Dentistry Pain Control When Cost is A Challenge

Dental procedures are expensive, and pain control is non-negotiable. How do we do right by our patients while working within the budgets of pet owners? The original anesthesia nerd Tasha McNerney is on the podcast today with FANTASTIC advice on how to do exceptional pain control without breaking the client bank! Let’s get into this episode!

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ABOUT OUR GUEST

Tasha McNerney obtained her CVT in 2005 and has worked clinically in the areas of anesthesia and surgery ever since. Tasha obtained her CVPP (certified veterinary pain practitioner) designation in 2013 and became a veterinary technician specialist in anesthesia in 2015.

Tasha has been a featured speaker on various anesthesia and pain management topics at several international veterinary conferences. Tasha is the author of many articles and blogs on anesthesia and pain management related topics.

In 2013 Tasha created the Facebook group Veterinary Anesthesia Nerds, which has over 65,000 members taking part in education and exchange of ideas from all over the world!

Tasha is crazy and bought a 1920’s fixer upper and is now obsessed with home improvement tutorials on YouTube. She lives in Philadelphia with her husband, son, one perfect cat, and one jerk cat. Trust me that cat is a jerk.

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome, welcome, welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with my good, dear, awesome friend, the one and only Tasha McNerney, a.k.a. the original anesthesia nerd. She’s a VTS in anesthesia, she is a fantastic lecturer, she is hilarious, she is one of my favorite people to talk to. And her last episode with me when she was on the podcast, we talked about analgesia for blocked cats. And it was very popular, because it was very good.

Dr. Andy Roark:
Guys, this is an equally good one. Dentistry pain control when cost is a challenge. That’s right. Money is a real thing and pet owners struggle with it. And also pain is a real thing, and pets getting dental procedures struggle with it. Let’s talk about cost effective management for that 11-year-old Yorkie who’s got trench mouth and whose owner has a fixed income. Guys, this is a great episode. I hope you’ll get a ton out of it. Let’s get into it.

Kelsey Beth Carpenter:
(Singing) This is your show, we’re glad you’re here, we want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast, Tasha McNerney. Thanks for being back with me.

Tasha McNerney:
No problem, thanks for having me. I love talking about anesthesia stuff.

Dr. Andy Roark:
You are so amazing. You and I have been friends a long time. How good of friends are we? The last text message you sent, do you remember it?

Tasha McNerney:
Oh yeah. I have to share this with the world. This is amazing.

Dr. Andy Roark:
I was just minding my business, then I got a text from you that said, “If you call this phone number, they will play Hall & Oates music.” And I did. And it’s real. There’s a-

Tasha McNerney:
It’s real.

Dr. Andy Roark:
It’s a real phone number that you just call.

Tasha McNerney:
And it’s Callin’ Oates, so you can call in and hear whatever song you want from Hall & Oates.

Dr. Andy Roark:
Callin’ Oates. But for those of you at home who are just like, I don’t believe this is true. It’s 719-26-62837. That’s 719-26-OATES. And if you call that phone number, they’ll be putting Hall & Oates. That’s the type of communications I get from you. And that’s why we’re such good friends.

Dr. Andy Roark:
The other reason we’re such good friends is because you’re brilliant. And because you are a VTS in anesthesia and because you are super down to earth, real world, you have worked in private practice almost your whole career. You did some lab animal stuff for a little while, but for the most part, you have been a private practice teacher and technician. And so you know how it really is. So anyway, I have a case that I would like your very specific set of skills on, if you don’t mind.

Tasha McNerney:
I can do it. Let’s go.

Dr. Andy Roark:
Yeah. They can’t see you nodding your head on the podcast.

Tasha McNerney:
I was trying to think of like have fun like Liam Neeson taking jokes to put in there, but I really couldn’t come up with anything.

Dr. Andy Roark:
That’s what I was going on. See-

Tasha McNerney:
I was like, “Oh, what?” I was trying to think about Taken 3, which actually my husband and I were surprised that they made a Taken 3. Like how many times can you get taken before you know you’re going to be took? I don’t just think … And I love Liam Neeson, but I feel like he really should have been more prepared for this.

Dr. Andy Roark:
Well, I agree. One of my favorite pieces of business management advice is if there’s something that you’re surprised by again and again, at some point you’re not surprised by is your business model. And I would say that to Liam Neeson. You need to take care of this and stop acting surprise when people take your children.

Dr. Andy Roark:
Let’s do this medical thing. I have got an 11-year-old female spayed Yorkshire Terrier named Tinkerbell. She is very loved by her elderly owner. And you can imagine her. She is your older Yorkie, she’s just … Look at her, look at her in your mind’s eye. She’s trembling, and she has trench mouth. She has a nasty, funky mouth that cannot be ignored. Mom loves her to pieces and has really been afraid of anesthesia for a long time, which is why we’re kind of in a hole here as far as her dental health and things like that.

Dr. Andy Roark:
Mom’s also on a fixed income. And so she has limited resources to spend here. So I have a significant dental procedure in front of me. And I want to make sure that Tinkerbell is comfortable. Pain management is going to be really important for me and I’m working under financial constraints. And so let me put it to you like that and say, “Tasha McNerney, how do you treat this?”

Tasha McNerney:
Yeah, this is a good one because I feel like this happens all the time in private practice. In fact, it happens at university level too in their dentistry departments. It happens all over because people are scared of anesthesia and I totally get it. If you were, I mean, I knock on wood have only had a couple of anesthetic experiences in my life, but I have to tell you, even though I know so much about anesthesia and very comfortable with it. It’s scary, right?

Dr. Andy Roark:
Yeah. I get it.

Tasha McNerney:
For this patient in particular, we have to look at, if our finances are really limited and we know we’re about to do multiple extractions, how can we provide the best experience for this patient and make sure analgesia is taken care of without breaking the bank. And there’s some ways that we can do that certainly. I think one of the first things is you have to look at what’s in your anesthesia, your analgesia spice rack at your clinic.

Tasha McNerney:
So if you have options, that’s going to be a little bit easier. Certainly, we can say, “I, Tasha McNerney, as anesthesia nerd, I love fentanyl and I love methadone. Those are really great analgesic opioids that I can choose for my patients. But if I’m looking at it purely from a cost perspective, then I have to maybe look at, “Oh, could I potentially utilize something like hydromorphone instead for this patient?” That’s going to be a little more cost effective of all my pure mu opioids. And yeah, hydromorphone would be a really good opioid for this patient.

Tasha McNerney:
Now let’s say in clinic, you don’t have access to any pure mu opioids. Either your clinic doesn’t utilize them or buprenorphine is maybe the strongest opioid you have. Well, that’s fine too. If buprenorphine is the strongest opioid you have on your shelf, then let’s use that. But from a cost perspective, yes, I would maybe not utilize the methadone in this patient because I know dollar per mil is going to be more expensive than something like hydro.

Tasha McNerney:
So let’s just say I’m utilizing hydro for this patient. And now, I don’t want to just give a huge walking dose of hydro to this patient. I don’t know what other comorbid disease it has, but if it’s an 11-year-old Yorkie that has a really, really diseased mouth, we know that it probably has some degree of infection going on, inflammation going on. Let’s just hope that it doesn’t have any cardiac issues going on.

Tasha McNerney:
Well, maybe we have an echo in the previous past, but because we are financially limited, probably you don’t. If you have the ability to, if the dog is amenable to it, I would suggest that your staff at least get a pre-op ECG and blood pressure on this patient. Any of those things that you can get beforehand are going to make it a lot easier for you intraoperatively and how to manage that case.

Tasha McNerney:
So if you notice that this patient’s normal resting heart rate is 162, or if you notice that it’s 82, that’s going to kind of guide where you’re going to go with your drug selection, your inhalant, maybe your blood pressure support, et cetera. Also, if you know any murmurs or anything like that, again, all of these things are just really nice to know before we start layering in a bunch of drugs.

Tasha McNerney:
If it is a smaller Yorkie, 11 years old, I feel like I say this a lot. I love dexmedetomidine, but this is probably not the dogs that I would go dexmedetomidine with only because I hate to be a breedist. But if it potentially has any cardiac or mitral valve disease underlying that we don’t know about because we haven’t followed it or got an echo, I don’t want to make things worse with dexmedetomidine.

Tasha McNerney:
So this is probably not a dog I’m going to hit with dexmedetomidine, which from a cost perspective that’s okay because dexmedetomidine, again, one of our more expensive dollar per mil drugs. So I’m probably going to go with something a little bit more cost effective, maybe a small dose of midazolam for this patient followed by my induction agent.

Tasha McNerney:
Now, we have a couple choices for induction agent. You can have alfaxalone. I know a lot of clinics are utilizing alfaxalone, or you can utilize propofol, which a lot of clinics are using propofol. Both really great drugs and both have a pretty nice safety profile when utilized correctly in the correct dose mg/mL. However, there are some studies, there were some claims that alfaxalone is going to be better as far as apnea or hypertension.

Tasha McNerney:
But what we found is that there really isn’t that much of a difference between alfaxalone and propofol when it comes to overall hypertension, if you’re using it within the dose range. So again, because of a cost per mil for this patient in particular, I’m trying to be cognizant of cost. I would probably choose the propofol, and be as low with my dose. Just get them induced and then get them on inhalant.

Tasha McNerney:
Now this patient in particular, we know has a trench mouth and it’s going to be a lot of extractions. This is where your local blocks, right? So if bupivacaine, lidocaine things that are very cost effective, this is where your analgesia heavy lifting is going to be done with the local blocks. So instead of putting this patient on maybe an expensive fentanyl CRI or something like that, you can do local blocks or four-point local blocks in the mouth and that’s going to cover everything.

Tasha McNerney:
So if you had to do even full mouth extractions on this patient, if you’re doing both of the mandibular and maxillary blocks that you should be doing on these patients, and let’s say your practice doesn’t even have bupivacaine, you only have lidocaine, great, utilize your lidocaine. That’s going to give you a couple hours of pain free. You’re then going to be able to keep your inhalant turned down.

Tasha McNerney:
And when you can keep your inhalant down and your oxygen down, that’s going to be cost effective for you as a clinic. So anytime you don’t have to have cranking high levels of oxygen, high level of inhalant, that’s going to be better overall, not only for our patient, but for our finances.

Tasha McNerney:
And then intraoperatively, if you feel like this patient still needs a little bit of bump of something and this patient is not a hypertrophic cardiomyopathy cat, we know it’s a little Yorkie, this is where a low dose ketamine CRI can be really nice for MAC reduction. Again, to keep your inhalant low, ketamine is very, very cost effective. So, a little bit of ketamine can go a very long way.

Tasha McNerney:
You can put your ketamine either into a bag and run it on a pump or into a syringe and run it on a syringe pump. But you can do a low dose ketamine CRI to reduce your inhalant, increase your analgesia. So those two things together, local blocks, low dose ketamine CRI, very, very cheap but very, very effective when it comes to analgesia and reducing the amount of inhalants.

Tasha McNerney:
And then as the patient’s waking up, then it’s kind of dealer’s choice how they do under anesthesia, and what their blood work shows, whether or not the clinician wants to add in the nonsteroidal anti-inflammatory.

Dr. Andy Roark:
Okay. I like it.

Dr. Andy Roark:
Hey, everybody. I just want to jump in real quick with a couple of updates. This week over on the Uncharted Veterinary Podcast, which is the other podcast I do with the one and only Stephanie Goss, I’m not on that episode. Stephanie Goss is talking about information security. Are you storing data in your practice like you’re supposed to? Guys, this is not an area where you want to get burned. If you are not up to date or you’re kind of feeling like, “Ooh, I should probably listen to that,” head over to the Uncharted Veterinary Podcast and check it out.

Dr. Andy Roark:
Uncharted Workshops coming at you, guys, on May the 21st, which is just a couple of days after this episode comes out at 2:00 PM Eastern, 11:00 AM Pacific. Stephanie Goss, she is teaching our workshop, retain your team, speak the languages of appreciation in your workplace. Guys, you’re trying to get your team motivated. You’re trying to keep morale up. You’re trying to keep people engaged. You want your team to stick around to enjoy the work that they’re doing and to feel like they matter to you and to the patients.

Dr. Andy Roark:
Guys, are you talking about appreciation in your workplace? Are you doing it effectively? If not, jump in. This is a little bit higher level. We had an entry level appreciation workshop. This is a bit more down into the nitty-gritty. I think people can get a lot out of it. It is $99 to the public. It is free to our Uncharted members. I’ll put a link down in the show notes below.

Dr. Andy Roark:
On June the 8th, my friend, Bill Schroeder, veterinary marketing specialist, CEO of InTouch veterinary marketing, he is going to be doing his lectures. It’s not lectures, a workshop, called Creating Content That Clients Crave. This is all about you spending your time smartly to make resources that educate clients, that answer questions, that protect your reputation, that do all of the things that you wish you had content for but you just don’t have all the time in the world to make.

Dr. Andy Roark:
Most of us are spending too much time doing things like posting stupid social media stuff. Guys, it’s time to get a strategy. It’s time to get smart about how we communicate digitally. Bill Schroeder is the guy to do that. It is $99 to the public. It is free for Uncharted members. Guys, both of those things are coming up. I’m going to put links of both of them in the show notes. Let’s get back into this episode.

Dr. Andy Roark:
Give me give me any pearls you have, any words or advice on the ketamine CRI. I know there’s a lot of people out there who kind of draw back a little bit from CRIs. I think it’s still one of those things. It’s become a lot more common, but I still think a lot of practices are just intimidated. When you say CRI, I think a lot of technicians, a lot of doctors kind of go, “I don’t know, it’s kind of scary.” Make it seem less scary to me.

Tasha McNerney:
Oh, sure. So I think when most of us when we think of CRIs, we think back to when we were in vet school or tech school and we were at universities. And we were seeing these animals that are on what we call like the tree of life, where they’re on multiple CRIs because their state is so critical that they have to be on fentanyl and lidocaine, and dopamine and norepi and something else and plasma. So, we’re not talking about that.

Tasha McNerney:
We’re just talking about adding in a little bit of extra pain control to make the procedure go smoother overall. And the only reason I’m talking specifically about ketamine in this one is because if we look at overall cost effectiveness, now I could say that a lidocaine CRI would also be a very cost effective. But for this patient in particular, I think a ketamine CRI is a nice adjunct analgesia-wise. Cost per mil, very, very effective. And it doesn’t require that you have to have a syringe pump.

Tasha McNerney:
So most of the time, they’re also thinking, “Oh, well. I don’t have a syringe pump. I only have my regular Baxter pump. I can’t run something as fancy as a constant rate infusion.” But you can add a small amount of ketamine to a 250 or a 500 ml bag of saline and figure out the math. I know the math is intimidating, but don’t worry. There’s lots of CRI calculators online that can help you with this.

Tasha McNerney:
The International Veterinary Academy of Pain Management or ivapm.org, if you go to their website or even the website on your phone, they have CRI calculators where you just punch in the patient’s current weight and what dose you want the CRI to be run at, and they’ll give you the mils or volume per hour that you should put into your Baxter pump.

Tasha McNerney:
So, don’t feel like you have to have a syringe pump in order to make this work. You don’t. You can just have, as long as you have some ketamine, a bag of saline and a Baxter pump, we can run this into our patient. And we’re just talking a low dose ketamine. So, low dose ketamine is also different because I know sometimes people kind of like, ugh, cringe a little bit with just the thought of ketamine because we have these ideas of 10 years ago when we were using much higher doses of ketamine. And we know that higher doses of ketamine, higher doses really of anything are going to cause higher incidences of side effects.

Tasha McNerney:
But in ketamine in particular, ketamine, once you get into the higher dosing range, it goes from analgesic to anesthetic and it has more of these central effects that we see. And I think that people were, and rightly so, I think a cat in a really high dose of ketamine can be kind of scary thing to watch, and they usually don’t have the best recoveries. That’s where that ketamine crazies saying came from, was really high dose of ketamine.

Tasha McNerney:
When I’m talking high dose, I’m talking about like 15 to 20 mg/kg, so like these big doses of ketamine, which we don’t tend to use anymore. And when we’re talking about analgesic doses of ketamine, we’re talking about 1 mg/kg make, 2 mg/kg maybe, so smaller, smaller doses. We’re not seeing the same type of side effects we used to in the past.

Dr. Andy Roark:
If I have doctors or technicians that want to brush up on their dental blocks, do you have resources you would point people to that say this is a good review of your blocks?

Tasha McNerney:
Yes. So for dental blocks in particular, I am a book reader. So if you like to read books, and actually if you’re interested in local blocks in general, there’s a really good textbook of regional anesthesia in the small animal patient. And I believe it is by Campoy and Read, Campoy out of Cornell. And I’m pretty sure that I got my copy on Amazon, but it goes through every single local block that you could think of from epidurals, to ring blocks if you had to take a toe off of a patient, to sacrococcygeal blocks if you had to do a tail amputation, to all of the dental blocks.

Tasha McNerney:
And there’s a bunch of different dental blocks that we can utilize. And I think there’s also a really cool thing about dental blocks that we also sometimes don’t think about, is that they don’t actually only have to be for dentistry. So sometimes, we will utilize an infraorbital block bilaterally if we have to go in and take a tumor off the nose, or if we have to do a rhinoscopy or something like that. So, they’re not just for dentistry.

Tasha McNerney:
I always tell people that, again, local blocks are going to do a lot of your analgesia heavy lifting during the surgery because we could just put our patients on 5% ISO and kick back and they’re not going to move. But that’s not really balanced anesthesia or analgesia. We want to make sure that we don’t have the patient on 5% ISO, that we have them on low ISO, and we’re doing a lot of local blocks to take care of those pain signals going to the brain.

Tasha McNerney:
And if you can utilize a local block for every single patient, whether it’d be a tooth extraction or a radius-ulnar fracture that’s coming in, to a skin incision, laceration repair, so there’s a local block for everything. And if we’re talking about lidocaine in particular, it’s very, very, very cheap way to provide pain management.

Dr. Andy Roark:
Perfect. That’s fantastic. I will put links to the book and then also to the CRI calculators down in the show notes. Tasha, thank you so much for being here and doing this with me. Where can people find you online? Where can they follow all the stuff that you’re doing? Because you’re doing a lot of things.

Tasha McNerney:
Yeah. We are doing a lot of things. So, I am most active on the Facebook group, Veterinary Anesthesia Nerds, and also on our website. So if you ever have any questions, hit me up on Anesthesia Nerds or send us an email through the website. Also, the Veterinary Anesthesia Nerds are kind of like going on tour together. All three of us administrators are … I know. We are going to all be present at the Fetch Conference that’s happening in Charlotte, North Carolina.

Tasha McNerney:
And then we’re also going to be present at the one that’s going to be in San Diego this year. So kind of East Coast, West Coast opportunities to do some stuff and talk about how we can elevate the standard of care for anesthesia patients.

Dr. Andy Roark:
Veterinary Anesthesia Nerds coast to coast is what I’m hearing. So good. Awesome. Well guys, thanks so much for being here. Tasha, thanks so much for being here. I always appreciate your time.

Tasha McNerney:
Yeah. Thanks so much for having me.

Dr. Andy Roark:
And that’s our episode. Guys, I hope you enjoyed it. I hope you got a ton out of it. If you did, please feel free to leave an honest review wherever you get your podcast. It really makes a difference to me. It’s how people find us. It’s the nicest thing that you can do when it only takes a moment. Gang, that’s all I got. Take care of yourselves. Be well. I’ll talk to you soon. Bye.

This content was originally published here.

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