Proceeding of the NAVC North American Veterinary Conference Jan. 8-12, 2005, Orlando, Florida

Proceeding of the NAVC North American Veterinary Conference Jan. 8-12, 2005, Orlando, Florida Reprinted in the IVIS website with the permission of the NAVC http:///

The North American Veterinary Conference 2005 Proceedings STANDARD OF CARE: REPTILE PRACTICE Douglas Mader, MS, DVM, DABVP Marathon Veterinary Hospital, Marathon, FL Stephen Barten, DVM Vernon Hills Animal Hospital Mundelein, IL INTRODUCTION The Classes Reptilia and Amphibia are traditionally lumped together as herpetofauna under the study of herpetology. There are over 8,000 species of reptiles and 4,000 species of amphibians. They range from less than a gram to more than a ton in mass, and less than a centimeter to more than 9 meters in length. They vary tremendously in anatomy, physiology, nutrition and behavior. They may be aquatic, fossorial, terrestrial, or arboreal. They may be carnivores, insectivores, piscivores, omnivores, herbivores, folivores or a combination of these. They may be calm and inoffensive or aggressive and dangerous. Some are venomous, some are poisonous. It would be difficult for any veterinarian without formal herpetological training to have expertise with, or be willing to treat, every species of reptile and amphibian. For instance, some might choose not to treat venomous snakes or large crocodilian/pythons. In those cases, referrals to more experienced and willing veterinarians should be available. Federal, state and local laws regulate endangered and dangerous reptiles and amphibians, and the attending veterinarian must be familiar with applicable regulations. Many, many species of reptiles and amphibians are available in the pet trade, both wild caught and captive born. Some individual specimens have great value as potential breeding stock, costing tens of thousands of dollars. Some keepers have dozens or hundreds of pets in huge, private collections. Many owners love their pet reptile as much as any owner loves their dog; thus these animals have great financial and emotional value. Reptile owners have increasing knowledge and sophistication, and they both demand and expect competent medical care for their pets and collections. With such diversity it is difficult to establish Standards of Care for herpetological medicine. It is even more difficult to establish finite standards for the husbandry of individual species, or the diagnosis and treatment of every disease in every species. There is a paucity of peer-reviewed literature, no College of Herpetological Veterinary Medicine and few recognized experts and fewer academicians - in the field. It is the goal of this document and this conference to offer a starting point for the establishment of a SOC. We hope to discuss basic standards covering most routine situations. Without doubt, our suggestions here will be altered, amended, or discarded as time passes and more knowledge accumulates. The purpose of this outline is to provide suggested guidelines for operating a reptilian practice. The guidelines offered here are based on the experience and opinions of eight recognized exotic practitioners combined with learned legal counsel. MINIMAL STANDARDS Continuing Education Most veterinary degrees provide little training or experience in reptilian medicine, so veterinarians who treat reptiles and amphibians should seek additional education. Specific herpetological continuing education (CE) is available through the Association of Reptilian and Amphibian Veterinarians (ARAV), which holds an annual conference with international speakers and attendees, several days of papers and wet labs. This is the international forum for the presentation of new information and findings in the field. The American Association of Zoo Veterinarians offers CE and a journal with regular inclusion of reptilian topics. Because the principles of basic small animal medicine and surgery apply to reptilian medicine, general veterinary meetings should be attended regularly. AAHA, ACVIM, AVMA, BSAVA, NAVC, WVC, WWVC and CVC offer quality continuing education, but state VMA annual meetings also have value. Experience may be gained with externship or postgraduate positions in established exotic animal practices with high reptile case loads. Levels of knowledge and experience vary tremendously between individual clinicians, so the learning opportunities can vary between practices. Reptile practitioners are encouraged to attend herpetological meetings in addition to veterinary medical events (e.g. local herpetological society meetings, regional herpetological meetings, herpetological expos, SSAR, HIS, etc). A veterinarian seeing small numbers of reptilian patients has no less responsibility to acquire clinical expertise and regular continuing education than one who sees reptiles more regularly. Species Recognition Veterinarians who treat reptiles and amphibians must be able to identify the species of the patient and know its natural history, diet, husbandry, behavior, anatomy, restraint, and common disease syndromes. Barring that knowledge, the veterinarian must have resources to quickly and thoroughly research the question at hand. Accurate identification of a patient and knowledge of both normal and abnormal traits of that animal are crucial when providing quality medical care. Staff Training Because reptiles and amphibians differ so from traditional small animal pets, specific training of staff is essential. History taking, husbandry, restraint, phlebotomy, lung and colonic washings, imaging, anesthetic monitoring, cytology, hematology, parasitology and laboratory techniques are essential skills. In general, a technician should be able to perform the same techniques on reptiles that they do on dogs and cats. A written checklist of individual procedures should be kept and mastered. The ARAV annual meeting has several lectures that are suitable for both novice and advanced veterinary technicians. They also sponsor excellent wet-labs on these subjects. Many of the national meetings mentioned above also have excellent wet-labs designed for technical staff. In-house training by veterinarians should be offered to staff on a regular basis and technician skills should be reviewed frequently. It is advisable to save a slide set of both normal and diseased blood smears, and preserved fecal, ectoparasites and cytology slides for teaching and reference. 1298

Exotics - Reptiles Recommended Memberships It is recommended that veterinarians stay current with herpetological medicine, dog and cat medicine, herpetology and herpetoculture. Membership in the following groups fosters exposure to research and new information. - Association of Reptilian and Amphibian Veterinarians (ARAV) - AVMA - Society for the Study of Amphibians and Reptiles (SSAR) (publishes Herpetological Review, which contains legislative updates; husbandry, field, and laboratory techniques; captive reproduction data; and book reviews, and the Journal of Herpetology) - Local Herpetological Society Recommended Library Libraries should be evaluated regularly since references are constantly being updated. What may be current now, may be out of date next month. Reptile Medical Texts - Mader, DR, ed. Reptile Medicine and Surgery, Second Ed. Elsevier, St. Louis, 2005 (in press). - Mader, DR, ed. Reptile Medicine and Surgery, WB Saunders, Philadelphia, 1996. - Jacobson, ER, ed. Biology, Husbandry and Medicine of the Green Iguana. Krieger Publishing, Malabar, FL, - Girling, S and Raiti, P, eds. BSAVA Manual of Reptiles, Second Ed. Blackwell Publishing, Ames, IA, 2004. - Frye, FL. Biomedical and Surgical Aspects of Captive Reptile Husbandry. Krieger Publishing, Malabar, FL, 1991. - Feldman BV et. al. Schalm s Veterinary Hematology, Fifth Ed. Lippincott, Williams and Wilkins, Philadelphia, 2000. - Wright, KM and Whitaker, BR. Amphibian Medicine and Captive Husbandry. Krieger Publishing, Malabar, FL, 2001. - Wyneken, J. Reptile Anatomy. Malabar, FL, Krieger Publishing, Malabar, FL, 2005 (in press) General Exotic Animal Medical Journals and Texts - Veterinary Clinics of North America: Exotic Animal Practice. Elsevier. - Seminars in Avian and Exotic Pet Medicine. Fudge, A., ed. Elsevier. - Carpenter, J et. al. Exotic Animal Formulary, Third Ed. Elsevier, Philadelphia, 2005. - Fudge, AM, ed. Laboratory Medicine: Avian and Exotic Pets. WB Saunders, Philadelphia, 2000. Herpetology Texts - Pough, FH et. al. Herpetology, Third Ed. Pearson Education, Inc., Upper Saddle River, NJ, 2004 - Zug, GR, LJ Vitt and JP Caldwell. Herpetology: An Introductory Biology of Amphibians and Reptiles, Second Ed.. Academic Press, San Diego, 2001. - Pianka, ER and LJ Vitt. Lizards: Windows to the Evolution of Diversity. University of California Press, Berkeley, - Greene, HW. Snakes: The Evolution of Mystery in Nature. University of California Press, Berkeley, 1997. 1299 - Ernst, CH, JE Lovich and RW Barbour. Turtles of the United States and Canada, Second Ed. Smithsonian Books, Washington, DC, 2000. - Ernst, CH and RW Barbour, Turtles of the World. Smithsonian Books, Washington, DC, 1992. - Ernst, CH and EM Ernst, Snakes of the United States and Canada. Smithsonian Books, Washington, DC, - Huchzermeyer, FW, Crocodiles: Biology, Husbandry and Diseases. CABI Publishing, Oxfordshire, UK, Species Identification - Behler J and King W. The Audubon Society Field Guide to North American Reptiles and Amphibians. Alfred A Knopf, New York. 1979. - Conant R and Collins J. A Field Guide to Reptiles and Amphibians: Eastern and Central North America. 3rd ed. Houghton Mifflin Co., Boston, 1998. - Stebbins R. A Field Guide to Western Reptiles and Amphibians, 3rd ed. Houghton Mifflin Co., Boston, 1993. - Bartlett PP et. al. Reptiles, Amphibians and Invertebrates: An Identification and Care Guide. Barron s Educational Series, Hauppauge, NY 2001. ** Regional field guides to local herpetofauna are available for almost every state. Practitioners should be able to identify local reptiles and amphibians in their area. Internet Sites - Veterinary Information Network (www.vin.com) - Network of Animal Health (www.avma.org/noah/noahlog.asp) - Kingsnake.com for species identification, species forums, care sheets, dealers, equipment, food sources, etc. - Melissa Kaplan s Herp Care Collection (www.anapsid.com) for detailed general husbandry advice, specific care sheets, recommended diets, and on and on. HOSPITAL PHYSICAL PLANT Because reptiles and amphibians are ectotherms, veterinarians must be able to provide escape-proof enclosures, cages of appropriate dimensions for varioussized species, adequate therma gradients and humidity levels, climbing branches for arboreal species, and aquatic setups for aquatic species. A hot room with continuous elevated ambient temperature and controlled humidity is valuable, but constant uniform temperatures are stressful and additional heat sources to provide thermal gradients are necessary. Individual incubators capable of adjusting both temperature and humidity are useful with small numbers of small and medium-sized patients. Isolation cages with the capability of individual internal temperature control, air flow and ventilation are needed when contagious diseases are being treated. Supplemental heat during surgery is important, and devices such as hot water circulating blankets or heating pads are required. VENOMOUS REPTILES Venomous reptiles present a special hazard and liability. Zoos have established protocols for handling these dangerous animals which should be followed closely. Extensive reptile experience and formal training in a zoo or

The North American Veterinary Conference 2005 Proceedings museum that routinely handles venomous reptiles is essential prior to attempting to deal with anything that is venomous. Special equipment, techniques and planning are crucial, including trained back-up personnel, appropriate antivenin on hand, an alarm system, a disaster plan that is routinely rehearsed, and the availability of physicians experienced in the treatment of snakebite at the local Emergency Room. Medical and liability insurance policies must be reviewed. EQUIPMENT Individual state Veterinary Practice Acts may dictate the minimal requirements for hospitals. Much of what is suggested here already may be required for all small animal hospitals in some locations. Vascular clips (small, medium and large) Radioscalpel and/or CO 2 laser Rigid endoscopy system Operating magnifying loupes Air pumps Sexing probes Radiology unit with a wide range of ma and kvp settings, and the capability of taking both vertical and horizontal beam projections High-detail radiographic film and/or screens Electronic, digital thermometer capable of rapid read-out with a range from freezing to greater than 100ºC; infrared temperature guns are useful Heat lamps or radiant heat panels with thermostats UVB light sources in cages Thermal water blankets Capture/restraint equipment (snake hooks, tubes, tongs, bags, plastic storage containers with appropriate ventilation, etc.) Ventilator, ambu bag or ability to manually ventilate anesthetized patients Pulse oximeter, Doppler flow meter, apnea monitor or similar equipment for anesthetic monitoring 1 to 4 mm uncuffed or Coles endotracheal tubes Dremmel or similar tool with appropriate bits for grinding beaks and nails Dremmel or similar tool or orthopedic saw for opening chelonian shells Oral speculums of various sizes and types Microliter or insulin syringes CLINICAL ASSESSMENT Every patient should have a thorough history taken, including source, husbandry conditions, cage, substrate, heat sources, UV light sources, thermometers, diet, frequency of handling, duration of signs and symptoms, previous treatment, and so on. The veterinarian should recognize inappropriate husbandry and diets for a variety of species and be able to recommend improvements. Every patient should have a thorough and systematic physical exam. Practitioners and staff must have knowledge of safe restraint (for patient and handler), normal anatomy, and the ability to extract chelonian heads from the shell and to open mouths. Every patient is given the problem-oriented medical approach with a SOAP (or similar standard medical record) list and rule outs, diagnostic and therapeutic plans, and follow ups. Practitioners must be familiar with diagnostic sampling and administration of medications by various routes in all species. It is not appropriate to simply treat every sick reptile with antibiotics. PROCEDURES Reptile practitioners should have familiarity with the following procedures including variations for various species. This does not mean that they must be able to perform the advanced surgical procedures; however, one must be able to determine when they are needed and where to refer procedures that are beyond their ability. Venipuncture Fluid therapy (routes and types) Injection sites Endotracheal intubation Gavage Pharyngostomy tube placement Coeliotomy and exploratory Ovariohysterectomy on a number of lizard, turtle and snake species Orchiectomy as above Liver, kidney and other organ biopsy (minimally invasive, surgical or endoscopic) Amputations (limb, tail) Cystotomy Gastrotomy/Enterotomy Enucleation Skin biopsy Bone Biopsy Bone marrow sampling Sample collection for bacterial culture and sensitivity testing and cytology (lung, GI) Wound dressing Splinting and fracture management Chelonian shell repair Beak and nail trims Necropsy DRUGS Drug use preferences and Pharmacokinetic / pharmacodynamic data are constantly changing. The practitioner must keep current on the most recent information. There are no currently FDA approved drugs for use in reptiles. Still the following classes of medications must be on hand: Appropriate antibiotics Appropriate anesthetics Appropriate anthelmintics Food and supplements (eg. species-specific diets for herbivores, carnivores, insectivores, etc.) Many medications come in forms that are difficult to accurately dose in small patients. The ability to compound medications in house or access to a trustworthy compounding pharmacy is essential. LABORATORY SUPPORT In house lab capabilities should include the ability to perform routine CBC, basic plasma biochemistry, fecal evaluation, cytology, and fluid analysis. Knowledge of and access to commercial labs with expertise in reptilian clinical pathology is necessary for some specialized tests, such as ELISA, PCR, culture, viral isolation, serology, cytology with special stains and histopathology. 1300

Exotics - Reptiles REFERRALS A list of veterinarians, animal hospitals, or referral centers with advanced training should be available for procedures that are beyond the expertise of the veterinarian or hospital. EMERGENCIES A list of veterinarians, animal hospitals, or referral centers that are capable of handling after hour emergencies for your reptile clients (if you do not provide that service) should be readily available. MISCELLANEOUS Reptilian practitioners should: - Have a thorough understanding of reptilian zoonotic diseases and prevention - Promote disease prevention and transmission in the workplace - Provide client educational material (handouts, brochures, videos, CD/DVDs) - Have thorough understanding of husbandry techniques for lizards, snakes, chelonians, crocodilians and amphibians - Understand herpetological anatomy, thermal biology, UV light and calcium metabolism, reproductive biology, behavior, nutrition and natural history (i.e., brumation) - Be familiar with local, state and national laws regarding endangered, venomous and dangerous animals - Have knowledge of recognized diseases and diagnoses from which they can compile rule out lists - Cultivate a network of local herpetological people who will assist in the rehabilitation of sick and injured native reptiles and amphibians. - Know where to go for help if a species is presented with which the practitioner is unfamiliar - Know where to go for more information SUMMARY Reptiles and amphibians have significant emotional and financial value. They and their owners both deserve skilled and competent medical care. It is not appropriate to assume that a client is unwilling to pay for quality medical care, and the best possible service should be offered to every client and patient. It may not be appropriate to agree to diagnose and treat a species that one knows nothing about. At the same time, the necessary information is available through research, study, consultation and referral. Veterinarians must constantly make the effort to advance their own clinical skills; at the same time they must recognize when a case is beyond those skills and should be referred to someone with more expertise. The Standard of Care outlined in this paper is not meant to be definitive, but rather a starting point. Herpetological medicine has advanced dramatically over the last several decades, and continues to do so on a daily basis. The SOC for reptilian practice must evolve along with medical and husbandry advances. 1301