We are all aware of the continuing trend of ownership of non-traditional species. Practitioners are also being asked to become veterinary consultants for zoological of exotic animal rescue facilities. With limited training in non-traditional species, veterinarians are being challenged with ill- preparedness for themselves, their staff and their clients. Veterinarians can build practice and team confidence in working with these species through a variety of tools, resources, and training. These can include using marketplace resources, providing on the job training/ continuing education for staff, developing informational databases, enhancing your practice equipment for multiple taxa, and sharing best practices in professional networks. Before you begin this adventure, however, you and your staff must pre-consider the philosophical, legal, and ethical implications of working with non-traditional species. Strong convictions in the popular and professional communities exist regarding working with these species. Therefore, you must whether or not you will consider work with some taxa such as venomous species, primates and exotic felids. Proactively consider how you would approach large cat patients and clients. Considerations include:

 Asking your clientele that have venomous herps to come after hours and provide an antivenin bite kit when they bring these patients to your practice

 Developing guidelines with primate owners that they agree to appropriate zoonotic testing for their species before you initiate that working relationship. You need to feel comfortable that you have full disclosure from a safety standpoint for both you and your staff.

 Developing practice policies regarding ethical issues such as declawing felids and primate canine extractions before your frontline staff receives the call.
Utilize policies developed by the American Veterinary Medical Association (www.avma.org) and American Association of Zoo Veterinarians (www.aazv.org) as guides for your practice

 Keeping abreast of the legal limitations regarding the species you are being asked to evaluate.
Dr. Adolf Maas provides an excellent overview in Veterinary Clinics Exotic Animal Practice of the legal implications of exotic pet practice.

The art of zoo practice lies in gaining those personal experiences for you and your teams, using your comparative medicine skills, a little intuition, and sharing this knowledge. You can take you practice on a wild exciting ride into the world of common diseases in uncommon species.

Zoo and Wild Animal Resources (Table 1)

Knowing the medical management of a variety of taxa can be overwhelming at times. It is critical that you utilize the information in the primary and secondary literature for reference materials. The wealth of information regarding natural history, husbandry, and medicine of exotic species is out there and can be tough to find at a moment's notice. Try to develop a resource center in your practice and consider an "owner" within your team to manage this database or library. By keeping these resources at an arm's length, you have quick reference materials for those unique species your encounter unexpectedly. Your support team will also have these resources to build their confidence in working with these species. Encourage your team to extrapolate information from better know species. Comparative medicine is the cornerstone of working with wildlife and zoo species.

If your in-house resources don't seem to meet the task, looking outward is a great opportunity as well. List serves exist in the field and exotic and zoo medicine, for both veterinarians and veterinary technicians such as Veterinary Information Network, International Zoo Vet Forum, and the Association of Zoo Vet Tech forum. Don't forget to "phone a friend" as well with your professional colleagues. Develop a relationship with your local zoo vet colleagues, local licensed wildlife rehabilitators as partners and resources for zoo and wildlife species. Consider inviting them to your practice as well for a meet and greet and continuing education session for you and your team. Various associations in the field and exotic pet, zoo, and wildlife medicine exist and can provide a plethora of information and resources for you and your team members. Membership for you and your team can provide additional benefits through their websites, newsletters, and journal subscriptions.

Table 1. Select Reference Materials, Organizations and Reading Resources for Your Exotics Practice

 American College of Zoological Medicine reading list: http://aczm.org/aczm_reading%20list.pdf
Editor's note: The current reading list is available on http://aczm.org/ in the Certification section.

 Merck Veterinary manual: http://merckvetmanual.com/mvm/index.jsp

 The Exotic Companion Medicine Handbook, editor Cathy Johnson-Delaney

 Exotic Animal Medicine for the Veterinary Technician, editors Ballard, B., Cheek, R.

 Manual of Exotic Pet Practice, editors Mark Mitchell and Dr. Tom Tully

 Invertebrate Medicine, editor Greg Lewbart

 Veterinary Clinics of North America: Exotic Animal Practice

 Exotic Animal Formulary, editor James W. Carpenter

 Veterinary Information Network: https://www.vin.com/

 American Association of Zoo Veterinarians: http://aazv.org/

 Association of Reptile and Amphibian Veterinarians: http://arav.org/

 Association of Exotic Mammal Veterinarians: http://aemv.org/

 Association of Avian Veterinarians: http://aav.org/

 International zoo vet forum (membership form required): http://aazv.org/

 Association of Zoo Vet Techs forum (membership required): http://azvt.org/

 Journal of Zoo and Wildlife Medicine (published by AAZV): http://bioone.org/perlserv/?request=getarchive&issn=1042-7260

 Journal of Wildlife Diseases: http://www.jwildlifedis.org

 National Wildlife Rehabilitators Association: http://nwrawildlife.org/

Job Training and Continuing Education (CE)

A well- trained team is a confident team that can maximize your efficiency in working with unusual species. The principles that your veterinary technical team uses day to day for sample collection, sample analysis, anesthesia monitoring, and critical care of the domestic or traditional exotic pets you see in your practice daily are not going to change. When you can empower your support team to perform the traditional technical procedures (regardless of the species), then you can utilize the anesthetic and procedure time on what you were trained to do- thorough physical examinations, well- thought diagnostic plans, and maximization of sampling to implement an efficient procedure for you and your staff. The short term investment of educating your team will lead to long term sustainability of your practice team.

Few veterinary and veterinary technical schools provide hands on experience and coursework on avian and exotic animals, but there are several meetings that have a high concentration of exotic, zoo, and wildlife lectures and wet labs. In addition to the EAMCP conference, meetings to consider include American Association of Zoo Veterinarians (AAZV), Association of Zoo Veterinary Technicians (AZVT), Association of Reptile and Amphibian Veterinarians (ARAV), the Association of Exotic Mammal Veterinarians (AEMV), and the Association of Avian Veterinarians (AAV). The North American Veterinary Conference (NAVC) has several sections devoted to special species including several days for exotic pet species and two, full day sessions for zoological and wildlife species. Tempering staff retention and maximizing practice financial performance can be a challenging benefit and risk balance. However, budgeting continuing education time and financial support for your technical team will prove beneficial for you, your team and their job satisfaction, and your long term practice success. It is often a great opportunity to require conference attendees from your practice to produce "nuggets of knowledge" they learned from the CE to the rest of practice in a written or verbal learning opportunity for all. More cost effective CE options to consider include encouraging your team to join local exotic species interest groups or conduct weekly brown bag or after work seminars on husbandry and management of unusual species. Encourage your staff to develop client education resources or utilize those provided through AAZV, ARAV, AAV, and AEMV regarding these topics. Online conferences (webinars) and courses such as those offered through the Veterinary Information Network (VIN) and IDEXX are great cost effective alternatives for training your team as well. Invite a consultant to perform in-house training sessions or seminars. Utilize your distributors for training during a lunch lecture especially when new drugs or equipment come into your practice to ensure your team has the know how to use and maintain these products.

Native wildlife euthanasia or mortalities provide unique opportunities for training and learning for you and your tech team. Allow your veterinary technicians to provide triage care to the wildlife patients that walk in the door to build their confidence of working with a variety of species. Local or regional zoological facilities often will provide shadowing opportunities for technical staff to gain experience in zoo veterinary technology and laboratory zoo procedures.

With the expansion or species you are seeing in your practice comes the responsibility to train your team about necessary safety skills with working with these species. Beyond the technical competence for your team, biosecurity and safety training must be considered.

 Routine zoonosis training, including blood borne pathogens, should be integrated into your traditional team training schedules. Veterinarians working with exotic animals should familiarize themselves and their teams with the common zoonotic diseases presented to their practice. Consider preparing education pamphlets for your owners that recommend hygiene practices to limit their exposure to zoonotic diseases.

 If you intend to utilize and carry the concentrated narcotics such as carfentanil, etorphine (M99®), or thiafentanil, it is critical that you and your team become certified in cardiopulmonary resuscitation (CPR) including artificial external defibrillator (AED) usage. Develop an accidental exposure kit including a portable AED and narcotics handling safety training (Table 2) should an accidental exposure occur. It is also suggested to notify and develop a relationship with your local first responders so they are prepared should an exposure occur.

Table 2. Concentrated Narcotics Management and Accidental Exposure Operating Guidelines (Example)

Carfentanil (Wildnil®), Etorphine (M-99®), Thiafentanil (A3080 ®) are synthetic opiates with a clinical potency up to 10,000 times that of morphine. They have a morphine-like analgesic mode of action and produce a rapid immobilization following intramuscular injection.

 Central nervous system effects: Sedation, lethargy, miosis, syncope, seizures, coma, respiratory depression and arrest. Rapid loss of consciousness leads to cessation of breathing.

 Cardiovascular/vascular effects: Hypotension

 Gastrointestinal effects: Nausea, vomiting

 Emergency treatment- Do not leave the patient unattended!

1.  Designate people to call 911: Tell them there is a narcotic exposure at your current location (be specific); Request immediate emergency medical transport

2.  Get the emergency exposure kit and oxygen case. The designated Veterinarian or Vet tech will draw up 30 ml (30 mg total) of Naloxone, draw up 10 ml (10 mg) of Naloxone, prepare oxygen for use.

3.  Monitor pulse and respiration rate

4.  Place the victim on their side to prevent aspiration and obstruction of airway by the tongue

5.  Get cool water, not hot. If the exposure was via the oral, ocular, or dermal routes, flush the narcotic exposed area with copious amounts of water. Avoid self-contamination.

6.  If patient is awake, alert, and coherent, observe only

7.  Initiate respiratory support as needed. Use mouth-to-mouth resuscitation until the oxygen tank and demand valve resuscitator can be used. Oxygen flow rate should be set at 6-10 liters/min. Designate someone to open AED unit and begin cardiac massage via chest compressions if arrest occurs. Use current CPR ratio recommendations for ventilation to chest compression. Continue until AED unit is initiated and ready to use.

8.  If the patient is losing consciousness, unable to walk, or follow commands, establish IV access. Use butterfly catheter and tape in place. Administer 30 ml of Naloxone IV push (slowly, to effect).

9.  If the patient is unconscious, and IV access cannot be quickly established, give 10 ml Naloxone into any visible vein or divide and give 5 ml IM into a shoulder or thigh, then attempt to place on IV catheter again.

10.  Continue to repeat Naloxone doses (10-30 ml) until the patient becomes coherent. Multiple doses may be required.

11.  Send this protocol and all unopened vials of Naloxone with the patient to the Emergency Room. Accompany the victim to the hospital if possible.

Informational Databases

Learning new techniques, developing anesthestic protocols, and identifying an unusual fecal protozoa are all great strides in expanding your practice competency in exotic species. However, keeping that information at arm's reach for those triage times when a kangaroo, squirrel monkey, or ocelot walks in the door on emergency is the key to retaining that experience for you and your staff. The "jack of all trades, master of none" expertise that dominates zoo practice demands developing databases of information to reference when working with these diverse species on a daily basis.

 Our technical team has developed rolodex units that can be used for quick references for anything from equipment, supplies and drug locations to lab information and sample requirements. This simple and inexpensive database example allows for more efficient information access without the expense and technology needs.

 Our practice has also developed a Microsoft Excel-based pharmaceutical reference sheet with calculation macros based on body weight that can be produced quickly for emergencies or routine procedures requiring anesthesia. Quick dosage/ dose references for triage, resuscitative, or commonly used therapeutics keeps your support team "ahead of the game" when drugs are requested during a procedure.

 Developing preventative medicine guidelines for common zoo taxa before your client or consulting zoo or exotic animal rescue calls for your expertise minimizes the preparation time needed for those species not traditionally seen in your practice. Preventative medicine guidelines are produced by the AAZV and can be accessed at www.aazv.org (Table 3 as an example). Also found at the website are links to Species Survival Plan (SSP) protocols, contraceptive advisory group recommended contraceptive methods (http://www.stlzoo.org/animals/scienceresearch/contraceptioncenter/), and necropsy and pathology protocols by taxa.

 Image databases are great references for species identification, unusual cells, blood and fecal parasites, and ectoparasites (Our tech team has found that digital cameras can be adapted to the microscope optic to take still images) to develop an image database notebook and/or posters for quick reference.

 Choosing diagnostic tests to run on the variety of zoo species can be a daunting task for you as a diagnostician as well as your support team. Such as seeking laboratories that will run the necessary diagnostics tests and confirming validation for the species you are testing. Large veterinary reference labs, such as IDEXX and Antech, can help direct you to the advantages/ disadvantages with diagnostic tests and can also refer you to other laboratories that may specialize in certain taxa, such as the Viral Reference Lab (VRL) for primates, or disease diagnostics, such as the Johne's Testing Center in Madison, WI, USA. Once your team has located these labs, keeping that information in a reference notebook is a great resource to access when needed.

Table 3. Example of a Preventative Medicine Protocol for Carnivores

Procedures

 Complete physical exam

 Dental exam

 Check transponder

 Check body weight

 Chest/abdomen (including pelvis) radiographs – recommended every two years for contact animals, every four years for non-contact animals

Diagnostics

 Blood collection for CBC, biochemical profile, serum bank

 Serology for rabies

 Serology for FIV, FeLV, toxoplasmosis – felids only

 Serology for CDV for large felids, at clinician's discretion

 Fecal culture for enteric pathogens (including Salmonella and Campylobacter) – required for contact animals only (i.e., fennec fox, ferret)

Prophylactic Treatments

 Monthly oral heartworm and flea preventative medication (Sentinel; milbemycin + lufenuron)

 For animals prone to post-anesthetic nausea, consider metoclopramide 0.4 mg/kg IM or SQ

Vaccinations

Vaccination schedule may be modified for each individual based on serologic monitoring. If titers are unavailable, vaccination schedule should be followed as below. If using individual titers, use threshold values below which an individual will be vaccinated as soon as it can be scheduled.

Please note if vaccinating based on serology: Rabies serology via RFFIT report in IU/L with 1:100 equivalent to 1.0 UL/L. Acceptable titer in humans, considered protective is > 0.1 IU/L. Domestic animal standards have not been established; but, a titer of 0.5 IU/mL is required for animals exported to most rabies-free areas. Booster recommended at < 0.5 IU/L.

 Rabies (Imrab product) – 1 ml IM biannually (except for felidae - 1 ml Purevax product SQ in the tail biannually*)

 FVRCP – 1 ml SQ in the tail biannually

 Canine Distemper (Purevax Ferret Distemper Canarypox Vaccine) - 1 ml IM annually; initial series requires 2-3 vaccines at 3 week intervals, then annual booster

 Infant carnivores – FVRCP, DHLPP, and/or Canine distemper vaccination series at 8, 12, 16 wks, and 1 yr of age; then as outlined above in routine vaccinations section. Rabies at 4 months and 1 yr of age; then as outlined above in routine vaccinations section.

Additional Procedures

 Gastric biopsy (formalin and frozen samples) for histopath (attempt to bx pylorus) and Helicobacter PCR (MIT) for large felids, at clinician's discretion

 Additional diagnostics as indicated by history in geriatric animals

Quarantine Procedures

Unless otherwise specified by the veterinary staff in conjunction with the curatorial staff, all animals will be quarantined for a minimum of 30 days.

Procedures

 Complete physical exam

 Dental exam

 Check or place transponder

 Check body weight

 Chest/ abdomen (including pelvis) radiographs

Diagnostics

 Blood collection for CBC, biochemical profile, serum bank

 Serology for leptospirosis – all carnivores

 Serology for FIV, FeLV, FIP, toxoplasmosis– felids only

 Serology for rabies– felids only

 Serology for CDV for large felids

 Occult heartworm Ab/Ag

 1 fecal culture for enteric pathogens (including Salmonella and Campylobacter)

 3 weekly fecals for P&O

 Cheetahs should have gastric biopsy and Helicobacter PCR (also serum gastrin) performed for baseline, if not recently done as part of preship exam. Consider for other large felids based on history.

Equipment For Exotics Species

It is certainly recognized that you need to balance the cost of having these supplies with the frequency of the need, but below are some practice equipment for consideration to bolster your practice for the variety of taxa that may challenged your team.

 Personal protective equipment: facemask/shield, gloves, gowns, gauntlet/bite gloves

 Capture equipment: Nets, remote injection equipment, humane live animal capture cages

 Small and large scales: digital recommended, accuracy to measure from 0.01 g to up to 250 kg should be considered

 Anesthesia: rebreathing and non-rebreathing circuits, induction mask varieties [traffic cones, small (0.5L), medium (1-2L) and large water bottles (18L) , OB sleeves], induction units and connectors for inhalant anesthesia delivery, ambu-bags in a variety of sizes

 Oral speculums: commercially available avian mouth gags, spatulas, credit/gift cards, guitar picks, PVC pipes, wood blocks are all great tool for oral exams

 Cuffed and non-cuffed endotracheal tubes: 2 mm to 24 mm cuffed and 2-10 mm uncuffed, smaller endotracheal tubes can be made from red rubber and polypropylene tubes

 Dremel and dental drills: stock a variety of bits for beaks, nails and teeth floating of macropod and small hoofstock species

 Radiology: non-stick tape for feathers, mammography or dental film (improved detail of images for small patients, i.e., passerines and dart frogs), field radiology unit (utilize university technique charts then refine techniques solely based on trial and error, take multiple films at various techniques)

 In house laboratory supplies: chemistry units that process small samples (Heska i-STAT, and Abaxis Vet Scan ®); hemacytometer, hematology stains (Natt-Herricks or Rees-Ecker), ethanol, isopropanol, polyvinyl alcohol and formalin for parasite preservations

 Pharmacy: consider which drugs you need in arm's reach versus drugs you can order as needed; develop a relationship with a reputable compounding pharmacy (Professional Compounding Centers of America http://www.pccarx.com/, International Association of Compounding Pharmacies http://www.iacprx.org/), Class II drugs such as the concentrated narcotics have specialized safe needs.

 Surgery: develop a shell repair kit with a variety of screws and wires and non-orthopedic cordless drill and epoxy products; consider purchasing clear drapes for surgery with special species, cordless and bipolar electrocautery

 Thermal support room: consider a space where you can change the environment or holding space to accommodate a variety of species with thermal, humidity (hygrometer included) and UV requirements

 Aquatic supplies: air pump and stones, tricaine methylsulfonate (MS222), aquariums or plastic holding containers with graded measurements of volumes

Communicating Best Practices

We have all heard the adage to "see one, do one, teach one" as the best way to learn and this is certainly the case in the exotic and zoo medicine business. This philosophy is what builds the "experts" in our field of veterinary "practice". And as you learn these best practices, share you anecdotes, both successes and failures, with your colleagues- whether over a beer, through the various forums and listservs, as well as presentations at conferences and publications in the primary literature.

In your day to day practice, take time to download or debrief with your team after a large procedure or after working with a unique species that your team does not traditionally see. Review what worked and what you would change next time you were to use this anesthetic combination, work with this species, or perform a particular surgery.

References

1.  Ballard, B., Cheek, R. (2003) Exotic Animal Medicine for the Veterinary Technician. Blackwell Publishing, Ames, IA.

2.  Lennox, A., ed., et al. (2005) The Exotic Pet Practice. Veterinary Clinics of North America: Exotic Animal Practice 8 (3): 393-405, 475-496, 497- 530.

3.  Hess, L. (2009) Round Table Discussion: The role of the avian/exotic animal technician. J Avian Med Surg 23 (1): 64-68.

4.  Kelleher, S. (2007) How to introduce avian and exotic patients to your practice. Proceedings Central Veterinary Conference.

5.  Mitchell, M., Tully, T. (2009) Manual of Exotic Pet Practice. Saunders, St. Louis, MO.

6.  Mitchell, M. (2007) Diagnostic tests available for exotic animal clinicians. Proceedings Central Veterinary Conference.

7.  Mitchell, M. (2007) Zoonotic diseases of exotic animals. Proceedings Central Veterinary Conference.

8.  Pye, G. (2008) Zoo Medicine Rounds, Veterinary Information Network (VIN).

9.  Shields, A. (2004) Preparation of a special species ER. Seminars in Avian and Exotic Pet Medicine 13 (3): 111-117.

10. Tully TN, Mitchell MA. (2001) A Technician's Guide to Exotic Animal Care. American Animal Hospital Association, Denver, CO.