Improving patient restraint in the veterinary clinic (Proceedings)

Effective restraint is one of those aspects of veterinary medicine that we simultaneously take for granted but also wish we could do better. Restraint techniques are passed on in an almost cultural fashion with little thought given to their logic and effectiveness. Historically, animals were restrained by physically overpowering them. This often resulted in injury to the animal or involved personnel, and/or the restraint attempt failed which prevented successful completion of the intended procedure.

Choosing techniques that build on natural behavioral responses results in more empathy and awareness of the animal as well as a greater likelihood of success. Safety and success are much more likely when personnel strive to reduce actions that the animal may view as threatening or aggressive. Adversarial handling typically increases the probability of the animal becoming aggressive or attempting to escape.

General Principles

A number of factors are involved in triggering aggression and/or escape responses in animals. The most common include fear, pain, punishment (which induces fear and anxiety) and excessive physical contact. Most animals show fear/defensive aggression because they find some aspect of the processes threatening. This may be the environment, the personnel, the equipment, the procedure, the restraint technique used or any combination of these.

Animals are particularly likely to react to handling of certain body regions as well. These include the head/neck, the legs and feet, the groin/perineum, the abdomen, and any area that is painful. These areas are natural targets in serious attacks because they are areas where it is relatively easy to deliver an incapacitating or fatal injury. Restraint techniques should be chosen with these factors in mind. In particular, avoid directly restraining the animal's legs whenever possible as this universally induces even more struggling and aggression. Protection of the legs is a biologically hard-wired behavior.

It also is important to remember that what matters is whether the animal finds an interaction threatening — not whether the technician or doctor does. Often, in the process of trying to be friendly to an animal, we portray body signals that actually mean the opposite. This is particularly true around horses and dogs. The way the average person greets a dog is a perfect example. Most people approach dogs from the front, lean over, and extend their hand to allow the dog to sniff it or to try to pet the dog. There are several elements in this approach that directly threaten the dog: the direct, frontal approach; making eye contact; leaning over; and reaching out over the dog's head. These are intensified if they are done in a quick, tense or agitated manner.

Good restraint is all about empathy, finesse, and technique – it has little to do with strength. If any procedure requires more than two people to actually hold the animal, there is something wrong with that technique for that procedure on that animal for that day. The more people that are involved, the more threatened the animal will feel and the more easily someone will be injured.

Restraint also does not necessarily mean immobilization. Animals have 5 basic reactions to stress or threat – the five "F's." These include fight, flight, freeze, faint, and fidget (or fooling around). The latter is an often overlooked sign of stress. Staff members frequently assume animals that are obnoxious and hyper in the room are just plain stupid or untrained, but this is a simplistic outlook considering the situation the animal is in. Keep open minded that the animal's hyperactivity might actually be a reaction to stress. Punishing these animals usually raises their stress level and exacerbates the behavior.

Restraint dictates that we move into the animal's personal space without the animal's permission. This puts personnel in the "critical zone" where animals are often more likely to attach rather than to try to run away, especially if escape is blocked. Making wise choices as to how you invade the animal's space can reduce this reaction in most animals. Always use the least amount of restraint necessary for the procedure and invade the animal's "intimate space" as little as possible. Restrain the animal for the behavior that it is currently showing – not for the behavior that you think it may show in the near future.

Restraint requires patience!!!!! Some animals need time to adapt to the process; trying to rush the animal will only increase its anxiety.

Personnel should move around and interact with the animal 25-50% slower than their natural inclination. A universal observation I have made in watching people handle animals is that they move too quickly and pay too little attention to what the animal is telling them at any moment. Animals almost ALWAYS warn before escalating attack or escape, especially dogs. The problem is that doctors and technicians miss these warning signs.

Doctors and staff should remain calm and neutral no matter how badly the animal may behave. Poor behavior should be ignored; however, any trend toward better behavior—no matter how small—should be immediately rewarded in some way.

In 98% of cases, injuries to humans occur because someone did something unwise, became complacent while working on the animal, or did not know how to read the animal's body language. Remember that behavior is constantly changing. Just because the animal is friendly at the beginning of the exam or procedure does not mean the animal will remain so three seconds later. Always assume the animal may injure you at any time – be cautious and prudent, but not paranoid. Always keep your body parts away from the animal's weapons. You may be bitten sometime, but there is little excuse for being bitten in the face. Your face should never be anywhere near a dog's or cat's head—it is dangerous for you and overtly threatening to the animal. Always avoid eye contact and approaching the animal from the front, whether it is in a cage, on a table, or on the floor. Do not attempt to approach or restrain fearful or aggressive dogs without first having control of the leash yourself. Always work from beside or behind the animal – do not hover in front of it. Keep control of the animal at all times, particularly its head. Be proactive in your restraint techniques for any individual animal. Sometimes restraint requires a little lateral thinking in order to accomplish your goal smoothly – be creative but remember behavioral principles.

Techniques

Restraint techniques should never involve any of the following: physical reprimands of any type (jerking on leashes, hitting or striking the animal, biting the animal, etc.); pinning the animal's head or neck in doorjambs or under your body; alpha rolls; scruff shaking; cuffing under the chin; hanging with leashes or choking the animal in any way; or "pile-ups" (having several people grab hold of the animal and pin it to the ground or table). Avoid scruffing cats as a routine restraint method. Scruffing actually is not a secure way to restraint a cat, and it aggravates many cats more than necessary. Scruffing does not trigger some magical relaxation in cats. Cats do a have a flexor reflex when picked up by the scruff when they are kittens, but there is no biological advantage for an adult cat to go limp when grabbed by the back of the neck. Adult cats are only subjected to this action in four general contexts: fighting, play fighting, breeding and predatory attacks. Alternative methods can be more successful.

Also avoid "half-nelson" (restraining the dog around its neck with your arm) type restraint techniques with dogs that are unruly, highly fearful of people, or aggressive to people. This technique is unsafe with dogs that respond in any of these ways. This technique is based on strength, not finesse. It is also a HIGHLY threatening thing to do to a dog and places the handler in a dangerous position.

Puppies and kittens are often not tolerant of much physical restraint, in part because the behavioral inhibition circuits in the brain are not fully developed. Distraction techniques work best for very young animals. Do not reserve this just for problem animals; offer it to every puppy and kitten. The most powerful of these will be food distraction such as squeeze cheese, canned food, baby food, liverwurst, peanut butter, etc. Offer it during the entire examination process. Physical distraction (e.g. patting, rubbing and massaging) or distraction with toys also is useful in many cases.

Adult dogs often require and are tolerant of more physical restraint. They usually are more accustomed to physical handling. Their experiences may have been positive and/or negative so a particular animal's reaction to such restraint may vary greatly even from moment to moment. Similar to puppies and kittens, food and physical distractions are still powerful tools for adult animals. Dogs should not be allowed to roam unrestrained during your procedures. They also should not be allowed to turn and put their faces near yours; keep their head directed forward by maintaining a guiding hold on the their collar (not the leash). Do not grip dogs around the muzzle during restraint. This is an extremely threatening thing to do to a dog, and you can easily be bitten with your fingers so close to the dog's mouth. Use a muzzle if necessary but be sure the muzzle is large enough that the dog can easily get its tongue out of its mouth. This helps reduce panic reactions, allows for normal respiration and thermoregulation, and allows you to try food distraction as well. It will also help prevent aspiration in potentially vomiting animals. Stiff Elizabethan collars (e.g. Saf-T-Shield) are an excellent alternative to muzzles for dogs that cannot be muzzled for behavioral or medical reasons (e.g. nasal tumor) and for aggressive cats.

Physical restraint techniques should be humane and focus on restraining over bony structures. When restraining a dog's head, cup the dog under the jawbone with the angle between your thumb and fingers on one hand. Place the other hand, with fingers facing forward toward the dog's nose, across the back of the dog's head where it meets the neck (the occipital region). This hold gives excellent control of the direction of the dog's head and keeps your fingers clear of the dog's mouth. It also prevents the holder from digging his/her fingers into the dog's intermandibular space or holding the dog around the throat – both of these actions are painful to the dog and will make it struggle. Particular care should be taken when examining the dog's ears, eyes and mouth until you know how the dog is going to react to the procedure.

For most dogs, jugular venipuncture is the safest and most humane method of collecting blood. It allows you to avoid restraining the legs and you can pull a large amount of blood in a short period of time. It also permits humane restraint without the holder having to lean over and put his/her face near the dog's head (as happens when holding off a cephalic vein). For dogs that are apprehensive about head restraint, a lateral saphenous vein is the next preferred method.

Dogs that are visually reactive often can be calmed by gently placing a towel completely over the dog's head. This is possible even during jugular venipuncture. Head collars (e.g. Gentle Leader®) are also useful for controlling fractious dogs.

There are a variety of special restraint tools on the market for dealing with cats. Some of these are useful while others are quite impractical (and often expensive). For the population of cats that can be handled safely awake, the procedures in question can typically be accomplished with six simple tools or steps. As with dogs, food and physical distractions can be powerful tools for feline restraint. Safety zones and towels are two of the most helpful tools for cats. Safety zones include cat beds and carriers. All cats should arrive at the clinic in a modern style cat carrier. Although, cats seemingly detest their carriers at home, the carrier often becomes the place they are the most comfortable once the cat reaches the clinic. Cats should never be dragged or dumped out of a carrier! Take the carrier apart and allow the cat to remain resting in the bottom half. Physical examinations, venipuncture, skin scrapings, vaccinations/injections, and other procedures can be accomplished with the cat still in the carrier. We have even performed cystocenteses with cats in their carriers. Cats should be transported around the hospital (e.g. to radiology) in their carrier. If the cat must be put in a cage, at least the bottom of the carrier should be placed in the cage with the cat if at all possible. Cats can be gently wrapped in towels in a variety of ways to control their head, forelegs and hind legs. This method is preferable to actually holding the cat's feet or legs with your hands since is it safer for the holder and less irritating to the cat. Cat muzzles have poor efficacy. Stiff Elizabethan collars (e.g. Saf-T-Shield) are an excellent and inexpensive alternative.

Feliway spray is a synthetic pheromone that appears to have anxiolytic properties in many cats. This can be sprayed on towels used to handle the cat, on Elizabethan collars or even on your hands. Analgesic doses (0.2 mg/kg IM) of butorphanol (or buprenorphine) often have a very calming effect on cats. This opioid is short acting and usually does not sedate the cat to objectionable levels. It is intended to take the irritable edge off the cat. Used in combination with Feliway and the above tools, it can make a dramatic difference in a cat's demeanor.

Sometimes simple changes in the immediate environment can dramatically affect an animal's reaction. These include where the procedure is performed (e.g. exam room versus outside the clinic), presence or absence of the owner, presence or absence of another animal, and the personnel's' attire (e.g. lab coats). Note: Animals should never be taken away from the owner in order to perform a restraint method that you would not be willing to do in the owner's presence.

Some animals are too distraught to be handled safely awake no matter how perfect your handling may be. These animals should be sedated promptly at the start rather than after someone has agitated the animal by trying to make the animal "submit". The safest restraint method for seriously aggressive dogs (dogs that cannot be touched at all) is the barrier method. The dog's leash is threaded through an open barrier such as a cage door or chain link fence. The dog's head is rapidly but calmly pulled up against the fence while someone else simultaneously injects the sedative intramuscularly into the dog's hind leg. This entire process should take less than 5 seconds. The dog should be immediately released and placed somewhere quiet to allow the sedation to take maximal effect. Rabies ("catch") poles should not be used on client owned animals. They are potentially very dangerous to the animal. Their use can habitually be avoided by adequately monitoring an animal's behavior and being proactive in making restraint and decisions. Always keep in mind that you can kill pets with your restraint procedures.

Summary of Important Points:

1. Staff should be trained in basic behavior for the species on which they will work. Learning to read body signals, particularly stress signals, is particularly important.

2. Avoid approaching animals, especially dogs, directly from the front whether in the exam room, treatment room, or in a cage.

3. Avoid sustained direct eye contact.

4. Handle the animal while facing the same direction as the animal is.

5. Avoid restraining cats by the scruff and avoid holding dogs around the neck with your arm, especially if the dog is fearful and/or aggressive.

6. Do not hold dogs by their muzzles.

7. Never lean into the animal's face or place your head or face near the animals head or its claws.

8. Remember that aggressive restraint episodes not only leave a lasting emotional impression on the animal (and the owner and staff) but also predispose the animal to potentially serious physiologic side effects (including death).