Since blood flow is the most important to monitor, much more than arterial blood pressure or pulse oximetry, the continuous flow Doppler monitoring provides a key to the knowledge of the patient's cardiovascular status on anesthesia depth and influence on the patient's heart and kidneys

Now with the addition of local anesthesia in the mouth where the tooth abscess is, with a combination of lidocaine, bupivicaine and the addition of diluted sodium bicarbonate to keep the injection for stinging, the pain that will caused by the tooth extraction and abscess debridement, is able to be managed before it starts. Techniques like this have saved many patient's lives and have "made my day" as one veterinarian said it. Yes many agree; doing a service like this for clients and their pets; being able to managed animal's medical conditions effectively, economically, and with safely make many a health professional team members day. Anticipating and being ready are KEY.

Being "in the ready" involves three areas

When you go back to your practice look around and see how you can position materials such as drugs, supplies, and equipment, to make everything more ergonomicly efficient. An example is having a paper towel dispenser, and waste basket near the site where your hands are washed, and having this all necessary to do the washing. Having oxygen supplied to an AMBU bag with a cone mask attached and a PEEP valve also attached allows immediate oxygen delivery with positive pressure ventilation able to be perform. This BiPAP ventilation system has been very life saving in patients with congestive heart failure and pulmonary edema.

A crash cart should be set up with suction, endotracheal tubes, laryngoscope, stylets, cuff inflation syringe, emergency drugs (epinephrine, atropine, sodium bicarbonate, calcium chloride, lidocaine, dopamine, etc.), ECG, defibrillator, Doppler unit, vascular cutdown and tracheostomy instruments, etc. (see below under Crash Cart)

I recommend setting up the OR with everything laid out (general pack, gowns, drapes, gloves, blade, suction, cautery, anesthetic machine and ventilator attached, monitors, IV pole with a bag of plasmalyte hanging and the drip set coilded up and ready to be used, lap pads, Balfour retractor, feeding tubes) everything needed to perform a resuscitatitive thoracotomy and aortic cross clamping).

The team of care givers; beginning with a veterinarian and including the support staff (technicians, assistants, receptionists, etc.). A minimum of two people is recommended in the management of emergency cases. Emergency care is stressful but keep smiling. Power of Positive Thinking is very important. This also helps owners who are naturally worried and stressed. Communication skills are also important and each team member must be mentally ready to face the demands of emergencies; unscheduled, stressful, long hours, after hours, and limited resources.

Practicing the assessments and emergency procedures , working together to perform them effectively and efficiently. Having training sessions frequently is recommended. Using cadavers to practice procedures and having drills where scenarios are worked through is a great way to keep the team "at the ready".

What is provided first – Putting it in perspective

That what we can provide first will have the most impact regarding how the patient ultimately does, such as applying that spica newspaper splint to a dog with a midshaft humeral fracture as apposed to putting on a Robert Jones made of cotton... the former giving the dog what he needs (stability and pain relief) and the latter only making the dog more painful and providing him with a "Ball and chain" to wear below the fracture and possibly causing radial nerve injury that will never heal... I have seen a number of these unfortunately. The veterinarian's intentions were good but the dogs suffered irreparable damage and never were able to use the limbs again and amputation followed.

Another example is Jake that underwent an emergency surgery for the removal of a foreign body. This required the removal a good length of bowel (approx. 50% of the jejunum). The bowel anastomosis that was done with 4-0 PDS and the simple interrupted sutures only had gasped the submucosal slightly. Five days later the dog represented with fever, vomiting and a painful abdomen... the bowel anastomosis had broken down and the leak of intestinal contents had caused severe peritonitis. If only the bowel anastomosis had been done with a non-absorbable polypropylene and serosally patched with nearby bowel loops as this has been proven to prevent anastomosis failures. The technique also has been very successful for the management of these breakdowns. Crowe, DT: Serosal Patch: Use in 12 Animals, Vet Surgery 13:29-38, 1984