Organizational Ergonomics

MASH Clinics

After writing this blog for a few years now, I realized that I haven’t explained what I do for my “day job” as an HQHVSN veterinarian. I am the Executive Director and Veterinarian at Spay ASAP Inc., a MASH-style spay neuter clinic in Vermont and New Hampshire.

(Parts of the content for this post are adapted from Chapter 34 of the textbook, High Quality High Volume Spay Neuter and Other Shelter Surgeries)

What is a MASH clinic?

MASH (Mobile Animal Sterilization Hospital) clinics are a type of mobile spay-neuter program in which clinic staff transport surgical equipment to a venue and set up a temporary surgical space in that location. Surgeries are not performed in the MASH vehicle, but instead utilize an existing space in the community.

American Legion in Claremont NH, a site of many of my MASH clinics.

Examples of clinic locations that I’ve used include animal shelter buildings, church basements, animal care (grooming and boarding) facilities, fire stations, town offices, school gymnasia, senior centers, and many more.

We also used to do MASH clinics in the old farmhouse that housed the offices of the Concord Merrimack County SPCA

MASH programs vary in the number of surgeons, technicians, and support staff, the frequency of surgery days, the number of consecutive days at a single venue, and in mission and organizational structure. Some MASH programs work independently of other humane organizations (independent MASH programs), while others conduct all their work in collaboration with other humane organizations (collaborative MASH programs). Over the years, Spay ASAP has been hosted by over 15 different humane organizations in Vermont and New Hampshire, and currently we are hosted by 8 different organizations and also have a few additional humane organizations that bring animals to our clinics.

Venues

When the space is small, shelving units for cat crates can optimize the available space

Venues for MASH clinics may be diverse and creative, but with few exceptions, MASH clinics require an enclosed space of a minimum of 1000 square feet (preferred 2000 square feet or greater) that can be maintained at a safe, comfortable temperature, and access to hot and cold water and electricity. In cases where running water is not available, hot and cold water may be brought to the venue. Facilities may be able to provide large nonmedical objects such as folding tables, chairs, and trash receptacles; if not, these items should be provided by the host organization.

Animal Housing

You seriously never know what cats will arrive in.

Since many MASH clinics do not take place in animal care facilities, animal housing often consists of pet carriers or folding wire cages. In these cases, host groups should be prepared to provide crates and bedding for housing dogs, as many owners will not have or will not be able to transport appropriate crates or cages for their dog. Cats and rabbits are generally housed in the carriers in which they arrive at the clinic, and community cats remain in their traps. It is wise to have additional crates available in which to house cats who arrive in inappropriate or inadequate housing.

Yes there are 3 cats in here. That is 30 pounds of black tomcats.

Dogs housed in folding wire cages provided for the day by the host shelter. The sheets over the cages give them some visual barrier between them and keep the room a little calmer and quieter.

MASH Equipment

Equipment requirements for a MASH clinic are similar to those in other clinic types, but all items must be compact and packable, and must have the durability to withstand transport, packing and unpacking daily. Choices for surgery table, surgery light, and anesthesia machines will be influenced by this need for packability and durability.

Vehicle

For our MASH vehicle, we needed space for 2 people and the necessary equipment. A small minivan, a compact SUV, a station wagon, or a boxy passenger car are adequate for a collaborative MASH program. Small, mass-market vehicles have the advantage of low purchase price, good fuel economy, and low maintenance costs.

Our current MASH vehicle, a 2016 Kia Soul

Anesthesia Equipment

Our tabletop anesthesia machine. Currently set up with a nonrebreathing system for patients under 5 kilograms

Like many MASH clinics, we use inhalational agents (isoflurane) for some of our patients’anesthesia. We have two anesthesia machines: one for the surgical prep area and one for surgery. This allows animals in the prep area to receive oxygen and anesthetic gas while they are being clipped and scrubbed, so that when they arrive on the surgery table they are on a steady anesthetic plane for surgery.

Tabletop anesthesia machines are easy to carry and need not be disassembled to pack in a small vehicle. Our current machines were custom made by Eagle Eye Anesthesia. We use a Tec 4 type vaporizer (the big, square-bottomed heavy ones) since they contain internal baffles that limit the movement of the anesthetic agent. Basically, they continue to deliver appropriate anesthetic concentrations even if the vaporizer is temporarily tipped or upended (ie, when the machine falls out upside down onto the ground when you open the car door).

For oxygen we use portable E cylinders in 2-wheeled oxygen cylinder carts and attached to the anesthesia machine via a regulator and oxygen hose. Oxygen cylinders should be immobilized in the vehicle for transport.

For anesthetic gas scavenging, we usually use passive scavenging (unless we are in a venue with a surgical suite with active scavenging). Passive scavenging options include exhaust through a window, through a hole made in the wall, or using an activated charcoal absorbent canister such as a F/Air canister.

Anesthetic gas scavenging options: out the window, out the wall, or using a charcoal canister.

Equipment Bins

Small equipment and supply items used during the MASH surgery day are packed in bins or totes for organization and ease of transport . We sort our bins by type of items: needles and syringes in one bin, anesthesia tubing and bags in another. We have smaller bins for surgery packs that hold about a dozen packs each.

Bulky supplies are contained in large (18 gallon) bins, and surgical packs are in smaller bins. A rolling cart aids in transporting items into and out of the venue.

A rolling cart is also helpful for venues with level entrances, allowing us to make fewer trips between the car and the surgery area during setup and takedown.

Surgery Table and Light

Surgery table made from old countertop and aluminum legs, placed atop a standard table. An instrument bin to the left of the table is used as an instrument stand, and an architect’s lamp with a compact fluorescent or LED bulb is used as a surgery light.

Some MASH programs require that host organizations provide appropriate height surgery and prep tables and a surgery light at each venue. This is most easily achievable if clinic venues are used repeatedly and are owned by the host organization. In these cases, steel food service tables or appropriate-height tables constructed by volunteers offer alternatives to commercial surgery tables.

At Spay ASAP, we went with a different option and have a portable surgery tabletop, allowing for greater flexibility in temporary surgery venues. A portable tabletop may be constructed using a piece of countertop with folding legs at a fixed or adjustable height that can be placed atop a standard height table– ours was made from a piece of countertop that once went over a dishwasher. We use a small bin (a surgical instrument bin) as an instrument stand.

Surgical prep table elevated on bed risers. An ergonomic standing mat is provided for the veterinary technician.

Other portable table alternatives would include using a small or standard folding table with bed risers or an adjustable-height folding table. We also elevate the surgical prep table to the appropriate height for the veterinary technician using bed risers or blocks.

For surgical lighting, we use an architect’s lamp with a compact fluorescent bulb of 23 watts or greater, or LED bulb of 16 watts or greater (equivalent to a 100-watt incandescent bulb). Alternatively, a head lamp may be used, but I find the weight of these lamps to be uncomfortable and am less impressed by the lighting quality.

Patient warming

Selecting a surgical patient warming device for MASH can be challenging, as some are too bulky to transport in small MASH vehicles, and those containing water may be difficult to transport due to spilling or freezing water during transport and storage (I used to use a Gaymar pump and water blanket but got frustrated by leaks and spills and the risk of freezing). A low-voltage conductive polymer fabric heating pad (such as Hot Dog or ChillBuster or Warm Blood if you can still find them) can be used, as they are compact and fairly durable.

Any postoperative warming devices that we use, such as heating pads, rice socks, or electric blankets, are supplied by the host organization, and should be used with caution (ie, no skin contact with the pet, and used only with direct human supervision) to avoid thermal burns.

Additional Equipment

Additional equipment transported by the MASH clinic includes a scale to weigh surgery patients, anesthesia monitor(s) such as a pulse oximeter or capnograph, anti-fatigue floor mats, and an insulated container for vaccines.

Safety equipment such as cat net, animal handling gloves, syringe pole, squeeze cage, and dog muzzles should be included, as many venues will not have adequate handling equipment. An additional useful piece of handling equipment is a snappy snare, which is a 3- to 5-foot-long stiff leash that allows the leash to be placed on the dog from a distance, and is useful for safely applying a leash to a frightened dog in a crate or kennel.

“Home Base”

Entrance to our rented room above a veterinary clinic

MASH clinics require a small area (minimum 10 x 10 feet) for receiving and storage of supplies and medications. At Spay ASAP, we rent a room on the second floor above a veterinary hospital. The ideal space would be easy to access with a convenient geographic location, a convenient physical location (first floor, near supply delivery area), and is temperature controlled for safe medication storage. Our space isn’t ideal from the point of view of deliveries, but we do have direct access via the fire escape.

If the MASH program is part of existing organization with a physical building, the MASH clinic can use this space.

If the MASH is a new organization or has no suitable site, possible sites include the home of a staff member or a rental space. Renting space from an existing animal care organization such as a veterinary clinic offers the advantage of on-site staff to receive deliveries of temperature-sensitive items such as vaccines or medications.

*Inside our storage room: just enough space for backstock and storage of the supplies that don’t fit in the vehicle*

If the home base is to be used for surgical pack preparation, it should contain or allow access to laundry facilities (unless all drapes and pack wrappers are disposable) and electricity, and should be large enough to accommodate pack assembly and an autoclave. During times when we have prepared packs in our rental space, we have rented additional space in order to have table space to prepare packs.

How to set up a MASH program: organizational structure and details

Everything from here on is more nitty gritty organizational detail, including more words, no pictures, and more generalizable information. It draws heavily from the MASH textbook chapter. It may be a bit too detailed for a blog post, but I wanted to get this information out and available for anyone who is really interested in starting up this type of clinic.

Can I MASH here? Legal issues:

Before considering a MASH clinic, be certain to check any relevant state or provincial veterinary practice acts and local regulations to be sure that MASH clinics are permitted. Some states and provinces require premise permits for any practice location, which may preclude MASH clinics. However, in some cases, states or provinces that require premise permits may allow exemptions for MASH clinics if asked in advance.

Who should MASH?

MASH clinics are adaptable and there are not specific prerequisites for regional population density or shelter animal intake. They are suitable for rural areas where low population density does not easily support a stationary clinic (like the border area of Vermont and New Hampshire), as well as for densely populated urban areas. MASH clinics are valuable for local shelters that wish to provide in-house HQHVSN, but either cannot afford to build and equip their own surgical suites, or that have surgical areas but lack veterinary staff. MASH clinics are also suitable for international and remote area spay-neuter programs.

For a veterinarian with surgery skills seeking spay-neuter work, establishing a MASH clinic can be one of the fastest and lowest cost ways of starting a HQHVSN clinic. This is what I did when I started Spay ASAP in 2006, and we went from registering the nonprofit in March to performing our first surgery in early June. In most cases, veterinarians who choose this route should be willing to operate the business aspects of the clinic and be able and willing to work with shelters and humane organizations in their target region.

In some cases, programs with limited startup funds may wish to offer surgery services before fundraising is complete or before a clinic site is located for a future stationary clinic. In this case, a MASH clinic may serve as a temporary economical option during the development of the HQHVSN program. Since any equipment purchased for MASH can be used in other models, the MASH clinic provides the opportunity for quicker startup without loss of equipment investment.While MASH programs are diverse, this chapter will focus on programs that utilize paid veterinarian(s) and technician(s) and operate within a prescribed region (as opposed to national or international scope). However, many of the descriptions in this chapter may be adapted to MASH programs that operate internationally and/or use volunteer veterinarians and technicians. For information on setting up international or remote area MASH clinics, the reader is referred to Susan Monger’s chapter on Operating a field Spay Neuter Clinic in the Field Manual for Small Animal Medicine.

Independent versus Collaborative MASH programs

MASH programs can operate their clinics independently of other humane organizations in a region or may collaborate with other humane or community organizations to host their clinics. Some MASH clinics may use a combination of these two approaches. There are advantages and disadvantages to each of these models. My own Spay ASAP clinics are collaborative MASH clinics so I’m biased towards that model and find it to be sustainable over the long term.

Collaborative MASH programs

Collaborative MASH programs are generally small organizations that collaborate with various local humane or community groups that act as their hosts in the communities within their service area. These host groups (or “ground teams”) must provide the venue and personnel, consisting of 2-5 staff members or volunteers, while the MASH program (or “surgery team”) provides the veterinarian, the technician, and all surgical supplies and equipment. The host organization is responsible for scheduling, admitting, and discharging patients, and for printing, preparing, and distributing clinic paperwork such as medical record forms, liability releases, discharge instructions, rabies certificates, and neuter certificates. Host groups are often required to provide non-medical supplies such as tables, chairs, animal bedding, extra pet carriers, and trash receptacles. In these collaborative programs, the MASH group generally works with several different host organizations throughout their service area to host clinic days. At times, more than one local humane group may work together to host a MASH clinic.

Collaborative MASH programs empower small humane organizations and shelters to host their own “Spay Days,” affording them the opportunity to enhance their community relations and outreach. The opportunity to host and assist with a MASH clinic enables staff and volunteers at host shelters to do something “fun” and different, compared to their usual shelter duties. These collaborations also allow opportunities for MASH clinic staff to share information and best practices for shelter medicine and HQHVSN with their host organizations.

Generally, it is the responsibility of the MASH organization to provide training and mentorship to new or potential new host organizations. Before hosting their first clinic, host organizations will need to know how to schedule the appropriate surgical load and how to determine the number and skill level of volunteers required. They need to understand the paperwork and be able to provide appropriate pre- and post-operative instructions to clients. An in-person meeting between the MASH organization and potential new hosts along with written instructions on hosting protocols and expectations is recommended prior to the first clinic.

Once a MASH organization has established relationships and carried out clinics with one or more host organizations, potential new host organizations can benefit greatly by visiting with and observing existing host organizations during MASH clinic days. This peer-to-peer mentorship helps new host organizations develop their own protocols and systems and allows them to see clinic flow and ask questions before their first clinic. In some cases, this mentorship may even continue, with representatives from existing host organizations attending the first few clinics sponsored by new host organizations, smoothing their transition into their role as host.

Advantages of the collaborative MASH model include flexibility and decreased operating costs. Staffing costs are decreased for the MASH organization because of the symbiotic relationship between the MASH organization and their hosts. The MASH organization pays only one veterinarian and one technician per day, in addition to an after-hours surgical pack preparation staff, and relies upon the host organization to provide additional resources (2-5 staff or volunteers, and venue). The hosts are motivated to provide this because they need the MASH program’s staff, equipment, and expertise in order to offer affordable HQHVSN clinics.

In contrast to an independent MASH clinic, the collaborative MASH clinic requires a relatively small vehicle given the small staff and minimal equipment required. Purchasing a smaller vehicle results in a lower initial purchase price, as well as lower ongoing fuel and maintenance costs. This decreased operating cost often means that a collaborative MASH clinic is able meet their budget entirely via low-cost fees for service, without additional fundraising.

Independent MASH programs

Independent MASH programs have sole responsibility for scheduling the venue, booking patients, securing volunteers and staff, and admitting and discharging patients. The independent MASH model is more likely to be adopted by large, pre-existing organizations, by new HQHVSN programs planning to transition to stationary clinics in the future, or by organizations doing MASH clinics intermittently. This is because developing and training the network of collaborating host organizations that is required for a collaborative MASH clinic takes time and effort. For large, established organizations that have the resources to perform ground team tasks in addition to surgical team tasks, this extra task of collaborator development may be unnecessary. For MASH clinics that operate intermittently, the collaborative relationships may languish and be harder to maintain.

In an independent MASH clinic, staffing and finances are likely to be similar to a stationary clinic or self-contained mobile surgery unit, unless adequate, reliable volunteer staffing is available. Minimal required staff would consist of a veterinarian, a veterinary technician, one or more veterinary assistants, and administrative staff for record keeping, patient booking and reception.

Independent MASH clinics may require larger vehicles than collaborative programs to transport staff, surgical equipment, and some nonmedical items such as animal bedding and extra pet carriers or crates. Since the staffing for this model of clinic is similar to that of a stationary clinic, the costs are higher as well, making this model harder to sustain financially than collaborative MASH clinics. However, independence can offer the advantage of more predictability by utilizing more consistent clinic staff and by not needing to rely on other humane groups to schedule clinic dates and locate suitable staff and volunteers.

Organizational structure

MASH clinics may be established within any organizational structure, including nonprofit, for profit, and government or tribal entities. In some cases, MASH clinics may represent a single program within a large, diverse existing organization. For example, an animal shelter with an in-house spay-neuter clinic may develop a MASH program to reach certain communities in their service area. In others, a new organization is formed for the purpose of offering MASH clinics, and this organization exists solely for the purpose of offering MASH clinics.

Financial investments and ongoing costs

Financial requirements for a MASH clinic are generally much lower than for a stationary clinic or self-contained mobile unit. There will also be some differences in the initial investments between MASH clinics following a collaborative model versus an independent model. In all MASH clinics, the major initial costs will include acquisition of a vehicle, surgical and anesthetic equipment, initial consumable supplies (for example, drugs, vaccines, syringes and needles, gauze sponges, antiseptics, and suture material) and an autoclave. In cases in which the MASH clinic already has access to a suitable vehicle, or if the MASH vehicle is purchased with a car loan, the initial investment to start a collaborative MASH clinic will likely range from $20,000- $35,000.

Ongoing costs for MASH will include personnel costs (salaries, wages, benefits, payroll taxes, workers compensation), consumable supplies, and vehicle gas and maintenance. Most MASH clinics will also need to rent a small, climate-controlled “home base” physical space for safe storage of consumable supplies (see “home base” section above).

Because overhead costs are low, it is possible to sustain a collaborative MASH clinic with low-cost fees for services, without additional fundraising. In cases where extremely discounted or free surgeries are to be offered, additional fundraising and grant writing by the MASH clinic or by one or more host organizations will be required to subsidize program costs.

Personnel

Minimal personnel requirements for a collaborative MASH clinic generally consist of one veterinarian and one veterinary technician. Some MASH programs employ additional staff for instrument care or for management. In many collaborative MASH programs, the veterinarian and technician handle instrument care and management responsibilities without additional staff. For example, the veterinarian serves as the program director/manager, and the technician assumes the responsibility for preparing surgical packs.

Independent MASH programs require additional personnel including veterinary assistants and administrative staff. The staffing model for these clinics is similar to that for a stationary or mobile self-contained clinic.

Surgical capacity

Surgical capacity for a MASH clinic should be comparable to other HQHVSN models, although in many MASH clinics, only one surgery table is available, so surgical flow and resulting speed is somewhat slower than in a fully-equipped stationary clinic. However, unlike in some self-contained mobile units, physical space for animal housing need not be a limitation for MASH clinics. Approximately 5 hours of surgery time is a full day for a MASH clinic, and this may consist of as few as 15-20 dogs or as many as 50-60 cats for one veterinarian depending on surgical speed and species and sex composition of the patient load.

Timeline

Startup time for a MASH program can vary. In the case of collaborative MASH programs, startup may be delayed if collaborating organizations need to be identified and persuaded. However, if collaborating organizations are prepared to host clinics immediately, a MASH program can start up in less than 3 months once finances are obtained.

Protocols

As with all HQHVSN clinics, MASH clinics should adhere to the ASV Guidelines for Spay-Neuter Programs. Surgery techniques, patient selection, and disinfection and sterilization of equipment are no different than in other HQHVSN clinics. Anesthesia and analgesia protocols are similar to those in stationary clinics, although care must be taken to select protocols that are suitable for same-day discharge of patients. As with all clinic types, proper medical record-keeping is essential, and clients must be provided with written and verbal postoperative instructions.

Post-operative care

As with other clinic types, there is a need to develop a postoperative care plan for emergencies and client questions. In most cases, this is achieved by providing a phone number to clients to contact MASH clinic staff in case of questions or emergencies. This phone may be carried by a veterinarian or a technician who can answer client questions and concerns and triage cases requiring veterinary care. For independent MASH clinics, administrative staff may carry this phone, triage calls, and refer medical questions to a veterinarian. Emergencies and rechecks will generally need to be seen by outside veterinary hospitals, as the MASH staff may be distant from the animal in question and may have no available facility in which to see patient rechecks. It is up to the MASH program to set policies with regards to client reimbursement or payment to outside veterinary hospitals seeing MASH clients. In many MASH clinics, as with other HQHVSN clinics, outside care is reimbursed if related to the surgical or anesthetic procedure, and if the client has generally followed post-operative instructions.

Some MASH programs have established relationships with specific local veterinarians or emergency clinics within their service areas who are willing to provide emergency care, and in some cases, the clients may be provided with this contact information instead of or in addition to contact information for the MASH clinic. Other MASH programs establish relationships with local practices as needed, as the geographical areas covered by some MASH programs are large enough that specific local relationships may be difficult to establish. Regardless, it is essential that the MASH clinic have a plan in place for how they will address follow-up or emergency care for their patients.

Surgical Instruments and their Care

In most cases, MASH clinics have no on-site autoclave. Most surgical instrument care, including ultrasonic cleaning, pack preparation and autoclaving, takes place after hours or between clinic dates. Thus, many small, collaborative MASH clinics maintain enough sterile surgical packs for multiple (2-3) days-worth of surgery or schedule time in between surgery days to provide time for packing and sterilization. This may be especially important if the pack preparation is performed by staff who are also members of the traveling MASH clinic team.

Surgical instruments should be soaked to remove organic debris and cleaned by hand by volunteers at the surgical venue, then rinsed and returned to the transport vehicle to be transported back to the home base with the surgical team. Further instrument cleaning, laundering of drapes and pack wrappers, pack preparation, and sterilization may occur at the MASH clinic’s home base, or alternatively may take place in a staff member’s home. This at-home pack preparation and autoclaving may be advantageous if the staff member lives far from the home base, or if the staff member has household obligations (such as small children) that make after-hours travel to the home base difficult.

MASH: The Day of Surgery

MASH clinics are typically located in different venues with a different layout each day. Collaborative MASH clinics work with different assistant staff each day, as provided by the host organization. These changes can affect clinic flow and efficiency, and they require the MASH veterinarian and technician to adapt to a variety of new situations and circumstances.

Setting up the clinic

In a collaborative MASH clinic, the host organization’s staff admits patients before the veterinarian and technician arrive, or while the veterinarian and technician are unpacking and setting up. In each new clinic venue, the MASH veterinarian and technician must plan the layout and flow for the clinic. The veterinarian’s and technician’s workspaces are re-created as consistently as possible but must be adjusted to accommodate the locations of windows, electrical outlets, and doors. Flow through the clinic should be optimized, although not every venue will lend itself to smooth flow between preop, prep, surgery, recovery, and postop areas.

Clinic Flow

Clinic flow in a MASH program may be somewhat slower than flow in a stationary clinic. Typically, a MASH clinic has one surgery table per surgeon, such that the surgeon must wait while patients are exchanged on the table. To improve flow while working on cats, the surgeon may alternate male and female cats, castrating male cats on a side-table or countertop while female cats are exchanged on the surgery table. MASH clinics also usually have only one prep station, which may be the rate-limiting step during fast surgeries. Also, since clinic layout and staffing vary between locations, ideal flow may not be achievable at each clinic site.

Clinic Day

The MASH clinic day includes travel, setup, and re-packing, in addition to the usual tasks related to operating a HQHVSN clinic such as performing patient exams, anesthetic procedures, and surgery. The total day length for the veterinarian and technician may be 11 hours, whereas the surgery time is only 4-5 hours. Thus, more than half the staff’s time is spent driving, setting up, and re-packing the surgery area. This time budget may be improved somewhat by changing clinic policies: driving time may be reduced by restricting the travel radius, and setup and takedown time may be reduced if the clinic is located in the same venue for multiple days.

The time required for these additional tasks of driving, setup, and packing means that MASH clinics are not the most efficient clinic model in regards to use of the veterinarian’s and technician’s professional time. A MASH that employs only one veterinarian and one technician may be operating “full time” (36-40 hours a week) with just 3 clinics—or about 100 surgeries—per week, if the technician is also preparing packs between surgery days, and the veterinarian is acting as administrator and business manager. However, despite achieving fewer surgeries per full-time veterinarian, the lower overhead costs mean that the cost-per-surgery is equivalent to that of a stationary clinic. This allows MASH clinics to pay hourly wages to the veterinarian and technician that are on a par with, or in some cases greater than, stationary or self-contained mobile HQHVSN clinics.

MASH clinics provide a flexible, low-cost, high-quality method for delivering spay-neuter services. The MASH clinic’s versatility, adaptability, relatively low capital investment, and short time to start up are the particular strengths of this clinic type, and makes these clinics useful both as short-term solutions as well as long-term, sustainable HQHVSN providers.

I hope you all enjoyed this intro to MASH clinics!

The Spay Neuter Textbook is Here!

Textbook cover image for High Quality High Volume Spay Neuter and Other Shelter Surgeries textbook.

Those of you who have spent any time with me during the past 2 years have probably heard about my work as the editor of the long-awaited Spay Neuter Textbook. Well, it’s finally here! The e-book version has been available for a few months, but the print copies just arrived at the publisher’s this week.

Want to order a copy? This link will take you to Wiley’s page for the book with links to various sellers. And when you receive your copy, let everyone know what you think by reviewing the book on Amazon.

This book is the product of the dreams and hard work of a lot of people: there are dozens of contributing authors with a variety of areas of expertise, and I have been honored and humbled to work with them all.

So what’s in the book? Who is it for?

I could write a long blog post on this from scratch, but I realized that I already answered these questions when I wrote the book’s preface and acknowledgements. So I’ve included these two sections here to answer these questions and to provide a sense of the history, context, and organization of the book.

I hope that this is the book you’ve been looking for — enjoy!

Why do we need a spay-neuter textbook?

Spaying and neutering are often the first (and in some cases, the only) surgeries that students learn in veterinary school, and are expected skills for every new graduate in general small- or mixed-animal practice. It can be tempting to dismiss them as “beginner surgeries,” the easily trivialized but sometimes terrifying rites of passage into the veterinary profession. Perhaps because spaying and neutering are skills learned so early and repeated so often in a general practitioner’s veterinary career, they are rarely the subject of continuing education seminars and articles, and general practitioners may go their entire career without modifying or even questioning the techniques for spaying and neutering that they learned as third-year veterinary students.

At the same time, spaying and neutering have been central to efforts to reduce the overpopulation and euthanasia of unwanted and unowned cats and dogs. The spay-neuter clinics and programs that arose over the past several decades recognized the need for minimally invasive, efficient techniques that would shorten surgical times and improve patient recovery. This textbook pulls together many of the surgical, anesthetic, perioperative, and operational techniques discovered, developed, and popularized over the decades by these innovative spay-neuter pioneers.

As the field of spay-neuter developed, practitioners recognized the need for greater acceptance and clarity. In 2006, a task force was convened that developed the first guidelines for medical care in spay neuter programs; this document was published in JAVMA in 2008 as The Association of Shelter Veterinarians veterinary medical care guidelines for spay-neuter programs (Looney et al., 2008). The goals of these guidelines were to promote acceptance of spay-neuter practice by the veterinary profession and the public, as well as to provide guidance for veterinarians and spay-neuter programs regarding standards of care and practices based on scientific evidence and expert opinion. The ASV Spay Neuter Task Force reconvened in 2014 to update and expand the document, resulting in The Association of Shelter Veterinarians’ 2016 Veterinary Medical Care Guidelines for Spay-Neuter Programs (Griffin et al., 2016).

High-Quality, High Volume Spay Neuter (or HQHVSN, the awkward but now widely used acronym adopted by the first Spay Neuter Task Force) is the field of veterinary medicine that began with the efforts of spay-neuter pioneers in the 1970s through 1990s and became firmly established and advanced by the publication of the 2008 and 2016 spay-neuter guidelines. HQHVSN is defined as “efficient surgical initiatives that meet or exceed veterinary medical standards of care in providing accessible, targeted sterilization of large numbers of cats and dogs to reduce their overpopulation and subsequent euthanasia”(Griffin et al., 2016).

Until now, practitioners new to HQHVSN or isolated in their practice have had no single place to turn to find out about HQHVSN techniques and protocols and the evidence supporting them, or about spay-neuter program types, their implementation and staffing, and their effects on animal populations and individual animal health. Many of the techniques used in HQHVSN have been taught at conferences and mentorship programs and shared and spread between practitioners, and many have been subjects of peer reviewed research; however, few appear in textbooks. Nevertheless, the medical, surgical, and perioperative care described in this book need not be limited to high-volume or shelter settings—they are applicable wherever veterinary surgery is performed.

This book is divided into two parts, and each of those parts divided into several sections. Part 1, Clinical Techniques and Patient Care, is concerned with evidence-based clinical knowledge and skills including perioperative, anesthetic, and surgical techniques. Part 2, Fundamentals of HQHVSN, introduces the high-volume surgical setting and the special organizational, logistical, and epidemiologic challenges that arise when striving to optimize the clinic’s operations and impact.

The book is intended for a range of audiences: from the veterinary student to the experienced HQHVSN practitioner, and from the veterinary technician to the aspiring spay-neuter clinic founder. Part 1 begins with chapters on determination of patient sex and neuter status, reproductive anomalies and pathologies, the selection of surgical instruments and suture, infectious disease control, asepsis, and stress reduction in the clinic. The sections on anesthesia and surgery cover general principles as well as specific techniques and protocols, including chapters on avoiding and managing both anesthetic and surgical complications, and a chapter on anesthetic and surgical techniques in rabbits and other small mammals.

While many of the techniques covered in Part 1 are well known to experienced HQHVSN surgeons, some of the anomalies, complications, and complicated presentations are unusual and may be once-in-a-lifetime cases for some. Experienced practitioners may also learn of useful variations on or alternatives to their accustomed techniques, or learn new ways of preventing or addressing frustrating complications.

Part 1 concludes with a section on other common shelter surgeries and associated anesthetic procedures, and can serve as a reference for shelter surgeons with a variety of levels of experience. This section includes amputations, eye surgeries, vulvar or rectal prolapse treatment, and dental extractions.

Part 2 of this book moves away from the clinical care of individual patients and into the structures and systems fundamental to HQHVSN, with sections on population medicine, human resources and wellbeing, and HQHVSN program models. Optimizing the potential of HQHVSN requires more than just proficiency in the clinical care (anesthesia and surgery) of individual patients. Effective HQHVSN programs must understand the effects of their interventions on animal populations and individuals; they must combine their clinical skills with appropriate staffing and facilities to allow an efficient and streamlined workflow; they must institute systems that are financially, physically, and emotionally sustainable. Chapter 23 serves as an introduction and roadmap to the second half of this book. The material in this second half of the book should be of interest to anyone seeking to establish a new HQHVSN program or improve an existing one.

Acknowledgements and Deepest Thanks…

First, I want to thank the original four editors of the book: Brenda Griffin, Karla Brestle, Philip Bushby, and Mark Bohling. These four veterinarians have been instrumental in establishing and promoting the field of HQHVSN; this book would not have existed without them. I have had the privilege of working with all four of these people in different capacities over the past decade and a half: as teammates on the ASV spay neuter task force and co-authors on the 2008 and 2016 Guidelines, as co-teachers in pediatric spay neuter wet labs, and finally as contributing authors to this textbook. Thank you for being my mentors and colleagues, and for believing I could do this. Thanks especially to Brenda, who during my editorship has been my cheerleader and sounding board, my informant and historian, and a bridge between the original vision for this book and its evolution and re/vision. The encouragement, context, and friendship you have offered throughout this process has supported and inspired me.

I also want to thank all the HQHVSN and shelter veterinarians I have met over the years in person and online. My early teachers in this field were all virtual (but real!) colleagues who took the time to explain and describe surgical techniques in words, back in the days of dial-up internet, before YouTube. From the sheltervet electronic mailing list that I joined in 2001 to today’s shelter veterinary and spay neuter Facebook communities and hqhvsnvets online group, you have been and continue to be my mentors and my inspiration. Thank you also to my online colleagues who contributed photos for this textbook—your eagerness, openness, and surgical and photographic skills have made this book better.

And a huge thank you to all the authors who have contributed chapters to this textbook. It is your expertise that has driven the field of HQHVSN forward and that makes this book all that it is. This book is a first edition, but it is also a revision: by the time I signed on as editor in early 2018, many of the submitted manuscripts had become dated. I want to thank the authors for their patience and willingness to revise or even overhaul these chapters in order to make the materials as relevant, timely, and useful as possible.

And finally, thanks to my wife Tina, who kept the refrigerator full and the woodstove stoked during my many long hours of writing and editing.

The HQHVSN Workplace

Years ago, in 2011, I set out to study spay neuter veterinarians with the aim of finding out about musculoskeletal pain risk factors and what we might be able to do about them. The resulting study was published here, but as with many research surveys, I collected data as background information that never made it into a publication (other than as a poster abstract in the 2012 Midwest Veterinary Conference proceedings). Although this extra data is not exactly groundbreaking, there are some interesting tidbits about our field, and even though the results are from a 2011 survey, I think many of the findings are still relevant. This is exactly the sort of research that the Journal of Incidental Findings and Freelance Inquiry (JIFFI) was designed to publish. So enjoy!

Characteristics of spay and neuter employment positions and contributors to efficiency

Methods: Online survey of veterinarians who currently or previously spay and neuter at least 4 hours per week. Responses were solicited via the Association of Shelter Veterinarians’ Sheltervet listserv, the HQHVSNvets listserv, and conference attendees at the 2011 SNIP Summit, yielding 228 useable responses.

Results:

Where do spay neuter vets work? Lots of places, though most are in a stationary venue. And a lot of spay neuter vets work in more than one place, too– more than one shelter or clinic, or doing mobile and stationary spay neuter work for the same organization.

Of veterinarians in the four most common clinic types, mobile veterinarians have the longest total workdays (median 12 hours) and perform the most surgeries (median 34 daily) with a large staff (median 4 per veterinarian), but their surgery time is similar to veterinarians in stationary clinics and shelter clinics serving the public (median 6 hours daily). Shelter-only clinics see fewer patients (median 18) in a shorter surgical workday (median 5 hours) with fewer staff (median 2 per veterinarian).

Clinics with 4 or more staff or volunteers per veterinarian performed more surgical units per hour (median 5.4) than clinics with one (3.28), two (4.57), or three (4.69) staff per veterinarian.

Approximately half of the surveyed veterinarians (116/216) work full time in spay/neuter. For part-time spay/neuter veterinarians, in addition to having other job duties that limit time in spay/neuter, factors preventing full time spay/neuter work include finances (14.8%), prevention of burnout (58.2%), physical and musculoskeletal health (45.1%), family (36.0%), and limited availability of spay/neuter jobs (41.6%).

I like lunch, so I asked about it. Most spay neuter vets don’t take a lunch break during their spay neuter work day. It’s not necessarily as daunting as all that, though– many vets finish surgery mid-day, so can eat before and after surgery rather than breaking in the middle of surgery. For my MASH clinics, though, I insist on a sit-down lunch break if the surgery day will last past about 1:30 pm. Less efficient, maybe. Less hangry, definitely.

Discussion:What are the takeaways from this snapshot into the spay neuter workplace of 2011?

For me one of the most obvious, intuitive, but potentially overlooked (by management) findings is that having more support staff equals more surgeries per hour.

Since finding out about staffing levels wasn’t the main objective of the survey, there is still a lot we can’t say about how staffing and surgeries per hour relate to each other. I assume that having more staff doesn’t actually make a surgeon cut and sew faster– it just means that the surgeon gets to spend more time cutting and sewing, and less time restraining, injecting, waiting, or doing any other activity that keeps them away from the surgery itself.

For low volume clinics, this decreased efficiency from lower staffing levels may not be a problem. Sure, things could go more quickly, but the work gets done. But for anyplace looking to increase their efficiency, increasing staffing level is a good place to start.

Is this what our field of HQHVSN looks like now? Probably, mostly yes. Maybe I’ll ask again in a few years…

Mega-MASH clinic: The Spayathon for Puerto Rico

MASH spay and neuter clinics are nothing new for me: during the past 13 years I’ve done well over 1000 MASH clinic days in Vermont and New Hampshire. My own MASH clinics are small: one veterinarian, one veterinary technician, and between 2 and 10 other volunteers or shelter staff. We set up our clinic for just a day at a time and see somewhere between 20 and 60 patients in a day (depending on dog or cat, male or female).

But recently, I’ve had the chance to participate in Spayathon for Puerto Rico: four, one-week-long rounds of multi-site, multi-vet MASH clinics. I’ve spent Spayathon Rounds 2 and 3 with the group Veterinarians for Puerto Rico, a fabulous new group formed in the wake of Hurricane Maria. The Spayathon for PR clinics are large: some sites like ours served between 150 and 200 (or so) patients a day with about 4-7 veterinarians in surgery each day, while the biggest location served about 500-600 patients a day with about 20 vets in surgery each day. Lots of people have posted cute pictures of pets and owners at Spayathon and talked about the rewarding and exhausting experience of volunteering– just search #spayathon4pr to see some examples– so here I’m going to talk about the logistics and flow (physical and organizational ergonomics) of running a large MASH clinic like this.

Before: The community center in Toa Baja that would become the Vets for PR surgery site during Spayathon4PR round 3. The surgery area pictured at the beginning of this post is the area to the left in this picture.

Without these volunteers, Spayathon would not be possible

Large MASH clinics are full of logistical challenges. How do we create a safe and efficient flow of animals through the clinic? How do we keep the animals and the people as safe and un-stressed as possible? How do we make the best use of the space we have for the clinic? How do we make the best use of the dozens of volunteers at each site?

This round, utilizing our limited indoor space as efficiently as possible was one of our biggest challenges in Toa Baja. While the community center looked large when it was empty, it was much smaller than the sports arena we had occupied in round 2 in Aguada.

A client waits with her dog until it’s time for her dog to go inside for surgery

One of the space-savers was using the covered balcony area for dog physical exams; clients and dogs also waited outdoors (under the cover of tents, on the balcony, in the shade of the building, or on the small lawn) until it was their dog’s turn for surgery. When it was time for the dog to come inside for surgery, the owner was there too. Pets who had received their anesthetic injection waited in their owners arms or on a bed on the floor until the sedation kicked in and they fell asleep.

Clients wait with their dogs in the induction area. The dogs closest to the curtain towards the back of this picture have received an anesthetic injection.

Cats were a little different (they’re cats after all…). We admitted the cats in their carriers into the building so that they could have physical exams in a confined space, rather than using the open-air balcony with the dogs.

Cats and more cats waiting for physical exams

Watching cats fall asleep may not be the most glamorous job, but it’s one of the most important.

Once the cats were examined, they could be injected with anesthesia and brought out to a post-induction table (aka Kitty Sleepover Party) where they could be under continuous observation until they were anesthetized enough to move to a surgery prep table.

Dogs too were moved into surgery prep– this is where their pathway merges with that of the cats. And after prep, patients were moved to an unoccupied surgery table.

Veterinarians for Puerto Rico surgery area during Spayathon for Puerto Rico Round 3 in a community center in Toa Baja. The Kitty Sleepover Party table is located in the lower left of this picture, and surgical prep tables are on the lower right. The entrance from dog induction is to the right, outside the view of the photo. In the background are the 10 surgery tables (8 around the edges, two in the center), each with an anesthesia machine.

As in many high volume settings (but not in my own MASH clinics), the Vets for PR surgery area had more surgery tables than surgeons. This mean the surgeons don’t have to wait for the exchange of patients on their table; they can re-glove and move directly on to the next surgery. It also allows the postoperative patients an extra minute or two on the anesthesia machine, to breathe oxygen and breathe out the anesthetic gases before being moved to recovery.

After surgery, animals were moved directly to Recovery 1, or “the beach.” Here they were attended by a team of veterinarians, technicians, students, and volunteers who watched their recovery and recorded their temperature, pulse, and respiration at intervals throughout their recovery. The beach was all soft padding, heating pads, and “warmies,” the hot water bottles and rice socks that were microwaved and re-microwaved throughout the day to help the patients warm up. (The air-conditioned facility, while comfortable for most of the workers, was chilly for anesthetized patients, so we had to make efforts throughout the day to keep them warm, including heating pads on the tables in surgical prep and in surgery).

Recovery 1 area (“The Beach” 🏖) located just off the surgery room. Dogs on the floor, cats on the countertop.

The beach 🏝 from above. Veterinarians and technicians from the MSPCA in Massachusetts set up for the influx of patients. Having the small patients at an easy-to-reach standing height table makes caring for and monitoring them easier on the volunteers.

Owners helped in recovery, sitting with and holding their pets until ready for discharge

Once patients were warm and alert, they could leave the Recovery 1 beach and be reunited with their owners in Recovery 2. Veterinarians, technicians, and other volunteers watched over the roomful of “pet parents” waiting with their animals until the animals were recovered enough for discharge. An instructional video played, and owners also received instructions from and were able to ask questions of the vets and techs. Once their animals were recovered and ready to go home, they were discharged with post-operative instructions and emergency contact information, along with donated pet supplies and pet food.

Once the animals were gone, the work wasn’t done: data had to be entered from all the medical records into a centralized database that would allow researchers to study the users (clients and pets) and outcomes of the Spayathon clinics. Our site in Toa Baja had such limited indoor space that the data entry station was in a tent outdoors that was in theory air conditioned but was in actuality a bit of a sauna. Also, the data tent was the volunteer lounge and lunch tent, so data warriors also got to be lunch patrol (“only two plantains per person!”; “save the pitas and hummus for the vegans!”). Next round, we’re hoping for a space that puts these folks back inside the building in a climate controlled setting.

She’s not just wearing a harness, it’s a dress. How could I resist an embarrassed calico?

Meanwhile, I got to spend my time between many different areas of the clinic, but mostly between induction, prep, surgery, and recovery 1, trying to keep an eye on the big picture and flow, and pitching in where I could (and trying to remember to take pictures here and there). It was a great experience working with so many talented and dedicated people, and I’m looking forward to going back to the fourth round of Spayathon for Puerto Rico in May!

Who uses Spay Neuter Clinics?

Ten years ago, I examined this handsome cat at a nonprofit spay neuter clinic.

This week’s Journal of the American Veterinary Medical Association (JAVMA) contains an article about the people and the animals who use nonprofit spay neuter clinics. The full title of the study is Characteristics of clients and animals served by high-volume, stationary, nonprofit spay-neuter clinics. I conducted this study along my co-authors Julie Levy and Jan Scarlett, two superstars of shelter medicine who were both great collaborators and great mentors on this project.

The data for the study comes from surveys of thousands of clients bringing their cats or dogs to stationary spay neuter clinics all over the US over the course of one year.

If you were lucky, you may have seen me presenting the results of this study in 2015 at the North American Veterinary Conference or at the SAWA/National Council on Pet Population research day. Below, I’ll describe the study using some graphics from these original presentations (which are more colorful and varied and less copyrighted than those in JAVMA). We have a press release available on the Million Cat Challenge website too, which you might want to check out to learn more about the study and its interpretation.

The Study Clinics

We wanted to be sure to include clinics and clients from all over the US, in case there were regional differences in the types of clients or pets who use spay neuter clinics. Similarly, we wanted to be sure to include different times of year, in case there was a seasonality to clinic patients. In order to make sure we chose clinics from all over, we divided the US into 4 regions (actually, the Census Bureau did the dividing) and tried to get proportional representation from each region. Here is what that looked like:

Once we selected the clinics, we asked them each to survey all clients bringing cats or dogs to the clinic during four specific weeks over the course of a year. Clients would fill out a survey for up to two animals and answer questions about themselves as well as about their pet. We didn’t ask feral cat caretakers or shelters and rescues to fill out surveys, and we also didn’t get surveys from clients whose pets arrived at the clinic in transport vehicles.

The Animals

Overall, about half of the 12,901 animals that clinics saw during the study weeks were brought to the clinic by owners, and the other half consisted of shelter animals, ferals, and animals arriving by transport vehicle.

Again, only the drop-off at clinic animals were eligible for the study. About 2/3 of these animals (4,056 animals) ended up being included. Among those, there was a pretty equal split between males and females, and between dogs and cats.

The ages of animals varied, but overall, felines were being altered younger than canines:

The age and species composition varied somewhat around the US, with the Northeast having more cats, and the West having more dogs.

Among the adult female patients, 28% of the cats and 17% of the dogs had had a previous litter. Most of these cats (66%) had only had one litter, whereas just over half of these dogs (51%) had two or more litters before being spayed.

Previous Veterinary Care

The animals, especially the cats, had limited previous exposure to veterinary medicine. For most of these pets, this was their first time seeing a veterinarian.

Even more alarming from a public health perspective, very few of the cats over 4 months old had ever received a rabies vaccination. The dogs were more likely to have had a rabies vaccine, which we attributed to licensing requirements and the availability of rabies vaccine clinics.

The Clients

We asked clients to share their annual household income, and found that most clients’ incomes fell below the national median household income, and below each of the regional median incomes. This was true whether they were bringing dogs or cats or both to the clinic, although cat owners tended to have lower income than dog owners:

We found similar income distributions among all regions, with the lowest client incomes in the Northeast, where the clinics also see more cats:

The Reasons

We asked clients why they were choosing to get their pets neutered now, and also why they chose to come to the spay neuter clinic. They were allowed to choose as many answers as they liked.

Population control, avoiding heat, and behavioral reasons were the top choices for both cat and dog owners when asked reasons for getting their pet neutered now:

Cost, recommendations, and reputation were the top reasons why clients chose the nonprofit spay neuter clinic instead of other options:

The Takeaways

Even though most of the study clinics didn’t screen for income, the majority of the people and animals that they served fell into the low income demographic, with about a quarter of clients falling below the poverty line. We can also see from the survey results that the majority of these pets had never seen a veterinarian before. For the most part, nonprofit spay neuter clinics are reaching the people who most need their services and who would likely not get those services elsewhere, or who would struggle to pay for those services if they did receive them elsewhere.

Penniless Pussycat is in need of a low cost clinic

Also, remember that client-owned animals only made up about half of the patients that participating clinics saw during the study period. These clinics also spayed or neutered thousands of homeless animals during the study weeks: remember that 24% of the clinics’ patients were shelter animals, and another 18% of the patients were feral cats. Even though these animals weren’t included in the study, they are a huge part of the work that nonprofit spay and neuter clinics do and should always be factored in to the value of what clinics provide.

As a spay neuter vet, I was also happy to see that clinics enjoyed a good reputation among clients such that reputation and referrals from friends were two of the top three reasons clients gave for choosing the clinic. So clients feel that they are getting not just an affordable service, but a high-quality service as well.

Complicated, Part 3

My first week back at work after my nephrostomy and abdominal drain were placed, I had a major wardrobe malfunction. I was wearing a leg bag on each leg, strapped to the front of my thigh with elastic bands. I was kneeling on the floor, examining a large, handsome hound dog, and I felt a dampness spreading across my left knee. My vet tech and the shelter staffer who were helping us saw it too.

Of course, it’s not too unusual to end up with damp spots on my clothing at some point during exams. Puppy pee, slobbery dogs, wet or muddy paws.

I said, “That wasn’t the dog”

I could feel the urine still running out of the leg bag. It had been pretty full, and I don’t know if the dog had bumped it, or if my scrub pants had rubbed against and dislodged the end cap as I knelt, or if just the pressure of my flexed thigh against the full bag was enough to push the cap off.

I stood up, laughing, embarrassed, trying to kink the end of the bag to stop the flow, but to no avail. Immediately the urine ran down my leg and filled my shoe. Someone handed me a towel and I wrapped myself in it, asked my tech to get my spare clothes out of the vehicle (pro tip: always have spare clothes in the vehicle), and ran to the bathroom to change.

I emerged from the bathroom barefoot but dry, my urine-soaked clothes and shoes stuffed into a plastic bag to launder once I got home. I slipped my feet back into the snow boots I had worn to work that morning.

“Do you want me to run those through the wash for you?” the shelter staffer offered.

“Are you sure?” This seemed a bigger imposition, and more personal, than the initial, urgent cleanup. And I was just the visiting vet, only there a day a month, not her friend or co-worker or boss.

She took the bag back to the laundry room, and by the time I was ready to go home, the clothes and even the shoes and socks were clean and dry.

Fortunately, I’m not a leader who relies on dignity or control over others to bolster my authority. I’m confident, but I joke about my weaker points and don’t mind occasionally playing the fool (or being, accidentally, made foolish).

Like most veterinarians, I had never studied leadership when I got my first job with management duties, nor later when I started my own business (Spay ASAP Inc, a nonprofit MASH mobile spay neuter clinic). Later, I was introduced to organizational ergonomics during my ergonomics masters program, and then I attended a 2-day course at Emancipet called Surgeon to Leader.

One of the topics we discussed was the difference between management authority and leadership authority. Management authority is structural: it comes from a job title, and allows you to say, “because I said so.” Leadership authority is granted by each individual: it happens regardless of whether you have managerial power. With leadership authority, people follow because they want to, not because they have to. They follow because they believe that together, you will achieve something worthwhile that neither of you can achieve alone.

In my own workplace, I have management authority over only one other person: the veterinary technician who I’m paying to be there. But I strive for (and can only function with) some level of leadership authority, to inspire those who work for other entities and those who volunteer to believe that what I’m asking them to do is useful and worthwhile. I could aim to gain that leadership authority by inspiring awe, but like the awkward alien in the Gary Larson cartoon, I’d be bound to fail (or fall) eventually. Instead, I earn what leadership authority I have by working hard and allowing others to feel involved in and integral to that work.

A few days ago, a veterinarian friend emailed about how she had been fighting the perfectionism in veterinary medicine by admitting openly to staff when she didn’t know something, instead of sneaking off to look up the answers. She points out her mistakes and near misses rather than trying to hide them, seeking to emphasize that we’re all human and therefore not perfect. When she does this, she may be not only helping to break down the harmful self-imposed norm of perfectionism in the veterinary profession, she may also be making it safe for the other people that she works with to look at, talk about, and understand error as well. And by doing that, as I wrote about last time, she may actually be making her practice safer– all by being openly imperfect.

Like my friend, I also try to point out to my staff the things I could have done better when I’ve made a mistake or had a complication. Also like my friend, I find it’s easier to admit my shortcomings to others than to accept them in myself. It’s funny how, even knowing what I do about complications and coping, it feels far less shameful to be soaked in my own urine than to know that I have caused harm to an animal. And while that shame can be a short-term motivator to change (no more leg bags at work for me, only fanny packs), it’s not a productive or sustainable way to generate process improvement because it’s hard and painful to think about something shameful, so it’s hard to use the experience to analyze, reconstruct, and modify a work process.

As for me, I’m counting down the days until my ureter reimplantation surgery (3 weeks and one day!). Between now and then I’ll be working at a half dozen spay clinics and attending a couple of conferences, the 2018 International Symposium on Human Factors and Ergonomics in Health Care in Boston, and the New England Federation of Humane Societies annual conference in Nashua, and hope to bring back all sorts of interesting ideas (and avoid wardrobe malfunctions).

Spay-Neuter Guidelines: New and Improved!

This week, The Association of Shelter Veterinarians’ 2016 Veterinary Medical Care Guidelines for Spay-Neuter Programs was published in the Journal of the American Veterinary Medical Association. With this new publication, the 2008 Guidelines have been updated to reflect findings from new research as well as to integrate research and ideas from beyond the traditional confines of the veterinary field into recommendations for spay-neuter practice.

Why am I so excited about this publication? Not just because I had the honor to work on its creation with a brilliant and kind group of veterinarians who passionately believe in elevating spay neuter practice. Not just because of the thoroughness of the research that went into this update, and the hours of work this entailed.

I am excited because this is the first time I have ever seen a veterinary practice guideline that takes a deep and practical view of operations management. By devoting nearly 2 full pages to human factors and ergonomics, the 2016 Guidelines acknowledges the central role that humans play in veterinary practice—that is, human bodies, human cognitions, human emotions, and human behaviors. The addition of this new section demonstrates a recognition that safe performance relies on close evaluation of procedures, and on redundant systems that can handle the unexpected. High quality, high volume spay neuter practices can strive to become high reliability organizations by exploring and implementing the ideas in the operations management section of the 2016 Guidelines.

The operations management section in the 2016 Guidelines shows that spay neuter practice— and indeed all veterinary practice— is an integrated system in which performance of each part affects the others. The 2016 Guidelines makes the connection between leadership style, work satisfaction, and musculoskeletal discomfort. Between process management and safe practice. Between ergonomics and performance. Between safety and leadership. And by making these connections, the 2016 Guidelines give practitioners the tools to accomplish continuous improvement in their workplace.

I’m also excited because the 2016 Guidelines is the first veterinary practice guideline that includes specific ideas in physical ergonomics, rather than simply stating that ergonomics is important in surgery (leaving the practitioner on their own to discover or research ergonomic solutions, or, more likely, to discover the scarcity of accessible ergonomics publications for veterinary practice). Musculoskeletal discomfort limits the practices of many veterinarians, but its causes and mitigation are rarely addressed in veterinary publications. It’s time that we recognize that our bodies and our minds are the most valuable pieces of veterinary equipment we have. That we need to learn, and to teach each other how to protect against wear and tear, and to alleviate the physical and mental stresses that accumulate. And that physical and mental discomfort are, after all, closely linked, so that making improvements in one is bound to improve the other.

In short, the 2016 Guidelines are a great reference for anyone working in veterinary medicine, and especially helpful for anyone working in spay neuter or shelter practice.

Want to learn more about human error and safety in complex systems? Here are some interesting books (also, explore other works by these authors):

The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries by James Reason

The Checklist Manifesto: How to Get Things Right by Atul Gawande