Prevention

The outcome of the first few veterinary visits can mean the difference between having a compliant patient that enjoys the veterinary hospital or a patient that is fearful or anxious. The goal of each visit is to make the experience positive and to minimise unpleasant experiences. The owners should be asked to determine which toys and treats are most favoured and to withhold them on the day of the visit until they arrive at the veterinary clinic. Reducing feeding prior to the visit can also increase the dog's motivation for food. The visit should be positive from beginning to end. Positive greetings from the staff and the use of favoured toys or treats can help ensure a positive association with the veterinary visit. Pets that are fearful or anxious in the waiting room can be taken directly into an examining room. Weighing, lifting, restraint, examination and injections should be closely monitored to ensure that they are not evoking fear. Favoured treats and play may help to distract the pet and associate each part of the visit with a positive outcome. Some highly sociable dogs merely need petting and verbal encouragement so that treats and toys can be saved to distract during the most unpleasant experiences. A nonslip mat on the table or scale may help to prevent a fearful experience. A DAP (dog-appeasing pheromone) diffuser in the clinic or examining room may also help reduce anxiety.

If there is any fear or anxiety, the pet should be given time to calm, before proceeding. Fearful or conflicted dogs may not be interested in food or play or may quickly grab the food treat. Avoiding eye contact, progressing slowly, talking in a happy voice, throwing food rewards in front of the pet, or having the owner offer the toys or treat, should produce a playful tail wag or a relaxed posture, at which point you can again slowly progress. Offering the treat from your hand and monitoring facial and body signals can help to determine whether the pet is willing and ready to be approached. Determine whether examining the pet on the floor or the table, or having it be restrained by the owners or one of the staff is least likely to evoke fear. If fear is excessive, the visit should be discontinued and desensitisation and counter-conditioning should be discussed.

Desensitisation and Counter-Conditioning of Fearful Dogs

Desensitisation and counter-conditioning is a means by which the pet can be exposed to each component of the veterinary visit and have a positive outcome before proceeding. Desensitisation refers to exposure to stimuli at a level that is below that which will cause fear. Counter-conditioning is when a favoured reward (e.g., toy, play, food) is paired with the stimulus so that it becomes predictive of something positive rather than something negative. To ensure the highest level of motivation, rewards should be withheld on the day of the veterinary visit and then paired with whatever might evoke fear. Reducing food prior to the visit may further increase the motivation for treats. Progress will vary from dog to dog, based on its level of anxiety and how motivated it is to take the rewards (cost-benefit ratio).

Before the visit the dog should become accustomed to the restraint devices which will be used for the veterinary visit (e.g., leash and collar, leash and head halter, muzzle, carrier). The dog can also be desensitised and counterconditioned to car rides, and any handling of the body, head, ears, mouth, legs and feet, that might lead to fear at future veterinary visits. Using a flashlight to look in the dog's eyes, teaching the dog to walk across and stand on a variety of surfaces, lifting the dog on to a table and desensitising and counterconditioning to teeth brushing, and mock pilling (using treats) can all be useful to accustom the pet to events that might later evoke fear either in the veterinary clinic or in the home. Dogs might also be more quickly and effectively desensitised and counte-rconditioned if they have been clicker or target trained.

Desensitisation and counter-conditioning should proceed through each step of the veterinary visit using play, toys or treats to:

 Drive through the parking lot

 Walk in the parking lot

 Walk past the clinic

 Walk on to the clinic porch

 Walk into and through the waiting room

 Walk into the examining room

 Stand in place with gentle owner restraint on the floor or on the table where it is to be examined.

Where possible have the staff give treats or play with the pet at each step of the programme. Finally the veterinarian would enter, give rewards and do a gentle or mock physical examination while owners and staff offer favoured toys or food.

If it is uncertain whether the dog may resist or bite during an examination or injections then a leash and head halter can often be used to successfully control the head and mouth while releasing and reinforcing whenever the dog is calm. End each session on a positive note. In addition, avoid turning and walking away as some dogs will snap at a retreating individual.

Handling the Fractious Dog

Dogs that have previously displayed aggression, are ill or in pain, or unfamiliar may pose the greatest risk. Medical records of animals that were previously fearful or aggressive should be clearly marked. Staff should be trained to identify normal and fearful behaviour. Obvious signs include barking, growling, freezing, retreat, cowering, ears back or to the side, tail between the legs, panting or sweating.

Also monitor ear carriage, eyes, position of the lips and mouth, tail carriage and general body posture for more subtle signs of fear and anxiety. Displacement behaviours, including yawning, scratching, lip licking or loss of urine control, might indicate that the pet is conflicted or uncertain about whether to expect a positive or negative outcome. Even if the dog shows appeasing or submissive gestures (e.g., crouching, averting eyes, licking, rolling over to expose the belly) further approach may lead to aggression.

Some pets might be less anxious if given a benzodiazepine prior to arrival (to reduce anxiety and improve appetite) and some can be controlled and calmed with a head halter. If rewards are highly motivating the outcome may be improved. The use of acepromazine and a muzzle may allow for sufficient restraint to ensure safety and may reduce anxiety if the veterinarian and staff no longer exhibit fear. Some pets do better if separated from their owners, especially if the owner is fearful or anxious, tries to soothe the pet, or the pet becomes increasingly defensive as it retreats towards the owners. Aggression that is redirected to the person closest to the face must also be prevented.

You may succeed if you work slowly, talk softly and offer treats. Walking directly at the dog, reaching over, cornering or looking into the eyes, or heavy-handed restraint are all threatening and should be avoided.

If the owner or any staff member is at risk, additional management aids should be utilised. These might include muzzles, leather gloves, pole syringes, snares, squeeze devices and induction chambers. Know the advantages and limitations of each. A blanket or towel may be sufficient for some small dogs. Basket muzzles are safer than cone, gauze or tape muzzles because they allow the dog to pant. Owners should be advised to desensitise the dog to the muzzle at home and to apply it before the veterinary visit.

Head collars can also be useful for aggressive dogs. The head collar allows the experienced handler to effectively control the head for examination or procedures that are minimally uncomfortable. The basket muzzle, a leash and head halter or even an E-collar can be left on the dog to enable it to be removed safely from the kennel.

Alternately injectable sedation should be considered either with the aid of the pet owner or a staff member plus a head halter or muzzle if safety is an issue. By pulling the leash up to the hinge side of a door, a needle can often be given while the head is safely restrained. However, this can be dangerous to the dog if the procedure is not quick and especially if the dog is wearing a choke collar. Drug selection should be based on:

 The age and health of the pet

 The level of risk

 The degree of sedation required

 The procedure, i.e., restraint, pre-anaesthetic agent, euthanasia.

Injectable combinations are usually safer and more effective than single agents and lower doses of individual agents can be used. Although medetomidine alone (which can be reversed) may be effective for young healthy dogs, the combination of an opioid with acepromazine, midazolam or medetomidine may be more effective. Acepromazine might be combined with an opioid and medetomidine. Off-label oral combinations of medications have also been suggested in high-risk situations such as a benzodiazepine combined with acepromazine, butorphanol or phenobarbital, or acepromazine plus phenobarbital.

References

1.  Horwitz D. Tips for handling fractious patients. Clinician's Brief, November, 2005: 69-70.

2.  Mosley C. Drugs for restraint of the unapproachable dog or cat. Proceedings of the North American Veterinary Conference, 2005; 70-71.

3.  Yin S. Simple handling techniques for dogs. The Compendium on Continuing Education for the Practicing Veterinarian, 2007; 29: 352-358.

4.  www.abrionline.org--head halter control during the veterinary visit

5.  www.behavior4veterinarians.com (veterinarians) or www.askdryin.com (public)--videos of desensitisation and counterconditioning