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Reception and waiting area
Many pets fret at the vets, but our waiting room is quiet compared to the average waiting room of a busy general practice. There is a good chance that you’ll have our waiting room to yourself when you come. So there is less likelihood of argy-bargy between pets that are waiting, and many pets don’t even seem to realise that they are at a veterinary practice. That having been said, please do keep dogs on a lead, and away from any cats that might be waiting in the room in their boxes. Our receptionists are really friendly and will be pleased to sort you out with a drink or point you towards any facilities that might be urgently required after a long car journey! There are weighing scales conveniently placed in the waiting room.
We have six consulting rooms. These will be much like the ones you are used to at your own vets, with an examination table, anatomical models, computers for viewing x-rays etc. As well as vet consultations, the nurses often use these rooms for dressing changes, for administering laser therapy and for physiotherapy.
“Walk-in” kennels and cages for dogs
Dogs and cats are kept in separate rooms to reduce stress for both species! The dog kennel room has large “walk-in” kennels (with glass fronts and high level utility bars for extra heating and / or ventilation) for larger and giant breed dogs. Smaller dogs can also go in these large kennels, but medium sized and small dogs are more usually housed in 10 stainless steel kennels with grill fronts. Dogs can get fresh air in secure outdoor enclosures to the rear of the building.
Dogs are bedded on thick “VetBeds” which are soft and forgiving, and which allow any moisture to wick away from contact with the animal. For larger dogs that are spending prolonged periods of time recumbent, we use padded foam mattresses under the VetBeds.
With a team of vets and nurses, communication is important. Everyone needs to know what the treatment plan is for each animal for the day. So every patient has its notes on the kennel door with the consent form and contact details for the owners, and a chart that shows what medications are to be given; when they have been given; the last time the patient ate, drank, urinated and defaecated; the patient’s weight each day (if they are in for a few days), and records of temperature and pulse etc.
Cats are kept in cages with glassfronts, and their notes are on their cage fronts as for the dogs. From the cages, cats can’t see other cats in the neighbouring cages. This reduces confrontation and stress.
Animals are prepared for surgery in the prep room. This is the “hub” of our building, with access to/from the kennels, consulting rooms, imaging rooms, the theatre suite, and the utility/laundry and store rooms. A large wipe board details the procedures planned for the day; which vet is doing the procedure and in what order; whether surgical kits have been prepared as yet; whether and when a discharge appointment has been planned, etc. In the prep room patients are weighed (if this hasn’t already been done in the waiting room), and they have an intravenous catheter placed, usually into a vein in one of the front legs. They are typically put on a drip and given premedication which typically includes an opiate analgesic drug, a sedative, and often an anti-inflammatory drug and antibiotics. Once we are ready to get on with doing their procedure, anaesthesia is induced with intravenous agents and an endotracheal tube is placed to allow oxygen and anaesthetic gas to be given.
Routine multi-parameter monitoring, including capnography (monitoring expired CO2 levels), starts in the prep room. Body temperature is closely monitored.
Patients can be kept warm with the aid of a heated mat and insulation. We aim to keep the patient at the right temperature rather than trying to correct significant temperature drift later. The surgical site is clipped and cleaned. Many patients require X-rays before, during and after surgery, and these are carried out, or at least developed, in the X-ray rooms (see later). Some patients require ultrasound or endoscopic imaging before surgery and this is usually carried out in the procedure room/CR X-ray room.
Most patients that need laboratory investigations doing will have had this done at their own vets in advance of referral. We are able to do basic biochemistry, haematology, urinary analyses and microscopy “in house”. So we can check kidney function, blood glucose levels, blood cell counts, urinary concentration and biochemistry in a matter of moments.
We can take blood samples and have these couriered to an external lab overnight for in-depth biochemistry and haematology. Results are received back promptly by email the next morning. For the occasional cases where in-depth analyses are required and time is pressing, we can have samples processed locally with a turn-around time of about an hour. We can do microscopy and staining of slides in house, but formal cytology (examination of cell smears under a microscope) and histopathology (examining pieces of tissue under a microscope) are skills that we leave to professional pathologists. Samples are again couriered to an external lab overnight. We have cytology results back the next day. Soft tissue histopathology results are typically back in 2-3 days. Histopathology results for bone can be 2-4 weeks or longer (this is because time consuming processing is first required on these samples before they can be viewed under a microscope).
It is a surprise to some how many different anaesthetic circuits can be used in the treatment of animals. There are various types suited to a range of different sizes of animals. Some are circle “rebreathing” systems that have a CO2 absorption system. We have a wide range of non-rebreathing and rebreathing systems, including the Humphrey ADE system which we use in the operating theatres. We use circle, Lack and T-piece systems in the prep-room and in X-ray. We have five anaesthetic stations (one in each operating theatre, two in the prep room and one in the x-ray room). Each station has a set of anaesthetic circuits, an oxygen generator and a back-up oxygen cylinder for emergency use. It is important that our nurses, experienced RVNs though they all are, stay in practice using all manner of anaesthetic circuits because they sometimes go out with Jon and Andy to other practices to do mobile surgical work, and they need to be comfortable and familiar with whatever equipment they will be using there.
From June 2019 we added CT scanning to our service portfolio. CT is useful for investigating a wide range of issues including investigating spine problems, assessing angular limb deformities, assessing elbow dysplasia and hunting for the spread of tumours.
The two X-ray rooms house all of the paraphernalia that we need for digital radiography. We have a CR X-ray machine that is an ex-NHS machine and this uses plates that are positioned behind the patient, exposed and loaded into the reader. It can process X-rays in seconds and we can digitally manipulate the images.
The DR digital X-ray in the adjacent room has an X-ray sensitive plate built into its table and produces X-ray views in the blink of an eye.
Health and safety rules abound in the X-ray room! The risk to the patient is vanishingly small, but work procedures are in place to protect staff who deal with X-rays day in, day out. When radiography is in progress, only staff involved in the imaging are present. We wear dose meters to monitor our X-ray exposure and these meters are regularly checked.
Some X-rays are taken under anaesthetic, and the X-ray rooms are each equipped with anaesthetic stations and anaesthetic monitoring equipment. We have a range of troughs, ties, and other positioning aids to help us get diagnostic images.
Many x-rays, for example follow up x-rays to check on bone healing after cruciate surgeries, are taken using a NOMAD hand held X-ray generator. The beauty of this system is that we can take images without the need for sedation /anaesthetic, and this can be done in a few minutes while the owners wait.
Ultrasonography can be done in the X-ray room or in the prep room … or even in the kennels … with one of our two ultrasound units.
We use modern multi-parameter monitoring in all four theatres which gives us constant information on oxygen and carbon dioxide levels, breathing and heart rates, heart electrical activity, blood pressure and body temperature. All of our operating theatres have overhead lighting which can be positioned by the surgeon, suction, a piped compressed air supply (for driving air tools like drills, saws and burs), and cautery (for controlling bleeding).
Operating theatres need to be scrupulously clean for obvious reasons, and a rigorous routine cleaning protocol is required. Ours have positive pressure ventilation, the ideal standard in human theatres. As well as judicious use of disinfectant, the theatres can be “air-bombed” using a vapour disinfectant to fumigate the room and permeate into every corner! Only essential equipment is kept in theatre to minimise nooks and crannies which could constitute a cleaning issue. Our surgical laser, arthroscopy equipment, and other items of equipment which are only used intermittently, are not left “out” in the operating theatres. Instead they are kept tucked away and covered when not in use to keep them clean and dust free, and they are brought out when they are needed.
Once in the operating theatre patients are positioned appropriately and the surgical site is given the final aseptic preparation. The surgeon and assistant gown and glove, open the surgical kits, and drape the surgical site with sterile and waterproof drapes. For some procedures there is no need for a surgical assistant to be scrubbed in to assist the surgeon. In one of the pictures below Lorna is working alone, using the operating microscope to perform eye surgery. In the case of some procedures, an extra pair of hands is required. For complex procedures like hip replacement surgeries we have two assistants scrubbed in as well as the surgeon. For some procedures, like thoracotomies for example, we consider it essential to have an anaesthetic team of at least two people, as well as the surgeon and the surgical assistant.
Keeping patients at the right temperature, rather than trying to correct their temperature when it has drifted is very much our ethos. For cases where they really need some serious help to stay warm after surgery, the HotDog warming system is an excellent (if rather expensive!) piece of kit to have available.
Theatre utility room
Instruments and surgical kits are prepared in the utility area. Kits are assembled for the various operations for the day and these are then packed in wrapped metal boxes. Other equipment is sealed into easy-open autoclave bags. Autoclaves are essentially big pressure cookers! Once packed, kits and equipment are heated up to 134 degrees centigrade under pressure to kill micro-organisms. Surgical equipment is expensive and cleaning, care and maintenance of the instruments, implants and power tools is time consuming! We sterilise some of the more sensitive kit with ethylene oxide gas sterilisation.
The scrub room is located between the operating theatres on the one hand, and the prep-room and the utility room on the other. The double set of doors between the prep-room and the utility areas (where there is a lot of activity and patients and kit preparation going on) helps us to keep the operating theatres immaculately clean. The double doors to the scrub area help to keep the air mass in the prep-room and utility areas separate from the air mass of the operating theatre. The surgical team scrub-up in the scrub area. Only theatre clothing and theatre shoes can be worn in the scrub area, and beyond into the operating area. The operating theatres and the scrub area are cleaned by the theatre staff, and not by our general cleaners who do the rest of the building.
We get a huge amount of gear delivered and we need a sizeable store room and delivery area to receive these deliveries!