious in the clinic. I can do a dose of 0.25 milligrams over an hour and it's just enough to like manage their mild pain and keep them quiet.

Yvonne Brandenburg, RVT, VTS SAIM:
That's crazy. Yeah, we do a lot of fentanyl series, but we use a syringe pump and so we're usually doing, I think, most of the times 2 to 4 micrograms per kilogram per hour. Which is, again, much smaller than like fentanyl patch. You're looking at, I mean, what is it? 12 microgram per hour patch for cats.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
You know, if we can monitor, or we can maintain them with a CRI infusion, then sometimes that's better.

Jordan Porter, RVT, LVT, VTS SAIM:
And I mean I'm a self-aware control freak. So, when we do something like a fentanyl patch, I feel like I can't control it so I don't like it. So, I prefer the CRI methods.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, we usually use the fentanyl patches like if they're stills a little bit painful, but we're sending them home.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
We don't use the patches a ton in clinic.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Because we can't adjust it if we need to.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly. So, kind of leading into a couple of cautions to look out for with your painful patients. We kind of already talked about the behavior changes and they can lash out. So, definitely go slow in getting in and out of the cage with these patients or bringing them into a room or putting them on the table or getting a weight or a temperature if they're painful. Every little thing is gonna be a little bit too much for them.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And also, remember, whatever you're doing, it may not be painful, but they're guarding themselves. Right? That's that behavioral thing where it's kind of like us when we're painful, we get really crabby and we lash out at people around us. Dogs and cats, they do that as well. So, go slow with them.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
Give them space to know it's OK.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. And educate the client too. Because the clients, I mean I don't know about you, but I've had a million clients tell me, "Oh Fluffy, I would never bite me." But, they could. I have a dog here who would never bite me. But,

Yvonne Brandenburg, RVT, VTS SAIM:
If you break a bone.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Exactly. I mean, it's painful. Muzzle needs to be an option to keep everybody safe, especially if they're not letting you pick them up.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And I think, too, with that client education, you know, especially if they call you, this is kind of a classic example. A client calls their dog was just hit by a car or their cat was just hit by a car. You'd need to have the discussion with them about somehow securing their mouth. Right? I've seen several clients come in because they've been bit by the dog that would never bite them because that pet is painful.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
So, I used a muzzle, but nobody has muscles at home unless their dog is a biter. Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
So, options to talk to them about is gonna be like belts, so looping a belt around their mouths to keep them from biting. Socks. I've had people use socks. I'm like use a tube sock, I don't care. Nylons, bathrobe ties, string. I say string as in thicker string, not string that's gonna cut any circulation off shoe laces, those kinds of things just to make sure the animal's not biting the owner.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. And I find towels go a long way to, or like thicker blankets even.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. I use blankets all the time in the clinic.

Jordan Porter, RVT, LVT, VTS SAIM:
I know.

Yvonne Brandenburg, RVT, VTS SAIM:
Clients can use them too.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah exactly. So, wrapping them up gently in a thick blanket and still I feel like it makes a lot of patients more comfortable if they can't really see someone coming at them.

Yvonne Brandenburg, RVT, VTS SAIM:
Yes.

Jordan Porter, RVT, LVT, VTS SAIM:
And then like it's soft and they're not going to hurt anybody and there's enough padding between your arm and the dog's face. So clients should be aware.

Yvonne Brandenburg, RVT, VTS SAIM:
I'm a big fan as well of e collars.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes!

Yvonne Brandenburg, RVT, VTS SAIM:
I will. A lot of times use an E collar over a muzzle, even in clinic because I work internal medicine. We have a lot of respiratory patients. I can't put a muzzle on something that can't breathe through its nose, or is in respiratory distress. So, using an E collar keeps the bitey part, not as much of an option. Yes, it can still happen, but an E collar hopefully gives you some leeway that your hands are not going to go in their mouth. So, that's an option for a client as well. You know, if they have any caller at home, tell them to put the e collar on and that, too, can help prevent an animal from seeing around them.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly. And I find that the longer e callers that are just too big for their face work best I mean, especially if I'm getting into the cage and like it's a painful pancreatitic patient who I just need to give an injection to the port, too. And they're just like, "no". So, I do find that very helpful. And kind of as we talked about, overmedicating is just as bad as under medicating. You have that dysphoria. You have, you know, all those other signs that you just can't tell us are painful or not. But you can assume that if you're over medicating, that it's just they're gonna be drunk. They're not going to want to eat. They're not, their bowels are going to move like they should. So, they're not gonna metabolize food like they should if they're getting too many pain medications. Just because GI motility can slow with opioids and it can cause temperature changes. So, if you're pre-meding in your patients prior to some sort of procedure and you notice that their temperature drops drastically and they're down to 98.1 you gotta kind of take into consideration "well, maybe I gave them too big of a dose."

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. Keeping an eye on their temperature is big, right? We don't want them to get cold because that also slows down metabolism. So, it's almost like a double whammy, right? You've got a slow of metabolism with the drugs and getting over medicated potentially, and then just temperature drops and then your metabolism slows. So, then there's more drug in their system that they're absorbing and not getting rid of. So, you know, close monitoring of your pet and your patients are good.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly. And I think, too, that people don't understand it, and I'll definitely go into this probably as some sort of blood talk that we talk about on a podcast. But hypothermia can also inhibit coagulation, too. So, if you've just done surgery and then post-op, you're noticing that they're oozing just a lot more than they normally do. Check the temperature. Or look back at the records during surgery and find out if they were hypothermic during the procedure, because then you can be like, "oh, that's why they're bleeding a little bit more", and really get them warm.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, yeah. Hopefully, hopefully your monitoring temperature pretty frequently with anything that's not super mobile and providing heat support. Right? That's big.

Jordan Porter, RVT, LVT, VTS SAIM:
And another big caution that I think a lot of that clinics don't talk about, unfortunately, controlled substances and they can be abused by clients. So, if you have a client coming in like, "my dog needs more tramadol, my dog means more tramadol." You really look up your state's guidelines to on how frequently you can prescribe that. I know in Georgia, we are only allowed to give a month's supply and you cannot rebuild any sooner.

Yvonne Brandenburg, RVT, VTS SAIM:
Oh, wow. Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
So really pay attention. And of course, coworkers can definitely abuse those controlled substances. So, it really needs to be kind of closely monitored when prescribing pain medications, how frequently it's happening. If you're having a certain person in the clinic who's the only one filling, dispensing those meds, you're really kind of got to keep an eye on it and bring it to supervisors' attention.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And with the co-worker, I mean, I don't know if you guys if you've heard about the I think it's called the Four Eyes Initiative.

Jordan Porter, RVT, LVT, VTS SAIM:
Hm-mmm.

Yvonne Brandenburg, RVT, VTS SAIM:
Where you have two people looking at it. And that's huge to go along with that. We talked about CRI's earlier. That is something, too, that you really need to be aware of is if a patient doesn't use all of the CRI.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Also monitoring where the waste goes. Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
You don't want,

Jordan Porter, RVT, LVT, VTS SAIM:
That fentanyl bag can't just be thrown in the trash.

Yvonne Brandenburg, RVT, VTS SAIM:
Well but, I mean if, you're right. Yeah. And it's definitely fake as well. But I mean you want to make sure that someone isn't taking the leftovers.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
You're like, "I'm going to throw it out". And then they don't. So, that's you know we have a policy when we're wasting medications at our clinic that you go to someone and have someone look and say, "yep, I'm wasting it." We use the Cubex in our clinic. So, then we go and we log in our Cubex that we wasted that medication. And then we put the two initials of who saw it. So, because unfortunately, I think we've touched on this a little bit is mental health in our industry. Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Uh-huh.

Yvonne Brandenburg, RVT, VTS SAIM:
And we don't want someone to get addicted to controlled substances and then lose their license. Or the worst case scenario is, they overdose or they take their own lives with the controlled substances. So, we just really need to be cognizant of that as well. And there are initiatives out there to minimize the amounts of the heavy duty controlled substances and going more with the multi-modal with, you know, the lidocaine blocks, just the nerve blocks themselves and NSAID's and all that stuff. So, just you know, that's a huge caution for industry. And I think everybody talks about it. It's something that we can help minimize.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, definitely. Especially if you have set protocols in place. So, that's also that's definitely something to kind of be on the lookout for.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
It's the tip of the week.

Jordan Porter, RVT, LVT, VTS SAIM:
So, tip of the week, we talked about the behavioral changes with pain medication. I personally like the Colorado State canine and feline acute pain scales. It shows pictures of like what a super painful cat would look like. I believe the scales one through four, maybe one through five. We'll put the link at the bottom of our show notes just to their principles so you can even put your only clinic's logo on them and have them around the clinic or even give them to clients so they can see, "All right, my cats ears are back. He's growling. He's kind of in a curled up position. This is where he falls on the pain scale, this pain scale.

Yvonne Brandenburg, RVT, VTS SAIM:
And to go along with that recording the pain score that you get on your medical records. So, having a line on your treatment sheet that says pain score and that way, you know, there's no mistaking from one shift to the next to the next. You know, was he good on this medication and not so good on this other one? So, using the pain score system that you have, if everybody uses the same pain scoring system, you're gonna have less of that subjectiveness and more the objective, which is why those are out there.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly. Don't underestimate simple things like if you have a patient in a hospital and you're in charge of them, simple things like extra bedding, moving them around more. I know that there are certain situations where you don't want to get them up and moving, but sometimes walking is good for them. Same with passive range of motion. If you get in the cage with them, you start moving that front limb if they're extremely arthritic. Hot and cold packs are always great too. I think people extremely underestimate hot and cold packs. They're simple things that can be done to try to help alleviate some pain.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And I will say that kind of think outside the box with this one. Remember, your older patients are going to have arthritis. So, getting them moving. That's super squishy bedding like we have, it's like the fleece material.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
I don't know if you guys use that or like egg crates and stuff like that. Putting that under something that's gonna be absorbent and you can clean. That really helps prevent pressure sores, which are painful. Helps you get them moving. So yeah, I definitely agree. Like the movement and making sure they're not getting those sores is huge.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Exactly. And then bottom line, some patients just need to go home. Some patients will act painful or just not thrive in a clinic setting so they won't eat. And so, you can't really tell cause pain or stress. So, some patients just need to go home. Obviously, with some adequate pain management and then the owners can assess in a normal situation how they think the pet is doing.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And we've done that in my clinic. Especially our pancreatitis or like our diabetic cats or even our kidney cats. Sometimes we're like, you know what? We prefer for them to still be here because they need to eat. They need to do some of this behavior that we're looking for. But it usually is extremely stressful for these kids because they've never been out of their house before. So, sometimes we just go, you know what? Take them home overnight. See how they do. If all of a sudden, they're much better at home, we'll touch base with you tomorrow. Maybe that's what they needed instead of staying in the hospital. So, sometimes we just make that choice. We're like, okay, let's try them at home and do the trials. So that's another part of that tip as well.

Yvonne Brandenburg, RVT, VTS SAIM:
Another quick tip, too, for those patients once they've gone home, so Internal Medicine For Pet Parents, we've created a journal for owners. And if you haven't seen them, the great thing is, is you can record the treatments, so medications and, you know, monitoring vitals, but you can also handwrite in their pain score. So, if you're sending home that Colorado State pain score handout, you can actually give that to them and then tell the owners, "hey, you know, monitor this and record it. So that way when we're talking to you, we can see, you know, are things getting better or are they getting worse?" We'll put the link in the show notes for that as well.

Jordan Porter, RVT, LVT, VTS SAIM:
Definitely. Definitely.

Yvonne Brandenburg, RVT, VTS SAIM:
And now for the Question of the Week.

Jordan Porter, RVT, LVT, VTS SAIM:
I think kind of as we wrap up: question of the week, of course, if you want to reach out to us, how does your practice manage pain and how do you educate your clients? What different methods do you use in your practice to help manage pain of your patients? And then, of course, do you have handouts to educate your clients, what do you tell them to look out for and what do you tell them to do if something happens? So, leave a comment resources to learn more. I got a lot of my information from my Bible. So, the Small Animal Internal Medicine for Veterinary Technicians and Nurses book.

Yvonne Brandenburg, RVT, VTS SAIM:
Yes!

Jordan Porter, RVT, LVT, VTS SAIM:
And then of course, in our show notes we'll leave the links to the blog post on Internal Medicine For Pet Parents for the pain education and then the Colorado State University Canine and Feline Acute Pain assessment sheets.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. So, and the other thing we'll link to is the American College of Veterinary Surgeons, kind of the article they have, which has really good information, so I definitely would recommend checking that out. And we'll also have a couple of the other things that we've talked about in here. Thank you so much for joining us. I hope that you get some stuff out of this pain episode. Let us know. Again, in the show notes what you got. Let us know if you've got any feedback. I think that's it. Unless you've got anything else that you'd like to touch on today.

Jordan Porter, RVT, LVT, VTS SAIM:
No, I mean, I love discussing pain. So, if anybody wants to reach out and ask for questions, feel free to contact us. Yeah. I mean, anything else that you might want to hear specifically in future episodes? Let us know.

Yvonne Brandenburg, RVT, VTS SAIM:
Sounds perfect. All right. We'll have a wonderful week. Enjoy taking care of your patients and your clients. And we'll talk to you next time.

Jordan Porter, RVT, LVT, VTS SAIM:
Okay, bye!

Yvonne Brandenburg, RVT, VTS SAIM:
Bye!

Yvonne Brandenburg, RVT, VTS SAIM:
Thank you for listening to today's episode of the Internal Medicine for Vet Techs podcast. If you'd like what you heard, we'd love for you to share with someone you think might enjoy the podcast. And make sure to subscribe so you never miss an episode. Want to give us a boost? Please leave a review on i-Tunes or your favorite pod catcher and we'll be sure to say thank you. Find out everything about us at InternalMedicineForVetTechs.com. Talk to you next week. Bye.

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Question of the Week

What are some methods you use in your clinic/hospital to manage a patient’s pain?

​Do you have any handouts for educating clients on their pet’s pain?

Let us know in the comments below!