Thoughts on protecting veterinary responders following natural disasters

Regarding the article titled, “A method for decontamination of animals involved in floodwater disasters,"¹ the section covering medical requirements for personnel should also include a full and current vaccine protocol for hepatitis A and B whenever staff is handling livestock or pets in a water-related disaster. During the Katrina disaster, when I was a volunteer with the Emergency Animal Rescue arm of the United Animal Nations, we limited unvaccinated personnel to post-decontamination duties because of the nature of the contamination involved, namely raw sewage. Most repeat responders are vaccinated for these, and more responders need to be encouraged to get vaccinated before their next experience.

At the Mississippi State Fairgrounds, we added an intermediate station following initial decontamination, where dogs and cats were vaccinated and dewormed according to University of California, Davis, Shelter Medicine intake protocols.² At a third station, the pets were bathed again before being placed in a cage or pen. Ten to 14 days after intake, we did not experience the widespread outbreak of parvovirus infection and distemper that eventually developed in other intake locations.

Ann Lesch-Hollis, DVM

Rocklin Park Veterinary Hospital, Rocklin, Calif

The authors respond:

We thank JAVMA for the opportunity to comment on the letter by Dr. Lesch-Hollis about our manuscript.¹ Dr. Lesch-Hollis raises the important issue of protecting veterinary responders from the infectious disease risks associated with deploying to regions affected by natural disasters. In particular, she mentions the importance of vaccinating against hepatitis A and B for water-related disasters and limiting unvaccinated responders to postdecontamination duties.

We agree with Dr. Lesch-Hollis that infectious diseases pose a risk following natural disasters and that preventative measures, such as vaccinations, should be a medical requirement for at-risk responders. Certainly, a review article which focuses on health issues would be of benefit to responders. In our manuscript,¹ we stated that personnel involved in the decontamination protocol should receive prophylaxis against the likely biological hazards that may be present at the disaster site. Apart from listing those hazards that are found globally (Escherichia coli, Clostridium tetani, and rabies virus), we deliberately avoided recommending specific prophylactic measures for infectious agents with more restricted distribution because these measures vary with the type and location of disaster and were beyond the scope of our paper. At the same time, however, we recognize that veterinary responders must become aware of the risks posed by infectious diseases when deploying to areas affected by natural disasters and that they must prepare accordingly. Part of the reason for this is to ensure that veterinary responders do not contribute to the excess morbidity and mortality caused by the disaster, which would only further increase the burden on the public health infrastructure of the region.

A second point that Dr. Lesch-Hollis made is that following initial decontamination at the Mississippi State Fairgrounds, the animals were vaccinated, dewormed, and then bathed again before being housed. To us, this suggests that animals were only partially decontaminated prior to being handled by the medical staff. In keeping with existing accepted general decontamination protocols, we believe that all surface decontamination should be completed in the hot zone prior to the animals being handled by medical staff in the cold zone. In this way, all contaminants remain in the hot zone and only decontaminated animals enter the cold zone to the awaiting medical staff. This ensures that contaminants are not spread throughout the cold zone by medical staff handling partially decontaminated animals. However, that said, just as there were no disease outbreaks during the almost one-month operation of the intake facilities in Hattiesburg or Gulfport, Miss, where the Océanographie Environmental Research Society Disaster Response Division² was deployed, the procedures used at the Mississippi Fairgrounds described by Dr. Lesch-Hollis also appeared to have worked, so who can argue with success?

Stjepan Soric, BSC

Michael P. Belanger

Carin Wittnich, DVM

Océanographie Environmental Research Society, Disaster Response Division, Barrie, ON, Canada and Faculty of Medicine, University of Toronto, Toronto, ON, Canada

More on pet insurance and the veterinary profession

Pet insurance, according to Dr. Brechtel,¹ wants to make me look and see if the sky is falling. The descriptions used are not applicable to indemnity insurance, the manner in which both Veterinary Pet Insurance (VPI) and Pets Best Insurance are registered in all states. I am board certified by the American College of Healthcare Executives and must be requalified every three years, so I need to stay current in the insurance dilemma facing human health care today First, most dentists want to take indemnity insurance, but concurrently, most will not accept managed care casualty programs. To change indemnity insurance, pet insurance companies would have to change the animals' role as property, then change home insurance and car insurance systems in every state—simply ain't gonna happen, folks! Second, when health insurance was shifted from the client/patient to the employer as a pretax benefit, health insurance left the insured's control. Indemnity is like home insurance or car insurance and is an agreement between the insured and the insurance company, and that relationship prevents it from going the way of human health-care insurance. Third, reimbursement goes to the client after he or she has paid the going rate at the veterinary practice. Veterinary practices may be familiar with VPI's published reimbursement rates, but Pets Best Insurance has an 80% reimbursement policy, so it does not matter what was done. Fourth, pet care comes from discretionary income, and while we may be entering a recessionary economy and watching gasoline prices escalate, clients are seeing their discretionary dollars decrease, so they are looking for third-party payers that are willing to share the risk of pet care (pet insurance only shares risk; it does not transfer risk like human healthcare systems).

Pet insurance and human medical insurance are not based on similar systems. It is time veterinarians stop using unfounded misunderstandings about human health-care insurance (risk-transfer systems) and applying those misunderstandings to pet insurance (risk-sharing systems). It is also time to tell clients that VPI and Pets Best Insurance have Wellness riders that return over $2 for every $ 1 of premiums paid, just for submitting their paid invoices to the insurance company If practices introduce Care Credit (90 days same as cash) concurrent with pet insurance, many clients will see the potential of “float money" by using insurance reimbursements for Care Credit payments.

There are advantages to indemnity health insurance, as illustrated by most all other health-care providers taking this form of insurance. It is time we start advising clients and staff about the advantages of the available risk-sharing programs. I commend the AVMA on its progressive awareness and for sharing that information, despite the bias and unfounded prejudices that exist in many of our colleagues.

Thomas E. Catanzaro, DVM, MHA

CEO, Veterinary Consulting International, Morrison, Colo

I wanted to offer my support for the comments made by Dr. Brechtel in his letter to the editor.¹ 1 have always felt that veterinarians are being sold a bill of goods as the insurance industry tries to use us to promote their products. When Dr. Jack Stephens was running Veterinary Pet Insurance, there was a stated commitment to keep pet insurance purely as an indemnity type of program where the pet owner pays the veterinarian and then is reimbursed by the insurance company With Dr. Stephens no longer in full control of Veterinary Pet Insurance and with other underwriters entering the marketplace, I fear that the idea of indemnity-only policies will fall by the wayside. As the percentage of policyholders increases, their force on the profession will be exerted such that they will demand that we get our payments from the insurance company, thus limiting their out-of-pocket costs. I fear many of our colleagues will go this route to preserve clientèle. We will then be pitted against one another with the insurance companies all too happy to stand on the sidelines waiting to step in and assume control of our fee and payment schedules. I, for one, would rather keep the examination room as uncrowded as possible by keeping the insurance company uninvolved in the decision-making process.

John Cirihassi, DVM, DACVE

Chicagoland Veterinary Behavior Consultants, Carol Stream, III

I completely agree with Dr. Brechtel's comments concerning the effect that pet insurance will have on the veterinary profession.¹

I don't understand the rationale behind the proponents' arguments. In my experience, the people who would euthanize for financial reasons are by far the ones who would not invest in pet insurance. Economic principle dictates that the middleman (insurance company) will have to make a profit. Guess who pays? And once again, why would we try and model ourselves after the human industry? I haven't met one physician who said insurance wasn't one of their largest headaches and didn't wish there was a different system.

We don't do a lot of insurance work, and it disturbs me how often roadblocks are thrown up by the companies in the little we do. One company wouldn't pay for a large tumor removal (the record stated the size of the tumor) unless the surgical record indicated the actual length of the incision! Another company denied preapproval of surgery for a ruptured cranial cruciate ligament on a four-year-old dog because they said it was a preexisting condition (the dog had been examined when it was six months old for a lameness!). Of course, this entailed time on our part to write a statement that it was not. I was also disheartened when I received brochures on plans from one company (we are considering it for our employees) because there were too many exclusions, even on premium plans. I did the math, and neither the business nor our employees would benefit.

When our employees or clients ask about insurance, I discourage it and recommend they start their own insurance plan. If they put $20 to $50 in a money market account monthly, they will keep the money, make interest on it, and have a nice little emergency fund for their pet.

Pamela Geiken, DVM

Small Animal Hospital, LLC, Milwaukee, Wis

Dr. Brechtel responds:

First, I appreciate all responses to my letter to the editor. My experience (and possibly knowledge) in the matter of insurance dealings seems to be of some question. However, unlike most readers of JAVMA, the main focus of my daily routine is insurance billing in my wife's human medical private practice. I have spent the past eight years billing thousands of claims (indemnity plans included), disputing hundreds of denials, and filing multiple state- and federal-level insurance company complaints. I recredential in insurance billing every day. This experience likely makes me one of the few veterinarians (who doesn't sell pet insurance) with firsthand insight into the problems that will ensnare the veterinary profession if pet insurance runs true to human health insurance. It is already evident (see Dr. Geiken's response) that some of the tribulations of dealing with insurance company tactics are beginning to emerge in the veterinary profession.

Animals may be property like a car or a home, but this does not limit the method in which contractual obligations are fulfilled between veterinarians and insurance companies once networks and preferred-provider contracts are formed. Inbreeding between auto companies and health-care networks delivering auto insurance injury-protection plan coverage already exists, obviating the need for any changes in state or federal regulations to allow pet insurance companies to institute managed care-type tactics. And, as we see in the courts, the boundary of animals as property is blurring. No one can therefore guarantee that pet insurance will stay indemnity-plan driven.

As Dr. Ciribassi has emphasized, pet insurance companies are profit driven. The means by which they increase profit is by raising premiums and decreasing their medical loss ratio. If Dr. Geiken's owner was merely going to get reimbursed for a medically necessary surgery, why would pre-authorization be required unless it was to control the medical loss ratio (sounding like managing care?)? Contractual associations will one day bind the veterinarian into insurance servitude as it has the medical profession, and most physicians I know are inventing ways to increase the cash components of their practice, while we in veterinary medicine seem intent on destroying ours.

But the real question still remains; will animal outcomes improve because of insurance? Will you have to euthanize fewer animals because their owner gets a discount on service or a reimbursement from an insurance company? This unanswered, unsupported assumption is not sufficient cause for the profession to enter into harm's way. Risk sharing sounds appealing, but it is inevitably more expensive. Using an 80% medical loss ratio, the cost of doing any procedure or service is at least 20% more when involving an insurance company. In addition, portraying an insurance company as paying two to one on any type of care is like Vegas saying its slots pay out double. Somewhere, someone has to lose for the house to turn a profit.

Casey Brechtel, DVM, PhD

Animalcrackers Chiropractic, Galveston, Tex

Questions data in study on hemangiosarcomas in dogs

I have some major concerns about the reporting of laboratory data in the article titled, “Prevalence of hemangiosarcoma in anemic dogs with a splenic mass and hemoperitoneum requiring a transfusion: 71 cases (2003-2005).¹

First, the authors use the term total solids (TS) throughout the paper. I believe, based on their results, that they are actually reporting total plasma protein as measured by refractometry Although medical re-fractometers use the angle of refraction produced by all solutes (TS) in a plasma or serum sample for measurement, they are calibrated to report total protein. The scales on the reticle are marked as total protein. The refraction produced by nonprotein solids, including all electrolytes, minerals, glucose, urea, cholesterol, and lipids, for example, is not included in the scale. If their refractometer was calibrated for total protein (as essentially all modern medical refractometers are), they are in error in using TS. The actual TS of the sample (all proteins and nonprotein solutes) would be approximately 1.5 to 2.0 g/dL higher.^2-4 Unfortunately, some veterinarians, when referring to refractometer results, use the terms “total solids" and “total protein" interchangeably. Such use should be discontinued, as the two terms refer to different measurements.⁵

Second, the authors compound their error in use of TS by reporting in units that are off by a factor of 0.001. In the text of the paper and Figure 2, they report TS in milligrams per deciliter. Proteins are in plasma in grams per deciliter or 1,000 times greater than they report. Again, the reticle on their refractometer should have had that information. If not, any clinical pathology textbook would have that information.

Third, the authors do not state the methods for obtaining their hematologie results. Although they refer to PCV, that term is appropriate only if results were obtained from microhematocrit centrifuge. If an electronic cell counter was used and the HCT calculated from erythrocyte count and MCV, then PCV would not be appropriate for reporting results. As the authors include platelet counts, I suspect that they are reporting results from an automated cell counter but cannot be sure. If different techniques were used on samples from different patients, they should not be grouped together, as they are not interchangeable.

These problems in reporting laboratory results distract from the paper and need to be addressed.

Jeanne W. George, DVM, PhD, DAVCP

School of Veterinary Medicine, University of California, Davis, Calif

The authors respond:

Thank you for your feedback on our article. We are happy to address the points you raised.

The term total solids was chosen as it is well accepted in the emergency and critical care setting and, as you pointed out, often used interchangeably with total protein. Since the information in this study was obtained on dogs in an emergency and critical care setting, use of the term total solids seemed most appropriate. That being said, we appreciate your point and, after reading your article, acknowledge total solids is not the most accurate term.

The units of the total solids reported was a typographic error. The units should have been given as grams per deciliter.

Finally, the packed cell volumes reported as a PCV were, in fact, spun down in a microhematocrit centrifuge in the critical care unit; hence, the term is correct. The platelet counts were obtained separately from an automated cell counter as part of a CBC

Tara N. Hammond, DVM

Angell Animal Medical Center, Boston, Mass

S. Anna Pesillo-Crosby, VMD, DACVECC

Animal Medical Center of New England, Nashua, NH

Options for treatment of cecocolic intussusception in horses

I am concerned that the recent paper on cecocolic intussusception in three horses¹ could be interpreted as promoting a bypass procedure over colotomy with little evidence that it would be superior. Risk of abdominal contamination and complete cecal involvement are weak arguments against colotomy^2,3 In 17 horses that underwent reduction through a colotomy in two large studies,^2,3 survival to hospital discharge was 100% and long-term survival was 93%. If the authors are also suggesting that ileal involvement is an argument against colotomy, I believe this is also questionable. Ileal involvement can be difficult to determine at surgery, and often, when it is suspected, surgical correction or necropsy findings can prove otherwise. Ileal viability is typically not compromised in severe cecocolic intussusceptions because in most horses, severity of the ischémie injury becomes progressively worse toward the cecal apex. I have to accept that the authors were correct in their judgment about the extent of ileal involvement, although other evidence of small intestinal obstruction, such as distended small intestine on palpation per rectum, on ultrasonography or at surgery, would be expected to some degree for the reported durations of colic.

Does simplicity make ileocolos-tomy the right choice? Although il-eocolostomy can work, are the risks of peritonitis and adhesions with this procedure acceptable?^2,4 These risks arise from leaving some compromised intestine in situ in the hope that it is sloughed or isolated from the abdominal cavity. In one report² of 18 horses treated surgically for cecocolic intussusception, the only deaths directly related to surgical treatment were in two horses treated by ileocolostomy without reduction of the intussusception. In another report,⁴ two of six horses died from complications related to leaving the intussusception uncor-rected. Leaving a potential space for entrapment after ileocolostomy, as the authors described, is also risky⁵ Recovering horses from surgery with two potential time bombs in place is difficult to justify when, with more time and effort, these horses could be recovered with a closer to normal abdominal cavity and a good prognosis after correction through colotomy

David E. Freeman, MVB, PhD, DACVS

Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Fla