Nov. 20, 2022

#81: Tick paralysis update 2022: How to manage the antiserum shortage, and what’s new in case management. With the Tick Paralysis Advisory Panel.

#81: Tick paralysis update 2022: How to manage the antiserum shortage, and what’s new in case management. With the Tick Paralysis Advisory Panel.
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Season 1

If you are a clinician working in a paralysis tick area of Australia then you’ll be well aware of the 2022 shortage of tick antiserum, and you very likely have some questions, like how do we ensure that we still do the best for our patients, where do our previous dose rates for TAS even come from, and why is it suddenly ok for us to use less? You might even be wondering how the vet boards will view deviations from the label dose if that’s what we’re required to do in response to the shortage. 

We’ve gathered some of the smartest people on the topic to get your questions answered. The smart people in question are Prof Rick Atwell, Dr Terry King, Dr Heather Russel and Dr Rob Webster, who are all members of the Tick Paralysis Advisory Panel, a group of veterinary and scientific experts who convene to review the latest scientific information regarding the prevention and management of tick paralysis to provide guidance and recommendations to vets and pet owners. This discussion covers what we know (and what we think we know!)  about paralysis ticks, their toxins and how it relates to antiserum dose, as well as new insights around managing tick cases beyond just TAS. 

Visit VETAPEDIA.com.au for additional resources on tick paralysis and many other Veterinary Emergency and Critical Care guidelines from the team at Animal Emergency Australia. 

Go to thevetvault.com for show notes and to check out our guests’ favourite books, podcasts and everything else we talk about in the show.

If you want to lift your clinical game, go to vvn.supercast.com for a free 2-week trial of our short and sharp highly practical clinical podcasts.

We love to hear from you. If you have a question for us or you’d like to give us some feedback please get in touch via email at  thevetvaultpodcast@gmail.com, or find us on Instagram.

And if you like what you hear then please share the love by clicking on the share button wherever you’re listening and sending a link to someone who you think should hear this.

 

 

 

Hello.It falters.This is a slightly special episode in that it will have relatively little to no relevance for a lot of our listeners and a lot of relevance for a geographically select group of you.If you don't live and work in an area of Australia where paralysis tick is.
A problem in the only reason for you to listen to this one is to listen to some really smart people.Talk about a really complicated and interesting problem and maybe also has a wake-up call to make you realize that we need to sometimes take an informed.Look at the things we do and the stories that we tell each other about why we do it and to make us realize that we don't always know as much as we think about some of those things.
Basically, it's a lesser than holding on to your beliefs a little bit less tightly.But if you've never treated a tick, case in your life and you don't think that you ever will, then feel free to skip this one and listen to some music or even sit alone with your thoughts for a bit.But if you are in a paralysis tick area, then you'll be well aware of the current shortage of tick antiserum and to put a time stamp on this.
I'm recording this introduction on the 19th of November 20, 22, and you very likely have some questions.Like how do we ensure that we still do the best for our patients, where our previous dose rates?For Tears comes from and why it suddenly okay for us to use less and whether you'll be in trouble with the vet boards if you deviate from the label dose in response to the Which I know I suddenly have this questions and many more.
So we've done what we do, you've gathered some of the smartest people on the topic and we pick their brains.The smart people in question are all members of The Tick paralysis advisory panel which is a group of Veteran and scientific experts.Who convened to review.The latest scientific information regarding the prevention and management of tick paralysis to provide guidance and recommendations to vets, and pet owners, IE to you and your clients.
We've A link to the most recent guidelines in our show description for you if you want to check them out.Although these are pre the shortage.So we might adjust some of those based on this conversation right here.Here's the thing as you'll hear from this conversation even the smartest veteran and scientific experts have some shortages in hard data when it comes to this topic purely because there's still a lot that we don't know for certain about tick paralysis.
So what that means is that some of what you'll hear?Yeah, will be opinion.Very well informed opinion but still Pinion.So if you're listening to this thinking that you're about to get the last word on exactly what we should be doing, not going to happen.What it does provide though is some incredibly useful food for thought and feedback from some of the people who've spent vasts amounts of times on the front lines with this condition and have done, the bulk of the research that is informed us on what we do know.
So, you'll be able to make your own informed and defendable decisions.So who are our panelists will just do a quick summary because of I read Each of their bios in fooled in this episode will be an extra hour.At least just to get through the buyers.First off, we've got the original gangsters of everything tick in southeast Queensland.
The Godfathers of Tears Professor Rick at well and dr.Terry King, both of them had been in practice since the late 1970s and have treated Morty cases than you can imagine in your worst nightmares.Both of them have played key roles in research and education over the past few decades at the University of Queensland, and in private specialty, practice.
And they've contributed greatly, Greatly to their perspective fields of medicine for prophetic and emergency and critical care for dr.Terry Professor Rick's research has focused heavily on paralysis ticks and he has published more than 200 papers and received numerous veteran e awards.
Dr. Heather Russell is an emergency vet and the clinical manager at Northside emergency vet in Sydney and has been a member of the Australian tick paralysis visor paralysis advisory panel since 2016.She's on the floor every tick season, trying hard to find better ways to save these patients.
And she joins us to tell us what they currently doing with their tick patients and how they will be changing what they do and then we've got dr.Rob dr.Rob Webster is a specialist in Veterinary, emergency medicine and critical care and a founding partner of Of animal emergency Australia or AES?
Do they clients and referring wits?They are a group of emergency vet hospitals with the vision to create the future of emergency medicine and critical care.And also the company where I do my clinical work at the moment and where I bump into Tech patients as part of the annual, onslaught of take patients that a is treats every year, Rob continues to work as an emergency veterinarian and is heavily involved in teaching and research in the field of ECC.
Rob's greatest achievement, however, is probably the fact that he's also Regular, contributor on the V8 V, clinical podcasts, on the emergency and critical key stream.One of Rob's dreams is to see tick paralysis eliminated as a cause of death of dogs and cats in Australia, just a quick plug here for a is incredible online information, resource vet pedia where you can find a wealth of info on everything easy.
See, it's kind of like having a really smart friend who you can call it 2 a.m. when you get that case, that you really just need some help with.But all your mates asleep.In and you feel too bad to wake up.Rob, you can find it at Veta pedia dot com.au, that's ve t a PE Dia.com you and it's free.
The link will be in the show description.Okay, tick paralysis test those his.What's new?How to save them?How to adapt to the changes while staying friends with the vet board.Let's do it.So hey, how are you guys looking with your stuck pretty low?
At the moment.I'm a little worried.We're down to 19 bottles at last count.I ran the figures.And last year, we went through about two liters in the next two months.So unless we get a supply soon, we're going to be in trouble, I think.Yeah.I think in practice, it's we're seeing shortages and that's quite unnerving.
I think it's a really, really hard thing to look at some of you've done for us.So long and just accept it as normal and then all of a sudden you've got to make some decision and yet from my point of view, there is enough data out there just so that we can use lower doses.I think there's a challenge now because have to change that those and that's a huge change for people to absorb everything and they're scared about the best surgeons board as well.
Then I hope you were recording already there Q because that was the big question that everyone is going to ask in practice.But if I use a lower Well, I am I doing the right thing by my patient and be is Terry coming to get me and he looks really gentle and peaceful there, but he's pretty ferocious when it is tracking down Veterinary malpractice.
I'm going to pretty big noise in the back pocket.Yeah, it's a bit boards and certainly Queensland but board is just concerned that contemporary practice is followed and you know, there's lots, isn't there?Heather brought up that one of the manufacturer's suggested?
That you used dexamethasone as a pre-medical actually suggest dexamethasone and an antihistamine.And while that is on his label, there is pretty good evidence.Very good evidence.How to show that those things do not prevent anaphylaxis.
So you will find that Veterinary.Village would take note, you wouldn't get into trouble because you use the stuff because it's a label use, but having said that, you wouldn't get in trouble for not using the stuff because there's very very We're evidence to show that you don't need to.So I think all of those things are taken into account, you know, I visited a practice yesterday and they had a little sign on his door that just said we are likely to be experiencing shortages of tick handy serum.
And when I talked to the practice owner he said that they had enough for for large dogs left and said we will be likely if this continues will be likely not to be able to treat your dog and we'll have to try and find somewhere that Does have a harem and if everybody runs out well, of course, there's nothing that can be done.
I feel strongly about this is enough data out there to say we use too much tea is and we find it very hard to change your point of view and I and it's very frustrating because I can't express to give writing a letter to the obj trying to put all the doses Etc together.
Yeah I get you but you'll also find that you know even in A paper.The mean, dose of dogs that didn't recover was as high as the main dose of dogs, that did recover their exactly what I do.And that says, that if it t, is was a key thing.
Those dogs would have more tea is, if you go to x the dosed up front, there should be more survival, but there's not.And as the reason is that, they died of respiratory failure.Come lung disease.They don't dive a lack of Tas.And on the basis of that at manly road, we've had A couple of meetings and we've convinced the Vets, the use point, two mils per kilo and three mils per dog depending which has the higher and I'd I do believe we've convinced them of it.
I mean it's very hard to tell young vets had to scratch their nose because they know it all and yet we were able to get it across because we presented data that sort of seems to support for those few.And the other thing is we better look at the the studies of other toxins that are effective After the same is Tick-Tock Sicily.
The other thing is Andrew, couldn't find the toxin in the blood and that makes a low stance because most of these, very tiny toxins.Believe the circulation very quickly, and we've got to think of toxins Supply rate and tissue Transit time and then rated binding.
But if you do all that, it just makes a complete story that has no contradictions in it.Now, I'm coming from advice point of view, but I've also had a lot of time to read Through all this stuff and I think we're on the right track, I firmly believe we don't need to use as much as we do.
Should we start with that just to help us understand the, the fight that we have with the toxin?Why do we know or what do we think?We know about the tick toxin?How much does it take to produce?Does it keep producing the longer it sits on there.
Where does it bind?What does it do?I don't know who that question is for what?What do we understand about the tux?I can answer some of that but based on what we've done, I mean, the toxin is very small, The Tick's secretes, then sucks then rests and they're just is a nice example.
How to explain tick size has no bearing on the outcome because it was determined by the toxins pyro so you got an old Tech.It's not going to suck and secrete and rest the cycle.That'll be a lot longer.Where's your buddy, young healthy exact they tend to Second cycle, much faster.
And that's why you get severe disease and progression of disease quite quickly.And if you think back to what we call the hot Seasons, you found that dogs were deteriorating much more quickly than normal, and that was because of the toxin Supply row.But once he gets out of circulation, T is can't do a thing.
And there's a very nice study is of 41-page review of botulism and the Like a re-run of that botulism is because we they have the data but we don't have it for our Toxin and they're very similar.And when they didn't use intensive care which obviously, a lot of people have tried and that to a very high level in there, when they didn't use in intensive care, will they had was an antiserum and that mortality rate was 70%, but once they could support their patients with the mortality rate was 5% and that was They have any cereal and the explanation that that is, the toxin is not very long in circulation.
That's why I think we only need a small amount of T, is to mop things up.And after that, after that, the dog is then dying of respiratory disease.Was that botulism in dogs?It's in dogs and people like.But mainly people with a measurement, a toxin that, the reason they had problems with antiserum and botulism is they usually take a couple of days to make the diagnosis because it's such Such a rare disease so it takes a while to make a diagnosis.
And then they find the antiserum is too late because the patient's already at clinical disease and the antitoxin can't chase the cocks in it.And I think we also forget about the size of things.I mean, a neuromuscular Junction is like 5 nanometers.Why?That's sort of like a 5 in a billionth of a meter 10 to the minus ninth.
So we're dealing with Incredible small things and your daddy series is a comparatively very large.And as I understand it, it can't escape the vascular tree as can the toxin.So, we've got a toxin that can escape very quickly and bind and produce eyes.
And when you think about, if that's right, when you think about it, the best time to use GIS is just before they develop songs, because if you put science, you have to have bound talks in, which means the daddy Sierra is not going to change that, it's only going to stop new toxin leaving the circulation.
The problem we have, we can't see the Toxin and we don't I know exactly what is in the tea is okay.They say it's about 500.But what does that actually mean in terms of antitoxic effect?And I don't think that's been recorded.So you could, I jump in with a just a couple of follow-up questions for Rick for people out there, in practice, creating tick, paralysis like Heather's team and the emergency vets all around the country.
Back with, you know, you were talking about resting and feeding cycle.And when these talks and is excreted Rick, is it still like to say that no toxin is likely excreted in the first two days of feeding.And then there's a rapid amount of toxin produced after that as the saliva Brands hypertrophy, or how does that happen, because we certainly see a significant way from tick attachment, you know?
Well, if you look at how texts work, they take three days to up regulate everything because they've been sitting on a bush a year, maybe and the all their systems are shut down.So, they need three days to up regulate, and if you look at the original work of Jan milk, use and also clunies Ross.
The dogs typically got sick on day four and they sort of died and a five, and Janet was the same, except it was a delay.And the reason for that is all the dogs, I happened to visit her at that time, and all the dogs were in the basement at the University of Sydney, which is a very cold environment.
So whenever you've got cold ticks, they don't secrete and suckers first, and the same thing with old six of End of the season, you will find that the teks artist toxic because the might in a did deteriorated State.Now, we're dead experiments.
And I think the figure is something like 16,000 ticks on five, Trials of 32, dogs, and 10, loadings of 10, ticks were dog.And on that.No, dog.Develop any signs of tick, toxicity up to 72 hours.
But, and for people out there because I've always Had this impression of tick paralysis being a slowly Progressive disease and we haven't treated our tick patient with the same urgency that we might treat a patient, that's just come in with a snakebite.
What you're saying, just to paraphrase is that although there's a delay in onset of paralysis after the tick attaches and feeds and it's at least 72 hours as soon as there is any clinical signs.That's when we want the tick off and the antitoxin, In a right at that moment.
So no delay, you know, expedite the treatment of these patients right to the front of your ability in your hospital.Yeah I think the first thing is to take off the ticket.Obviously that's just took like two toxin in that paper that prospective study of 588 and we're dealing with black and white things like low life and death in.
That's very well once again just going better.Clue clue, clue.Clue and his rice original work, the very best starter out of that poll.That paper is the fact that plucking ticks This gives Anna gives the best results.So if this goes against all the stuff that comes out of Sydney with regard to meet allergen everything.
If you squeeze the ticket and remove it, you do not secrete toxin.It's impossible the way the the ticker architecture inside the tickets impossible for pressure to have to be applied to the slobbering ads and secrete.And you think about we're probably dealing with an eighth of a meal over 20 over the period of attachment.
So it's incredibly small amount of toxin it's was saying before word is so Holly compared to that the Andy serum and I volume comparisons aren't necessary real but it's so small compared to the amount of anesthesia and we got that and it's so tiny.It gets through vessels very easily and once you've got signs that means Terriers doesn't work against the toxin causing the science because it's it's now bound and it to buy it.
It actually has to go inside the the neuronal cells so it's got to get inside the cell and then it we don't know what happens after that, but it causes a Particular opportunity.If you like there's five ways to destroy please Circle.And obviously, botulism does one and probably our talks, and I'll do some other, but effectively it stops the o.c. oats, if secretion.
So if you've got clinical signs, you've got to have bound talks in which means T is can't work.It can track their and it's already bound.So when it gets inside the stairwell, this is botulism.Now, it has a long chain to breaks into the cell and then a short chain, which there's Opposites the proteins around the basically, it's all protein interactions and it's Ultra microscopy attended the - tonight.
So, I mean, we've got to sort of, in spite of the having to be practical.You also got to think about the reality here, we're dealing with incredibly small amounts of toxin.Can I just jump in there?But when we come back to label doses of text, so I've got the ABS L, do some front of me on the label.
We're looking at what they say is as a guide, a dose of one meal per kilo.Live weight of a vsl excited.He's hello cyclist anti-venom should be taken as that dose required to effectively counter, A1 A2 to be paralysis produced by one tick in a susceptible animal.
So to me, that's and then it goes on to say doses as high as four meals, peculiar may be required in severely affected patients.So that's going against what you're saying, Rick is.Yeah, I agree with what you're saying, but there is no data.There is no data to support that.
Nick clearly said, the other day was empirical, and if I can go back 52 years, I was working to practice Wong, Doug, Cummings was the name of the vettii with their only about 10 beds in Brisbane.Then if he had a tick case, he simply went to a farm and it bled the farm dogs and then brought it back, says separated.
And then gave a dose.I mean, there was no dice with that, there's no proof that I'm trying to work.There is no data to support the dose rate.There is no doubt at all.All, and if you only need five meals in you giving 15 mils, you get the same result.But in our mind, we're trapped by this high dose and there's no other addi serum in the world that's done, is dosed on a weight basis.
Yeah, that was my question.I was going to say, why do we care about the size of the animal?Because, with suggested, which we care about the size of the snake?The not about the weight of the dog.Is there a reason for it?Anybody in the Terry anyone?Or was it just that?I guess that comes from traditionally.
On volume of distribution of your antiserum, you wouldn't give the same dose to a 50 kilo Greyhound of propofol, that you would put four kilo cat because the volume of distribution, wouldn't aneesa ties your dog.So it all comes back to that.
That's where that's traditionally done.Okay.So it's not not so much about the number of antibodies in the violets about big enough, volume to make sure it actually gets to where it needs less spread of those antibodies.So, yes, if You gave us a 1000 antibodies, IGG, to a Great Dane.
You'd expect it to have 50 antibodies per kilo circulating around somewhere where, as if you gave the same, to look at the volume of distribution would be a lot higher and and I can see Rick Rick.
But that's that that we're gonna come Terry is she's I'm trying I'm trying to project the truth and if that was the case, what wise and botch lows have been tetanus and all these other things in people, why do they just dose set like two meals per vial or something like that?
But they don't What, why are you bad for the size of the paging?Whether it's a child or an adult.So if you give injection in something within seven seconds, it's all over the body, it's in the brightest everywhere because the circulation, mixes things so quickly.And the Tas is just so, so big compared to the toxin.
So, you've just got to imagine a huge vacuum, going through the blood, sucking up the Toxin.And there's not a lot of toxin.There is my is Andrew was saying the other day.He clearly said, I've looked for toxin I've never found it except in the Euro.
So it says, toxin gets out of the circulation quickly, if it's in the Eurozone, it is out of circulation and if it's in the your muscular Junction.The same thing is out of circulation, I don't think Terry was saying that that's necessarily the way we have two dose and he serum but more the background around, why we might be using a mil per kilo dose thing, wreck not necessarily saying, it's rational it.
Where you Terry.We've It is very hard to break.Its tradition.Isn't like we've been done this forever and we feel if we don't do it, you know, we'll get into trouble now.Look, I don't know how persuasive I am, but manly rotor using points blue and three as of last week and okay, you say I have any dogs died.
Well, you know that dogs have died but that doesn't prove a thing.Obviously they've got a severe case and then give it to you is and find it in tight and then blame the Tas days.But dogs are dying all the time and robbers.Think would agree.It's 5 to 10%.Depending on what paper you read or what river dog, you've got and approve that like if you've only got five percent death to prove an advantage, you better do a lot of dogs with different dose rates because the mortality rates so low and I don't know if anyone's done that experiment.
Yeah, because you could do .5 and .25 and one meal and see if the results are the same and I'd bet pounds of peanuts, they would be the same.But this is a study that we need to do, isn't it?Because we've Some observational evidence that challenges the status quo, and we've got some interesting parallels that you've highlighted with botulism, but we don't have controlled, do studies on dogs in.
We're using this naturally occurring disease and they will be difficult.Because as we all know, most of these patients, especially the dogs die of respiratory failure, pulmonary parenchymal disease, not as a result of their paralysis so it'll be a challenge.
Challenging study and that's why it's not being done.But I think we need it to be able to that level of confidence for vets about dosage I know where we've reduced our dosages, but if I if I asked our guys to drop it down, 2.2 mils per kilo.
I don't know what you what your guys would say, Heather.But I think the AES vets would just nod their head and do what they've been doing the other complexity and it's a very confusing issue.The other thing is we don't know exactly the If level of IGG in different batches of Tas.
So, even doing that experiment, we could well have different amounts of IGG in the two different groups if you, like, if you know what I mean.Because we know it's above 500.We don't know how far it is.And therefore two batches may have different antibody levels.
So that's another complication.When you're doing a do study like that, Heather, what are you guys using?Or what have you been using?We've just been using our standard dose.Others.So, we've been using up to 25 mils in a dog and 10 mils of non purified.
Taz in a cat and 5 mils of purified, but our order only came in yesterday and I were talking about this a bit Affair before but we ordered 40 bottles of Taz and received two.So for us that's really concerning looking forward when we're going to need about 2 liters moving forward over the next couple of months.
So for us we are looking at doing pretty substantial do Decreases as a result.And I think as long as the there is published data, which we do have to support those lower doses.Then I think like this is a time and the opportunity for us to challenge the status quo so well I think we've got no choice if there's two shortages truth, how can you justify treating one dog?
At say you know one meal and then the next five cases, you got to treat a point one because you don't have enough sits here.I mean, it's not from a fairness point of view.That's Not fair at all.Those five, dogs should have the same dose so the 10 mils that we used to use for cats because rub, that's what today is, our protocol was not 10 miles of known purified tears for a standard cat, but there are a lot of GPS I speak to in the area.
They've been using 5 moles for a long time for cats.And they're like, a, why do you guys use 10?Where's that even from?Yeah, we've always used to task to access.There's never been any limitation to the Taz and it's gone from one of the most expensive parts of treatment to one of the cheapest and Also, one of the key determinants of survival.
So, what we've always done is used a mil per kilo per dog or 20 mils.And in cats, we've used 10 mils in our revised protocol.For this year, we've dropped our dosage for cats down to 5 mils or five mils of the purified, Taz, we've not split those vials because there's no preservative in them and so it would be an infection risk to administer them on different days and so 5 mils of wrought iron.
Taz or five mils of peat as for a cat.And in dogs, we're using a mil per kilo with a minimum dose of five mils and a maximum dose of 15 mils.And so we really significantly drop the dosage of dogs.Nothing near as much as what Rick and the guys at manly Road have done yet but from our calculations that will get us through this period at least until the middle of December.
So fingers crossed so far.Yeah I think the other point is that You've used one meal per kilo for it forever.And it, that I guess in essence, it doesn't matter how much you give.But the question now is, how little can we give and not run out of tea, is, I mean, it is no big deal if it's 1.5 etc, etc.
All I'm saying is, I believe we don't need near as much as we use, but there's nothing to stop us using two meals per kilo.My response would be it's not going to improve the dog.If you got a severe case, it's the V because the toxin is all bound.
And even if you give a second dose of Tas the next day, the mortality is the same, it doesn't change.And as Terry said to start with it, there's over a thousand dogs that we've followed, where we knew the do.So bigoted, about all the other subjective things, we knew the dose and the dose of survivors and nonsurvivors.
They're saying now, if Tas with critically important in those bad cases, that those dead dogs would have had much less Tas and that's why Do I?But it t is is not the keep Factor, the key factor is how much Toxin and how much for paralysis you get plus long.
He's a teacher.In other words, the for diesel, okay, see the more bound, the more severe, it is the less bound the less severe that, but there's no big deal.I mean, all we're doing is trying to get the lowest effective dose because we've got a supply problem.We're not trying to convert the world if you want to use five minutes, we get our go ahead.
And we will generate some new out of here too.We need data all the time we need data because otherwise we're just, you know, we're telling Tales.So to me, there's there's two components to this.The one is a week, as always, we want to save patients and foremost practices, we want to keep them off the ventilators, and I want to figure out practically how to do that.
The other component is going to be the legalities which we'll come back to in a second theory.But first of all, just to try and save those patients or Keep them off the ventilators as much as possible.So I want to recap what you've said about the tick and how this works, because this is really interesting.So Rico am I understanding correctly.
So tick attaches sits there for three days to switch on the Machinery.So to speak before it starts becoming dangerous.Yeah.And exactly.Right.Then it will spur sporadically injector s2j creased and it's injecting.Tiny amount of toxin that goes into circulation for a very lovely brief period of time.
And then binds.And then, once it binds, nothing we can do about that dose that.It's injected, it's the nice.Exactly.Right.It's the next little dose that we try and address with that says, hmm.So the key things here, for trying to save them is to get that ticket.As you said, you get that tick off there.
So we stopped at pushing, more Venom in because once that Venom is in, its going to escape us basically relatively soon, we only not for everybody.I, it's just that was that either the dogs that had their tics plucked immediately.Lee and plucked mean squeezing and all those other things that people have spoken about or it's going to make the dog worse.
Well the dog has a disease that is Progressive, so no matter what you do to you scratch, it behind the ear is still going to get worse because the disease is Progressive in those dogs.Those 16,000 ticks, I mean, we had 10 ticks per dog and we take them off at 72 hours.
Now, those dogs have no signs at all.None of the dogs got toxic as far as clinical Since concern.So we know there's a period where they're not secreting enough toxin to produce disease and by day four and a five.If you look at the data, dogs died, a 5 or a date.
If you know very cold environment ticks on cold guys they don't load properly, they will not load, so climatic conditions.So heat is not so much to do with how many ticks are out and about it's to do with how excitable those dicks.
I have had they working So then we've got our ejecting a little bits of toxin into the bloodstream.So I tears is really there to mop up.Whatever hasn't gone through yet.So you get your tick off, they remove the sauce, get your tears in quickly, rub, that's what we learn and get it in because they we don't know how much of that toxin is still circulating in that interim.
So you want to get it in there really quickly.How long are we talking?Do we know how long it hangs around for?No one can find it in the circulation?Well, if you can't find it, it means it's either very small or it's not there.And if it's in the year on which I think Andrew said that I might be wrong in that, be says something that Toxin and Huron.
If it's in the Cure out it means it's gone out of circulation.So it t is card effects.It's a rapid treatment, really like the how much there's is the big question.Some tears.Sounds like the answer is to go to mop up.What is still there?And then once once that ship has sailed it sailed and then we stuck with, that's right.
And then it is about critical care to keep them going exactly, right.Critical Care is the answer.Yeah.Rub Critical Care has come so far, Heather.You know, I'm sure you would have seen the same thing over the last 10 years or so.In emergency, in the old days, we couldn't even keep up with the number of patients.
We would treating, you know, just to give him, the Taz was hard enough, but now we're much better as Veterinary intensive, care facilities, at recognizing, respiratory failure, early and treating it aggressively.And I think that's something that we should try.
Communicate today is that that is Paramount to a to a successful outcome in these patients.They're all.They're all much sicker than they look.Is is a safe assumption.Yeah, they definitely do often go downhill.Very quickly and certainly, I know Ellie mentioned at our meeting that you guys are seeing a sort of a, about of tech cases come through, where they're presenting as one ages, and then rapidly deteriorating and heating ventilation.
And that's something we're appreciating in Sydney as well.So, I think you have to assume and warn owners that they can all head south and that they can all be quite unpredictable.So talk to us.Heather about recognizing, watching for recognizing and what do we do about it?Eh, when they, when they deteriorate like that.
So, Rob from your research and what you guys are seeing here.That is that aspiration is that when we start shifting from, can't breathe, because I'm paralyzed, your can't breathe, because I've got pneumonia happening.Aspirations are a game changer and just one single vomit can really change.
The outcome of a case.So regurgitation I should say.So I think it's really important to have these patients monitored if possible Round the Clock, because often these things will happen overnight in clinics when there's no one there.So, yeah, absolutely.We're seeing pneumonia as being the leading cause of death in these patients.
So what do we do about it?Because as you say, we wanted to them like where I watch them like Hawks and then we go, oh shit, yeah, so he gets early support so things like oxygen.Therapy.So we're using a lot of nasal oxygen in these patients early antibiotics as well.
So I know Rob's done a study that's proven early antibiotics will change outcomes.So we do escalate to antibiotics, we're doing a lot of entry point of care, ultrasound looking at lungs.This season actually doing a study in that in clinic at the moment.Yeah.So early antibiotics Advanced care.
If they are regurgitating a lot offering intubation and ventilation to protect our ways early on rather than leaving it like leaving a dog sitting there regurgitating for Days on end actually protecting that Airway actively all of those things what we're working towards in our Clinic the interested in the in the ultrasound Heather is that for research purposes or you're actually using it to make decisions.
Well, be looking for bigfoot, be lines and yeah it's a bit of both.We're looking at the studies looking at whether it changes our treatment so we're making an assessment in what we would do whether that patients going to get a standard treatment and then a studies happening.
Whether performing an ultrasound and then filling out a questionnaire as to has this changed, what we're going to do and we are finding that we are changing treatments.It's very early days in the research.So I'm not going to make any statements about it at the moment but yeah, it's more antibiotics are being used.
I'd say as a result of the study.How does that with that?Because we stuck in that Spirit of we're saying okay we should all use your antibiotics but it sounds like with ticks.We should not delete Ellie.Yeah.When When is the When do you go right?I'm starting on antibiotics and then when we start whatever using so any animal on on oxygen is getting antibiotics with us, any patient that's persistently, regurgitating and not an intubation, we would start on antibiotics as well.
And also using our be Pocus findings, whether that that will also help escalate.If we're seeing shred signs, if we're seeing be lines starting antibiotics in those patients to, and, which antibiotics are you using?We're using Ivy Club.I know that differs to what Rob's using and then, For ventilator cases where we've picked has on those ones is our you use from, we had IV, clave, that would be an excellent choice but we're using generally broad-spectrum penicillin, so IV ampicillin or kefir zsalynn on these patients but much much earlier.
So, what we'll do is, when when we see obstructed breathing, there's got to be some degree of pulmonary parenchymal disease, The Tick, paralysis itself, doesn't cause obstructive breathing.So we're using That has a point of care ultrasound as a point at which you might investigate further.
And ideally we'd say take it chest x-rays but that's not always the case at the very minimum start antibiotics.Once those patients are intubated and on ventilators and we're generally amending that protocol the pain, the antibiotic use depending on culture and sensitivity.
But I really wanted to hear from Terry about the vet surgeons board.And so I thought, you know, maybe we could move Terry and find out.What things are we doing to get?Get complaints to the vet surgeons board outside of tick dosage because it has hosted you ever come up Terry?
No, well, not certainly not in my time and I've also done a bit of a straw poll around some previous board members and none of them remember any time that it does has come up now, it may come up if this shortages does come out but I would doubt it.
It's For a person, like you asked for an opinion on a Case, being handled would be on how that case has been handled clinically.And we thoughts just expect that narak to act as to what would be expected in the veterinary community and the bit about offer for referral.
Absolutely.So for example, if you had a veterinarian in west of birdsville, Veterinarian.They would not be expected to be able to ventilate a patient, but as long as steps were taken in there was, what's called informed consent?
Whereas a vet in South East Queensland, for example, would be expected to offer referral, even the person out in the bush and say it might take you six hours to get in, but you'd be better off going into a 24-hour Center and as long as the client understands that or is told that, and it really is Helpful.
If your document that occurred.Well, then it's informed consent as to you you and you know, made a decision on what was the next partner in treatment of that dog?That complaints that have come up in?They've been quite a number in my short time on the board over a year where the complaints have been on a Mystic.
So the dog has gone on and died.And another tick has been found or and the other one was not treating the dog early enough.Like I turned up at four in the afternoon but dog was paralyzed or getting wonky.They said, take it home and come back.
If it gets worse or by the next day it's very much worse and goes on and dies.So to me the things we've been really trying to get out to our practitioners is if you think it's a tech strongly, consider creating a protect and secondly, the minimum standards that you guys came up with for tick.
Search is as long as that's documented, that's it.I've been a tick search because we know from Rick's experience is just how difficult these things are to find.Even experienced, people can't miss them.So, boards are very much saying you're not expected to find a hundred percent of ticks 100% of the time, but you are expected to search for ticks 100% of the time, okay?
So to recap Terry to keep us out of trouble, and it fits with the also trying to save the patient's, most effectively.So when they come in, Of at, as if there's a tick, don't go.Well, I think I don't know his clinical.Let's see if we can avoid treatment, go home and watch.
So say, yep.There's a big Corporation is a great as it risk, and then listening to a drink said, it sounds like.Well, that is really the probably the ideal period to treat this to go.Well, there's a tick there might be some toxin in.They give it some tears, you can bet based on to use to, it's just before they develop clinical signs and it in theory, so we offer tears.
And then I say, yeah, let's treat.And then we're going to say next, They always worried about the second tick, so advised that you're going to do it to clip if it's appropriate.And this, it's a very short head there.Feel something particular pit, so that you can say to the board.Yes, we did everything within our power to try and find that second thing that caused the deterioration of this animal.
So, treat early shave them if they don't look great of a referral, if possible at all, within back to the, as opposed to the purpose of this recording, back to the dose again.So, in the past, those And been an issue with the board, probably because we all just used kind of standard doses.
Right now, if we're at a point where people are going to start getting creative with those has, why does a safe dose?Let's say somebody listens to this and goes I like what Gregg says I'm going to use bricks dose, is that the kind of get you in trouble potentially even if it makes clinically sense?
Can there be a question mark around the head with a board?Might say, well that's Rick's going out on a limb with that and I we don't make sure about that or is it It's fine.You gave some tabs and make sense this data to back it and it's defendable.Yeah, I think as long as you argue the case, why say, for example that there doesn't end up being antiserum shortage at all, you might have to explain a little bit more.
Why you chose the very low dose do straight and you would quote those papers of course.And I would, I would be very surprised if that would not be accepted.That you decided on that.And you said to the client, the manufacturer says this, we've got a very big shortage and we've got some very experienced people that believe that we don't need to give as much as what we did.
And I'm afraid that's what we've got to give.Then I would sit don't see a problem.The client could make the decision, perhaps, that they might ring, the guy next door and see if they've got more and I can see where all this is going.
It's it's not always in the patient's best interest to be moving him around all the time.Yeah, but you would have to make that informed decision with the client ugly.So we do, do you recommend discussing the change of those with our clients?Is it something we would go look, we never told the clients how much Tans were giving anyway so are we going to just know?
So I we never have and so are we going to say to should we be saying so claims?Hey there is this situation because of that we are giving less than we used to Are you okay with that or just you have no choice?That's what we're doing because that not open the door up for complaints.If something goes wrong then they're going to say Well it gave less and that's where my dog died.
Should we just yes?Somebody's sensitive?That's a decision.You got to make.Is that that will that cause a problem with the client by saying it.But if it was my client, I'd say absolutely yes.It's I'd believe I can inform.Most of my clients along the way.
Now, it's a very difficult time.I and I know what's happened, but Late nights and weekends.When emergency centers are overrun that you've got to sit down and have another discussion again on the dock.But if there's any condition that causes problems associated with vets and their clients, it's dick paralysis.
So I think it's got to be part of your long discussion with every single tick.Case, Heather.What are you guys doing?Are you going to tell people?Yeah, well, this this opens opens it up, does it really?It is a really challenging position to Yourself in as a bit working in emergency clinics.
Particularly I know the majority of our clientele might be happy with getting a reduced dose.They want their dose their full dose for their pair, that's in front of them, we can call around to other emergencies and vital.Yeah.So, it really does put us in an awkward position.
I've advised my vets to do like a gentle dose, reductions that we don't have to discuss with the owners more in line with what Rob's doing and I I think that it's defendable.If I'm going to the board I'm taking it with me to argue, I keep thinking, hey there we have this recording.
People can just send this link to this podcast, but it's a well, listen to this.This is why I did what I did.Yeah, look that's and that's, that's the difficulty being in this Tech advisory panel that you know, you're making these recommendations and we don't all have the data.So I think the published studies that we've got will support lower Doses and we just have to reduce our dose and I think it's a really difficult.
And as a vet, I rang actually rang the New South Wales, bet practitioners board and they said, you know as a vet you can use an off-label dosage.So my understanding was that, as long as you could defend it, it was reasonable to do that without telling the client that you're giving them potentially a in their view, a sub optimal treatment really.
But I could be wrong Terry.I'm not sure you probably have got more knowledge around that then you would never get there trouble from the Queensland.Resurgence board in that regard because of the way you've just said it.Yeah, I would suggest and it was me.
And I treat tick paralysis dogs for 45 years, but I'd be being gentle with my dampening down of the dose purely because of my historical usage of the stuff.And I'd take on board everything that we've talked about.But I'd be trying to be a little bit gentler with the dropping of, and that's just me Rick's idea with manly Road sounds wonderful.
To me and will be great to see How their year goes with that too and I know that won't mean 100% but it'll be a pretty good guide for my money for next time.And I'm fervently hoping that we don't have to do this for much or or if, if at all and we'll get back to where we were going back to that to the label utzon, absolutely.
A label used means that you can't get into trouble on that Dost or would be very difficult to get in trouble, but look at how much label use Raise and how much evidence has come out of label, use you know, different drugs, look at trial or stone example.
The label uses three to six milligrams per kilogram.Once a day, there's absolutely irrefutable evidence out in the veterinary literature.Now to show that one mccaig be ID, so somewhere between a third and a half, the label dose is more effective.
So totally did you know, it's a drug not an antiserum.I'm just using a drug a result.Label use 11, make the cake SI D, very good battery.Literature the show that you need to give a twice a day to for it to be effective.
Now, it's an off-label use in dogs anyway, but the label use tends to not get you into trouble, but you can argue off-label uses all the time in the world.Heather T in Queensland, we have a lovely supportive, Veterinary surgeons board, a better climate and that you don't mention that lots of awesome Physicians for Urgency veterinarians up here as well.
So you probably and, and with got about any bottles that kicks, the deer.That's very, very lovely, but I hope none of the New South Wales, emergency vets are listening, so, I hope they come to our practice.
Yeah, there's definitely an emotional component to this because I'm quite happy with the dose reductions and especially right, listen to Rick and I go well, logically, that makes a lot of sense to me and then I thought, But what's going to happen if my dog accidentally, let's say we slip up on my beloved Billy.
Dogs were Vector 1 month and he ends up at the hospital.Am I going to be brave enough to go to reduce those for him?Or is he going to get to full?And and it's again it's just that habit of its Star Comics.Are we missing anything?No, I don't think so.I was going to put my two cents in on client discussions in that in our grooves.
We're definitely not mandating that that's talk to clients.What we're doing is coming up with the most effective strategy that we can use.And if we need to defend that strategy, we will.But because of the complexity of the number of clients and the number of different veterinarians and the Really heightened level of stress.
In emergency at midnight, the chance that we can regulate.Those discussions is really low.It's more likely we believe that we're going to trigger more complaints by having those discussions at the Time because as soon as something goes wrong which 9 it 9 out of 10 times is going to be pneumonia or client running out of money.
It's going to come back to, we gave a lower dose of kick Andy serum than was recommended.And yeah, the client will have a reason they can point at that something went wrong.So they are group is reached a decision to what we believe we can support for veterinarians using and then we'll support that wherever we have to take it.
Hats off to Terry though.I'm sure Terry you.Communicate that effectively to every client.You see.But I just think we've got too much complexity there.Yeah, I get you.I get you the trouble.Yeah, I think that's a reasonable way to go because what would happen, for example, if that went to the veterinary surgeons border complained about your treatment and it was picked up that you gave .01 middle per kilo of adding serum.
The veterinary board would probably want another an outside opinion on that to say whether or not that so they would send it out.Usually to imminent veterinarian.So we would be likely to send it to Heather Russell and asked her, if she would be willing to provide an opinion on that on the way that animal was treated.
And has she agreed to it and then that opinion would be fairly waited upon in the board's deliberations.And we also being Queensland to, we have a Awful lot of history of knowing of Rick at once, work are Rick and others work to show that, we can see that there's an enormous variation.
So, yeah, I actually get you that, you wouldn't bring that up as part of the client, it's discussion the ones that are very important.I think is whether you want to give tick serum or not, whether you want to click the dog and keep searching your night.
And secondly, where you're going to go next with your Treatment, are you happy with?The fact that we may be going ventilation or we may want to intubate your dog.All of those sorts of things.They're more important in our view.That's super helpful.
Thank you, Terry.Alright, think it's probably time that we start wrapping this up.We could talk about this forever.It's really, really interesting.Thank you, everybody for your time.You know, there's a saying that says, if you're the smartest person in the room, you're in the wrong room.
I think I'm all right.But this room Rob, thank you for pulling this together.I'll get it out this soon.Thank you for all your input.If you like learning on the go through the magical medium of podcast and you like our format of questions do and insights from people at the top of their game, then you should check out our clinical podcast at VV n dot.
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