VetInfo Digest September 2002
This month’s VetInfo Digest is ALL about Equipment at Veterinary Hospitals.
What to Look For and Why.
This Month's Note:
T
he second year that I was in practice I had a new client come to me specifically because I had graduated from school two years previously. I remembered an odd conversation in which a phone shopper had asked me what year I graduated from veterinary school, but I did not connect the question with the woman in my office. At least not until she said that she was glad to find a veterinarian exactly two years out of school. I asked her why this was important and she said that before she moved she had asked her veterinarian how to find the best veterinarian in a new town. He had told her to look for someone two years out of school. His logic was that a veterinarian who had gone to school recently would be well versed in the most current knowledge about veterinary medicine available. If they had also been in practice at least a year or two, they would have the practical experience to go along with the knowledge. Brand new graduates might have even more current knowledge but it is sometimes hard to put that knowledge into practice. It even takes time to become skilled at relatively simple tasks like expressing anal sacs, hitting a vein for blood samples and knowing how to separate the important aspects of the medical history from the flood of information that some clients tend to give when asked "what’s wrong with your pet?"I thought it was a reasonably good recommendation, although there are obviously older veterinarians who do keep up with the current knowledge and new vets who didn’t learn some of it in the first place. I’m not sure what the lady would have done if we had all been older vets, back then! Another way to evaluate veterinary hospitals is by the services they offer. This month, I’ll try to explain some of the equipment available to veterinarians to allow you to better understand what your vet is offering in routine and advanced care options. How do you get a look at your vet’s equipment? The best bet is simply to ask for a tour of the hospital. We have two or three clients every year who ask us to show them around. We are happy to do this and I think the staff at most veterinary hospitals enjoy showing off the place occasionally.
Veterinary Medical Equipment
It might seem strange to devote an article in the VetInfo Digest to veterinary medical equipment. After all, you aren’t going to be buying any equipment soon and you probably don’t have much control over the equipment your vet has. However, being aware of what equipment is available and what it is used for can help you decide if your vet is trying to stay up to date, how hard your vet is trying to provide for the safety of his or her patients and sometimes even whether or not you need to find another vet.
In Virginia, very little equipment is actually required by law at veterinary hospitals. It is likely that requirements are similar in other states. To practice in Virginia a veterinarian can get by with an autoclave, a hot water heater, a microscope and a contract with another veterinary hospital or outside lab to provide X-ray and laboratory support. From a practical standpoint it is usually hard to get a close competitor to take a veterinary hospital’s radiographs for them, so an X-ray machine is close to a requirement. Cages must be provided. Exam and surgery lighting must be adequate. Some form of surgical monitoring must be done, but it is acceptable to have a person monitor the patient continuously, if surgical monitors are not available. While this list of equipment is sufficient to practice at the legal minimums, most veterinarians would find it frustrating to work with just this equipment and most veterinary clients would eventually recognize the need for their vet to provide more technologically advanced care. Autoclave
I have only been in one veterinary hospital that did not have an autoclave. This is the machine used to sterilize equipment for surgery, dentistry and other procedures requiring sterile instruments or equipment. It isn’t likely that you will ever encounter a hospital without this basic equipment, but many clients ask me what my autoclave is, so I am including it in this newsletter so that you won’t have to ask when you see one. Almost all autoclaves have a pressure chamber and a door that seals to the chamber, so looking for the door sealing mechanism usually gives the autoclave away. Obviously, all veterinary hospitals need this piece of equipment. The one that I saw without it was part of a chain of veterinary hospitals and they claimed that a local member of the chain was doing their autoclave chores for them. I’d be suspicious of any such claim.
Veterinary practices should have a good microscope. Binocular microscopes are preferable to monocular ones if there is only one microscope. Having one microscope for routine fecal examinations and one microscope for evaluation of fine needle aspirates, blood smears and other more sensitive procedures is best but is not a common practice.
Most veterinary hospitals have a refractometer to measure urine specific gravity. This is the most accurate instrument for doing this in a clinic setting. Some veterinary hospitals rely on specific gravity readings from test strips, which we have found to be lacking in accuracy in our clinic. Other veterinary clinics send urinalyses to an outside lab for evaluation. There is not problem, other than the delay in getting results, with this system. Urine specific gravity readings can be extremely helpful in diagnosing and monitoring the progress of a number of veterinary disorders, but is especially important when monitoring chronic renal failure. The refractometer is an instrument that your veterinarian has on hand.
An ophthalmoscope is necessary for really complete evaluation of the eyes. There are several types of ophthalmoscopes, which vary significantly in their appearance. The simplest is a bright light and a handheld magnifying lens. A more sophisticated version of this is the indirect ophthalmoscope which looks like the head lamps worn by surgeons but is made specifically for ophthalmologic examination. A direct ophthalmoscope is the most common type of ophthalmoscope and is the one that most clients think of when they hear the word ophthalmoscope.
The direct ophthalmoscope is a light source coupled with magnifying lenses that the veterinarian looks through to examine the eye. A new version of the direct ophthalmoscope, the Panoptic (tm) ophthalmoscope, looks like a short tube on a battery handle. The vet looks through one end of the tube and the dog or cat’s eye is encircled by a rubber gasket at the other end of the tube. This scope provides a much wider view of the retina and is generally easier for practitioners to use. We really like the Panoptic scope. The specialized indirect ophthalmoscopes are also very good. They allow visualization of the entire retina at one time, which can help a great deal when looking for small changes. Your vet should have an ophthalmoscope and it should be used at least occasionally when your pet is examined. The Panoptic scope is on the left in the photo.
Otoscopes are the instruments used to look into the ears. Handheld direct view otoscopes are the standard at the present time. Otoscopes are a necessary item when a comprehensive examination is desired. There are several new video otoscopes on the market. The best feature of these otoscopes is that the display through a monitor or television. When we show pet owners what the inside of an infected ear looks like they seem more likely to properly medicate the ear and to come back for rechecks when they are needed. Several of the video otoscopes allow surgery to be performed through an operating channel in the otoscope, which is very useful for treating ear tumors. The small size of the tip on some of the video otoscopes also allows better visualization of the ear drum when the ear canals are narrow. A good handheld otoscope is acceptable. A video otoscope can be helpful, especially when chronic ear infection is being evaluated or managed. Video otoscopes range from $1000 to $10,000. Operating otoscope picture.
Stethoscopes are used to listen to the heart. Almost everyone knows what a stethoscope is and most people have listened to a heart through one at one time or another. There are several newer versions of the stethoscope, though. Electronically amplified stethoscopes are available. It is unclear at this time whether they really provide much improvement in auscultation of the heart, though. They may be very helpful for hearing impaired practitioners in some cases. A standard stethescope is fine for most practices.
Blood pressure monitoring is becoming a bigger issue in veterinary practices at the present time. It is clear that older cats often suffer from high blood pressure (hypertension) and that older dogs also have this problem less commonly. In addition, low blood pressure during surgical procedures can be life threatening or can lead to serious consequences, such as blindness. Direct blood pressure measurement is usually not done in pets, since the only way to do this is to place a central venous catheter and measure the blood pressure through the catheter. The difficulty of this procedure made the development of indirect blood pressure measurement necessary. There are two types of indirect blood pressure monitors that are commonly used in pets, oscillometric blood pressure monitors and Doppler blood pressure monitors.
Oscillometric blood pressure monitors work well in large dogs and bigger animals like horses. These machines have a cuff that is wrapped around the pet’s leg or tail and is hooked to the machine. The cuff is automatically inflated and deflated by the machine and it usually provides three types of blood pressure readings and the heart rate. These machines can measure systolic blood pressure, diastolic blood pressure and mean arterial pressure. Most of the time veterinarians worry the most about the systolic blood pressure but the other values are helpful in certain circumstances. In small dogs and in cats these machines often are more inaccurate. Their readings can be inconsistent enough in cats to make it questionable if the blood pressure measurements are valuable. We have found that we can get good readings on most cats with oscillometric measurements but that we get wildly inaccurate readings in a few cats. You can usually recognize an oscillometric blood pressure monitor by the display of three or four numbers on the monitor.
Doppler blood pressure monitors allow recognition of blood flow through an artery. This is useful in small dogs and cats because it is not always possible to hear the blood flow with a stethescope in small animals. A standard blood pressure cuff attached to a sphygmometer (the familiar device with a pressure bulb and pressure dial) is placed around the pet’s arm or leg. The Doppler probe is placed over an artery below the cuff and blood flow identified. The pressure cuff is then inflated until blood flow stops. It is then slowly deflated and the Doppler used to detect the very first blood flow. This is the systolic pressure. Most veterinarians only try to detect systolic blood pressure with a Doppler blood pressure device. There is some controversy about whether it is even possible to detect diastolic pressure but some vets do believe they can do this. The Doppler pressure monitors are pretty accurate once the operator is familiar with the device and if they are used in a consistent manner. We use both an oscillometric and Doppler blood pressure monitor at the present time when checking blood pressure measurements in cats. Up to 60% of cats experiencing chronic kidney failure also have hypertension. It is probably acceptable still to make a clinical judgment about the need for blood pressure medications, but having the ability to monitor blood pressure is a definite plus for practices that see cats.
I waited a really long time before purchasing blood pressure monitoring equipment. I was put off by the controversy over which type of machine was better and worried about the learning curve associated with the Doppler pressure monitors. Doppler monitors are available for less than $1000 and oscillometric monitors usually cost between $2000 and $2500. I can’t say that I blame general practitioners who are not measuring blood pressure still. However, we finally decided just to purchase both types of machines. In the short time we have had these machines we have found them to be extremely useful. In fact, I just saw a dog with hypertension this week and I am not sure that I would have trusted my clinical impression of the problem. It was very reassuring to have the necessary equipment to measure the blood pressure before putting this dog on medications to control hypertension.
Eye pressure measurement can also be important in veterinary medicine. Glaucoma (high eye pressure) occurs in pets just as it does in humans and low eye pressures can also indicate the presence of eye disease. Tonometry is the measurement of the pressure inside the eye. Eye pressure may be measured by Schiotz tonometry, in which an instrument resembling a thin tuning fork is rested briefly on the eye to measure how much indentation occurs. The indentation is compared to standard charts to determine eye pressure. Eye pressure can also be measured by applanation tonometry using a Tonopen (tm), which is easier to use and usually more accurate than Schiotz tonometry. There is a great difference in cost between these machines, though. Schiotz tonometers cost around $200 and Tonopens are about $3000. Veterinary ophthalmologists strongly recommend the use of the Tonopen over Schiotz tonometry due to the difference I accuracy. Glaucoma is common in older dogs and cats. Your veterinarian should have some method for measuring eye pressure.
Most veterinary practices don’t have a dental X-ray machine. There isn’t much question that it is easier for a practice to take dental X-rays when they have a machine specifically devoted to this purpose. It is possible to take dental X-rays with a regular X-ray machine, though. It is what we do in our practice since we are small enough that we have enough time to devote to this. However, a dental X-ray machine is on our want list because it is clear to us that we would offer this service more often if it was easier for us to do and that we should be offering it more often. If you want to take really good care of your pet’s teeth they should be X-rayed prior to dental procedures to ensure the best possible dental care is provided. It is reasonably certain that most veterinary hospitals would have dental X-rays machines and would take more dental radiographs if it was not necessary to use anesthesia to obtain the films. This is a legitimate concern, but when anesthesia is necessary for dental procedures, anyway, it is best to have dental X-rays taken if possible. Dental disease is much easier to detect, to evaluate, and to treat when X-rays are taken. Cost is around $3000.
Photo of 300MA X-ray control console Photo of 300MA Tube Stand and Table
The 300MA machine, or larger, is the recommended size for standard use in a veterinary hospital. It is possible to get by with smaller machines, especially in all cat practices, but having a machine in this category is generally indicative of making a better effort to have good quality equipment.
Electrocardiograms are measurements of the electrical impulses generated by the heart. For many years the ECG and X-rays were the only ways to evaluate heart disease. When this was the case, the ECG was more useful than it is now and interpretations were made of estimated heart size and function, as well as of the heart rhythm, which is the more natural use of the ECG. This is still the best method to evaluate many arrhythmia problems. These are not the most common heart problems but when one is present it is good to have the capability of evaluating the ECG. Some practices utilize transtelephonic ECG services, in which the ECG is actually recorded at a remote facility and often evaluated by a cardiac specialist there. The major advantage of this procedure is the evaluation by the cardiac specialist and the major disadvantage is that the specialist isn’t seeing the patient, just the ECG. For this reason, I think that it is just as effective at most practices if the ECG is done in the clinic. Newer ECG machines cost about $2000.
Ultrasonagraphy has mostly replaced ECG as the method of choice for evaluating heart disease and it is useful for many other conditions, as well. For cats, cardiac ultrasound examination is often the only accurate way to assess the heart’s condition. Ultrasonography requires expensive equipment, and is not useful unless the operator has the skill to obtain good views and to interpret them correctly. In larger practices it is often possible for one or more the staff veterinarians to become very good at ultrasonagraphy. In smaller practices it is more difficult, but not impossible, for a veterinarian to become good at ultrasonagraphy. For this reason, it is less common to find this type of equipment at smaller practices. Evaluation of heart disease by ultrasonagraphic examination seems to require even more skill in positioning than other forms of ultrasonagraphic examination. It may be best to consider using the services of a cardiologist or specialist in ultrasonography for these examinations. When a practice can provide good quality ultrasonagraphy this is a great advantage but it is not yet standard practice in veterinary medicine. Good quality ultrasound systems usually cost between $15,000 and $30,000.
Endoscopy is the use of a scope, either rigid or flexible, to evaluate areas of the body, such as the nasal passages, digestive system or respiratory system that would not ordinarily be possible to evaluate. Endoscopic examination can be useful in many situations. Emergency clinics tend to have the most use for simpler endoscopic procedures, such as the retrieval of foreign objects from nasal passages and the digestive tract. Examination of the nasal passages is also useful for tumor detection since this area is difficult to X-ray. One situation that seems to require more practice than others is evaluation of the upper digestive tract for the presence of inflammatory bowel disease. It may be best to consider referral to a specialist for this particular examination unless your vet is very comfortable with endoscopy and works with a good pathologist. Arhroscopy, or examination of the joints, also requires practice. As with ultrasonagraphy, it is more likely that a larger practice will have the caseload to allow one of the staff veterinarians to become very good at this procedure. Good quality endoscopes tend to run in the $10,000 to $20,000 range, depending on the options, so they are not yet standard equipment in veterinary hospitals.
Anesthetic monitoring of some sort is required by many state veterinary boards and associations. There are many types of anesthetic monitors, though. While there is no absolutely clear standard on the best way to monitor anesthesia, there are some guidelines that are generally agreed upon . I think it is fair to say that pulse oximetry is considered to be the best single monitoring method IF only one is to be used. It is also fair to say that most veterinary anesthetists clearly prefer to have more than one monitoring method during anesthetic procedures.
There isn’t a monitor that can replace the attention of a well trained veterinary technician or veterinarian monitoring the patient during a surgical procedure. I would not hesitate one second in choosing between an anesthetist armed only with a stethescope and knowledge of anesthesia over a surgeon operating alone in a room with several monitors. Unfortunately, anesthetic monitoring in veterinary medicine is often relegated to machines that do their thing while a surgeon works on a pet alone or with a surgical assistant whose main focus of attention is the surgery itself. If you have a choice, always choose to have a dedicated anesthetist present. A good technician is as good or better than most veterinarians, so it is not necessary that the anesthetist be another veterinarian, although for really complicated procedures you might want to seek a hospital that does offer a dedicated anesthetist or even a board certified anesthesiologist.
Pulse oximeters measure the oxygen saturation of capillary blood vessels. Since the brain is extremely sensitive to oxygen deprivation it is obviously a good choice to be monitoring oxygen levels. These machines are a fairly sensitive indicator of problems during anesthesia. They usually provide both the oxygen saturation values and the pulse rate, which is also a reassuring parameter to be measuring. Surprisingly, pulse oximeters are not always the most sensitive indicator of problems during anesthesia, even though they are preferred for their reliability and ease of use. Pulse oximeters can be purchased for as little as $750, so it is reasonable to expect your veterinary hospital to offer monitoring with this machine or possibly others discussed below.
Some veterinarians believe that blood pressure is the most sensitive indicator of anesthetic problems. Either type of blood pressure machine can be used to monitor patients during surgery and the accuracy limitations are the same for surgery as they are for non-surgical blood pressure monitoring. However, the inaccuracy of the oscillometric blood pressure machines may be slightly less concerning in this use, since they still indicate relative changes in blood pressure, even if they don’t indicate accurate blood pressure overall. Obviously, there is room to argue this point either way. A major advantage of Doppler blood pressure monitoring in surgery is that it requires a second person to come into the surgery room and manually take the blood pressure measurement, which at least ensures that someone is monitoring the pet during anesthesia.
Capnography is a relatively new form of anesthetic monitoring for veterinary practices. It is possible to purchase capnographs that do not also provide pulse oximetry, but most practices either have both machines or a combined pulse oximeter/capnograph. The capnograph is a visual aid that provides a graph of carbon dioxide measurements taken from the endotracheal tube (breathing tube) during surgery. This is very useful as it can show problems that might be overlooked otherwise, such as depletion of the carbon dioxide scrubbing granules in the anesthetic machine, a kinked endotracheal tube or leakage of air around an endotracheal tube. In addition, the end stage carbon dioxide measurement is a very sensitive indicator of impending respiratory difficulties. It is desirable, but not absolutely necessary, to have both pulse oximetry and capnography to monitor anesthesia. Capnographs cost between $3000 and $4000 dollars.
Some veterinarians use electrocardiographs to monitor anesthesia. The biggest drawback to this approach is that the electrical impulses often continue on for as long as several minutes after the heart actually stops beating effectively. This can provide a false sense of security. ECGs do allow early recognition of some forms of heart stress, though. They are probably best used in conjunction with some other form of monitoring.
The simplest forms of anesthetic monitors measure respiratory effort. They measure air flow through the endotracheal tube and usually make an audible sound with each breath. Respiration can slow down, or become shallow during surgery. This happens slowly enough that it is almost imperceptible some patients and over time this can lead to complications despite the presence of regular respiratory efforts. These monitors can be useful but are also best used in conjunction with some other form of anesthetic monitoring. These are the least expensive monitors can be purchased for as little as $250.
Hot water or hot air circulating heating pads and heated surgery tables can make a big difference in the success of surgery in some cases. They are also important for dental procedures when the patient is positioned on a grate over a sink or tub, which is a common practice since dentistry often involves the use of equipment that sprays water constantly. Loss of body heat during surgery can lead to severe complications. This isn’t usually a problem in short surgeries, including most of the routine surgeries such as spaying and neutering. It is important that the heat source be specifically designed to provide warmth to anesthetized patients. Regular electric heating pads can cause severe burns in patients who are asleep, as they are not made to be in contact in one place for long periods of time. While it may not be absolutely necessary that your vet provide a warmed table or a water circulating heating pad during surgery it is a sign that your vet is trying to provide protection against as many complications as possible. A good quality warm water circulating system costs about $400. Photo of hot water circulating heating pad and pump.
I think that veterinary hospitals should have medical records that are legible and that can be readily accessed and readily transferred to another veterinary hospital when necessary. The best way to accomplish this is to use computerized medical records. These "records" should be more than a list of transactions between you and your vet, though. They should be the complete medical record for your pet, including presenting complaints, examination findings, laboratory results and diagnostic comments. Look for this information if you ask for medical records for your pet. If you are given a sheet that just lists items charged for during the lifetime of your pet ask for a copy of the medical history file. Computers have become part of veterinary practices because they help practices make money by allowing better tracking of procedures and inventory. Specialized veterinary software is available for as little as $1500 but it is not unusual for the software to cost $15,000 or more. Almost all veterinary software packages offer some way to computerize records but most veterinary practices still use handwritten paper records. The software pays for itself through its business functions so the medical record keeping features are often a secondary concern.
There are veterinarians with legible well organized medical records that are kept on paper and filed in drawers. I practice in an area in which many people have summer homes. I see the records from many other veterinary hospitals due to this. Based on this experience, it is just more likely that your veterinarian’s records are hard to read and that fax transmission of them makes that situation even worse. Good medical records are one of the cornerstones of good veterinary practice. It is worth asking your vet for a copy of your pet’s medical records just to see what you get. If all you get is a list of transactions or if you get copies of hand written records that are totally illegible, you should consider whether this is acceptable to you. Your pet’s records should be legible, well organized and appear to provide enough information to allow someone else to understand them and work from them. If this is the case, your vet is doing a good job on one of the most important aspects of health care.
Again, it is not absolutely necessary that your vet have computerized records but computerized records can be a big improvement over handwritten records when the vet’s handwriting is poor. In some cases, being able to read and evaluate the medical history will be the difference between saving a pet’s life and missing important historical clues that could have prevented a disaster.
An Internet connection is almost an essential now for veterinary practices to keep up with current information. There are several online information services for vets. The commercial ones (usually better) cost between $500 and $1500 per year but are well worth the expense. Ask your vet if he or she belongs to one of the online veterinary services if your pet’s case seems to be perplexing your vet. It might prompt him or her to look online for information!
Clients who come to our practice from city practices are often impressed that we can do most routine blood chemistry and blood counting tests at our hospital. They seem to be used to the veterinary hospital sending blood out for testing. This is a practical solution for practices in most urban and suburban areas. Commercial laboratories tend to have better quality control checks and are staffed by people trained to perform the lab work and very experienced at it. On the other hand, you have to wait for the test results, sometimes overnight. In our case, if we send blood work to a lab it usually takes two days to get results due since we have to send it by mail or by FedExÔ. This was just unacceptable, especially since we provide emergency services a good deal of the time. Blood chemistry machines cost between $4000 and $20,000 dollars. The lower cost ones often provide high quality test results but cost more to run individual tests on or require more "hands on" time. Blood cell counters and cell count estimators are similar priced and it is necessary to buy both to provide more complete blood work. On the whole, our in-house laboratory machines provide reliable information. It usually costs a little more to run a blood panel on our machines than to send it to a lab, so we have both the cost of the machine and the cost to run the samples to consider. If a practice can obtain quick lab results using an outside lab there is no question that it is less expensive for them (and usually you) to do so. In addition, if they pick a good lab, the results are going to be slightly more reliable -- but not much if your veterinarian is making an effort to get good samples and use good machines. The tradeoff is that there is a waiting period for the results and some patients will be treated inappropriately or sent home without necessary medications while waiting on lab results. I am impatient and so I really appreciate having blood results during the office visit. This is particularly important for emergency care situations.
Vetscan blood chemistry analyzer QBC blood cell count estimator iStat electolyte/chemistry analyzer
I have to put in a plug in for air driven dental tools before wrapping up this issue. Many veterinary practices use less expensive alternatives to air driven equipment and there really is no comparison. I intend to spend some time on dental care in an upcoming issue of the VetInfo Digest, so I won’t dwell on this. However, if your pet needs dental extractions, consider asking your vet how the extraction is done. If you see the dental equipment, look for the little handpiece that sprays water and air (most people recognize this part of the air driven dental machines). If you don’t take a tour of the dental area, impress your vet by asking if he or she uses a high speed handpiece to split teeth when necessary. Or listen for the unmistakable whine of a high speed dental drill, the sound you hate to hear at your own dentist’s! Having this equipment is a good sign that your vet takes dental care seriously.
When you take a tour of your veterinary hospital --- and you should if you haven’t already --- pay attention to the machines that are present and ask your tour guide what they are used for. If the receptionist is showing you around he or she might not be able to provide an accurate accounting of the use of each machine but if you have some idea what to look for that won’t matter as much. Knowing what services your vet offers and whether proper equipment is present to provide these services is important. It gives you additional clues as to how your vet approaches practice and when it may be necessary to get a second opinion from a vet who has the equipment to provide the best answer for specific problems. If you add up the costs of the machines discussed, you can see that not every practice will be able to offer every machine and there are many other machines that are available for specialized procedures. If your vet can’t offer every procedure that is not a problem as long as he or she is open about the limitation and willing to send you to a neighboring practice or veterinary specialist who does have the necessary equipment and expertise to use it properly.
You may notice soon that when you click on the index page of www.vetinfo.com you are sent to either www.vetinfo4cats.com or www.vetinfo4dogs.com. We are dividing our site up for better organization and in the hopes of providing more concise information for each species.
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The VetInfo Digest is published by:
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The opinions expressed in this newsletter are those of Michael Richards, DVM., author.
Copyright 2002, TierCom, Inc.
This page was last edited 06/20/04
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