Guidelines for Operating Remote Clinics

Transcription

1 Guidelines for Operating Remote Clinics Susan Monger, DVM Founder and Director International Veterinary Consultants Web address: Facebook: International Veterinary Consultants Operating a safe and humane spay/neuter clinic requires planning, patience, communication and flexibility. This is especially true when planning a clinic in a remote or challenging location. Operating a clinic in a culture different than one s own, or in a location that lacks normal and routine amenities, requires additional planning and even greater flexibility. Establishing a minimally acceptable standard of care to be demonstrated before, during and after the clinic based on availability of equipment, supplies, trained staff and volunteers, ensures the individual welfare of each animal as well as safety for all team and community members. If individual animal welfare may be compromised during the clinic, the goals need to be reassessed. Demonstrating respect to each, individual patient throughout the clinic demonstrates respect to the community and the veterinary profession, building a relationship which enhances animal welfare and decreases animal suffering around the globe. 1.0 Introduction Every spay/neuter clinic requires tremendous effort in planning no matter the setting. Executing a well-run, safe and humane spay/neuter clinic under field conditions in remote areas requires even more planning and organization. Unique challenges that field clinics in remote areas face include access to locations, limited access to materials and medications, inconsistent electricity and water, as well as prospective patients with compromised or marginal health. Many firstworld amenities that we take for granted are luxuries in these remote areas and must be accounted for when developing the clinic. Regardless of the challenging conditions, a minimal standard of care exists that clinics should mandate to ensure the safety and well-being of the animals as well as the clinic staff and volunteers. These standards not only affect the immediate and long-term outcome of the patient, but also the relationship and education within the community. Cultural, professional and diplomatic sensitivity is imperative to the success of the clinic itself as well as the future of animal welfare and health within the community. Protocols and standards should be established for each individual clinic with an adequate understanding of the unique characteristics of that

2 locale. If a clinic cannot establish and/or maintain an acceptable level of practice and care then one must reassess the approach to a field clinic and goals for that community. It is recognized that there is a wide range of what is considered minimally acceptable protocols and standards. We base our recommendations on hundreds of spay/neuter clinics that have been organized both nationally and internationally, lessons learned from failures and successes, in addition to constant evaluation within the changing arena of field clinics and shelter medicine. This chapter provides guidelines and suggestions to plan a field clinic and establish a minimally acceptable standard of practice and care based on availability of equipment, supplies, trained staff and volunteers. For more detailed descriptions on anesthetic procedures, sanitation, and the spay/neuter surgical procedure itself, please refer to the relevant chapters within this book. A list of relevant websites and guidance documents is also available at the end of this chapter. Practical tips for success Tip #1. Determine what is an acceptable standard of practice and level of care in the conditions you are working. There are ideal practices in an ideal setting. Field clinics however are often not in an ideal setting and may require a redefined minimal standard of care. Establishing and maintaining an acceptable standard of care to each animal/patient is the guideline for establishing what is acceptable in the place you are working. Tip #2. Learn to say no. If the individual welfare of an animal is compromised due to lack of supplies, sufficient staff or logistics, reassess clinic goals and capabilities. Prior to the clinic one should: Determine the type of clinic: stationary, MASH-type, mobile. Determine the project s budget, which will dictate supply and medication ordering. Assure adequate staffing. The number of experienced veterinarians, technicians, clinic assistants and volunteers should be sufficient to adhere to the best practice possible and ensure adequate standard of care and safety to patients and staff. Tip #3. Be willing and able to adapt to the circumstances. The best-laid plans can sometimes go awry. Tip #4. Cultural awareness is imperative to the success of the clinic. Every attempt should be made prior to the clinic to gain knowledge and insight to the country and area you will be working. Tip #5. Assure translators will be present if needed. If there are different languages spoken by participants and the local language differs from that of the staff, there needs to be sufficient, medically educated translators in order to ensure proper communication.

3 Tip #6. Recruit and utilize volunteers with field experience. The reality of the clinic and the conditions of the animals can be shocking to some volunteers. 2.0 Planning Field clinics require extensive planning well in advance. Even with great attention to detail, unforeseen circumstances can undermine the best-laid plans. Potential obstacles, particularly those that could completely halt clinic operations, should be identified well ahead of time. Sterilization surgeries are almost always optional surgeries and the safety of each individual animal as well as the staff and volunteers must be kept in mind. In general, first time clinics require more time to plan than subsequent clinics. It is recommended to plan a reconnaissance trip of just organizers to evaluate potential needs, identify problems and establish a relationship with local residents to aid in planning and logistics. Some field clinics are more logistically challenging than others. This may be due to difficulty accessing the location, a large, proposed number of surgeries and/or days of operation, or a large professional and support team. Repeat clinics or clinics close to an operational base may have a shortened timeline due to proximity and/or known site logistics. The most important planning considerations are included below. 2.1 Determine the type of clinic appropriate to the working site Stationary clinics take place at a fixed site and structure or building that can have many of the same supplies and equipment of a high quality clinic. MASH-type set-ups can include anything from a tarp stretched over a cleared area in the jungle to a gymnasium. These clinics can be set up for one or multiple days. A major downfall of these settings is that they can be labor intensive as the clinic may require setting up and tearing down to move to another site. Excessive movement can cause wear and tear on equipment and supplies. Mobile clinics usually involve a clinic on wheels that can be driven and parked in various areas. These permit easy access to areas where animal transport is challenging. Downfalls of this type of clinic include a high initial overhead and expensive upkeep. The weather and roads may dictate the ability to drive to certain locations. If lacking sufficient space to kennel and recover daily caseload, accessory facilities and clinic materials for intake and recovery will need to be determined and moved accordingly as well. 2.2 Create a timeline and checklist of to do tasks and goals. It s necessary to keep track of specific items to attend to well in advance of the clinic. This should be done 6-8 months prior to the clinic start date. Many staff and volunteers require significant notice in order to attend the clinic. A suggested timeline is included as an addendum.

4 2.3 Investigate in-country communications Identify an in-country and on-site person in charge of local details and communication. The success rate of a clinic and future clinics depends on a reliable on-site person to coordinate logistics and be available for follow-up communications. This person must be able to communicate with other organizing personnel in a common language. Key team members must have local language skills in order to adequately communicate with locals. This also demonstrates respect to the community, which aids in gaining their trust. Internet/phone availability on-site must be considered. It must be recognized and acknowledged that cultural differences and/or the difficulty of access to computers and the internet may affect the frequency of communication. Every effort should be made to meet with local government authorities. This can be challenging due to many factors: animal welfare is often not a priority; there may be an expectation of monetary support from the local or national municipality; there is often a lack of knowledge, even among the locals about who is the right person or department to communicate with. Successful collaboration is worth the effort however as it can facilitate immediate and/or future assistance with planning, monetary, in-kind or personnel support, advertising, and community education regarding the clinic. Seek out and meet with any local veterinarians. It is important to be cognizant that the field clinic may be perceived as a threat, infringing on livelihood, and that the difference in professional experience and education may create a feeling of embarrassment of veterinary knowledge, skill and professional standing. However, by approaching and communicating with any local veterinarians we may create an educational opportunity to elevate local standard of medicine and skill set in the area, long-term. 2.4 Acquire permits This can be one of the most difficult, time consuming, frustrating and sometimes expensive aspects of the clinic. Any country has the right to hold or confiscate equipment and supplies upon arrival at customs. Export and import regulations vary from country to country. Find out specific requirements well in advance of travel dates. If equipment and medications (especially pharmaceuticals) are to be imported, import permits are often required. These requirements may include official permits issued with regard to a specific equipment and medication list provided by the importee, lists of lot numbers, manufacturers and expiration dates of medications and vaccines, and letters of invitation and support from the local organization sponsoring the clinic and proof of professional licensure.

5 We recommend bringing multiple copies of permits and communications upon arrival in the country How to acquire permits Permits always require a local person capable of communicating with authorities. Ask other animal welfare groups working in-country for advice on the proper permitting process. Reach out to human medical or dental groups working in that country. It may take several attempts and perseverance to identify the proper governmental agency. Attempts to contact the proper authorities may not be acknowledged. If this is the case, it is advisable to have copies of attempts to communicate with the local authorities to acquire the proper permits. These communications can sometimes suffice when attempting to enter a country or to receive proper authorization to export or import equipment and supplies. Almost all official permits are in the recognized language of the destination country. Some official government organizations may require official translation into their respective language. Ex: The United States Drug Enforcement Agency (DEA) requires translations into English of permits received from the destination country. Official customs brokers can ease the import process but can be expensive and there are no guarantees. Ensure they are legitimate and credentialed. Know the laws. Just because one veterinary aid group provided care without permits does not mean their import process was legal Consider controlled substances Bringing controlled drugs often require separate permits from the country of origin and destination country. Whenever you are transporting controlled drugs, the transporter must hold a valid DEA (or equivalent) and veterinary license, and carry copies of both. Keep in mind that drugs that are not considered controlled in one country may be a designated controlled substance in another. For example, acepromazine is a recognized controlled substance in El Salvador yet it is not a controlled substance in the United States. Controlled drugs considerations The DEA import/export department in the United States contact information: The DEA in the United States has contact information for the recognized Competent Authority (host country equivalent of The DEA) which is the recognized point of contact by the DEA of the respective host country. For countries other than the United States, it is recommended to contact the government agency responsible for granting exportation of controlled substances. Consider the possibility of left over controlled drugs and how you will address surplus

6 controlled drugs Even with all the correct paperwork in order, supplies may be confiscated, held in customs and/or taxed for import. Unexpected fees may need to be addressed. In a worst case scenario this could lead to a trip cancellation and/or severe compromise of clinic s goals. 2.5 Determine local and national holidays Local and or national holidays can greatly affect the success or failure of a clinic. Many foreign countries completely shut down in order to celebrate a specific religious event or holiday. It is thus advisable to check the local calendar for such holidays and events before setting dates for a clinic. This can vary from region to region even within the same country. Unforeseen celebrations and rites of passage such as a funeral or a wedding sometimes occur simultaneously with planned clinic dates. These cannot be avoided and must be respected. 2.6 Obtain medical evacuation coverage Medical evacuation policies are relatively inexpensive and strongly recommended for each team member to obtain prior to travel. It is recommended the lead organizer create a list of all team members, their respective contact and evacuation policy information in case of an emergency. Suggested sources: MedExAssist: International SOS: Plan airline travel Have identification and flight information inside and outside on luggage. Identification should also include destination contact name and address if at all possible. Plan ahead in regards to luggage. Excess baggage fees can be costly, especially if over specific weight limits, thus it may be worth considering dividing up supplies amongst travelling team members so as one or two lost bags do not overly compromise the whole trip. Division of supplies among team members also helps diminish excess baggage fees. Check with airline prior to travel dates regarding supplies to be carried on or in checked baggage Know your embargos Weight embargos: Certain airlines have specific times of year that limit the amount and weight of checked baggage. Box embargo: Certain airlines occasionally have a box embargo. American Airlines has been known to disallow boxes such as Rubbermaid Action Packers at some points throughout the year.

7 2.8 Investigate professional licensure restrictions There is a wide variation of licensure requirements of veterinary professionals providing services in foreign countries. The United States has strict requirements with regard to licensure of foreign veterinarians practicing in the United States, yet other countries may have few or no such requirements. The cost of services provided may affect this as well. Some countries do not object if the services are provided free of charge whereas charging for services may affect the need to acquire and/or demonstrate licensure. It is the responsibility of the person in charge of organizing the clinic to investigate any specific requirements of licensure. All veterinarians should be of good standing and licensed to practice in their respective countries. All veterinarians should carry copies of their respective country s licensure and controlled drug permit if indicated. 2.9 Determine a supply list One must determine what supplies are critical to the success of the clinic. This can vary widely from clinic to clinic, and will be determined by the protocols in place for the respective clinic. Team members should be aware of the likely possibility of little or no availability of even basic supplies and/or drugs in the country of interest. Economics of the clinics may not support a wide variety of supplies or the safest yet expensive medications or monitoring equipment. However, many clinics are performed humanely with minimal supplies and only basic medications Create a supply manifest A manifest or checklist of equipment and supplies and approximate amounts will help minimize the lack of appropriate materials and medications to adequately and humanely provide services. A manifest broken down into categories addressing all areas of the clinic will more easily assure having the appropriate equipment and supplies for each area of the clinic. It is best to include everything you can think of, then pare down from there depending on the specific details of the clinic and the ability to transport supplies. (A suggested complete manifest is included as an addendum) Acquire supplies in-country It is recommended to investigate the cost and ease of acquisition of supplies in the host country versus the cost of supplies in the country of origin. One must include the physical cost as well as the logistical cost of time and effort of exporting medications (controlled drugs for example) and import permits to get supplies into the country. Sometimes an increased cost in the host country is worth it if it minimizes the incurred cost of transport as well as the concern about customs and permits. If working in a foreign country, it may be difficult or impossible to acquire specific medications or equipment. This is especially true with regard to opiates and analgesics that are easily available and affordable in first-world countries. There can be a marked difference in quality of

8 medications acquired in-country. It has been noted that a routine dose of some specific anesthetics acquired in-country will not be sufficient to arrive at and/or maintain a surgical plane of anesthesia. As an example; ketamine acquired in one foreign country required almost twice the recommended loading dose to attain a surgical plane of anesthesia for the patient and several patients demonstrated seizure like activity such as tremors or convulsions while under anesthesia. Be sure to also have a plan in place for safely and adequately storing leftover supplies or donate them to local veterinary professionals Arrange food, lodging and transportation Specifics regarding food, lodging and transportation will vary according to the accessibility of the site and number of team members. No matter the overall intent of the clinic, food, lodging and transportation need to be addressed in order to address safety of all team members and accommodate them as best as possible under the specific circumstances. The time taken to arrange these details prior to the clinic versus during the clinic may drastically affect the amount of time devoted to the clinic. Additionally, when team members know what to expect and can plan for it accordingly, they will be happier and more efficient Food and water Every effort should be made to address the dietary considerations of each team member as well as the host country. Do your research and prepare your team ahead of time to ensure the local culture is respected. If a team member has specific dietary restrictions that fall outside the cultural or physical capabilities of the host site, they should be responsible for supplementing their diets in a manner sufficient to address their dietary restrictions throughout the clinic. Cultural considerations are necessary to respect the local culture. Ensure team members thank whoever is providing food and lodging. Food and water to be provided throughout the working days should be addressed by the local organizer prior to arrival. Clarify who will be responsible for providing food and water, and ensure supplies are adequate. Local restaurants and community members can often be organized to support the clinic by providing food and meals. Team members should be encouraged to bring supplemental food and water sources as sometimes even the best laid plans fall through and meals and/or water may be scarce Lodging Identify and confirm secure, safe lodging for the appropriate number of team members prior to arrival. Inform participants ahead of time what amenities they can expect. In some locations showers, beds, and blankets may or may not be available, and participants need to be informed

9 so that they can prepare accordingly. Plan ahead and advise team members so they may bring what they need to be comfortable. Local hotels and community members are often willing to support the clinic by hosting team members. Again, ensure team members thank the respective people or lodging sites for assistance and support Transportation Arrange and confirm transportation for team members arriving to the country or clinic site to their lodging prior to the clinic. If daily local transportation is needed for team members from lodging to the clinic, arrange and confirm this prior to the clinic. If the clinic is MASH-style and will require moving equipment and supplies, arrange and confirm these arrangements as well prior to the clinic. Vehicles with 4-wheel drive may be a requirement for transportation in some locales. Discuss this with the in-country coordinator prior to arrival as 4-wheel drive vehicles may require time to reserve and be expensive Communications and advertising If the intent of the clinic is to address owned animals, advertising is necessary in order to inform the community of the intent. Advertising is also a means to educate the community as to the benefits of the clinic. If the intent is trap/neuter/return (TNR), then the community needs be aware of this as many free roaming dogs and cats are owned yet roam free, and some owners or care givers may object to sterilization without consent. If more than one language is spoken, assure that there are enough people for adequate translation when required. Advertisement methods Radio Schools Churches Local markets Social media Flyers Mobile public announcing* (this consists of loud speakers in the back of a truck or on top of a car driving through the community announcing clinic details) Local government officials such as mayors and public health officials *One of the most commonly used methods in large regions of the world

10 Organizational meetings Organizational meetings are essential to team building and identification of key personnel. Ideally much of the logistical information and information about the host country or clinic site should be shared with the group prior to arrival. This provides essential information and common ground for the organizational meeting. Attendance is required even if it is a small number of team members and even if a team member has participated in many clinics prior to the clinic in question. If team members and volunteers are arriving throughout the clinic, establish a meeting or method as to inform them of key personnel and chain of command, such as T-shirts of a specific color to be worn by key personnel. Clinics can become chaotic with the number of people and animals waiting and any number of other issues that may arise. A chain of command minimizes miscommunication and possible fallout with an owner or a community. The pressure on the person in charge is tremendous. Identifying key personnel who can address specific aspects of the clinic will maximize efficiency and minimize complications. The meeting should address the following: 1. Identification of team leaders and team members Team leader(s) o If there is only one team leader, this should be a veterinarian in order to be able address veterinary issues that may arise May be shared position, i.e. Local coordinator and Lead veterinarian Professional staff o Veterinarians o Technicians o Experienced volunteers Volunteers o Volunteer coordinator o Identification of areas requiring help o Identification of experienced and inexperienced volunteers 2. Chain of command Identify who is in charge of specific areas Identify how to and who will make specific decisions regarding clinic issues Identify who is responsible for final decisions regarding the treatment and care of an animal Rounds Rounds held at the end of each day permit discussion of veterinary cases and/or logistical issues, maximizing efforts and minimizing complications in the ensuing days. This can be challenging

11 as many clinic days are long and tiring. Minimally, key team members should meet and discuss logistics and/or veterinary issues. Rounds or a debriefing held at the end of the clinic can address specific issues and improve the logistics of the next clinic Assessing local needs, caseload selection, patient selection Assessing the local needs of dogs versus cats, and owned versus trapped animals, will help address what supplies will be necessary, as well informing the local community of the intent of the clinic. Clinics designed to address a specific population (TNR) may be overrun by requests by another segment of the population (community members wanting the same services for their pets), creating logistical as well as public relations issues. Establish and communicate clear intent prior to the start of the clinic to minimize public relation issues that may arise Caseload selection The clinic organizers will decide how the caseload will be determined. Whatever approach decided (appointments, first-come, first-serve, TNR), the parameters should be clear prior to the start of the clinic. Have a plan in place to address possible miscommunication or emergency procedures such as a pyometra or dystocia. Caseload considerations Will the caseload rely on the public bringing animals on a first-come, first-serve basis as result of local advertising? Will it be by appointment? If so, identify how and who will be responsible for making and confirming appointments. In many cultures, there exists a high rate of no-shows even if confirmed the day before. Be aware this may affect overall numbers of surgeries. Will the caseload be reliant on trapping of community animals? Will it be a combination of the above? Will there be a fee for service? Determining daily caseload The selection and number of surgeries that can be done safely and humanely in one day will vary greatly depending on staffing, anesthesia capabilities, available surgical skill, and availability of supplies and logistics. Sufficient, experienced veterinarians, technicians, clinic assistants and volunteers are necessary to ensure an adequate standard of care and safety to all patients and team members. Overly ambitious plans regarding the number of surgeries planned can easily compromise the humane care and life of individual animals. Be prepared to scale back expectations.

12 Daily caseload is usually determined by lead veterinarian in conjunction with the local coordinator The predetermined number must be acknowledged and accepted by all team members. This number may be increased or decreased as logistics reveal themselves over the course of the planning or the specific day. The number should only be adjusted by the lead veterinarian. o Identify animal holding capabilities o Organize and confirm animal transport prior to the clinic Surgical candidates often present in less than ideal health: Surgical candidacy is determined by veterinary staff. It is important to remember that most sterilization surgeries are elective procedures, and that sometimes it is best to postpone or cancel surgery. If this is the only opportunity to sterilize this patient, one must weigh the risk of surgery against the benefits to the animal Working with the local veterinary community Many field clinics are held in areas that lack local small animal veterinary professionals. It is one of the reasons we provide veterinary services through field clinics. The in-country or on-site clinic organizer needs to determine if small animal veterinarians provide services in the general area. If so, introducing yourselves and the goals of the clinic to the local veterinarian(s) demonstrates respect and may be integral to the success of the clinic. This allows one to gauge their reception to a clinic in their community and their desire to participate. Additionally, it is likely that the local veterinarian(s) will address any post-operative cases or complications, and therefore should be given the opportunity to be informed and cooperate with the field clinic. In our experience many welcome the opportunity to work with foreign veterinary professionals when offered. This cooperation establishes a professional relationship conducive to a mutually beneficial clinic. It may pose some challenges as it can be difficult to assess clinical or surgical skills as standards of care vary widely all over the world, and experience may not equate to competence. It may also be difficult to evaluate and challenge a local veterinarian s techniques and methods without him/her feeling inconvenienced and threatened Bite incidence Establish an animal bite policy prior to the start of a clinic. Many clinics are in a remote location with limited to no access to medical services. Research the incidence of rabies in the working area prior to the trip and determine the location of the nearest medical facility to the clinic site. Animal bites can easily become infected with potential long lasting sequelas. Access to adequate medical care should be known even if it is logistically difficult to travel to the nearest, adequate facility. All team members must acknowledge the bite policy, and a protocol must be in place should a team member decline the advice or protocol of the clinic.

13 Many countries have very extensive rabies vaccination programs yet the vaccination status of an animal is often unknown and/or the caregiver does not have proof of vaccination. Quarantining animals for 10 days is often difficult or impossible to do. The team organizers must discuss, develop and agree on a bite policy and possibility of quarantine prior to the clinic. There are many examples of bite policies available online. The policy in place for the clinic will depend on the logistical aspects. Know which team members have previously received rabies prophylaxis vaccines with protection confirmed by current titers. You may even consider whether a current rabies vaccine needs to be a requirement for staff and volunteers, depending on the level of risk in the region you are operating in. Have a signed release available for team members. 3.0 Site consideration Site consideration is critical to the success of the clinic. When choosing a site, one should determine the ability to transport equipment, supplies and team members to the site, accessibility to water and electricity, the ability to adequately clean and disinfect the site prior to and throughout the clinic, the ability to provide safe handling of the animals, the ability to deal with the elements and employ the practices that are essential for humane surgery in field conditions. Field clinics can be held in almost any location. They can be MASH-type, mobile or stationary, and many are held outdoors, on soccer fields, in garages or community centers, with or without access to water or electricity. 3.1 Clinic type - Determine if stationary, MASH-type or mobile (Discussed under planning) 3.2 Accessibility Accessibility of the site to all team members will affect cost as well as success of the clinic. Investigate the distance, cost and ability of the clinic organizers and team members to arrive safely including: Ease of access and time necessary to arrive at final destination Cost to arrive and depart for team members. Ability to arrive safely Food and lodging details Consider the accessibility to members of the community. Many community members do not have access to cars. Many will walk, carry, bicycle, motorcycle, horseback ride or tuk-tuk their pets long distances just to receive services. Investigate if there are local taxis or similar local transportation such as a tuk-tuk that service people with dogs or cats

14 Consider transportation of post-operative patients as these patients cannot walk home. Same-day release patients are often still experiencing the effects of anesthesia and their neurologic status is impaired. Walking home after a surgical procedure will contribute to increased post-operative complications. Observe the method of transportation home. Some caregivers may not recognize the invasiveness and seriousness of the surgical procedure. Some may not recognize the need for an acceptable method of transporting their pet home. Cats warrant special mention as many caregivers carry their cats to the clinic with no visible means of restraint or confinement and expect to carry them home in the same manner. Many anesthetic protocols employed in field surgery have a long-lasting effect on cats. There is an increased potential for a cat to escape or inadvertently hurt their care giver if one is carrying the cat home without some method of confinement or restraint. 3.3 Weather patterns and altitude Weather patterns and altitude can and will affect certain aspects of the clinic and team members. Investigate annual weather patterns and determine if there is a rainy, monsoon, hurricane or other natural weather pattern that may affect the ability to arrive safely, the ability to conduct a clinic safely and the ability of local community members to attend the clinic Investigate temperature fluctuations and any hot or cold season as this may affect ability to do surgery and recover animals safely when considering thermoregulation effects of the environment on surgical candidates. Some team members may not perform well in very hot and humid climates or cold climates. Altitude may also affect some team members and possibly anesthesia 3.4 Water Access to clean water is essential to the clinic. This can be challenging in some places due to scarcity, access to, and cost of running water. Many team members are used to an unending source of water in their respective work places. When working in places in the world where water is a scarce and expensive commodity, this needs to be recognized by all team members. Running water is essential in high volume clinics and is preferred overall, yet this may not be available. If so, plan how to get access to adequate, clean water throughout the clinic to address patient needs, patient and surgeon preparations, and cleaning and sanitation of kennels and animal care products. Buckets, tubs, clean dish pans, hoses stretching to a remote water source and other necessary equipment will be needed to assure a supply of clean water throughout the clinic. Hot water is preferred but not absolutely necessary to conduct a clinic. Consider the fact that the use of hot water will contribute to the cost to the community as well.

15 The availability of sinks or similar areas to wash hands, instruments and other clinic supplies should be noted by the on-site organizer. Plan for the eventuality that there may not be any sinks. Avagard, or other proven, recognized, waterless surgical hand preparation products, can drastically reduce the amount of required water for the clinic. Over the counter hand sanitizer strategically located throughout the clinic will also reduce the amount of required water. 3.5 Material to dry hands, instruments and clinic supplies Supplies to dry hands, instruments or other supplies should be on hand. Hospitals in the United States throw away a tremendous number of huck towels (blue surgery towels) every day. Many hospitals are willing to save and collect these towels to donate to different organizations. Old sheets and towels from local hotels are another good source of material for drying and bedding. This also reduces the amount of paper towels consumed over the course of a clinic. Investigate the ability to do laundry in a timely manner to maintain adequate towels and rags throughout the clinic. 3.6 Electricity Electricity can be very expensive in many places in the world. Some places restrict access during certain parts of the day to conserve resources, there may be many power outages, or it might not be available at all. Even if electricity is available, one should plan for the unexpected disruption in availability. Strategies for handling operating with limited or no electricity Headlamps, flashlights and batteries Generators Invertors that attach to a car battery or a solar generator with a 12 volt output. Both of these will convert 12 voltage battery power to 110 voltage. Battery back ups Note the number of functioning outlets in planning. Plug an electrical device into the outlet to determine if it is functioning rather than relying on the fact that there are a lot of outlets present. Have extension cords and power strips. Be careful of overloading fuses. Fuse boxes in many places are unable to handle a heavy demand on electricity. It is easy to blow fuses when too many electrical devices are used at the same time or strong devices such as a microwave are in use. 110 versus 220 voltage If working in a country with different voltage than your home country, it is imperative to have adequate numbers of adaptors. Everyone on the team must be aware of this difference in electrical voltage. You will ruin any electrical equipment plugged into an inappropriate voltage source.

16 An adaptor is easily available online from amazon.com or in numerous stores such as Recreational Equipment Incorporated (REI), Home Depot or Walmart. Note the difference between adaptor and convertor: o Adaptor adapts the local electricity to the electricity required of the electrical instrument o Convertor actually converts electricity from one voltage to another and is usually much more cumbersome 3.7 Light Lighting can be one of the most challenging aspects of a clinic. Many areas of the clinic do not require high wattage lighting. There are many simple and easily adapted lighting sources for these areas. Surgery requires sufficient light to be able to visualize the tissue and body cavity well. Many places have sufficient natural lighting during the day but it is not adequate for early morning, late afternoon or evening surgery, or for any complication deep in a body cavity. Surgical lighting can be augmented with lights on the end of the table, headlamps on the surgeons and surgical assistants and, if necessary, flashlights held by a volunteer to illuminate the body cavity. 3.8 Disinfecting and cleaning (See Chapter 11 for additional information) Sanitation tips and tricks Have squirt bottles of disinfectant available in multiple places throughout the clinic Potassium peroxymonosulfate (Trifectant, Virkon ) is a broad spectrum disinfectant. Tablets are inexpensive and easy to transport. Dilute as per instructions. The tablets absorb moisture and crumble with time in high humidity and should therefore be stored in low humidity environment or in a refrigerator. Bleach is usually readily available. A diluted bleach solution can be used as a general disinfectant providing removal of organic material and cleaning precedes disinfection. Hand sanitizer in strategic locations helps reduce the reliance on water and decreases contamination and the spread of disease. 3.9 Laundry and newspapers There should be an adequate amount of clean towels, sheets, newspaper and other clean, soft and absorbent material to address sanitary patient care throughout the clinic from admission to surgery and recovery. Announce the need for newspaper and laundry material well in advance of the clinic, assuring there is adequate material. Potential sources include local community members, old sheets and towels from local hotels and local businesses. Newspaper provides a source of thermoregulation, is easily disposed of after single use and reduces the amount of laundry. Towels and sheets may be required for more critical

17 thermoregulation and are better material to assist with cleanliness but may be more difficult to acquire and will require laundry facilities to clean. Laundry facilities can range from a local laundromat to a community member volunteering (or being compensated for) their services. One must be aware of the degree of contamination (fecal material, blood) of some of the laundry and appropriate measures taken to address cleaning. Blood and fecal material may be culturally offensive to some local volunteers. Laundry tip Blood contamination can be addressed by having a large enough container with hydrogen peroxide mixed 50:50 with water and placed in strategic locations such as surgery. Hydrogen peroxide assists with breaking down the red blood cells and permits more thorough cleaning Proper disposal of sharps materials and biologicals Proper disposal of trash and sharps materials can vary from location to location and country to country. It is the responsibility of the team leader to dispose of the sharps in a manner acceptable to the rules and regulations of the community in order to eliminate the possibility of human and animal injury from said material. Some community members may not have shoes. Dogs, chickens, pigs, horses and other animals are often free roaming and may be injured in any number of ways by inappropriate disposal of sharps materials. Although local disposal may not be more than burying the sharps container in the ground, filling them with concrete, or burning the containers in a fire, every effort must be made to minimize injury and contamination. Local health departments, clinics and hospitals are a good source of information regarding the proper disposal. They also often offer to supply official sharps containers and methods of disposal. Some countries have strict laws regarding the proper disposal of body parts while other countries can be extremely lax in these requirements. Local cultural beliefs may dictate if or how body parts are handled and disposed of. The clinic organizer is responsible for investigating local rules, regulations and cultural practices regarding the proper disposal of biologics. Disposal suggestions Official sharps containers and biological bags, both usually red, are often available from the local health department. Biologicals (body parts and tissue) may require specific trash bag (usually red and heavy duty) and a specific manner of disposal. Many containers suffice as sharps containers such as recycled plastic milk cartons and plastic soda bottles. The containers should be closed with the proper lid or taped shut with heavy tape such as duct tape. Place a trash bag on each surgery table as well other strategic locations throughout clinic. Trash should be collected and disposed of so as to minimize possible damage and spread of

18 garbage by free roaming dogs and cats Bathroom facilities Bathroom facilities vary greatly from country to country. Team members should be aware of possible differences prior to the clinic as some bathroom facilities or lack thereof may be shocking to some team members. The need to adapt to local custom is important for several reasons: Cultural sensitivity There may not be many available facilities Septic systems may not exist or may be insufficient to deal with toilet paper and personal hygiene products in the system. It is often disposed of in a wastebasket. 4.0 Staffing and volunteers An ideal number of team members and volunteers is dependent on many variables. It must be emphasized that a clinic should have the appropriate number of staff and volunteers to ensure each, individual animal is cared for in a safe and humane fashion from capture or admission to recovery and their ability to return to their respective homes. If there is not sufficient staffing for the proposed numbers of surgeries then it is the lead veterinarian s responsibility to determine how many surgeries can be done safely and humanely with the number of staff and volunteers present. Volunteer recruitment tips Recruiting experienced and sufficient team members and volunteers can be challenging. Many are passionate and dedicated to animal welfare and want to share their passion in places less fortunate than their own, yet are unfamiliar with the sometimes striking differences in cultural or professional settings addressing field medicine and surgery. Many volunteers lack experience in animal handling, restraint and recovery monitoring. There are many avenues of recruitment, but determining the degree of experience and skill of potential volunteers can be challenging. Skills required in field clinics can be very different than skills exhibited in one s regular place of work. Field clinics often lack diagnostic and monitoring equipment. Even the most experienced veterinarian or technician in a high quality, first world clinic can be challenged by having to determine how many drops per second of an intravenous fluid to deliver, how to administer the correct amount of injectable anesthesia to maintain a surgical plane of anesthesia as gas anesthesia may not be available, or how to correctly use chemical disinfection for surgical instruments. Every effort should be made in advance to inform the team members of conditions where they will be working. That being said, often times the reality of the clinic and the conditions of the animals can be shocking to some team members.

19 The person in charge of the clinic needs to be able to effectively address situations that may arise. Some may require asking team members to assist in other areas more suitable to their skill set. Some may require asking team members or volunteers to leave. The cohesiveness of the working team is paramount to demonstrating to the staff and volunteers as well as local community, the team s desire and ability to provide services which will improve animal welfare. Veterinarians, technicians and volunteers lacking experience in field clinics should be willing to work with other, experienced team members in order to gain an appreciation of the nuances of field clinics. Anesthesia warrants particular attention as anesthesia drugs and protocols may be very different than those employed in their usual place of work. Ideally one veterinarian should have a person to monitor anesthesia and one to attend to additional surgical supplies as needed but field clinics often lack this ideal number. 4.1 In-country or on-site coordinator An in-country, or on-site, coordinator is critical to the success of the clinic. This person is often responsible for everything from community education and advertising the clinic to assuring the specifics of food, lodging, transportation and clinic essentials are ready when the team arrives. They are the ambassador of the team. Local language skills are essential and they must be familiar and respectful of the culture. If they do not speak the local language, it is essential to have a translator on site that can help with communication. If a person in addition to the on-site coordinator is addressing logistical details from outside the site or country, the on-site coordinator must have ability to communicate and liaison with designated said person. 4.2 Lead veterinarian The designated lead veterinarian is responsible for all final decisions in regard to clinic protocols relating to the animals. These decisions and protocols may be developed by team communication and discussion before the clinic, and amended during the clinic with discussion. Decisions regarding specific animals and cases can be difficult to make in field clinics, but ultimately, the lead veterinarian is responsible for final decisions and protocols. If a patient is owned, the decision of the owner in regard to their pet must be respected. It takes skill and diplomacy to explain difficult cases and options to an owner and a community. The lead veterinarian oversees these communications and assures every aspect of the patient or case is addressed as best as possible. They are also responsible for communication of these difficult decisions to the team.

20 If a decision must be made regarding a free roaming patient, then a decision must be made that is in the best interest of the patient. Often a team has the skill to address a serious medical or surgical issue yet the aftercare will be difficult to impossible to administer. The lead veterinarian takes responsibility for making these decisions. Cultural sensitivity is also a factor, especially in regard to the practice of euthanasia. This can contribute to the degree in decision making as some cultures and/or animal care givers do not believe in the practice of euthanasia. Specific cultural practices may be difficult for some team members to understand and accept. It is the responsibility of the lead veterinarian to discuss these decisions with team members. 4.3 Recruitment methods There are several methods and venues for recruiting volunteers and staff for a field clinic including: Personal recommendations Word of mouth Posting on recognized listservs such as the High Quality, High Volume, Spay/Neuter (HQHVSN) and The Association of Shelter Veterinarians (ASV). One must be a member of these groups to be able to post. Recruitment via a program or organization s webpage and application process Local advertising o Local volunteers and community members o Ex-patriots living in the area Social media Facebook is used widely by many organizations and campaigns. It is recommended to have a person affiliated with the field clinic or campaign to address and filter the Facebook inquiries and applications 4.4 Areas requiring professional staff and volunteers (additional details under Clinic Flow section of this chapter) The number of designated stations of a clinic will vary depending on the specifics of the clinic. A mobile clinic, due to limited space, will have fewer stations than a stationary, high volume campaign. A clinic focusing on free roaming animals will require staff experienced in animal capture and transport. The number of required staffing in each area will vary greatly depending on the type of clinic, the goals of the clinic, and the number of experienced team members. Clinic areas requiring staffing Animal trapping/capture - If planning on addressing feral or free-roaming animals Animal transport If planning on an animal capture-based campaign or if providing transport services to owners and animals to or from the clinic. Check in and admission