The primary consultation is the first consultation when a patient is presented for any particular illness or clinical signs.

Aldeburgh Vets offers a 20 minute appointment as standard. Most practices in the UK allocate 15 minutes or less to each vet visit. In fact about 40% of practices in the UK still use 10 minute slots.  At Aldeburgh Vets, we feel this is simply too little time for everyone concerned and results in a rushed-job, compromised care and explanations of practitioner stress, irritability and burnout.

Below are some useful tips to help make your primary consultation go smoothly.

What we will always need to know about your pet’s symptoms

Whilst we may need to know a range of information about the pattern and progression of your pet’s symptoms, we will always want to know three things about each of the symptoms you describe.

1. How suddenly they appeared – gradually or suddenly?
2. How long they have been present for?
3. How frequently they have been occurring, as well as changes in frequency over time?

Restraining your pets during an examination

The success by which we can examine and treat your pet often depends on how well we are able to restrain them.  The single most useful piece of equipment for restraining your dog is a properly fitted collar!  I challenge you to try and hold an enthusiastic dog without a collar – or one that’s only wearing with a slip-lead.  It is virtually impossible to restrain a dog well that isn’t wearing a collar without either scuffing it (which we don’t like!) or almost ‘choking’ it on its slip-lead.

So, even if your dog doesn’t normally wear a collar when at home, we really appreciate having one when your dog visits us at the practice as it allows much better restraint. Remember, 90%+ of the time, you will be holding your pet, whilst the vet needs both hands free to examine or treat your pet.

Another useful tip is to take your dog’s lead off once it had been placed onto the table.  This frees up your hands to hold your dog effectively.

A word on muzzles. Of course we try to avoid muzzling your dog if at all possible.  However it is important to realise that your dog may behave differently when experiencing ‘up-close-and-personal’ contact with a stranger! – especially if they associate the practice with negative experiences.  One of the most common phrases we hear is “He has never done that before!”   Not uncommonly, this happens within a minute of us hearing “Don’t worry. He won’t bite you!”  I can guarantee you that there’s not a vet in the world that doesn’t appreciate a forewarning of a patient that can be nervous whilst at the vets.  That doesn’t mean we will reach straight for the muzzle, but it does mean that we might decide to give everyone a little more time to settle into the experience. This is why having a little more time (20 minute consultations) helps patients ‘warm-up’ to the experience as opposed to feeling pounced on by vets in a rush.  After 25 years, Brian has said that he is still baffled when he hears the phrase after a dog snaps at us; “Yeah. He bit the last vet!”

Restraining cats

Whilst most dogs can be cajoled into doing what we want them to, cats often do what they like!  We normally get around 3 minutes of contact-time with a cat before they get bored and have had enough!  Cats are about as receptive to being rushed as a traffic-cop is to being told to hurry up when issuing us with a speeding-ticket. Often we have to grin and bear it and we usually get there in the end!

A ‘presumed-diagnosis’ versus a ‘definitive-diagnosis’

When vets (or doctors!) make a ‘diagnosis’ they are offering an explanation as to the cause of a patient’s symptoms or illness.

There are 2 sorts of diagnosis;

1. A presumed-diagnosis
2. A definitive-diagnosis

A presumed diagnosis occurs when the vet or doctor suspects that a patient’s symptoms or illness is most likely caused by condition X – although they should acknowledge that it is not possible to be certain, with the information currently available. In other words, the vet or doctor makes an ‘educated-guess’.  This is by far the most common type of diagnosis in first opinion veterinary and human GP practice. Approximately 75% of patients at our practice are initially treated based upon a presumed-diagnosis. The benefits of this type of diagnosis is that it is often sufficient to resolve most presenting symptoms. This is particularly relevant in veterinary practice, where animal owners have to pay for veterinary care, and therefore a presumed diagnosis is usually the cheapest option. This is fine – as long as the diagnosis is correct the first time. It is important to note that a vet or a doctor cannot be 100% sure (ie. certain) that their presumed diagnosis is correct. There is a difference between ‘assuming we are correct’ (without the hard evidence to prove it) and ‘knowing we are correct’ (because we have the hard evidence that proves that we are).  A vet or a doctor who assumes that their presumed-diagnoses are always correct, or even 99% of the time, is either arrogant or deluded…both of which are equally as dangerous!

A definitive diagnosis on the other hand occurs when the vet or doctor suspects that a patient’s symptom or illness might be the result of condition X, Y or Z, and the exact cause is then confirmed via a diagnostic test. It is important to realise that vets (and doctors) can only acquire a certain amount of information about symptoms using their physical senses.  Vets and doctors don’t have ‘x-ray-eyes’ or ‘microscopic-vision’ and it is impossible to be certain about what is happening inside the organs of the body using only our ‘bare’ hands, eyes, ears and nose.

The limitations of the information that one can acquire using our physical senses is particularly relevant to veterinary practice, whereby our animal patients cannot give us as much information as human patients. How we long to be able to speak ‘dog/cat/rabbit/horse/cow/sheep/pig/bird/reptile…and marsupialese’ and ask them “Where does it hurt?”

In an ideal world, we would prefer to confirm every diagnosis by performing a confirmatory test – but diagnostic tests cost money which is particularly relevant when animal owners have to pay for them…and animals have to ‘endure’ them.

How many diagnostic tests will be required?

The causes of some presentations can be diagnosed after a single diagnostic test (such as a blood sample of x-ray), whereas other presentations require a series of diagnostic tests.  Generally we are able to diagnose around 50% of the symptoms we are presented with after our first test, 75% after 2 tests, 90% after 3 tests and 95%+ after 4 tests.  Furthermore, some conditions, such as epilepsy, don’t have a definitive test and can only be ‘assumed’ after all the other suspects have been ruled out.

It is therefore important that we recognise the limitations of what vets (and doctors!) can accurately ‘diagnose’ using only their ‘bare-hands, eyes and ears’ and that unless we confirm a diagnosis there is inevitably a degree of uncertainty associated with a presumed-diagnosis.

Similarly, we need to recognise that even though we may be able to make a definitive diagnosis, there is also uncertainty about how many tests will actually be required to do – and therefore how much that will cost and how long that will take.

This is why it is challenging to provide exact quotes when estimating the cost of veterinary care in any given case.  This is where pet insurance comes into its own.

The follow-up re-check consultation – which is booked after the initial primary consultation – is a crucial part of veterinary care. Whilst a follow-up re-check consultation is not required for every single case, we tend to use them for approximately 80% of cases.  The main purpose of the follow-up re-check consultation is to check that our patient, your pet, is responding as expected. This is particularly important when a patient is being treated based upon a presumed-diagnosis.  If a patient is not responding as predicted, it is logical for the vet to ask themselves whether the presumed-diagnosis is in fact correct. Deciding whether it is or not often requires further diagnostic tests.

Continuity is key

There is little doubt that continuity of care within the ‘vet-client-patient’ relationship is beneficial to all concerned when managing a patient’s illness. Continuity of care is a key principle of veterinary care at Aldeburgh Vets and we aim to try and maintain that continuity of care where possible. That doesn’t mean that you will only ever see one vet at the practice, but it does mean that we typically try to stick with the same vet throughout the course of the patient’s illness – unless the vet is not available when follow-up care is required.

Charging for follow-up re-check consultations 

Some clients get frustrated when they are charged for a follow-up consultation, especially if their pet is 100% better when they attend it. We understand this can be frustrating but let us explain why follow-up re-check consultations are so important.

Approximately 80% of patients cases that are presented for primary consultation are back to normal within 2 weeks, with approximately 50% of those patients getting back to normal within 1 week of the primary consultation.  This means that 50% of patients are not back to normal 1 week after a primary consultation. Proactively scheduling follow-up re-check consultations enables us to pick up and intervene with persistent, recurrent or even new clinical signs before they deteriorate too far.

But why not just ask owners to “Come back if he’s not getting better?”

There are 2 reasons why this is an ineffective strategy, both of which relate to the impact on continuity of care within the ‘vet-client-patient’ relationship.

1. It is not uncommon for continuity of care to get broken if patients need to be seen within normal working hours at relatively short notice.
2. Furthermore, a break in continuity of care is extremely likely should follow-up emergency care be required urgently outside of normal opening hours. Brian did a survey of emergency out of hours calls several years ago. The findings were striking; more than half of the of patients surveyed that were seen out of hours had been seen by a vet during normal hours within the previous 7 days but no follow-up re-check had been arranged to check that they were progressing as expected.  In contrast, if follow-up re-check appointments are proactively scheduled within a few days of the primary visit, any warning signs that all is not going to plan are often present.  This enables earlier, and less urgent interventions in many, if not most, of these unresponsive patients, resulting in less distress for the animals, less concern for the owners and much less of a cost to rectify.

Our point is; a relatively small fee for a follow-up re-check consultation is a wise investment as 1) it costs much less than the alternative of taking diagnostic tests at each and every primary consultation (as we know 75% of patients get better without them) and 2) it costs much less than the cost of an emergency out of hours consultation that can often be avoided if unresponsive patients are noticed sooner rather than later.

There are 2 types of vaccination consultation – both of which are combined with a health check as well as a general discussion about what preventative healthcare your pet requires or receives.

1. The primary vaccination
2. The annual booster vaccination

Whilst the details of what and when we vaccinate dogs, cats and rabbits against is covered within the vaccinations section of the website, we wanted to mention a few features relating to the actual consultation.

How long can my pet go between vaccinations?

Dogs, cats and rabbits need to be vaccinated against at least something every year. Whilst the vaccine manufacturers advocate that annual boosters should be given every 12 months, we know that a patient doesn’t suddenly stop being immune on exactly 12 months. Whilst each individual patient’s immunity may last longer or shorter than others, it is generally accepted that a patient remains immune for up to 3 months after its annual due-date.  However, should a patient go more than 15 months between vaccinations, you will be advised that a second vaccination will be required in order to ensure your pet develops the appropriate level of protection.

Will my pet receive a health check as well as its vaccination injection?

Yes.  We will always perform a clinical history and examination before administering the vaccination injection.  This is to ensure that your pet is capable of receiving the vaccination as well as screening for any longer term health concerns.

Can I discuss medical problems at the vaccination consultation?

Yes.  Whilst the vaccination consultation involves immunising your pet, a key purpose of the consultation is to provide your pet with a health check. Clients often arrive at the vaccination consultation with a list of non-urgent medical concerns that they would like to discuss…. Sometimes however, these lists are very long and include complex, long-standing medical issues that cannot be dealt with ‘whilst we’re here’.  The vet will decide what medical issues can be addressed, which may depend on the time available or the possibility that some medicines cannot be given simultaneously. Sometimes we may even postpone the actual inoculation if it is inappropriate to vaccinate your pet given its medical symptoms.

Preventative Healthcare considerations

Brian likes his acronyms! Brian has created the PREVENT IT acronym as a way of remembering all the areas that are typically checked and discussed during a vaccination consultation.

• P    Preventative Healthcare Plan
• R    Reproductive Management (ie pros and cons of neutering versus breeding)
• E    External parasite control (fleas, ticks, lice and mites)
• V    Vaccinations required including optional vaccines (such as kennel cough in dogs)
• E    Endoparasites – ie worms (roundworms, lungworms, tapeworms)
• N    Nutrition
• T    Teeth and dental disease
• I     Identification and awareness of the pros and cons of different types of Pet Insurance policy
• T    Training and socialisation

The re-prescription check consultation refers to the consultation with the vet in order to monitor an ongoing medical condition.  These consultations are required for both medical and legal reasons.

• Medical reasons include the need to check that patients with ongoing healthcare issues are receiving sufficient and appropriate medical care.  A long-term medical condition is one that usually cannot be cured but can be managed in order to improve quality and length of life. Some long-term medical conditions would result in a rapid externally obvious decompensation of the patient if untreated, whereas others increase length of life without any obvious external signs.

• Legal reasons refers to the need to examine a patient before re-prescribing or adjusting ongoing medical therapy.  A “veterinary prescription” is only valid for up to a maximum of 6 months.  Note that the term “veterinary prescription” refers to the ‘decision to medicate’ as much as it does of the piece of paper that represents the order for the medicine prescribed. In order for a vet to be able to be able to re-prescribe an ongoing POM (Prescription-Only-Medicine), they must acquire a full clinical history and conduct a full physical examination of the patient at least twice a year. Whilst a clinical history could be conducted over the telephone or via an online consultation, a physical examination cannot.

Whilst a clinical history and physical examination are the minimum levels of information required to re-prescribe an ongoing Prescription-Only-Medicine (POM), they are often not insufficient to assess the actual medical status of the patient’s condition. Many organ systems have a significant buffer of reserves that mask ongoing deterioration from our physical senses.  Therefore it is not possible to tell how an animal’s liver, kidneys or hormones are performing using only our external physical signs.  Monitoring a long term medical condition by ‘waiting and seeing’ until a patient develops noticeable external signs as a result of ongoing internal changes is akin to skydiving with your eyes closed.

Whilst some long term medical conditions only require one medicine to remain stable, many conditions require more than one medicine at one time. Often the need for an extra medicine can only be determined by monitoring a physiological or biochemical change within the body that is not detectable by observing externally visible signs.

There are a range of laboratory and imagery tests that can be used to monitor ongoing medical conditions; the exact tests depend on the condition.

We appreciate that more tests and more medicines comes with extra costs.  Ultimately, the degree to which you wish to pursue tests and treatments is yours.  Our job is to make you aware of the options with respect to managing your pet’s health, as well as the pros and cons of each, including the associated costs and answer any queries you may have.

Aldeburgh Vets regularly receives requests for second opinions from clients belonging to other veterinary practices. Our regulator, the RCVS, insists that we must acquire the clinical records from your previous vet in order to give you a second opinion on the case.  However, when we advise clients of this requirement, we find many are reluctant to consent to this as they are embarrassed to be seen to be doubting their current vets’ opinion.  We understand this.  However, this is necessary so that we are up to date with your pet’s clinical story as so that we do not repeat previous investigations unnecessarily or administer medicines that would be contraindicated with any previous therapies.

Second opinion consultations cost £65 because they involve more administration and preparation regarding acquiring and familiarising ourselves with your pet’s clinical notes.

After a second opinion consultation you have the choice of remaining registered with our practice or remaining with your current veterinary practice.

It goes without saying that euthanasia is often the most difficult decision a pet owner has to make.

There are many variables that relate to the decision and the practicalities of euthanasia when the time comes to say goodbye. Whilst everyone’s circumstances are different, the following themes have to be considered in relation to the euthanasia of your pet.

1. When?
2. Where?
3. How? To sedate or not to sedate?
4. Options regarding your pet’s body

When?

Sometimes pet owners just know the end is approaching and have the time to prepare for the euthanasia, whereas at other times euthanasia is indicated with little or no warning, such as when a sudden illness or injury occurs. Decisions relating to ‘when’ to euthanise are most relevant when owners are aware that their pet is deteriorating, either through old age, or as a result of a long term medical condition.  The main challenge in these circumstances is to decide when is the right time – not too soon, but not too late.

One of the most common questions we get asked is “How will I know when it’s the right time?”  Whilst it is impossible to give definitive guidance on this, timing relates to the following considerations; those relating to the pet, the client and the physical circumstances.

The following rules of thumb are useful.

Avoiding regrets

When considering the timing of euthanasia it is important to consider the avoidance of 2 ‘regrets’; the regret of saying goodbye too soon as well as the regret of saying goodbye too late.  The ‘right time’ lies between these two points in time.  Some vets say that “they would rather an owner said goodbye a week too soon than a day too late”.

Bad-days versus good-days?

Some clients find the notion of saying goodbye to their pet ‘unfair’, despite physical and mental deterioration, because their pet is still having some ‘good-days’.  They therefore conclude that it isn’t fair to end a pet’s life when they are still having at least some moments of enjoyment. Whilst this is entirely understandable, it is important to maintain a perspective about the overall quality of life. Pets are not like batteries that should be drained of all life.  As sentient beings we should consider an animal’s relative proportion of good-days versus bad-days over a period of time. The exact period of time will vary as your pet’s status deteriorates, but generally when a pet is having more bad days than good days within any given month, unfortunately that time is approaching.

Signs to consider

There are many clinical signs that can prompt the need to consider euthanasia – they include:

Physical pain and distress

Some species display signs of pain more obviously than others.  For example, rabbits and other so-called ‘prey’ species evolved to hide signs of distress because it helps protect them from attracting attention from predators – this can make it difficult to know if they are in pain. Similarly, cats are renowned for masking signs of pain. Common indications that an animal is in pain include:

• Crying out, especially when moving
• Difficulty breathing
• Open, bleeding or infected lumps or wounds
• Regular collapse or fitting

But please note that just because an animal is not exhibiting these symptoms, this does not mean they aren’t in pain.  The two most common under-rated or misinterpreted symptoms relating to the presence or absence of pain are 1) stiffness on rising and 2) a retained appetite. Many owners assume that if an animal isn’t crying out or is still eating that they can’t be in that much pain. Whilst stiffness and limping may not manifest as agony, they are definitely signs of discomfort. Whilst this may not indicate the need for euthanasia just yet, it implies these animals do need some assistance managing their pain, often for the remainder of their lives.

Psychological pain and distress

• Pacing and persistent restlessness
• Random vocalisation
• Confusion
• Aggression that is out of character

Signs of physical deterioration that may not be compatible with life that may or may not be associated with pain.  These include an inability to perform vital functions unassisted such as:

• Inability to rise and move to access drinking water
• Inability to urinate +/- urine overflow
• Inability to defecate +/- regular faecal soiling whilst recumbent

When the decision is made to euthanise, the next decision to consider is where.

At home or at the veterinary practice?

Whilst most pets are euthanised at the practice, some owners prefer to say goodbye to their pets at home in a familiar environment. There is absolutely nothing wrong with this option as long as you are aware of some of the following considerations.

Considerations relating to saying goodbye at home

• Timing
  • It is important to anticipate that the vets may not be able to attend your home at relatively short-notice due to pre-scheduled consultations and operations. That said we would never want an animal to suffer and would do all we can to attend promptly.
  • It is not uncommon for clients to request a home visit for euthanasia ‘in the evening’ when members of the family who wish to be present have returned from work.  Once again, whilst we will do all we can to accommodate your wishes, the logistics of arranging for the vet and nurse to attend your home outside of normal work hours usually need to be pre-planned.
• Restraint
  • Gentle but adequate restraint is essential in order for the euthanasia process to go smoothly. This is because the euthanasia agent is delivered intravenously (see below).  In order to achieve clean and secure intravenous access, a veterinary nurse or care assistant usually has to hold your pet.  Should you wish to hold and hug your pet as they drift away, we will have to consider how to best restrain them.
• Light and visualisation for iv access / catheterization
  • Achieving intravenous access requires an adequate light-source. Whilst we understand that a dim candle-lit ambience is soothing, it is important to realise that the vet will require adequate light to achieve uncomplicated access to the vein.
• Cost
  • The practice charges more for home visits because of the significant time they require for a vet and nurse to leave the surgery, travel to your home as well as insurance charges on vehicles used for a business-related journey.

How is the euthanasia carried out?  What to expect?

• Euthanasia is performed by the intravenous administration of an overdose of powerful anaesthetic that renders your pet unconscious
• Typically the animal sniffs, sighs, licks its lips and goes unconscious. This takes about 20 seconds from injection until the animal is deceased.
• Reflexes are common, some include;
  • Gasping – this is known as agonal breaths. It occurs when the diaphragm spasms once the brain has shut down. Dogs typically take 3-6 gasps.  This reflex can occur up to 2-3 minutes after unconsciousness
  • Toileting – it is not uncommon for animals to urinate and even defecate as their bodies relax once deceased
  • Vocalisation – this is the symptom that causes owners the most distress. It only occurs in about 1% of dogs, but it can sometimes be quite loud and sound terrible. It is hard to predict which animals will actually vocalise but it seems to occur most commonly in dogs that are ‘confused’ or ‘stressed’. Pet owners often wonder if something has gone wrong when their pet vocalises during euthanasia. This is understandable, but it is a recognised, but rare, response to inducing unconsciousness. Human anaesthetists tell us that people can very occasionally display a range of behaviours as they become unconscious as anaesthesia is induced ranging from laughter, shouting and even aggressive cursing.

To sedate or not to sedate?

Some vets prefer to sedate all their patients before administering the final injection. There is no right or wrong approach and each individual circumstances differ.

Some of the Pros include:

• Less manual restraint required
• Less awareness and less distress

Some of the Cons include:

• Unpredictability of effect – especially if the sedation cannot be given intramuscularly.
• Intramuscular injection can cause discomfort
• Accessing the vein to deliver the euthanasia injection can be harder with with diminished blood pressure
• There will be an extra cost

To catheterise or not to catheterise?

Some of the Pros include:

• Clean, secure access to the vein
• Owners can hug the pet during the euthanasia

Some of the Cons include:

• Some vets will not attempt to place an IV catheter in front of the client and prefer to take the pet away from the owner. However, we prefer not to separate a pet and owner in the last few moments of the pet’s life.

Options regarding your pet’s body

You have 4 options regarding your pet’s body:

1. You can take your pet away from the practice for burial
2. You can have your pet cremated but without any ashes returned
3. You can have your pet cremated and have their own ashes returned in a casket with your pet’s name on it
4. You can have your pet cremated and have their own ashes returned in a pouch that can be opened to scatter the ashes

How to cope with Bereavement

Losing a pet can be a very challenging and emotional time – there is pet bereavement support out there to help, from knowing the right time, to grieving after the death of your pet.

For help and advice please take a look at the websites below.

RSPCA – https://www.rspca.org.uk/adviceandwelfare

PDSA – https://www.pdsa.org.uk/taking-care-of-your-pet

Blue Cross – https://www.bluecross.org.uk/pet-bereavement

Support line – https://www.supportline.org.uk/problems/pet

Cats Protection – https://www.cats.org.uk/what-we-do/grief