Episode 21 - Two Week Takedown. Chewing on needle caps, regurgitating BOAS patients and bleeding bitch spays. Feat a VERY special guest - BRADLEY VINER

1.The GP hook

The fortnight’s most useful GP talk: what actually helps BOAS regurg risk, how to rescue a sliding ligature, a big blocked‑cat study, the dental ABs evidence—and why “just a GP vet” needs to leave our vocabulary. Featuring Bradley Viner.

You’ve still got the needle cap in your mouth. The cervix knot’s just slipped. Brachy booked for surgery — what are we doing about regurge? Blocked tom at 2am — owners panicking about creatinine. If that sounds like your last fortnight, welcome. This is your practical two‑week takedown: what actually helps (and what doesn’t), how to rescue a sliding ligature, where the evidence is weak, and why “just a GP vet” should be retired from our language. Featuring Bradley Viner on complaints, disciplinary thresholds and why good record‑keeping matters.

2.Needle caps: bin the habit

If you still tuck needle caps in your mouth, stop. It’s a habit, not a necessity. The risk isn’t just to you — saliva on a cap transfers to hands, surfaces and patients.

Practical fixes

Common trap

• Make a team agreement: caps go on a clean tray or in a sharps/needle pot — not in mouths.
• Teach an alternative motion: park the cap, ask for a second pair of hands, or keep a spare cap on a tray.
• Use kind prompts and a two‑minute safety huddle to reset habits: “Caps stay off lips — where do we put them?”
• “It’s only me” — once saliva’s on the cap it’s an infection control problem for the whole room.

3.Bitch spay bleeds: don’t be proud of tiny incisions

Small incisions are tidy but can load tissue and ligatures under tension. Pulling a cervix hard through a cramped wound can lead to a slipped knot and brisk haemorrhage.

When a knot slips

Practical autotransfusion tip (anecdotal, from practice)

Quick checks

• Extend the incision rather than frantically poking through a narrow field.
• Rapidly swab, visualise the vessel, and re‑ligate decisively.
• Your nursing team makes the difference: clear roles for swabs, suction and instrument handling reduce time to haemostasis.
• If you have access to canine blood bags with anticoagulant (CPDA‑1) and sterile syringes, you can aspirate fresh intra‑abdominal blood into syringes containing a small volume of anticoagulant, run it through a blood filter and return it to the patient. Teams in the episode found this stabilised MAP quickly in a severe bleed. Follow your practice protocols and product guidance; label the process in the notes.
• If coagulation tests look normal in a bleeding bitch from a lungworm area, consider a lungworm test — coagulopathy from lungworm can present atypically.
• If the abdomen is tense or the uterus won’t exteriorise comfortably through your incision, extend the exposure. Patients heal across, not along.

4.Intra‑op ketamine to support blood pressure — titrate and watch

When MAP sags during long dentals or soft‑tissue cases, small ketamine boluses are a handy tool to reduce inhalant and nudge pressure up. We shared approaches you can use but align with your anaesthesia lead.

Practical approaches from the pod

Label these as practice experience and follow your local protocols.

• One pragmatic method: draw up a larger calculated dose (some teams use 1 mg/kg for convenience), give a fraction (e.g., half) as a test bolus, reassess after a few minutes and titrate rather than pushing the whole amount.
• An alternative split approach: give 0.25 mg/kg first, reassess, then top up to around 0.5 mg/kg total if needed — some clinicians feel splitting reduces the chance of brief respiratory apnoea.
• Expect occasional short respiratory pauses after ketamine; anticipate, monitor closely and be ready to support ventilation.
• If medetomidine has been used, factor that into recovery decisions — many cases recover fine without reversal, but plan case‑by‑case.

5.Breaks, contracts and culture: lunch isn’t a luxury

An employment tribunal case highlighted the real consequences of missed breaks, unpaid overtime and poor support — burnout, stress and financial awards follow. Clinic rosters are messy, but teams can protect people.

Practical moves

Unpaid overtime is a red flag — set an explicit practice stance about when after‑hours work is expected and how it’s recorded/authorised.

• Clarify break expectations in contracts and daily workflow: how and when are breaks taken and authorised?
• Add a daily “Break Check” on the whiteboard and empower nurses/reception to enforce short pauses or micro‑breaks when the rota gets tight.
• Flexibility matters: if you’ve done a post‑emergency late finish, ring‑fence a longer break the next day.

6.“Dr” vs first name: pick a style and be consistent

Some clinics use “Dr Surname”, others first names. Clients value consistent, confident communication more than a title. Beware signalling hierarchy: introduce all team members (RVNs, ACAs, CSRs) with clear roles and equal respect.

7.BOAS, regurgitation and what actually helps

Regurgitation in brachycephalic patients is about passive oesophageal dysfunction, not vomiting — that’s key to treatment choices.

Evidence and practice points from the episode

Clinical consequences to watch for

Safety pause

• Current evidence does not support metoclopramide or maropitant as effective at preventing passive regurgitation in brachycephalics. Antiemetics that act centrally won’t reliably stop passive reflux.
• Proton pump inhibitors (PPIs) are commonly used pre/intra/post‑op to reduce oesophagitis risk; scheduling ahead for elective cases helps, since acid suppression takes time to fully develop.
• A recent randomised controlled trial (reported in Feb 2026, ~49 dogs in the study) found less post‑op regurgation after an intraoral lignocaine + phenylephrine spray versus placebo in dogs having upper airway surgery. Mechanism may involve topical anaesthesia plus vasoconstriction; teams should check local governance and read the full paper before changing practice. It’s an intriguing option to investigate further.
• Oesophagitis after regurg is painful and commonly prevents oral intake and medication compliance.
• Aspiration pneumonia can range from mild to rapidly fulminant sepsis — early recognition and monitoring are essential.
• For GI‑obstructed patients with distended, fluid‑filled stomachs, decompress (NG/OG/stomach tube) where safe before induction. Build a “regurg risk” pre‑induction pause into your routine.

8.Blocked toms: large real‑world study and talking to owners

A multicentre study of ~601 male cats reinforced common clinical observations:

Practical counselling

• Recurrent block cats tend to present earlier and are less likely to be azotaemic on arrival — owners often spot recurrence sooner.
• Most azotaemia improves within 48 hours after relief of obstruction, even when values are initially high.
• No meaningful difference in catheterisation or hospital stay between first‑time and recurrent cases.
• Owner conversation: “Two main risks — re‑block and bladder irritation. We’ll aim to get him comfortable, watch kidneys and electrolytes closely, and most cats’ bloods improve within a day or two once flow is restored.”
• Indwelling catheter or not? Reasonable clinicians differ. Consider temperament, how atraumatic the unblocking was, and your monitoring capacity: some remove early once urine clears and the cat is brighter; others keep the catheter until discharge to reduce in‑hospital re‑block risk.
• For repeat catheterisations, small IV sedation (e.g., medetomidine titrated) often smooths the procedure — adapt to local protocols.

9.Dental antibiotics: evidence gap, apply stewardship

A systematic review highlighted a research gap around peri‑procedural antibiotics for routine small‑animal dentistry. There’s little evidence linking standard dentistry to infective endocarditis or sepsis.

Practice approach

A realistic example from practice: severe feline chronic gingivostomatitis with extensive extractions and a patient unlikely to tolerate oral meds — a single long‑acting injectable antibiotic was used as a pragmatic, case‑by‑case judgement. Not a blanket policy.

• Default can be “no routine antibiotics” for uncomplicated dentistry; reserve antimicrobials for clear, justified exceptions (severe systemic disease, deep infection, immunosuppression, or when owner can’t administer oral meds and an injectable is clinically indicated).
• Document your reasoning when you depart from a no‑antibiotic default — why this case is an exception.

10.RCVS complaints and disciplinary process — practical takeaways from Bradley Viner

Bradley walked us through the key ideas you need to know:

A reassuring anecdote

• Thresholds: negligence = performance below expected standard; serious professional misconduct is “far below” what any reasonable vet would do. The bar for striking off is high.
• Most complaints never reach a public hearing: many are handled at filtering stages and remain confidential; only a small percentage proceed to formal disciplinary hearings.
• Your best protections are communication, informed consent and contemporaneous records. If you depart from SPCs or common practice for safety reasons, document your clinical reasoning in real time.
• The complaints pathway is staged: initial case management/triage, preliminary panels, and then escalation only if there’s potential for serious professional misconduct. There are informal routes (mediation) and formal ones; most cases resolve without public sanction.
• Charlotte shared a stressful personal experience: using out‑of‑date ketamine for a high‑risk home euthanasia and facing a police referral. Practical reality: documenting your clinical rationale and focusing on safety are crucial; common sense and context do matter in case review.

11.Take‑home points

Final word

GP vetship is a specialty of breadth — complex, demanding and repeatedly under‑valued. Whether you’re rescuing a slipped knot, juggling anaesthesia, or counselling a worried owner at 2am, own your skills. You’re not “just” a GP vet — you’re the person who keeps the whole system running.

• Stop keeping needle caps in your mouth — make it a team habit.
• A sensible, slightly larger spay incision often beats a tiny one; if ligatures are under tension, extend the field and re‑think exteriorisation.
• Small intra‑op ketamine boluses can reduce inhalant requirements and support MAP — titrate, split doses if it helps you avoid brief apnoeas, and monitor closely.
• BOAS regurg: antiemetics like metoclopramide/maropitant don’t reliably prevent passive regurgitation; PPIs are used for oesophagitis; intraoral lignocaine + phenylephrine spray is an intriguing, recent trial result but check the paper and local governance before routine use.
• Blocked cats: recurrent cases often present earlier and less azotaemic; most azotemia improves within 48 hours after relief.
• Dental ABs: there’s no good evidence to support routine peri‑procedural antibiotics for uncomplicated dentistry — use them only when justified and document.
• RCVS complaints: the system tends to be proportional; keep clear contemporaneous notes, communicate well and document consent.