The Vet Vault 3.2.1.

Practicing POCUS, if not metronidazole then what, and unsexy (but real) mindfulness.

Jun 20, 2024

3 Clinical Pearls.

1. The perfect ultrasound dummy

From episode 157 on the ECC feed. With Dr Søren Boysen and Dr Serge Chaloub.

Back in May I shared Dr Søren and Serge’s pearl on how to use ultrasound to help you find tricky veins. But you don’t really want to practice any new stabbing techniques in real live animals, right? Which is why I loved their technique for creating a phantom model to practice this on:

Raw chicken breast, sliced open.
Partially water-filled balloon (the long skinny ones that you use to make balloon animals) burritoed inside the chicken breast (A balloon is a fair approximation of the resistance of the wall of a vein to a catheter, while something like a drip line is too rigid.)

If you’d like hands-on guidance on this technique, and all things POCUS, Dr Soren will be in Aus for a series of practical workshops in August this year. If you have an ultrasound machine, but you don’t know how to do POCUS this opportunity to learn from the godfather of AFAST/TFAST is a must. You can join in Sydney on 17 and 18 Aug or in Townsville on 24 and 25 August.

2. So what DO we do for those acute colitis cases if we can’t use metronidazole?

From episode 164 on the Medicine feed. With Dr Elke Rudloff.

You know the case: owners have been up all night (or they are about to be!) because their dog is constantly pooping out small squirty slimy bits of blood. Not the AHDS/HGE case that needs iv fluids - the classic colitis case. In the past I would have given this dog metronidazole for its supposed anti-inflammatory effect, and many vets still swear that it helps. And they may actually be right… In this episode I learnt about a study that looked at the efficacy of treating acute colitis with metronidazole, vs a placebo, vs a probiotic, vs highly digestible dietary fibre like psyllium. The result:

Metro did better (ie sped up resolution of clinical signs) than a placebo, the same as a probiotic, and worse than psyllium.
So yes, metronidazole helps (we’re not sure why - the anti-inflammatory effect is not really a thing), BUT
Probiotics and psyllium do not f up the microbiome, unlike our friend metro.

So, in summary: a highly digestible diet with added fibre should clear up colitis diarrhoea faster than metronidazole, or probiotics, with no down side.

3. So how wide DO we cut?

From episode 157 on the surgery feed. With Dr Brendan Janssens.

In the last newsletter I confused you with Dr Brendan’s statements about margins in soft tissue sarcomas. So, when do we think we’re likely to get away with narrow margins, and when should we consider going big, like referring for fancy flaps, or even amputating? Here’s Brendan’s guidelines: Your nemesis is more likely to be nasty with a need for margins as wide as possible if:

It’s fast-growing.
It feels fixed, vs being more mobile.
It’s very large.
The skin on the mass is ulcerated.
There’s lots of oedema around the mass.
IMPORTANT NOTE: Incisional biopsies will under-predict the grade of soft tissue sarcoma by about 30%, which means that your final pathology will be a higher grade than what your incisional biopsy showed you.

Listen To The Podcasts

2 Other things (about money).

“The money that one possesses is the instrument of freedom; that which one strives to obtain is the instrument of slavery.”
- Jean-Jacques Rousseau
“When wealth is used to garner praise, it only fools fools.”
- Mariana Alessandri

1 Thing to think about.

‘Mindfulness’ is a term that is used so ubiquitously in the popular media that its meaning and impact can become obscured. When you hear it (again!) it’s hard not to picture a cross-legged guru floating on a cloud, or the modern version: an active wear-clad influencer feeling #grateful #blessed for their avo toast, soy latte and high cheekbones.

Which is why I loved this contrarian way of thinking about what being mindful actually means in messy day-to-day life - the kind that doesn’t involve 2 hour meditation sessions at a Hinterland retreat (with the selfies to prove it). It’s from the Blindboy podcast. In it, Blindboy describes a ‘mindful walk’, where he focusses on the breeze on his skin, the sounds around him, the detail of what he’s seeing, and smells, like the smells of spring, and… dog shit. He also notices / notes his reaction to the smell. Then the segue, the practical application: mindfulness is noticing the smell of dog shit, and then realising that you don’t have to step in it.

How often do we step in the emotional equivalent of dog shit? Usually because we’re too distracted to notice it. Sometimes because we lack the skill (or will) to take a step to the side. Mindfulness practice can help with both of those.

Much love,

Hugh