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TRIAGE, TIMING, AND TINY THINGS
by Dugie Gemmill, Parkside Veterinary Practice
The word ‘triage’ derives from the French verb ‘to sort’. It was during the
First World War that the predominant use of triage became medical. It
was the process by which the priority of wounded patients’ treatment
was determined by the severity of their injury or likelihood of recovery.
In the context of war, or disaster and yes, pandemic it can be a very
bleak word. As we have embraced the principles of social distancing
in the world of veterinary practice, we have been applying some facets
of triage within the context of our daily routines. Telephone triage has
allowed vets and General Practitioner doctors to evaluate the needs of
the patient and to decide whether a telephone or video consultation, or
a physical examination at the practice best suits those needs. Over the
telephone, the process requires a detailed history to be taken from the
client (or patient), combined with knowledge of likely conditions relating
to the patient’s complaint and sometimes further coupled to a degree of
intuition that comes with experience.
The ability to recognise when examinations and interventions are needed
and to be able to make those interventions timely, is a valuable skill.
Sometimes the decisions are more straightforward than others. One busy
Monday afternoon at the beginning of June while finishing a surgical
procedure, Tracey, our team’s receptionist called through to say that a lady
was on the phone saying that her Cocker Spaniel had a sore ear. Those
Spaniel owners amongst you may know this is sadly, hardly unusual. “How
long for?” I enquired. Since his walk yesterday afternoon was the reply – a
light bulb glowed dimly in my head. “Did he start shaking his head after the
walk?” Apparently, he did – and now he was rubbing his ear on the floor. The
light bulb was glowing significantly brighter. The lovely Bailey attended the
practice immediately and despite the late hour we sedated him and removed
a grass seed which was sitting on top of his ear drum. Timing is important,
and here the timing of Bailey’s frantic head shaking was the clue.
It is obvious that medical and surgical knowledge are important but so is a
familiarity with one’s patients and their history. In April, we had fallen in
love with a handsome Dachshund called Beau, who had been unfortunate
enough to develop a complete obstruction of his bladder, having developed
a form of bladder calculi (stones) formed from a compound called cystine.
We had removed his obstruction surgically creating a temporary extra orifice
to pee through, and he progressed well with preventative treatment in place.
In early June, his vigilant owners noticed he was taking a little longer than
usual to urinate, although he did not seem unduly bothered. However, as we
knew Beau’s history this change was suspicious. A radiograph showed us his
bladder contained many calculi, and an obstruction with several tiny stones
was developing once again. This prompt and timely recognition meant that
we could intervene before Beau became seriously ill. An afternoon's delicate
surgery, and superb care from my nurse Lisa, saw him home with a new, now
permanent extra orifice (urethrostomy) through which any further stones
could pass.
In mid-May, Tracey took a telephone call with the vaguest of clinical
clues. Molly, who had been quite normal on her walk had returned home
and refused her breakfast and seemed quiet. I knew Molly and her owners
very well, having performed cruciate ligament surgery on both of her
knees. Neither Molly nor her owners were given to drama. Sometimes
things are not vague, but subtle, and experience has often shown that we
should give credence to an owner’s intuition. Molly sat happily in the boot
of her car, basking in the sunshine while I sat on the ledge chatting to her
parents. Her abdomen felt indistinctly round and as I applied the lightest
pressure Molly gave a slight cough. In my dim and distant past, I had spent
some time in a cattle practice in the borders of Scotland – the little cough
illuminated a memory of a cow with a wire in her stomach and abdominal
pain. We performed and ultrasound examination and radiograph on Molly
and that afternoon performed a splenectomy and removed an unpleasant
and rupturing spleen. On this occasion the reliance on intuition and the
recognition of the subtlest of signs to inform our triage meant Molly barely
missed a step in her recovery having avoided the serious consequences of
haemorrhaging into her abdomen. Happily, subsequent tests showed that her
condition was not a tumour and I saw her just last week, once again basking
in her sun-soaked car boot, as happy and healthy as ever.
Effective triage requires us to keep both our eyes and our ears open and to
apply our knowledge and experience. This is a principle we must also apply
to our daily lives particularly in these times of uncertainty – our vigilance
and sensible assessment of the world around us will keep us safe and well.
26 wirrallife.com