Guidelines for Implementing a Low-Cost Volunteer Desexing Skills Training Program for Veterinary and Veterinary Technology Students
Publication: Journal of Veterinary Medical Education
Volume 47, Number 1
Abstract
Although desexing surgeries are considered a core clinical skill for small animal veterinary practice, it can be challenging for veterinary schools to provide students with adequate training opportunities in the traditional curriculum. At the Massey University School of Veterinary Science, we recently established an innovative extracurricular volunteer program designed to have students teaching other students how to perform different elements of desexing procedures as they progress through their degree. This program includes administrative and assistant roles for first-year students (responsible for client communication, patient restraint, and medical record keeping), physical exam and recovery roles for second-year students (responsible for assessing patient fitness for surgery, drawing up anesthetic drugs, and monitoring patients in recovery), anesthesia and neuter surgeon roles for third-year students (responsible for inducing, preparing, and monitoring spay patients and performing cat neuter surgeries), and spay surgeon roles for fourth- and fifth-year students (responsible for performing cat spay surgeries, discharging patients, and following up with clients to monitor recovery). This program has been successful in improving student confidence and competence while also providing a valuable low-cost desexing service to the community. In this article, we discuss the practical considerations and processes involved in implementing this program, including mapping the existing surgical curriculum, recruiting patients, setting up the surgical facilities, purchasing equipment and supplies, establishing standard operating procedures, developing training materials, maintaining clinic records, and monitoring program outcomes. These resources can serve as guidelines for other veterinary schools looking to expand desexing surgery training opportunities for students.
Introduction
Although desexing surgeries are considered a core clinical skill and Day One competency for small animal veterinary practice,1–4 it can be challenging for veterinary schools to provide students with adequate training opportunities. This is due to a combination of factors such as limited time available in the overcrowded curriculum, multiple degrees and larger class sizes putting pressure on teaching resources, low routine desexing surgery caseloads in the teaching and referral hospitals, and the reluctance of those in private practice to let students perform surgery on client-owned animals. Many veterinary schools are also located in more remote towns and cities where the opportunities for students to volunteer with local animal shelters to gain surgical experience may be limited. Consequently, many students graduate lacking both confidence and competence in performing desexing surgeries.5
In August 2017, we implemented a new volunteer program at the Massey University School of Veterinary Science to provide students with more opportunities to practice desexing surgical procedures before their final-year clinical rosters. The program works in partnership with the local Society for the Prevention of Cruelty to Animals (SPCA) branch to recruit low-income clients who cannot afford to have their cats desexed at a private veterinary practice. The clients receive a heavily discounted service with the understanding that students will be performing the entire procedure from start to finish under direct veterinary supervision. The surgery clinics themselves are run using well-tested shelter medicine protocols to minimize operating costs while still providing high-quality veterinary services. The learning environment is highly student driven and follows the “see one–do one–teach one” model under veterinary supervision to encourage students to take a more active role in their own education.6 On the basis of our anecdotal observations, the program has been highly successful in improving student clinical and surgical skills after only 6 months in operation. In this article, we provide an overview of the program as well as a series of guidelines and resources that can help other institutions establish similar initiatives.
Existing Clinical and Surgical Curriculum
Massey University is the only veterinary school in New Zealand. It offers a 5-year Bachelor of Veterinary Science (BVSc) degree for training veterinarians and a 3-year Bachelor of Veterinary Technology (BVetTech) degree for training veterinary technologists or nurses. Starting with the 2016 intake, the class sizes were expanded from 100 students per year to 125 students per year for the BVSc degree and from 25 students per year to 40 students per year for the BVetTech degree. Most students start their degree directly after high school and have limited prior hands-on experience working in clinical practice. The veterinary school is located in the city of Palmerston North, which has a small population of 80,000 residents and one local SPCA branch that provides animal intake and adoption services only. All desexing surgeries for this animal shelter are contracted out to private veterinary practices. The nearest animal shelter with permanent surgical facilities that offers student volunteer opportunities is the SPCA branch located 150 kilometers away in the capital city of Wellington. The Community Practice service at the Massey University Veterinary Teaching Hospital (MUVTH) has an average desexing surgery caseload of 120 dog spays, 100 dog neuters, 65 cat spays, and 60 cat neuters per year.
Veterinary students are currently taught physical examinations in the first semester of the second year, anesthesia in the first semester of the third year, and basic surgical principles in the first semester of the fourth year. The surgical principles class includes practical sessions on instrument handling, knot tying, suture patterns, and sterile gowning and gloving. In the second semester of the fourth year, each student performs one terminal surgery on a sheep to practice soft-tissue surgical procedures, which may include a spay depending on the case. Most hands-on clinical and surgical training occurs during fifth-year clinical rotations, with desexing surgeries primarily taught during the mandatory 1-week shelter medicine rotation at either SPCA Wellington or SPCA Auckland, mandatory 1-week community practice rotation at the MUVTH, and elective private practice rotations at various veterinary clinics across New Zealand. In previous years, a small number of students participated in extramural desexing rotations in Samoa. We recently surveyed the BVSc students who completed their final clinical year in 2017 about their experience and confidence in performing desexing surgeries at the time of graduation and found that many students were concerned about their skills.7 The actual number of desexing surgeries performed before graduation was highly variable and depended on the surgical caseloads during the rotation weeks as well as the willingness of veterinary clinics outside the MUVTH to allow students to perform surgery on client-owned animals.
Veterinary technology students are taught physical examinations in the second semester of the first year and anesthesia and surgical nursing in the first semester of the second year. Clinical training makes up a significant part of the second and third years of the degree. Of that time, students spend 2 weeks of their second year and 2–6 weeks of their final year in both anesthesia and surgery and sterile supply departments of the MUVTH working alongside final-year BVSc students. They are also taught communication skills, reception training, practice management, and business management skills throughout their degree. Final-year veterinary technology students are expected to autonomously carry out the duties of a clinical nurse with minimal supervision. This extensive clinical experience allows them to oversee and guide second- through fourth-year BVSc students, who have not yet been on clinical rotations, in areas of client communication, anesthesia induction and monitoring, surgical preparation, patient recovery, and patient flow. It gives them real-world experience in preparation for working in clinical practice.
How the Volunteer Program Works
The surgery clinic days are run on Saturdays and Sundays through the MUVTH facilities when the university is closed to minimize the impact on normal operations and to minimize scheduling conflicts for staff and student volunteers. Patients are admitted through the main entrance of the MUVTH and transported to the student practical lab facilities where all procedures are performed. The practical lab facilities include fixed oxygen and waste gas lines for the anesthesia machines, a scrub bay with sinks and running water for surgeon preparation and equipment cleaning, metal surgery and instrument tables, and storage cabinets for the clinic supplies. The decision was made not to use the main MUVTH anesthesia and surgical suites to prevent possible contamination because of the high volume of inexperienced students volunteering through the program. The program is currently limited to cat desexing surgeries because the patients can easily be housed in their individual carriers throughout the day and the desexing surgeries are relatively quick to perform with low complication rates even in a teaching setting.8–10 However, we have plans to offer dog desexing surgeries as well now that the logistics of the program are well established.
Staff Volunteer Roles
The program relies heavily on staff volunteers who are willing to spend approximately 3–4 hours on a weekend day to supervise veterinary and veterinary technology students. The staff volunteer roles are as follows:
•
Surgery teaching veterinarian: responsible for scrubbing in on three cat spays and three cat neuters with their student surgeons. All surgery teaching veterinarians must be currently registered to practice with the New Zealand Veterinary Council because of liability concerns with students performing surgeries on client-owned animals.
•
Clinical teaching veterinarian or veterinary nurse: responsible for supervising students while they perform physical examinations, drug calculations, patient preparation, anesthesia induction and monitoring, and patient recovery.
The staff volunteer pool includes a wide range of individuals who either are currently involved with clinical teaching at the MUVTH or have non-clinical roles at Massey University and want to stay involved with clinical work. We always aim to schedule at least two veterinarians on each clinic day so there is support available for more inexperienced teaching veterinarians in case of complications. We also provide the opportunity for inexperienced staff members to scrub in with an experienced teaching veterinarian to learn how to identify and troubleshoot common student surgical errors.
Student Volunteer Roles
Each scheduled surgery teaching veterinarian is assigned a team of four student volunteers on each clinic day. Students have different roles and responsibilities depending what stage they are at in the veterinary or veterinary technology curriculum (Table 1). These roles and their corresponding learning objectives are as follows:
| Class year | Semester 1 | Semester 2 |
|---|---|---|
| BVSc 5 | Cat spay surgeon | |
| BVSc 4 | Anesthesia and cat neuter* | Cat spay surgeon |
| BVSc 3 & BVetTech 3 | Physical exam and recovery | Anesthesia and cat neuter* |
| BVSc 2 & BVetTech 2 | Administration and assistant | Physical exam and recovery |
| BVSc 1 & BVetTech 1 | Administration and assistant |
* Cat neuters performed by BVSc students only
BVSc = Bachelor of Veterinary Science; BVetTech = Bachelor of Veterinary Technology
•
Administration and assistant student volunteers (AA)
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Obtain a brief patient history from clients to identify any issues that may affect fitness for surgery.
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Restrain awake patients for physical examinations and injections.
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Practice monitoring temperature, pulse rate, and respiration rate and listening to heart sounds on anesthetized patients in recovery.
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Perform an intramuscular injection, subcutaneous injection, and microchipping on an anesthetized patient in recovery.
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Maintain appropriate medical records for desexing procedures.
•
Physical examination and recovery student volunteers (PE)
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Perform a physical examination to assess a patient’s fitness for surgery.
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Correctly determine anesthetic drug doses and draw up the medications appropriately.
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Administer intramuscular injections to an awake patient.
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Follow the correct procedures for extubating a patient.
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Monitor patients in recovery until they are safe to be returned to their carriers.
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Anesthesia and cat neuter surgeon student volunteers (AN)
Anesthesia
•
Set up, test, and operate anesthetic machines, including re-filling isoflurane levels if needed.
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Follow the correct procedures for inducing and intubating patients.
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Palpate the abdomen to identify pregnancies and express the bladder if needed.
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Correctly clip and prepare spay and neuter sites for surgery.
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Open surgical kits and consumable supplies for the surgeon in a sterile manner.
•
Monitor patient anesthetic depth and make appropriate adjustments to the maintenance drugs as necessary.
Neuter (BVSc students only)
•
Ensure that the patient is correctly prepared and in a sufficient plane of anesthesia to begin surgery.
•
Perform a complete cat neuter, ensuring that correct surgical technique is followed to minimize the risk of complications.
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Complete the appropriate clinical records to document the surgical procedure.
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Discuss the discharge instructions with clients to ensure the patients receive appropriate post-operative care to prevent complications.
•
Follow up with clients to ensure the patient is recovering well from surgery and answer any additional questions.
•
Cat spay surgeon student volunteers (SS)
◦
Ensure that the patient is correctly prepared and in a sufficient plane of anesthesia to begin surgery.
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Perform a sterile scrub with open gloving in preparation for aseptic surgery.
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Perform a complete cat spay, ensuring that correct surgical technique is followed to minimize the risk of complications.
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Complete the appropriate clinical records to document the surgical procedure.
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Discuss the discharge instructions with clients to ensure the patients receive appropriate post-operative care to prevent complications.
◦
Follow up with clients by phone within 2 days of discharge to ensure the patient is recovering well from surgery and answer any additional questions.
A student leader is also assigned for each week. The student leader is responsible for coordinating student and staff volunteers, booking patients, providing training and instructions on clinic day procedures, ensuring clinic records are completed, and re-ordering consumable supplies. By the time the students have sequentially undertaken all four volunteer roles, they should be comfortable with all the basic steps involved in performing cat desexing surgeries, from admitting patients through conducting follow-up phone calls to monitor patient recovery. Having BVSc students work closely with BVetTech students is also valuable so that veterinary students gain an appreciation for how much knowledge and experience veterinary paraprofessionals provide in clinical practice.
The learning objectives align with what the students are concurrently being taught in the core veterinary or veterinary technology curriculum, and the different volunteer roles provide a valuable opportunity for the students to apply their learning to real clients and patients. The program is structured so that students must complete at least one volunteer shift in a lower role before progressing to the next role and so that students in higher roles are responsible for helping to train students in the lower roles. This structure is based on the “see one–do one–teach one” model widely used across physician and nursing training programs.6 For example, PE students are responsible for teaching AA students how to correctly complete the administrative paperwork, and AA students will have the opportunity to observe and assist with the clinical tasks performed by PE students so the AA students are better prepared for their next shift in the PE role. Similarly, AN students have the opportunity to observe the spay procedures being performed by the SS students while they are monitoring the patients; the SS students are then responsible for showing the AN students how to prepare their neuter patients and perform an effective neuter technique. Each student is required to complete an online learning module for their role ahead of time, which includes written descriptions of their responsibilities, step-by-step guidelines with accompanying pictures or video clips demonstrating the clinical techniques, and quiz questions to assess learning. This has helped to ensure consistency in the messages that are being communicated by the students. The teaching staff also monitor the students to make sure that safe procedures are being followed and intervene when necessary.
Starting in July 2018, we are implementing a new requirement that students who have completed a SS role must agree to tutor new SS students using practice materials and spay models in the student clinical skills lab before the surgery day. This tutoring will involve walking the new SS students through the different procedural steps from draping through removal of the uterus on home-built plastic and fabric models so the students develop muscle memory. There is also a suture station in the clinical skills lab with materials available for students to practice correct instrument and suture handling for their linea and skin closures. We believe this will significantly reduce the time spent teaching and correcting these basic skills while the patient is under anesthesia and give students the opportunity to reinforce their own skills by teaching other students. Published studies from other desexing surgery training programs have shown that the use of spay models for preparatory practice improves competency.11–13
Clinic Day Procedures
On a typical surgery clinic day (Table 2), the student volunteers arrive at 7:30 a.m. and are briefed by the student leader on the procedures for the day, including patient and volunteer safety information. Each student team assigned to a surgery teaching veterinarian is then responsible for setting up their stations in the surgery lab, making sure that all the consumable supplies are available and that all of the equipment is operating correctly (Figure 1).
| Time | Administration and Assistance | Physical Exam and Recovery | Anesthesia and Cat Neuter | Cat Spay Surgeon |
|---|---|---|---|---|
| 7:30 a.m.–8:00 a.m. | Student briefings and surgery lab set-up | |||
| 8:00 a.m.–9:00 a.m. | Patient admissions | Examine first spay patient | ||
| 9:00 a.m.–10:00 a.m. | Physical examinations | Cat spay surgery 1 | ||
| 10:00 a.m.–11:00 a.m. | Patient recovery | Cat spay surgery 2 | ||
| 11:00 a.m.–12:00 p.m. | Cat spay surgery 3 | |||
| 12:00 p.m.–1:00 p.m. | Cat neuter surgeries | Cat neuter anesthesia | ||
| 1:00 p.m.–2:00 p.m. | Surgery lab clean-up and completion of paperwork | |||
| 2:00 p.m.–3:00 p.m. | Patient discharge |
Figure 1: Diagram of the surgery lab stations and set-up
PE = physical examination
The patients are admitted to the clinic between 8:00 a.m. and 9:00 a.m. by the AA and PE students. All patients are fitted with a disposable paper name collar, and a label is placed on their carrier to ensure correct identification. As soon as the first two female patients arrive, they are brought back to the surgery lab to be examined and prepared by the AN and SS students so that the first spay surgeries can begin by 9:00 a.m. The patients are induced using an intramuscular injection of dexemedetomidine–ketamine–butorphanol, which is generally effective in producing a surgical plane of anesthesia within 10 minutes of administration. Patients that are not fully anesthetized during this time period may receive an additional half dose of the induction drugs intramuscularly. The patient is then intubated after a lidocaine splash block on the larynx, clipped, and prepared for surgery. To help minimize errors with drug calculations, we have prepared cheat sheets that list the correct drug doses by patient weight. Anesthesia is maintained using isoflurane usually set at 0.5%–1%, and the only monitoring equipment currently available to students is their stethoscope. Patients are assessed by regular monitoring of respiratory rate, heart rate, mucous membrane color, jaw tone, eye position, and palpebral reflexes. While the first spay surgeries are being performed, the AA and PE students examine the remaining patients, calculate the drug dosages, and get the induction medications drawn up into labelled syringes. The PE students are then responsible for recovering patients while the AA student assists the PE and AN students as needed and completes the patient paperwork. All surgical patients receive a microchip, meloxicam injection, and atipamezole injection in recovery and are placed on a hot air warming blanket until they are awake, sternal, and normothermic.
The spay procedure is performed using a ventral midline approach, isolating the non-pregnant uterus with a spay hook, a two-clamp technique with one or two encircling ligatures for the ovaries, no clamps with one or two encircling ligatures for the uterus, a simple continuous closure for the body wall, and an intradermal closure for the skin. For late-term pregnant spays, the fetuses are euthanized with pentobarbital after the uterus has been removed. The surgery teaching veterinarians are asked to adhere to this procedure to ensure consistency in the general surgical approach, but they have flexibility in choosing how they explain the different steps to students. We recognize that there are many different opinions within the profession about how best to perform and teach desexing procedures.14,15 Most students are able to complete the surgeries using a single pack of a swaged-on 3-0 absorbable suture and within 45–60 minutes depending on whether the animal is pregnant. Common errors encountered during the procedure are holding the forceps incorrectly (gripping with the fingertips like tweezers rather than a pencil), poor awareness of the sterile field boundaries (particularly with moving instruments and suture from the instrument tray to the patient), lack of confidence in tying surgical knots (unsure of which direction to pull their hands to avoid making a granny knot), and poor handling of suture while running the suture patterns (tightening suture by pulling the material straight upward rather than gathering).
As soon as the three spay surgeries have been completed, the SS student takes over the anesthesia and patient preparation for the cat neuters while the AN student performs the neuter procedures. All surgical procedures are typically completed by 1:00 p.m., and the students clean the surgery lab and equipment from 1:00 p.m. to 2:00 p.m., which gives the patients more time to recover from anesthesia before discharge. During this time, the students also complete the discharge instruction sheets, microchip registration forms, and skills progress logs (roles completed and how many surgeries performed). The SS and AN students are responsible for discharging their patients from 2:00 p.m. to 3:00 p.m. and must call their clients within 2 days of the procedure to follow up on how the patient is recovering. This is an important part of the process because it gives students a sense of accomplishment to realize that they have successfully performed medical procedures on real patients.
The student leaders and student volunteers manage all of the administrative tasks for the program. Staff volunteers are only required to be present from approximately 8:30 a.m. to 1:00 p.m. to supervise the clinical and surgical procedures. If there are any concerns or complications, clients are instructed to make an appointment with the MUVTH Community Practice service during normal business hours or to bring their cat through the Massey University Pet Emergency Centre after hours. The cost of treating complications is generally fully covered by the volunteer program and MUVTH unless there was a clear issue with clients failing to follow post-operative instructions (i.e., allowing the cat to roam freely outdoors immediately after surgery).
We should also note that we decided not to make the skills learned during the volunteer days eligible for sign-off as part of the BVSc clinical skills assessment (a list of basic clinical competencies that students must achieve as part of their graduation requirements that includes administering injections, monitoring a patient under anesthesia, and performing a spay). This was primarily because we wanted to remove the pressure of assessment from the volunteer program and preferred to have these skills formally assessed through the normal school procedures.
Practical Considerations
Setting up the program required more than 6 months of pre-planning to identify and address the main logistical issues before running our first 2 trial days in August 2017. We then ran a 6-month trial period from October 2017 through June 2018, during which we continued to refine the standard operating procedures and training materials so that the program management could be transitioned entirely to the student leaders. Over this time period, we ran a total of 40 surgery clinic days involving 9 staff volunteers, 225 veterinary student volunteers, and 3 veterinary technology student volunteers. We performed 237 cat spays and 183 cat neuters with a low complication rate (3 spays with post-operative seromas, 2 spays with a partial body wall dehiscence, and 1 spay with an incisional infection), which were partly attributed to clients not following the discharge instructions correctly and allowing the patients to roam outside during the immediate post-operative period. These rates are consistent with those in published studies of other desexing surgery training programs.16–18 The program has been incredibly well received by both staff and student volunteers with initial anecdotal evidence that it is improving student confidence and competence of final-year students on clinical rotations. This will be formally assessed beginning at the end of 2018 by analyzing data from new evaluation sheets that are currently being completed by the student and supervising veterinarian when the students are performing spays during the Community Practice rotation in the MUVTH (Appendix 1). We also repeated the cross-sectional survey of graduating veterinarians in November 2018 and compared the results with those of the previous class year in 2017.7 We have also observed that students tend to be more relaxed and ask more questions during these weekend surgeries than in surgeries conducted in the regular degree program because they are not under pressure from being assessed.
We next summarize the main practical issues we encountered and strategies that we found effective for resolving them.
Recruiting Clients and Patients
The system for recruiting clients and patients was modelled after the SPCA Desexing Caravan program, which is a mobile surgical vehicle that rotates among cities in New Zealand every few months to provide low-cost desexing services. We partnered with SPCA Palmerston North, who advertised our desexing program through their email lists and Facebook in September 2017 and has since been maintaining a waiting list of low-income clients who cannot afford to have their cats desexed at a private practice veterinary clinic. To participate in the program, clients must present a valid Community Services Card (a card issued to low-income residents by the New Zealand government) at the time of patient drop-off, which is our primary method of means testing. The vast majority of clients have reported on the patient admission forms that their cats have never been to a veterinarian, so it is highly unlikely that our program is directly competing with local veterinary practices for desexing surgeries. For patient and volunteer safety reasons, all cats must be aged younger than 7 years, not currently lactating, and able to be safely handled. We decided not to perform trap–neuter–release surgeries because of the ongoing controversy over feral cat management in New Zealand. Despite concerns that we may run out of patients, the waiting list still had more than 150 female cats and 75 male cats after the 6-month trial period with no additional re-advertising by the SPCA since October 2017. We have also had clients who live up to an hour’s drive away from Palmerston North bring their cats in for desexing. We therefore have an adequate patient supply for the foreseeable future.
Recruiting Staff and Student Volunteers
With the exception of public holidays and student exam periods, we have not yet encountered issues of having sufficient staff and student volunteers to run the surgery clinics. The students are highly motivated to participate because they gain valuable hands-on experience and one-on-one clinical instruction from teaching veterinarians that significantly improves their confidence and competency. The surgery lab is also a low-stress environment in which the students feel comfortable asking questions without the fear of being marked down or extensively grilled on their knowledge. With the large number of students in the BVSc and BVetTech programs (more than 500 total), the time commitment for most students is 1–2 hours of preparation to review the training materials and then one to two weekend volunteer shifts per year. The students are recruiting eight leaders from across all years of the degree program so that no student leader is responsible for more than two shifts per month and can schedule shifts when there are no conflicts with other assignments or examinations. Students volunteer for shifts in the program at a time that suits them as opposed to being assigned to a mandatory practical session, which has added to their motivation to learn and fully engage on the day. One of the main challenges is that there has been more student interest in volunteering than available volunteer shifts, and we have implemented a system to randomly select students from the volunteer pool.
The staff volunteers have also found it rewarding to work with the students in the program. It is easy to see how much difference it makes to the students, and for those with non-clinical roles at Massey University, it is a chance to stay engaged with clinical practice. Setting up the program was quite labor intensive for the staff involved at the outset, but now that management has been transitioned to the student leaders and many students are familiar with the surgery clinic procedures, staff commitment has been reduced primarily to the 3–4 hours of clinical instruction per surgery day. We recognize that there could be issues with staffing in the future if volunteers become fatigued or staff leave the university. Given the immense benefits of the program, it may be possible to negotiate for staff that volunteer on weekends to take time off in lieu during the week or to make it part of the normal clinical teaching responsibilities. We have also considered opening the program to veterinarians outside of Massey University who are interested in volunteering.
Developing Standard Operating Procedures
With the large number of staff and student volunteers participating in the program, it has been important to establish detailed standard operating procedures and step-by-step guidelines with pictures or videos showing each task involved in running the surgery clinics:
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Guidelines for the program administrative tasks
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Scheduling staff and student volunteers,
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Booking clients and patients,
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Ordering equipment and inventory,
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Briefing new volunteers on health and safety procedures,
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Maintaining clinic records and data, and
◦
Monitoring program finances.
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Clinical and surgical procedures
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Patient admission and discharge,
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Physical examinations,
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Administering injections and microchips,
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Sterile scrubbing and gloving,
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Anesthesia induction and intubation,
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Patient preparation (shaving, positioning, and scrubbing),
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Spay surgery procedure,
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Neuter surgery procedure, and
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Recovery procedures.
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Station supply lists and set-up instructions
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Patient admission and discharge station,
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Physical examination station,
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Drug station,
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Anesthesia station,
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Surgery station, and
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Recovery station.
•
Administrative forms
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Admission and medical record sheet,
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Microchip registration form, and
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Desexing certificate and discharge instructions.
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Drug dosage charts for induction drugs, emergency drugs, and post-operative drugs.
Copies of these resources are available from M. Carolyn Gates on request. It took approximately 4 months to finalize these resources because we ran into new questions or issues with the students not following instructions correctly. Common errors have included students forgetting to mark down the time and volume of drugs given on the medical records and not completely and correctly filling out information on the medical record forms. We have also experienced occasional problems with students being unable to appropriately restrain nervous or fractious cats because most BVSc students do not start clinical rotations until their final year and have minimal to no experience working in clinical practice. This has resulted in the need to expand the training materials with resources on interpreting cat behaviour and body language. We have introduced rules that particularly fractious cats are to be handled by staff members only.
All the training materials have been placed on a course website, and students are required to read through the guidelines for their roles before the surgery clinic day, which can be monitored by tracking student activity logs through the online course management software. Students have found it particularly helpful to have information on what to do if something goes wrong and how to handle common intra-operative and post-operative complications. We strongly encourage all students to have a staff member or student leader (for non-surgical procedures only) observe them the first time they perform any procedure in case the student is unaware that she or he has learned it incorrectly.
Preparing the training materials generated a lot of interesting discussion among staff members pertaining to what surgical, anesthesia, and analgesia protocols should be used in a student teaching setting. For example, staff members questioned whether we should be teaching ovariectomy instead of ovariohysterectomy and hemostat ties (autoligation) instead of suture ties for the ovarian pedicles. We also require students to monitor patients using basic clinical observations rather than other monitoring equipment. Moreover, we do not place intravenous catheters for the surgeries or require surgeons to wear gowns, which some clinicians argue are essential requirements for surgery. Our current protocols are based on the M. Carolyn Gates’ experiences working and teaching in a high-volume shelter setting. Given the paucity of evidence in the literature documenting the superiority of any given protocol,19–21 this prompted us to conduct a national survey in May 2018 to catalogue what New Zealand veterinarians are currently doing in clinical practice (the results are currently under review or have been accepted for publication22), and we are also planning to conduct additional research studies to compare different anesthesia and analgesia protocols. We should note that any schools looking to implement a similar program can easily modify the protocols to suit their preference.
Maintaining Equipment and Inventory
When the program initially started, we borrowed most of the equipment and supplies directly from the MUVTH. This created problems over time because most of the staff and student volunteers were unfamiliar with where these items were located and how to properly maintain them according to MUVTH protocols. Subsequently, we made a formal equipment and inventory list (Table 3) and began ordering most of our own supplies. To make it easier for students to set up the surgery lab with minimal guidance, we made plastic bins for each station that contain the required supplies. These bins are kept in a separate cabinet in the surgery lab for easy access (Figure 2). The student leader is responsible for checking the supply list for each bin at the end of each surgery day and ordering any items that are running low. The cabinet also contains a small, bolted-down drug safe that can only be accessed by the teaching staff.
| Equipment items | Consumable items |
|---|---|
| Surgery equipment | Surgeon preparation consumables |
| 2× surgical lights (floor lamps with LED bulbs) | Sterile gloves (sizes 5.5, 6, 6.5, 7, 7.5, 8, 8.5) |
| Spay surgery kits (per kit); 12 kits total | Tie-on face masks |
| 1× Olson-Hegar needle driver | Disposable bouffant caps |
| 1× Mayo scissors | Chlorohexidine scrub brushes |
| 1× Metzenbaum scissors | Non-sterile latex gloves (sizes S, M, L) |
| 1× spay hook | Drugs |
| 1× rat-tooth forceps | Dexmedetomidine |
| 1× Adson-Brown forceps | Ketamine |
| 2× Kelly hemostats | Butorphanol |
| 3× Mosquito hemostats | Lidocaine |
| Neuter surgery kits (per kit); 12 kits total | Meloxicam |
| 1× mosquito hemostat | Atipamezole |
| Anesthesia equipment | Isoflurane |
| 2× anesthesia machines | Pentobarbital |
| 2× Nonrebreathing circuits | Surgery consumables |
| 4× ET tubes (sizes 2.5, 3.0, and 3.5) | Size 15 scalpel blades |
| 2× laryngoscopes with blades | 3-0 Monocryl suture with RC needle |
| 2× cat face masks | 2-0 PDS suture on a reel |
| 2× Bair hugger units + blankets | Histoacryl tissue glue |
| 2× kidney dishes for scrub gauze | Gauze sponges |
| 1× emergency drug box | Fenestrated disposable drapes |
| 2× surgical clippers | Kimguard wrap (spay kits) |
| 1× isoflurane bottle adaptor | Autoclave sleeves (neuter kits) |
| Clinical examination equipment | Anesthesia consumables |
| 2× thermometers | Chlorohexidine surgical scrub |
| 1× cat scale | Methylated spirits |
| 1× microchip scanner | Gauze sponges |
| Other equipment | ET tube ties |
| 1× scissors | Artificial tears eye lubricant |
| 6× clipboards | 1 ml syringes |
| 4× plastic storage bins | 23 g needles |
| 20× towels | Thermometer lubricant |
| 4× waste bins | Other consumables |
| 1× drug storage safe | Disposable patient collars |
| White tape | |
| Carrier labels | |
| Plastic garbage bags |
Note: Items in italics are still borrowed from the Massey University Veterinary Teaching Hospital
LED = light-emitting diode; ET = endotracheal.
Figure 2: Organization of the supply storage cabinet in the student surgery lab facilities
PE = physical examination
Financing the Surgery Clinics
The desexing program is currently operating almost at cost thanks to the generosity of staff in volunteering their weekend time, small fees charged to the clients ($10 NZ for a cat neuter and $20 NZ for a cat spay), and donations from several organizations. The MUVTH sponsors the facilities costs, waste disposal fees, oxygen supply, and staff time to autoclave the surgical kits during the week. The SPCA has provided the microchips implanted at the clinics and is covering the client costs for registering their pets with the New Zealand Companion Animal Register. We received funding from the Massey University School of Veterinary Science teaching budgets and the New Zealand Companion Animal Council to put toward purchasing the new equipment, which cost approximately $1,400 NZ (including 12 surgery kits, two anesthesia circuits, two surgery lights, assorted endotracheal tubes and face masks, laryngoscope with blades, drug safe, and plastic storage containers). A spare used autoclave was donated by the Pet Doctors veterinary group. Several major pharmaceutical companies and veterinary supply companies (MSD, Zoetis, Boehringer Ingelheim, and Shoof International) have provided free or heavily discounted consumable supplies. Now that the program is well established, we are also looking to create online donation pages that will allow individuals to sponsor or contribute toward desexing surgeries.
Evaluating Clinical and Teaching Outcomes
To monitor the long-term outcomes of the program, we have designed and implemented a number of research studies:
•
We administered a short, three-page survey to the BVSc class of 2017 to collect baseline data on the number of desexing procedures they had performed before graduation and their overall level of confidence in performing the procedures.7 Only 3 of the 95 graduating students had participated in the new training program. We repeated this survey for the class of 2018 and will repeat it for class of 2019 to determine how much the program has affected their surgical competency. We also hypothesize that providing better clinical and surgical training during the fourth year will increase the opportunities students will have to perform desexing surgeries outside of Massey during their fifth-year clinical rosters.
•
We implemented a new surgical skills evaluation form for the Community Practice Roster in 2018 that will allow us to assess whether students who participated in the desexing volunteer program perform better on average than students with less previous experience or those who did not participate in the program. We will also implement this evaluation sheet (Appendix 1) for the desexing volunteer program to conduct an additional study comparing students’ perceptions of their surgical competence with staff evaluations of their surgical skills.
•
We ran a national survey of practicing veterinarians in New Zealand from April 1, 2018, to May 31, 2018, to collect information on the techniques they use for performing dog and cat spay surgeries and their opinions on supervising BVSc students and new graduates in performing desexing procedures. The responses from these surveys will be used to redesign the teaching materials if necessary to better prepare students for clinical practice.
•
We are also maintaining data on the geographical location of patients that are desexed as part of the program and will be comparing this against the cat intake data at the corresponding local animal shelters to determine whether providing low-cost cat desexing services to the community is having an impact on the number of admitted animals.
Discussion
This program has proven to be highly successful in increasing the clinical and surgical training opportunities for students earlier in the BVSc and BVetTech curricula while providing a valuable low-cost desexing service for the local community. In particular, we have found that having students take responsibility for their own learning as well as for teaching others appears to be particularly effective in reinforcing key clinical knowledge. The students have also seemed to develop a stronger sense of accomplishment in having performed the procedures on real patients and having the opportunity to follow up with clients to monitor how their patients are recovering. We look forward to seeing how this program continues to evolve in the future.
Acknowledgments
We thank the Massey University Veterinary Teaching Hospital, New Zealand Companion Animal Council, Zoetis, MSD, Boehringer Ingelheim, Shoof International, SPCA Palmerston North, and Pet Doctors for their generous support of the program. We are also extremely grateful to Margaret Gater and Daniela Harris in the Massey University BVSc Class of 2019 for their dedication and hard work in helping to develop the training materials.
References
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Clark W, Kane L, Arnold P, et al. Clinical skills and knowledge used by veterinary graduates during their first year in small animal practice. Aust Vet J. 2002;80(1):37–40. https://doi.org/10.1111/j.1751-0813.2002.tb12830.x.
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Greenfield CL, Johnson AL, Schaeffer DJ. Frequency of use of various procedures, skills, and areas of knowledge among veterinarians in private small animal exclusive or predominant practice and proficiency expected of new veterinary school graduates. J Am Vet Med Assoc. 2004;224(11):1780–7. https://doi.org/10.2460/javma.2004.224.1780. Medline: 15198262
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Greenfield CL, Johnson AL, Schaeffer DJ. Influence of demographic variables on the frequency of use of various procedures, skills, and areas of knowledge among veterinarians in private small animal exclusive or predominant practice and proficiency expected of new veterinary school graduates. J Am Vet Med Assoc. 2005;226(1):38–48. https://doi.org/10.2460/javma.2005.226.38. Medline: 15646571
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Hill LN, Smeak DD, Lord LK. Frequency of use and proficiency in performance of surgical skills expected of entry-level veterinarians by general practitioners. J Am Vet Med Assoc. 2012;240(11):1345–54. https://doi.org/10.2460/javma.240.11.1345. Medline: 22607603
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Bowlt K, Murray J, Herbert G, et al. Evaluation of the expectations, learning and competencies of surgical skills by undergraduate veterinary students performing canine ovariohysterectomies. J Small Anim Pract. 2011;52(11):587–94. https://doi.org/10.1111/j.1748-5827.2011.01120.x. Medline: 22026742
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Tuthill J. See one, do one, teach one. Lancet. 2008;371(9628):1906. https://doi.org/10.1016/s0140-6736(08)60818-1.
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Freeman LJ, Huse D, Lee R, et al. Teaching veterinary anesthesia and surgery: the impact of instructor availability on anesthesia, operative, and recovery times in dogs undergoing ovariohysterectomy or castration. J Vet Med Educ. 2014;41(4):390–9. https://doi.org/10.3138/jvme.0813-120r. Medline: 25270651
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Griffon DJ, Cronin P, Kirby B, et al. Evaluation of a hemostasis model for teaching ovariohysterectomy in veterinary surgery. Vet Surg. 2000;29(4):309–16. https://doi.org/10.1053/jvet.2000.7541. Medline: 10917280
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Zeugschmidt EL, Farnsworth CH, Carroll HS, et al. Effects of an optional clinical skills laboratory on surgical performance of third-year veterinary students. J Am Vet Med Assoc. 2016;248(6):630–5. https://doi.org/10.2460/javma.248.6.630. Medline: 26953915
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Smeak DD. Teaching surgery to the veterinary novice: the Ohio State University experience. J Vet Med Educ. 2007;34(5):620–7. https://doi.org/10.3138/jvme.34.5.620. Medline: 18326773
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Farnworth M, Adams N, Seksel K, et al. Veterinary attitudes towards pre-pubertal gonadectomy of cats: a comparison of samples from New Zealand, Australia and the United Kingdom. N Z Vet J. 2013;61(4):226–33. https:// doi.org/10.1080/00480169.2012.738591. Medline: 23227915
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Jupe A, Rand J, Morton J, et al. Attitudes of veterinary teaching staff and exposure of veterinary students to early-age desexing, with review of current early-age desexing literature. Animals. 2017;8(1):3. https://doi.org/10.3390/ani8010003.
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Kennedy KC, Tamburello KR, Hardie RJ. Peri-operative morbidity associated with ovariohysterectomy performed as part of a third-year veterinary surgical-training program. J Vet Med Educ. 2011;38(4):408–13. https://doi.org/10.3138/jvme.38.4.408. Medline: 22130417
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Hazenfield KM, Smeak DD. In vitro holding security of six friction knots used as a first throw in the creation of a vascular ligation. J Am Vet Med Assoc. 2014;245(5): 571–7. https://doi.org/10.2460/javma.245.5.571. Medline: 25148099
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Appendix 1
Date: ________
Student Name: ________ Student ID Number: ________
Section 1: Prior Surgical Experience (students to complete before commencing surgery)
1.
Please describe your prior small animal abdominal surgery experience.
| Experience | No. of surgeries | Points per surgery | Total Points |
|---|---|---|---|
| Primary surgeon for canine spay | 3 points | ||
| Assistant for canine spay | 2 points | ||
| Observer for canine spay | 1–4 5–9 10–14 15–19 ≥20 | 1 point 2 points 3 points 4 points 5 points | |
| Primary surgeon for feline spay | 1 point | ||
| Primary surgeon for canine or feline abdominal surgery other than spays | 1 point | ||
| Assistant for canine or feline abdominal surgery other than spays | 1–4 5–9 10–14 15–19 ≥20 | 1 point 2 points 3 points 4 points 5 points | |
| Total score |
2.
Have you participated as a spay surgeon in the Massey–SPCA weekend volunteer program? ❍ No ❍ Yes On a scale of 1 (least confident) to 10 (most confident), how confident would you feel at this stage in performing the following desexing procedures unassisted in clinical practice?
3.
Cat spay ____________________ Dog spay ____________________ How concerned are you with your current skills in the following aspects of desexing surgeries?
| 1 (extremely worried) | 2 (quite worried) | 3 (indifferent) | 4 (reasonably confident) | 5 (completely confident) | |
|---|---|---|---|---|---|
| Post-operative bleeding occurring | 1 | 2 | 3 | 4 | 5 |
| Leaving ovarian remnants behind | 1 | 2 | 3 | 4 | 5 |
| Taking longer to do a surgery than you think is appropriate | 1 | 2 | 3 | 4 | 5 |
| Performing too large a skin incision | 1 | 2 | 3 | 4 | 5 |
| Performing too small a skin incision | 1 | 2 | 3 | 4 | 5 |
| Post-operative infection occurring | 1 | 2 | 3 | 4 | 5 |
| Ligating ureters | 1 | 2 | 3 | 4 | 5 |
| Suture material selection | 1 | 2 | 3 | 4 | 5 |
| Herniation | 1 | 2 | 3 | 4 | 5 |
| Placing skin sutures too tightly | 1 | 2 | 3 | 4 | 5 |
| Post-operative pain in patient | 1 | 2 | 3 | 4 | 5 |
Section 2: Surgical Competency (veterinarian to complete after the surgery)
Species: ❍ Dog ❍ Cat Breed: _____ Weight: _____ kg
Surgery Start Time: __________ Surgery End Time: __________ Total Duration: _____ min
Incision Length __________ cm Appropriate incision length for size of patient? ❍ Yes ❍ No
Was the animal pregnant? ❍ No ❍ Yes If yes, approximately what stage? ❍ Early ❍ Mid ❍ Late
Please rate the student’s competency with the following aspects of the procedure.
| Procedure | Very poor | Poor | Acceptable | Good | Very good |
|---|---|---|---|---|---|
| Preparation | |||||
| Scrubbing | ❍ | ❍ | ❍ | ❍ | ❍ |
| Gloving | ❍ | ❍ | ❍ | ❍ | ❍ |
| Gowning | ❍ | ❍ | ❍ | ❍ | ❍ |
| Placement of surgical drape(s) | ❍ | ❍ | ❍ | ❍ | ❍ |
| Skin incision | |||||
| Handling of scalpel blade | ❍ | ❍ | ❍ | ❍ | ❍ |
| Knowledge of landmarks | ❍ | ❍ | ❍ | ❍ | ❍ |
| Celiotomy | |||||
| Stab incision & handling of blade | ❍ | ❍ | ❍ | ❍ | ❍ |
| Location of the incision (on or off linea) | ❍ | ❍ | ❍ | ❍ | ❍ |
| Extending the incision | ❍ | ❍ | ❍ | ❍ | ❍ |
| Ovarian pedicles | |||||
| Placement of clamps | ❍ | ❍ | ❍ | ❍ | ❍ |
| Breakage of suspensory ligament | ❍ | ❍ | ❍ | ❍ | ❍ |
| Uterine body | |||||
| Breaking and/or ligating the broad ligament | ❍ | ❍ | ❍ | ❍ | ❍ |
| Location of the ligatures | ❍ | ❍ | ❍ | ❍ | ❍ |
| Abdominal closure | |||||
| Incorporation of the external rectus sheath | ❍ | ❍ | ❍ | ❍ | ❍ |
| Appropriate spacing of sutures | ❍ | ❍ | ❍ | ❍ | ❍ |
| Skin closure | |||||
| Appropriate selection of 2-layer vs. 3-layer closure | ❍ | ❍ | ❍ | ❍ | ❍ |
| Apposition of skin layers | ❍ | ❍ | ❍ | ❍ | ❍ |
| Basic knowledge and skills | |||||
| Knowledge of procedural steps | ❍ | ❍ | ❍ | ❍ | ❍ |
| Circumferential ligation | ❍ | ❍ | ❍ | ❍ | ❍ |
| Buried knots | ❍ | ❍ | ❍ | ❍ | ❍ |
| Tissue and instrument handling | ❍ | ❍ | ❍ | ❍ | ❍ |
| Selection of suture material and size | ❍ | ❍ | ❍ | ❍ | ❍ |
Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Did any of the following complications occur during the procedure? (check all that apply)
Sterility break: ❒ Touched non-sterile item with hand ❒ Instrument/suture touched non-sterile field ❒ Dropped pedicle ❒ Bleeding from ovarian pedicle ❒ Bleeding from uterine body
1.
On a scale of 1 (no intervention) to 10 (significant/constant active intervention), how would you rate your level of intervention in the following aspects of the surgery?
Guidance through procedural steps _________________________ Tissue and instrument handling _____________________________
2.
On a scale ranging from 1 (least confident) to 10 (most confident), how confident would you feel allowing the student to perform the next desexing procedure unassisted in clinical practice? ____________________
Information & Authors
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Published In
Journal of Veterinary Medical Education
Volume 47 • Number 1 • February 2020
Pages: 27 - 38
PubMed: 31009278
Copyright
2019 AAVMC.
History
Published online: 22 April 2019
Published in print: February 2020
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