Nursing at Fitzpatrick Referrals

by Josey Kilner, Head Nurse (of Training)

It seems a lifetime ago that I worked in a primary care practice, even though I was there for 22 years...

Life is very different here, and I still marvel at the size of the place as I drive towards the three huge converted barns that are Fitzpatrick Referrals. The surgery is situated in the middle of farmland on the edge of the small Surrey town of Godalming.

The day starts at 8am when the duty Kennel Nurse for the week completes a ward round with our Night Nurse. The night nurses do a wonderful job, caring for our in-patients overnight, ensuring analgesia is maintained and giving that ever important TLC to the dogs and cats that are missing home.

The Nurses and Kennel Assistants get on with the job of walking the dogs, cleaning and medicating. Our Kennel Assistants are fantastic and as part of their job, they walk, feed, groom, clean and generally care for the inpatients, alongside the nurses and veterinary interns. They also have the courageous task of loading our huge, industrial washing machines and tumble dryers that are forever full of dirty bedding!

Our unique, custom designed patient wards are unlike any other kennel facility.  The wards boasts bacterial-resistant wipe-down wall coverings and floor surfaces with underground heating, and air conditioning optimised for high efficiency particulate air to minimise the possibility of infection.  The reinforced glass doors, rather than gates or bars, permit a wide field of view for the animals and allow them to feel as much at home as possible. Each kennel has a space for medication and notes, and a “quick reference” daily guide is written on the glass door each morning to ensure continuity of care and ease of visibility for all. Each kennel has a radio and many are equipped with televisions (slobberproof!) to provide auditory and visual stimulation – creating a home from home experience for patients.   Some of our nurses are tempted to take up home there! With the thick orthopaedic mattresses, frequent feeding and in-house media, it’s almost better than home!

After the Veterinary Surgeons’ ward round, the nursing of the in-patients starts in earnest. Our patients often have serious, debilitating injuries such as multiple pelvic fractures, spinal injuries or elective surgeries such as Total Hip Replacements or TPLO’s (Tibial Plateau Levelling Osteotomies) which all require physiotherapy to assist and speed their recovery. We have two physiotherapists who work alongside the nursing staff and design individual plans for each of the patients. The nursing staff are trained to continue with the rehabilitation process and particularly enjoy this element of their job.

Some of the patients are booked for hydrotherapy sessions once their skin wounds have healed. The nursing staff accompany the dogs (and cats sometimes!) to the pool, often using specially made slings, to support them. The hydrotherapists don wetsuits for the pool and encourage the patients to enter the water down a gentle slope. Many of the patients benefit hugely from the hydrotherapy sessions, and it is a wonderful feeling when you see a dog that had no movement previously in their hind limbs, kicking out in the water. They also look super cute with their Thermatex coats on!

The Kennel Nurse continues with her work of medicating and caring for the in-patients whilst the rest of the nurses return to the prep room to organize the day’s surgeries.

The prep room is a huge area with a central column that has four anaesthetic machines attached to it. The nurses set up and damp dust each of the three operating theatres and then prepare kit for the scheduled surgeries. The amount of kit required for an orthopaedic operation is enormous. The tables used to hold the sterile kit are large enough to make any dining room proud! A lot of the equipment which need to be sterilised is large and boxed, requiring careful packing. We have three autoclaves at the practice, two of which are taller than me (I am only 5’ 3’’ but even so…) plus the table top variety for our delicate powered instruments and air hoses.

Around mid-morning, patients begin to arrive for their six week post operative x-rays. These are generally carried out with the patient under domitor (medetomidine) and torburgesic (butorphanol). We have direct digital radiography which means the image gets transferred immediately to a computer screen, where it can be centred, collimated and even have the exposure enhanced to better demonstrate bone or soft tissue. More importantly than all that is, of course, that we don’t have to go running around with a cassette and fiddling about in a dark room for hours on end!

Patients scheduled for surgeries that day are given their pre-anaesthetic medication once we have checked their heart, respiration and temperature. Their anaesthetic forms are then filled in to prepare for the procedure. All patients have an intravenous catheter placed prior to induction to allow access for intravenous medications and fluid therapy during their anaesthetic. Once the patient is stable under their anaesthetic they are moved to radiography, CT or our MRI suite for diagnostic imaging prior to surgery.

The MRI machine is lovingly cared for by Eli, our radiographer, who ensures no-one is allowed to enter unless they have been divested of all metallic objects (such as collars with dog tags attached). These are attracted to the huge magnet and many MRI machines have been damaged due to items flying through the air to adhere to them, not excluding the damage that can be done to personnel from these air borne items. Once the patient is positioned correctly our radiographer and the anaesthetic nurse retreat to the scanning room where the anaesthetic is monitored through the use of a capnograph, pulse monitor and the visual aid of a camera positioned at the head of the patient. Our radiographer then produces the images of the area being studied onto computerised screens to enable full analysis. The MRI process can be quite lengthy, depending on the complexity of the area being screened.

Once the patient is returned to the prep room and surgery has been decided on, the patient is prepared for theatre. A nurse will clip the fur over the surgery site and then scrub the area with a chlorhexidine solution to remove gross debris. The patient is then transferred to theatre and a final skin scrub completed. The anaesthetist attaches the patient to the monitoring system which provides information on the circulatory and respiratory system throughout the surgical procedure. The patient is also placed on intravenous fluids to help support the circulatory system.

A scrubbed, gowned and gloved veterinary intern wearing a surgical hat and mask will unpack the sterile kit and drape the patient to ensure an aseptic area is maintained around the operation site. The surgeon then commences the surgery. Some surgeries, such as Total Hip Replacements, Total Elbow or Knee Replacements, SHO (sliding humeral osteotomies) and some spinal surgeries require a number of surgeons to assist with the procedure. Luckily we have three large, well equipped operating rooms so we never feel crammed in. The surgeries are often very complex and the anaesthetic can be quite lengthy. The anaesthetist will ensure the patient maintains its body heat by using a Bair Hugger, which is a warm air blanket that can be placed under or over the patient.

Once the surgery is finished and the radiographs taken, the patient is returned to the comfort of the kennel room, where they continue their recovery on a comfortable orthopaedic mattress under the watchful eye of the dedicated nurse.

Overnight the patients are cared for by a veterinary nurse, who ensures they are given their medications, fluid therapy and lots of TLC.