In consultation with Matt Gurney: talking about anaesthesia, arthritis, and approaches to pain management

Matt Gurney is a European Veterinary Specialist and an RCVS Recognised Specialist in Veterinary Anaesthesia and Analgesia. One of Matt’s passions is pain management, and he co-founded The Zero Pain Philosophy, an education resource for veterinary professionals on pain management in practice. He also was involved in creating the Dechra anaesthesia app and is involved in telemedicine ventures, alongside leading the anaesthesia team at Anderson Moores Veterinary Specialists. Matt sat down with Vet Report to discuss anaesthesia, arthritis, and approaches to pain management.

Interview by Alexia Yiannouli

Could you start by telling us a bit about your background and your career so far?

I graduated from Liverpool, having really enjoyed large animal and equine practice as a student, and I really wanted to go into mixed practice. I have so much respect for people going into practice, because it was such a challenge to be as good as you possibly can be with such a diverse range of species on a day to day basis. I spent two and a half years in mixed practice before deciding that I really wanted to sink my teeth into one specific area – and anaesthesia was one of those areas where I realised that I could utilise my mixed background and still be really good at one particular area of veterinary medicine. An anaesthesia residency came up in Liverpool and I applied, and I was really surprised when I got it. I went back to Liverpool and really enjoyed my residency, dealing with all animals, from dogs and cats, to sheep and cattle. Throughout my residency I became much more interested in pain management. Towards the end of my residency, the recession hit, and the job that was waiting for me at the end of my residency was no longer available due to lack of funding. I contacted a local referral centre and they suggested a role for me in anaesthesia, which is where I really started my career in referral practice. I stayed there for ten years before coming to work at Anderson Moores in 2018, and I currently lead the anaesthesia team there.

You’re the co-founder of the Zero Pain Philosophy – what inspired you to create it, and how did it come to be what it is today?

I co-founded it with my partner, Carl, who is also a specialist anaesthetist, and a friend, Brent Higgins, who is a specialist surgeon. Carl and I were doing some CPD for Brent in New Zealand, and we had been there a couple of times before that. We started to think about how we could spread the message about pain management. We were giving CPD to a room of around 30 vets, and we realised that we wanted to spread the word with regards to acute and chronic pain management. We thought about starting a website – it’s so easy now to just grab your phone and film particular techniques, mainly things like local anaesthetic techniques, and upload them online. We think that’s the best way to get people accessing the techniques, as it’s not always easy or practical to look in a textbook. The website also evolved to include a pain management section. It’s set out almost like a blog, which includes topics and cases that are commonly presented in practice. If we get questions about a particular topic, we’ll write a pain update on it. It allows us to keep going back and amending the website as more information becomes available. We’ve recently co-authored a textbook, which is a great experience, but it means that the information won’t be updated for seven to ten years. We know from analysing the web statistics that most people access the website from their phones, so it’s most likely people in clinics looking for the most up-to-date information quickly. We evolved from posting videos to also creating webinars. We were initially doing a lot of webinars for other people before we thought about running them ourselves. It has allowed us to choose topics which we think people have the most questions about. It’s also ideal because if we notice a hot topic, we can jump on and do a webinar about it.  We also have the telemedicine side of things as well. All we want to do is improve access to specialist pain management services, and we offer a wide variety of telemedicine options to veterinary professionals – which encompasses vets, nurses, physios, and anyone in the profession who has an interest in pain management.

Since the start of the pandemic, have you noticed any changes in how veterinary professionals are using the Zero Pain Philosophy?

People are much more tuned in to the concept of telemedicine. Telemedicine has been there in the background for a while now. Specialist referral practice is utilising it in a slightly different way to first opinion practice. We are doing vet to vet consultations, not consulting directly with owners. There are always two types of telemedicine; client-to-vet communication, and vet-to-vet. There are barriers to the concept, but people are starting to think around that. With consultations moving online, the pandemic has really helped people in the telemedicine sphere. We are also seeing a lot more people wanting bespoke online CPD. Although we are all a lot more used to doing CPD online now, we’re really busy, and it can be really hard to get everyone in a practice in the same (virtual) room at the same time. We record all of the sessions, so if someone can’t attend they are still able to catch up in their own time. This is the new normal for us now!

What is your opinion on the future of telemedicine?

The future of telemedicine is massive. There are a whole host of people offering specialist telemedicine services at the moment, and they’re all very willing to engage with people with the aim of offering the very best options to their clients and their pets. When I was in first opinion practice, I remember sometimes thinking to myself, ‘I really don’t know what I’m doing with this case’ and so now when people contact me about pain related questions and mention other things that are wrong with the animal, I’ll suggest a telemedicine consultation with an internal medicine specialist. Within 30 minutes they can speak to an internal medicine specialist, have their questions answered, and formulate a plan for working the case up. If referral isn’t an option for an owner, then the cost of a telemedicine consultation is dramatically reduced compared to a conventional referral, and it helps point vets in the right directions in terms of actions they can take with that case. If they then hit a wall, referral is still  an option. I think we can offer clients so much more, and it’s an education for us as well – every telemedicine consult you learn something new!

What inspired you to create the Dechra anaesthesia app, and could you tell us a bit about how it can be used?

I was approached by Dechra initially. They had got so far with developing it, and then we gave them specialist input. I worked on it alongside another specialist anaesthetist, Joost Uilenreef, from the Netherlands. It’s a European app, so it was useful to have a UK and European slant on it. In the next few months we are planning to start looking through and updating the app. As you can imagine, it’s a huge task sitting down to design all of the potential protocols. A lot of that was done by an anaesthetist who worked for Dechra, which was amazing. It was then our role to proof the protocols and make edits, which was a really big task! We know there are still gaps there, but we have plans to update the content and hopefully fill those gaps over time. We really focused on choosing specific procedures that people struggle with in practice, or areas where vets needed more confidence. It’s really useful to have all of that information available on your phone in your pocket when in practice.

How do you balance and fit in working in referral practice with all of your other projects?

That’s a really difficult question! I have two Fridays off a month from working in practice, and that’s when I squeeze in all of my other things. I’m fairly driven by using my evenings and weekends for work, but maybe not in a good way! I enjoy working, but sometimes I do need to stop myself from doing any work on a weekend. If I worked 100% of the time in one place, doing only one thing, I would get bored. I like the fact that I can do other things as well. Technically all of the other things I do are work, but it’s a different kind of work. I can fit it into my own agenda and do what I want, when I want, and do as much as I like. I like working on projects and engaging with people outside of the clinic. I normally do a lot of travelling – I’m the kind of person who finishes work, goes straight to the airport, and gets on a plane to somewhere else. I managed to get three trips in before lockdown, but 2020 has certainly been an interesting year…

In your opinion, how could pain management be taught differently at vet schools?

Undergraduate teaching is so much better than it was when I was a student. We have to bear in mind that the time available for undergraduate teaching of every topic is limited, so I think that actually the unis do a really good job. Graduates come out with a lot of knowledge, asking lots of questions. It’s the first two years in practice that we really need to focus on, to prevent the default setting of just doing things in the same way as everyone else in practice. We know that Zero Pain is always available, and we also recognise that new graduates are likely coming up against more senior vets in practice telling them they can’t do something a certain way, which is what I remember happening when I first went into practice. It’s a really easy resource to share, and vets can easily go onto Zero Pain and discuss and show things to their colleagues. We’ve created those webinars to get everyone on the same page. Our aim is to put all the evidence out there and for it to be used as a basis for practice discussions. I think vet schools are doing a good job – it’s when people graduate and go into practice where the focus needs to be. I’m hoping that we’re doing as much as we can to fill that gap. 

In practice, what have you noticed are the biggest mistakes made when treating a pain management case, and how do you think they can be improved in practice?

My biggest take away message would be to not cram everything into a ten minute consultation. I’m going to use arthritis as an example, because 90% of our pain clinic cases are arthritis. Conservative estimates suggest that 20% of dogs will suffer with arthritis, but it’s more likely that it is actually up to 40% of the canine population. There’s always a big caseload for pain management in practice, but it just can’t be squeezed into a ten minute consultation. We need a reset in arthritis management to highlight all really important factors in treating it – weight, diet, exercise, physiotherapy and hydrotherapy – before we even start talking about drugs. Pain scoring is also important, and so is talking to the owners – and that can take some time. We need to work out what vets and nurses can do with arthritis clinics in first opinion practice, because together as a team they can do a really great job. We’ve got the caseload in practice, I hope we’ve got the people that are keen to manage the cases, and we know that nurses who are running clinics are screaming out to see more of those cases. We need to also build those relationships with clients. My number one thing for anyone reading this would be to ask yourself: how am I going to manage arthritis better in my practice?

What would you like to see in the future in terms of advancements with pain relief and management in veterinary medicine?

There are some exciting things in the pipeline from a drug point of view. Zoetis are about to upgrade a monoclonal antibody against nerve growth factor. There’s a lot of initial information out there about nerve growth factor, and if we can target it, then it could present a different option beyond NSAIDs. My understanding is that the market authorisation hasn’t been approved yet, so we can’t really talk about specifics, but as soon as the Summary of Product Characteristics (SPCs) is signed off I’m sure we’ll be hearing a lot more, which will be really exciting! We’ve got a lot of options from a drug point of view. It’s about having a focus on everything available and building bonds with the clients, which will enable us to manage cases well. I think there’s also a feline version for monoclonal antibodies, and I’m hoping that will soon be launched because it would be a game changer for a lot of cats. They’re difficult to medicate, they have fewer NSAID options, and they’re not ideal cases for diet management and exercise programmes, which are easier in dogs.

Is there anything we can take from human medicine in terms of pain management?

I think we probably do a better job – there might be things they can take from us! Often you hear pain specialists at conferences talking about how they only have ten minutes per patient, and are expected to see 60 patients per day. Vets are lucky with the amount of time we can spend with our patients. Human medicine uses a few therapeutic nerve blocks, and it’s something we’re just starting to do. The fact that we’re essentially practising private medicine means that we can use a very individualised approach for our patients. 

Do you have any projects or plans lined up for the future?

I have a lot! For Zero Pain, we would love to do some in person courses again in the future. We run a really good local anaesthetic course in Denmark, which we started last year. It’s useful being able to watch those techniques on a video, but that course allows delegates to practice that under our guidance on a cadaver, which is really useful. It would also be great to get back to travelling the world and doing more teaching as soon as we’re able to! 

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