1
Introduction to Low-Restraint and No-Restraint Veterinary Care

1.1 First, Do No Harm

Veterinary Technician’s Oath

I solemnly dedicate myself to aiding animals and society by providing excellent care and services for animals, by alleviating animal suffering, and promoting public health. I accept my obligations to practice my profession conscientiously and with sensitivity, adhering to the profession’s Code of Ethics, and furthering my knowledge and competence through a commitment to lifelong learning.

Veterinarian’s Oath

I solemnly swear to use my scientific knowledge and skills for the benefit of society through the protection of animal health and welfare, the prevention and relief of animal suffering, the conservation of animal resources, the promotion of public health, and the advancement of medical knowledge.

First, do no harm. While these four words do not appear in the oaths, this short sentence certainly describes our mission as health care professionals. Our oath to prevent, relieve, and alleviate animal suffering and the oath’s implication of doing no harm apply to both physical and mental or emotional suffering and illnesses of the body. Stress and fear are subjectively harmful and unpleasant on their own, but their physiologic effects of increased heart rate, respiratory rate, blood pressure, temperature, blood glucose levels, cortisol levels, and so many more clearly hold the potential for harm as well.

Recognition and treatment of stress and fear in veterinary patients is not a new concept, but progress is still needed. Dr. Sophia Yin was a pioneer in this field, and her work is still timely and relevant today. She brought the idea of low-stress veterinary care to the mainstream. Dr. Marty Becker has spearheaded the Fear Freesm Practice movement in the veterinary profession. We owe thanks to these people and so many more who have come before us, paving the way for this book, which will continue the work of improving veterinary care for patients, clients, and the entire veterinary team. This guide will help the veterinary team take low-stress, compassionate, patient-centered handling to the next level. Mirroring the pediatric model for patient comfort, developing training programs for fearful patients, and embracing the techniques used by progressive zoos and aquariums in their husbandry training programs will all be taught in this guide.

We deserve to take great care of ourselves as well. Veterinary professionals are at high risk for burnout, compassion fatigue, depression, and suicide.1 Turnover in the veterinary profession is common, with technicians in particular citing burnout. Experiencing stress and potential emotional harm when we are trying to make patients healthy can take a serious toll on veterinary professionals. By using methods that allow patients to relax and cooperate for care, we can make it easier to fulfill our vocation of relieving and preventing animal suffering while keeping our own emotional and mental wellness.

1.2 Stress, Fear, and the Veterinary Clinic

Stress is how the body reacts to a challenge, or stressor. This response is necessary for life. The fear response is a self-protective mechanism that prompts an animal to flee, fight, hide, or react in another helpful way to defend its own safety and well-being. Fear and anxiety can be provoked by either real or perceived threats, or stressors. These stressors and potential threats are abundant in the veterinary setting. How an individual animal responds to specific events or stressors is unique to each pet, and can change over time with learning history – for better, or for worse.

While the stress of veterinary visits can provoke avoidance, hiding, and defensive aggression, stress and fear can also induce the state of learned helplessness.2Learned helplessness is a state where an animal (or person) learns that avoidance, escape attempts, or other responses to something unpleasant or threatening are ineffective, and eventually gives up attempts to escape.2 In pets, this often looks like the pet is “a statue,” “frozen,” or “stoic.” Learned helplessness can mask important findings on physical examination like changes in range of motion, pain in the abdomen, or other findings that rely on patient responses. Conversely, animals who are defensively aggressive because of fear may react by vocalizing, snapping, or moving away during examination. This response may be difficult to discern from a pain response, making diagnosis and treatment more challenging. In each of these cases, the animal who is undergoing treatment is suffering emotional distress, and deserves our empathy and respect. Each time the pet visits our office and has a negative experience, the fear will potentially worsen. This learned fear of the veterinary hospital is much easier to prevent than it is to reverse.

Preventing fear in the veterinary office isn’t just about stopping the problems associated with fear; it is also about reaping the great benefits of working with patients who are less anxious. Patients who are comfortable and less anxious will allow more complete physical examination; allow better positioning for tests; have more accurate parameters, such as blood pressure, heart rate, temperature, and respirations; have more accurate lab results; and enjoy visits much more. Wouldn’t it be wonderful to see patients who are happy to see you? We think so, too!

1.3 Freedom, Wants, and Needs

Dr. Temple Grandin is a world-renown expert in animal behavior and animal welfare. In her book Animals Make Us Human, she discusses what are called “The Five Freedoms” in animal care, originally developed by Dr. Roger Brambell in 1965 (Table 1.1).3 When we cause fear and anxiety in our patients while we are trying to care for them, we are infringing on their freedom from environmental discomfort, freedom from anxiety and distress, and freedom to express normal behaviors. One of the first steps in restoring these freedoms is identifying the difference between wants and needs in the veterinary office.

Table 1.1 The Five Freedoms.

The Five Freedoms

Freedom from hunger and thirst Freedom from discomfort Freedom from pain, injury, or disease Freedom to express normal behavior Freedom from fear and distress

Animal welfare is a crucial factor in animal care, and The Five Freedoms were developed by Roger Brambell and popularized by Temple Grandin.

To protect freedom from anxiety for our patients, we recommend setting up guidelines for assessing animals during procedures. We will discuss assessment tools throughout the book, but the first step is understanding when to stop and assess the patient. One guideline for when to stop a procedure involving restraint is to use the 2-2-3 rule. If it requires more than two arms to gently stabilize the patient, if a dog struggles for more than 2 seconds, or if a cat struggles for more than 3 seconds, pause the procedure, assess the patient and the situation, and then make a plan for how to best continue.

Determining when to perform a procedure relies on identifying the difference between wants and needs. Needs are urgent, life-saving treatments. Wants are everything else. While we may not want to pause or postpone some procedures, pause, retry, or postpone is always an option for wants. By keeping our priorities clear about wants versus needs, we can avoid causing unnecessary harm, and do our very best to keep the stress and fear levels as low as possible for our patients. Keeping fear levels low helps to protect our patients from emotional harm.

1.4 Iatrogenic Behavioral Injury

Iatrogenic means an illness or injury caused by medical treatment. Iatrogenic behavioral injury (IBI) is a term to describe mental, emotional, and/or psychological harm caused to patients while we are trying to provide veterinary care. Preventing IBI is one of our responsibilities as veterinary professionals. There are many modalities we can use to prevent IBI, including: recognizing the risks of IBI; using the human pediatric model for most treatments;4,5 staying up-to-date on medical treatments for fear, anxiety, and stress; and using low-restraint and no-restraint veterinary care.

The pediatric health care model has changed considerably over the past 20 years. A new emphasis has been placed on the importance of reducing stress for children and parents during medical care. Some techniques used in the pediatric model include explaining procedures to children using words and pictures prior to treatment, bringing comfort items such as a blanket or favorite toy from home, playing music clinically established to have a calming effect, allowing children to sit in a parent’s lap and be held or hugged, using distraction techniques, practicing good caregiver continuity, and helping children to cope with pain levels.5 Medication is given when needed for anxiety or fear, and ongoing research is searching for effective calming methods for children in medical settings. While we can’t mirror all of these techniques in veterinary medicine due to the communication barrier between people and pets, we can certainly make use of the concepts...