Practical Bootcamp – A good idea…

I just got off the phone with my best friend, who told me she really wants to come to one of our workshops but she can’t afford it. 

She’s a locum and like most locums she makes $400-$700 (before tax) per day depending on her skill set. Of course she needs to cover herself with insurance and pay her own super and gets no holiday or sick leave, but she’s been a vet for over a decade and she’s really good at what she does. 

Yet like most of us, she’s still nervous after closing an exploratory laparotomy, and she still spends 30-45min extracting a molar tooth… She knows she can be better, which is why she wants to come to theVetPrac Practical Skills Bootcamp

But she told me she cant afford it. 

So I asked “Can you really, not afford it”
“I can”, she replied… “it’s just a lot of money…”

And she’s right. It is a lot of money. And here’s why…

We always tell our clients the good stuff costs the most because it works the best. 

We always hear the saying “You’ve got to spend money to make money” because it’s true. 

At a VetPrac workshop you will leave being able to DO more for your clients, which means you’ll be able to CHARGE more for your services and in turn be able to EARN more for yourself, FASTER. 

So, assuming you’re an average 3-5yr out locum earning $400/day for a 10hr shift with reasonable skills you would expect to be able to increase this because you can tell your prospective veterinary contract that you have skills in these areas with confidence. 

If you can do 3 dentals in a day instead of 2, you will earn 30% more revenue for the hospital. 

If you can manage a CPR case without losing a patient or the morale of the vet team you work with you are priceless

If you can close an exlap and gastropexy without reasonable fear of dehiscence then you can sleep at night and not worry that you are not on call to deal with the consequences, because its less likely there will be any.

So, if you spend $2500 a year on your self development and the payout increased your earning potential from $60,000 to $80,000+ wouldn’t you want to do that? And it’s tax deductible and fun… wouldn’t you take the opportunity while it exists?

We don’t know how long these practical workshops will be available to us. The nature of learning and science is changing. And still, everyone agrees, nothing compares to handling real tissue with real instruments, under the guidance of experts. 

So then I asked her again, can you really NOT afford to come to this workshop?

Of course she booked. She’s a smart woman. I bet you are too…

VetPrac Practical Skills Bootcamp
February 5-7th, 2015

For any vet that needs to kickstart their skills. New Grads, Locums, Return to Work Mums or Dads and Tired Bosses. We have fun while learning. We Promise.

I got 99 problems but my system ain’t one!

Dr Dave Nicol is a veterinary hospital owner based in Sydney, Australia.
Dave has published five ebooks for vets and pet owners and is a feature writer for Veterinary Economics (US), Veterinary Team Brief (US) and The Veterinary Business Journal (UK). He is a popular presenter at veterinary conferences around the world, including NAVC and BSAVA.

Problems in vet practices (aka small businesses) happen. It’s normal and to a certain degree unavoidable. Sure it’s better to prevent than cure, but some stuff you are not going to be able to legislate. Trust me…

Stuff like:

  • Not enough clients coming in this month.
  • We didn’t make the sales target today.
  • Something died under anaesthetic.
  • We can’t retain nurses and always seem to run short-staffed.

I don’t know exactly what your problems look like, but I’ll guarantee that you have some. Life’s like that as a manager or owner, it can be stressful and it can be painful. In the short term that’s fine as it provides some motivation to take some remedial action (after – in extreme instances – a couple of days of foetal rocking).

Where things get unhealthy is when the stress and pain seem never ending. I call this spinning plate disease. Or more accurately, dropping plate disease.

 

Keeping your plates spinning

As managers we are required to undertake a lot of tasks each day/week. When one starts to go wrong it can consume the time we would normally spend on the others. Life as you may have noticed has this awful habit of conspiring to crap on us when we are farthest from a bar of soap.

Ever had something like this happen?                                                                 Two team members leave at the same time your head nurse tells you she’s pregnant. Your BAS, super and tax bills all land right when your cash flow takes a dip. Your team go sick on the one day you need to be someplace else.

The point I’m making isn’t that stress and problems are completely avoidable. The very notion is pure nonsense. It’s that the only way to handle this kind of stress is to deal with your problems effectively.

Easy to say right? But actually way harder for some people than it seems. That’s because once we are stuck in a full blown “panic mode”, the part of your brain responsible for rational thought gets beaten down by your hyperactive and (slightly demented) limbic system.

The result is that we may find shoot-from-the-hip quick fixes. Or worse, simply swim (and drown) around in stress hormones unable to find our way out of trouble.

Decision making while under this stress rarely leads to great outcomes and can cause us more issues down the track.

So how do you deal with problems effectively so your life gets better?

I recommend a three pronged approach. Use it and you’ll find your crisis management not just improving, but becoming less often required.

 

Step 1: Don’t act right away.

You’re fired up, you’re emotional and you’re crazy. Your neanderthal fight-or flight-limbic system is cajoling you to do something silly. Instead, put some distance between your instinctive emotional response and your resulting reflex action. I call this an emotional buffer zone. If there’s someone pushing your buttons take a breath, go for a walk, count to ten. Whatever it takes to avoid acting rashly.

Though TV shows like 24 or the West wing move at breakneck pace, they are not a good guide for how we should approach the big decision in practice. OK in a surgery if something is bleeding you need to act fast. But in your business there is almost always time to take stock and think about your next move. Act in haste, repent in leisure.

 

Step 2: Examine the system.

(Say whaaaat?) OK, everything in your practice is a system. Right now it might not look that way, but it is. By inference everything is connected in someway to everything else. And your job as a manager or owner is to know the systems inside and out. If you don’t know the system then how can you possibly know which bit broke? How can you know what fixing one part will do to another part?

This, I suspect, is the bit you might need to work on and it will take a bit of time to understand it properly. Though you might not be aware of it, you have a marketing system. You have a recruitment system. You have a performance management system. You have a financial system. You have a clinical system. These systems may not be intentional or effective but one way or another you have them.

Patients, people, products and money take journeys into and around your practice. Your practice interacts with the environment in which it exists (the local pet and business ecosystem).

Once you start to think of your clinic in these terms, it becomes a lot easier to take control.

Let me give you an example. If you don’t have enough clients per vet then the wrong response is to buy a bigger advert, or spend more on Google – that’s classic limbic system fight-or-flight silliness. The right response is to examine your marketing system thoroughly and work out which bit needs fixing.

 

Step 3: Act with wisdom (preferably based on facts) and without judgement.

Once you work out what you need to do, then just get on and do it. Again easily said, but sometimes hard to do. Let me give you another example.

If you have lots of clients walking through your doors but your monthly revenue has dropped then you have either got a problem finding work (clinical system), fixing things (clinical system) or billing problems (financial system).

Analysis will reveal which issue is the problem – in this circumstance however you are likely to have a tough conversation with a team member. What makes this easy is that by gathering accurate data, you are giving feedback based on numbers (facts), not your opinion. This does make those combat conversations a heck of a lot easier, and often much more constructive.

One final tip I’d add (at no extra charge), is to try never to do the same piece of work twice. Life is just too darn short. So once you work out what your systems are and what the regular problems/fixes are, document them and use this as your reference manual in future.

Approached like this, stress melts away, and your effectiveness as a manager will increase exponentially.

 

Dave writes a free monthly business blog for vets called The Hamster Wheel Biz Report which you can follow here.

 

Three things I learned about sutures

 

By Dr Anne Fawcett

This post was originally published on Small Animal Talk November 7th 2014.

My desk on the day. Combine this with a good tutor and this is my idea of a productive day off.

 

Last week I attended a workshop on suturing. Suturing, you ask? Isn’t that something you should know already? Yep, and I’ve done it pretty much most days for the last ten years. All the more reason to tweak and refine – a process which really shouldn’t end.

 

Dr Ilana Mendels, founder of VetPrac, thinks the same way. So she organised a half-day suture workshop. It was attended by new and recent graduates – veterinarians one or less years out of university – but also a range of experienced vets, with ten, twenty or more years of practice.

 

One thing many outsiders don’t realise is that while employers provide some expenses for veterinary continuing education, it’s often done on a vet’s day off, and at their own expense. I’m a big believer – where possible – in investing in one’s own education and training.

 

So our little group gathered under the tutelage of surgical specialist Andrew Marchevsky, from the Small Animal Specialist Hospital. His surgical caseload is incredible. He generally doesn’t find himself performing routine desexing procedures, but tends to take on things like spinal surgery, radical oncologic surgeries and skin reconstructions. And he’s not above obsessing about sutures. In fact, that’s what makes him a great surgeon.

 

During the workshop, we were provided with surgical instruments and an endless supply of different types of suture material.

 

What did I learn?

Complications occur in the best hands. Even with the best surgeons, the best instruments and the best facilities, intestinal resection and anastomoses break down in at least 10 per cent of cases – and that’s a statistic from the human medical field. Second surgeries are not uncommon and – even where we think it is unlikely – we should inform owners that this is a possibility.

 

In general, Australian veterinarians at least use suture that is too thick. According to Dr Marchevsky, we should be using finer suture – 3/0 in the gut, 4/0 for cats. He believes 2/0 is too thick for skin and ligatures in most cases.

 

The aim of skin sutures should be for gentle apposition ONLY. There should be no tension and they should be slightly lose when placed.

 

Suture materials are categorised by the length of time it takes for 50 per cent of the original strength to be lost. Bladder is the only tissue that returns to 100 per cent of its original strength following surgery (14 days, in fact). Skin takes around 365 days to get to 70 per cent of its original strength.

 

Dr Marchevsky feeds animals following intestinal surgery sooner rather than later. It was once argued that animals should be fasted for at least 48 hours to prevent leakage of the surgery site. That ignores the fact that around 1L of gastric juices are produced every day and have to go somewhere. “They don’t leak because you feed them,” he said.

When closing the linea alba, the less muscle you include in the sutures the better. The external fascia is the tension holding layer and this should be the focus.

Dr Marchevsky is a big fan of intradermal sutures and demonstrated his technique. He talked about the pros and cons of different suture patterns and did some troubleshooting.

For the nerds out there, I had also forgotten just how much physics and chemistry is involved in suture design and production. And it was also a nice opportunity to review the history of sutures. For example, absorbable sutures were introduced in the 1970s. These days sutures are sterilised with gamma radiation or ethylene oxide, depending on the material they’re made of.

Sutures are absorbed by hydrolysis, leading to gradual disappearance of the thread over a particular time.

We were taught to almost uniformly avoid braided sutures because they cause tissue drag and potentially a saw effect when they thread through tissue, but advances in coating such materials mean this is a reasonable choice in some cases. Capillarity of the suture is defined as the ease through which fluids can be wicked along the thread…its present to high in multifilaments due to “the loose intersticies of their fibres”, and monofilaments have no capillarity.

Braided suture is more flexible and has less memory than monofilaments, making it easier to use. (Memory is the capacity of the thread to return to its former shape. Thread memory has an impact on the way we USE suture, ie if it has more memory it likes to tie itself in knots spontaneously, which can frankly be a pain).

Knot security is determined by knot fixation which depends on: thread stiffness, coffecient of friction, elasticity and plasticity. According to the experts at B Braun, knots should have at least three loops with 3mm long ends. Cutting down those “ears” to make it neater isn’t helpful beyond the 3mm mark! What was interesting is that there remains a lack of consensus about knots. According to the B Braun literature, “it is commonly accepted that 4 knots are necessary for securing a braided suture and 6-8 knots are required in the case of a monofilament suture”.

Knot tensile strength is usually 30-50% less than the linear tensile strength of a suture – hence the need to get it right.

Thread gauge is standardised according to the European Pharmacopoeia decimal classification, although the packets us the United States Pharmacopoeia classification.

 

USP EP (Decimal) Thread gauge in mm
5-0 1 0.10-0.149
4-0 1.5 0.15-0.199
3-0 2 0.20-0.249
2-0 3 0.30-0.349
0 3.5 0.35-0.399
1 4 0.40-0.499

From “Suture Glossary” – B Braun

The diameter applies to both needle AND thread. Suture glide describes how well the suture passes through tissue, and, to throw some physics around “is a function of its coefficient of friction”. Monofilaments have better glide.

 

Definitely a course I would recommend!