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Today's VETgirl online veterinary continuing education sponsored blog is Dr. Ross H. Palmer, DVM, DACVS (Colorado State University). Thanks to IMEX Veterinary, Inc. for sponsoring this blog. Please note the opinions in this blog are the expressed opinion of the author, and not directly endorsed by VETgirl, LLC.

The Two Most Common Fracture Treatment Errors in Primary Care Veterinary Practice

Somewhere between “no good deed goes unpunished” and “the road to hell is paved with good intentions” sits the veterinarian faced with complications encountered after he or she offered their services to help a pet with a fractured long bone. I would add “life is too short for postoperative complications” to this list of proverbs.

The good news is that it doesn’t have to be this way because most orthopedic complications are preventable.

Today let’s tackle 2 of the most common – most avoidable – fracture treatment errors in veterinary practice.

• Intramedullary pin fixation of a fractured radius
• Intramedullary pin & cerclage wire fixation of a non-reconstructable fracture

Both errors are rooted in a desire to help pets & people, but we can learn from our complications thereby protecting ourselves, our patients and our clients from future misery.

#1: Intramedullary (IM) Pin Fixation of a Fractured Radius

The radius simply does not lend itself to effective use of IM pins, in part, because of its narrow intramedullary canal. On the one hand, it is typically recommended that an IM pin fill 60-75% of the intramedullary canal; on the other hand, the bending strength of an IM pin is proportional to its radius raised to the 4th power. A small change in IM pin diameter has a profound effect on its ability to stabilize a fracture! In the case of the radius, the small intramedullary canal all but abolishes the IM pin’s ability to effectively control disruptive forces that seek to delay or prevent bone healing (Fig 1). Some veterinarians attempt to augment the fracture stability by adding a splint or cast (Fig 1C), but the combination of internal fixation and coaptation seldom brings out the best of either treatment especially when treating fractures of major long bones.

A simple truth: When it comes to fractures of the radius, put down the IM pin and nobody gets hurt!


Fig 1 – Radiographs of 3 individual patients each of whom suffered complications as a result of IM pin fixation of radius/ulnar fractures.

#2: IM pin & cerclage wire fixation of a non-reconstructable fracture

Intramedullary pin fixation in combination with cerclage wires is an effective means of treating a very few selected fractures. This fixation modality is best reserved for treatment of long, oblique/spiral diaphyseal fracture configurations of the femur, humerus, or tibia. IM pin and cerclage fixation must be avoided in treatment of non-reconstructable fracture configurations …so I guess we better learn to identify those!

A non-reconstructable fracture (sometimes called non-reducible) is any fracture with multiple cortical fragments, especially small cortical fragments. Close scrutiny is often required to identify small cortical fragments (Fig 2). If in doubt, classify the fracture as non-reconstructable because fractures are always more difficult to anatomically reconstruct than one anticipates.

Cerclage wire fixation requires perfect anatomic reconstruction in order to create the interfragmentary compression that allows exertion of its mechanical ability to resist fracture rotation and collapse of the bone along its axis. Remember the saying, “almost only counts with horseshoes and hand grenades”? Notice that cerclage wires are not on that list because “almost perfect” is not effective with cerclage wire fixation.

When multiple, small, cortical fragments are present, it is simply not feasible to achieve perfect anatomic reconstruction regardless of our intentions or abilities (Fig 2). In our zeal to achieve the impossible, we unknowingly compromise the health of the very soft tissue attachments that represent “the lifeline” to these bony fragments.

A second simple truth: When you see multiple small cortical fragments on your preoperative radiographs, put down the cerclage wire and nobody gets hurt!


Fig 2: Pre-op (2A), post-op (2B), and post-complication radiographs of a failed attempt to use IM pin & cerclage fixation to treat a non-reconstructable tibial fracture. Note that very close scrutiny of the pre-op radiograph (2A) is required to identify the small cortical fragment that could not be perfectly anatomically reconstructed (2B) and contributed to fixation failure (2C).

So what is a veterinarian to do?

You may well find yourself thinking that “this all sounds nice, logical and understandable, but now I’ve been rendered incapable of helping the very client and pet that I seek to help”. Not to worry, External Skeletal Fixation (ESF) or simply “ExFix” is ideally suited to grow the spectrum of fractures that can be effectively treated in the primary care practice setting (Figs 3 and 4).

ExFix can effectively overcome both of the common IM pinning errors detailed above and do so in an exceptionally “bio-friendly” manner that fosters rapid bony healing. In fact, many of the new minimally invasive plate osteosynthesis (MIPO) implant systems and their application techniques were, consciously or not, developed to ascribe to internal fixation the many inherent advantages of external fixators. Nowhere is this more evident than in the description of locking plate/screw devices as “internal fixators”.


Fig 3: A Type I-b ExFix applied in a bio-friendly closed fashion to a radius/ulna fracture using a hanging-limb position (left). Radiographs made a 6-weeks showed ample healing to permit staged frame disassembly.

Additionally, ExFix has the advantage of being affordable as it does not require an inventory of every length of screw, bone plate, etc. and many components are re-usable.

Despite the many advantages of ExFix to the primary care veterinary practice, veterinarians should be cautioned that training in ExFix is strongly advised in order to fully realize ExFix advantages and side-step their disadvantages…because, after all, “life is too short for postoperative complications.” If interested in comprehensive continuing education in external fixation, courses like the Complete Course in External Skeletal Fixation are available to assist veterinarians in the path to developing skills with ExFix.


Fig 4: A non-reconstructable tibial fracture stabilized with minimal Type II ExFix in a bio-friendly closed fashion (4A). Note that no attempt was made to anatomically reconstruct the cortical fragments; instead, closed ExFix application permitted preservation of fragment viability so that they could participate in the bone healing. Radiographs made at 6 weeks (4B) showed ample bone healing to permit staged disassembly to a Type I-a frame.

Thanks to IMEX Veterinary, Inc. for sponsoring this blog. Please note the opinions in this blog are the expressed opinion of the author, and not directly endorsed by VETgirl, LLC.

The post The Two Most Common Fracture Repair Errors in Dogs and Cats | VETgirl Veterinary Continuing Education Blog appeared first on VETgirl.

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VETgirl wants to give a HUGE shout out to Zoetis for sponsoring a FREE Facebook LIVE webinar on "Facebook LIVE: Canine Influenza Virus"

VETgirl and Zoetis have made the recording available to you! If you are a VETgirl ELITE Member, you can also get CE credit for this webinar!

Not a VETgirl ELITE member? VETgirl ELITE members receive 40+ hours of RACE-approved, online veterinary CE/year ($199). That way, you know that you have flexibility to view any of our webinars and listen to our podcasts when you have time.

All the webinars are recorded and can be viewed 24/7 after their release date for CE credit. If you’re watching the recording later on, don’t forget to take the CE quiz with it when you’re done to get your CE certificate!

Join HERE!

*Note: Viewing this webinar is for individual use only; VETgirl webinars are not designed nor meant to be viewed in a group setting due to RACE-CE audit purposes. Inappropriate sharing or viewing of the webinar may result in revoking of membership.

RACE-CE provider name: VETgirl, LLC
RACE Provider number: 785
RACE Program number: 33007

This program 785-33007 is approved by the AAVSB RACE to offer a total of 0.5 CE Credits being available to any one veterinarian: and/or 0.5 Veterinary Technician CE Credit. This RACE approval is for the subject matter categories of: Category One: Scientific using the delivery method of Seminar/Lecture Interactive-Distance/Non-Interactive-Distance. This approval is valid in jurisdictions which recognize AAVSB RACE; however, participants are responsible for ascertaining each board's CE requirements. RACE does not "accredit" or "endorse" or "certify" any program or person, nor does RACE approval validate the content of the program.

The post May 23, 2018: Facebook LIVE: Canine Influenza Virus with Dr. Jane Sykes appeared first on VETgirl.

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VETgirl wants to give a HUGE shout out to Zoetis for sponsoring a FREE Facebook LIVE webinar on "Panting, pacing, vomiting...is it all in the dog’s head? Distinguishing motion sickness from car phobia"

VETgirl and Zoetis have made the recording available to you! If you are a VETgirl ELITE Member, you can also get CE credit for this webinar!

Not a VETgirl ELITE member? VETgirl ELITE members receive 40+ hours of RACE-approved, online veterinary CE/year ($199). That way, you know that you have flexibility to view any of our webinars and listen to our podcasts when you have time.

All the webinars are recorded and can be viewed 24/7 after their release date for CE credit. If you’re watching the recording later on, don’t forget to take the CE quiz with it when you’re done to get your CE certificate!

Join HERE!

*Note: Viewing this webinar is for individual use only; VETgirl webinars are not designed nor meant to be viewed in a group setting due to RACE-CE audit purposes. Inappropriate sharing or viewing of the webinar may result in revoking of membership.

RACE-CE provider name: VETgirl, LLC
RACE Provider number: 785
RACE Program number: 32546

This program 785-32546 is approved by the AAVSB RACE to offer a total of 0.5 CE Credits being available to any one veterinarian: and/or 0.5 Veterinary Technician CE Credit. This RACE approval is for the subject matter categories of: Category One: Scientific using the delivery method of Seminar/Lecture Interactive-Distance/Non-Interactive-Distance. This approval is valid in jurisdictions which recognize AAVSB RACE; however, participants are responsible for ascertaining each board's CE requirements. RACE does not "accredit" or "endorse" or "certify" any program or person, nor does RACE approval validate the content of the program.

The post May 22, 2018: Facebook LIVE: Panting, pacing, vomiting…is it all in the dog’s head? Distinguishing motion sickness from car phobia appeared first on VETgirl.

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Podcast Quiz: What to do with that infectious coughing dog (Method of Delivery: Non-Interactive Online)

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    TRUE OR FALSE: Enrofloxacin is the first choice for bacterial etiologies for CIRD.

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    TRUE OR FALSE: Pulse therapy with 3 days of doxycycline followed by 3 days of enrofloxacin are recommended for Mycoplasma.

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In this VETgirl online veterinary continuing education podcast, we interview Dr. Leah Cohn, PhD, DACVIM, on the approach to the infectious coughing dog. In this podcast, she reviews what Canine Infectious Respiratory Disease (CIRD) is, what the diagnostic work up is, and how to treat these patients. She'll also review what vaccines are available for the different etiologies, and how it's more than "just kennel cough." Check out this important Guideline and Recommendation from the American College of Veterinary Internal Medicine here:

ACVIM Antimicrobial Use Guidelines

Today's VETgirl podcast is sponsored by Merial, now part of Boehringer Ingelheim. Ask your sales representative from Merial, now part of Boehringer Ingelheim, for more information about RECOMBITEK Oral Bordetella.

The post What to do with that infectious coughing dog | VETgirl Veterinary Continuing Education Podcasts appeared first on VETgirl.

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Join us for a 1-hour VETgirl online veterinary CE webinar, where where Dr. Jessica Pritchard, VMD, DACVIM talks about all things ticks! Ixodes ticks have experienced a population explosion and expansion since the 1990s, which means the diseases they transmit are spreading rapidly as well.

In this lecture, learn how Lyme affects both dogs and humans, how to address newly seropositive symptomatic and asymptomatic dogs in your practice, and best practices for treating and preventing Lyme disease in this one hour webinar. Thanks to Elanco Animal Health, this webinar is free to all!

Topic: Lyme disease - emerging markets are growing!
Speaker: Jessica Pritchard, VMD, DACVIM (SAIM)
Date: Sunday, July 22, 2018
Time: 9-10pm EST (8-9pm CST, 7-8pm MST, 6-7pm PST) - Need time zone help? CLICK HERE
Total RACE-approved CE credit hours: 1 hour
RACE Program #: 785-33312
Cost: Complimentary (Value: $99)
Thanks to sponsorship from Elanco Animal Health, free to all!

Register Here!

Have questions about the VETgirl, GoToWebcast platform? CLICK HERE!

What if you are unable to attend at that time? All VETgirl ELITE members have the flexibility to view any of our webinars when you have time. All the webinars are recorded and can be viewed 24/7 after their release date for CE credit. If you’re watching the recording later on, don’t forget to take the CE quiz with it when you’re done to get your CE certificate! The CE certificate for the live viewing of the webinar will be emailed to the VETgirl ELITE members within 48-72 hours of the webinar, after confirming their attendance and VETgirl ELITE status.

*Note: Viewing of this webinar is for individual use only; VETgirl webinars are not designed nor meant to be viewed in a group setting due to RACE-CE audit purposes. Inappropriate sharing or viewing of the webinar may result in revoking of membership.

Not a VETgirl ELITE member? VETgirl ELITE members receive 40+ hours of RACE-approved, online veterinary CE/year ($199). That way, you know that you have flexibility to view any of our webinars and listen to our podcasts when you have time.

All the webinars are recorded and can be viewed 24/7 after their release date for CE credit. If you’re watching the recording later on, don’t forget to take the CE quiz with it when you’re done to get your CE certificate!

Join HERE!

*Note: Viewing this webinar is for individual use only; VETgirl webinars are not designed nor meant to be viewed in a group setting due to RACE-CE audit purposes. Inappropriate sharing or viewing of the webinar may result in revoking of membership.

RACE-CE provider name: VETgirl, LLC
RACE Provider number: 785
RACE Program number: 33312

This program 785-33312 is approved by the AAVSB RACE to offer a total of 1 CE Credit being available to any one veterinarian: and/or 1 Veterinary Technician CE Credit. This RACE approval is for the subject matter categories of: Category One: Scientific using the delivery method of Interactive-Distance/Non-Interactive-Distance. This approval is valid in jurisdictions which recognize AAVSB RACE; however, participants are responsible for ascertaining each board's CE requirements. RACE does not "accredit" or "endorse" or "certify" any program or person, nor does RACE approval validate the content of the program.

The post July 22, 2018: Lyme disease – emerging markets are growing! appeared first on VETgirl.

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In this VETgirl online veterinary continuing education blog, we interview Dr. Leah Cohn, PhD, DACVIM, on the approach to the infectious coughing dog. In this podcast, she reviews what Canine Infectious Respiratory Disease (CIRD) is, what the diagnostic work up is, and how to treat these patients. She'll also review what vaccines are available for the different etiologies, and how it's more than "just kennel cough." Check out this important Guideline and Recommendation from the American College of Veterinary Internal Medicine here:

ACVIM Antimicrobial Use Guidelines

Today's VETgirl podcast is sponsored by Merial, now part of Boehringer Ingelheim. Ask your sales representative from Merial, now part of Boehringer Ingelheim, for more information about RECOMBITEK Oral Bordetella.

The post What to do with that infectious coughing dog | VETgirl Veterinary Continuing Education Blog appeared first on VETgirl.

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VETgirl wants to give a HUGE shout out to Elanco for sponsoring a FREE Facebook LIVE webinar on "Benefits of low dose volume vaccines in dogs and cats"

VETgirl and Elanco have made the recording available to you!

Not a VETgirl ELITE member? VETgirl ELITE members receive 40+ hours of RACE-approved, online veterinary CE/year ($199). That way, you know that you have flexibility to view any of our webinars and listen to our podcasts when you have time.

All the webinars are recorded and can be viewed 24/7 after their release date for CE credit. If you’re watching the recording later on, don’t forget to take the CE quiz with it when you’re done to get your CE certificate!

Join HERE!

*Note: Viewing this webinar is for individual use only; VETgirl webinars are not designed nor meant to be viewed in a group setting due to RACE-CE audit purposes. Inappropriate sharing or viewing of the webinar may result in revoking of membership.

The post May 16, 2018: Facebook LIVE: Benefits of low dose volume vaccines in dogs and cats appeared first on VETgirl.

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Podcast Quiz: Breeds predisposed to aspiration pneumonia (Method of Delivery: Non-Interactive Online)

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    TRUE OR FALSE: Scottish deerhounds are at higher risk for aspiration pneumonia.

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    TRUE OR FALSE: The prognosis for aspiration pneumonia is fair, but requires rapid diagnosis and treatment.

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In this VETgirl online veterinary continuing education podcast, we discuss whether certain breeds are more predisposed to aspiration pneumonia or not.

Do you see a lot of patients with respiratory signs in your practice? Do many of them have aspiration pneumonia? Aspiration pneumonia results from infection of the pulmonary parenchyma and alveoli due to entry of microorganisms into the lower respiratory tract during inhalation or aspiration. Predisposing factors include inability to protect the airway, which can be due to a number of causes including sedation, anesthesia, upper airway disease, neurologic impairment, esophagitis, vomiting, regurgitation, the list goes on.1

While a definitive diagnosis is generally based on some kind of airway sampling (e.g., broncho-alveolar lavage, endo- or transtracheal wash), many cases are diagnosed based on a compatible history and radiographic signs of an alveolar and/or interstitial lung pattern, often in the right middle, right cranial and caudal segment of the left cranial lung lobe(s).2

So, Greenwell et al out of Australia wanted to conduct a study called Aspiration pneumonia in the Irish wolfhound: a possible breed predisposition to evaluate if there were any breeds that were overrepresented with aspiration pneumonia. The authors felt like they were seeing a disproportionate number of Irish wolfhounds with aspiration pneumonia, and wondered if there might be some underlying predisposition to developing aspiration in the breed. So they retrospectively reviewed records from 2008-2012 to look at breed incidences of aspiration pneumonia.

So, what'd they find in this study?

In this study, canine patients were diagnosed with aspiration pneumonia based on radiographic findings (alveolar or interstitial pattern in dependent lung lobes), acute onset of clinical signs, and lack of other disease processes. Over the five year period, the overall incidence of aspiration pneumonia was 0.5%. Irish wolfhounds were the breed with the highest incidence of AP (9/25 dogs, 36%). The other breeds with the highest incidence of AP were Maremma sheepdogs (12.5%), Basset hounds (8.8%) and Bulldogs (6.4%). Of the 9 Irish wolfhounds with AP, 4 had an underlying cause identified: 1 had a choking episode, 1 had gastric dilatation, and 2 had laryngeal paralysis. The other 5 did not have a cause identified. None of the dogs have evidence of megaesophagus on thoracic radiographs. 8/9 dogs survived to initial discharge. Of the 5 dogs with unknown cause of their AP, 4/5 had recurrences of AP, 2 of which were ultimately euthanized.

So, what can we take away from this VETgirl podcast?
This study suggests the incidence of AP is increased in Irish wolfhounds. Since the study was retrospective, complete diagnostics weren’t done on all of the dogs – none had cardiac evaluations, and only one had a BAL. These limitations make it difficult to completely assess these cases, but their presumptive diagnosis of AP is reasonable based on established criteria. While a previous study has shown that megaesophagus was the most common cause of AP, none of the dogs in this study had evidence of megaesophagus on thoracic radiographs.3 The authors suggest that subclinical laryngeal paralysis may be present in this breed and may be a predisposing factor for AP.

Limitations of this study include its retrospective nature, small case numbers and lack of complete clinical work-up for all of the cases. That being said, this paper is the first to report on a potential predisposition to AP in Irish wolfhounds and as such, is important to be aware of.

Overall, this study suggests that AP may be more likely in Irish Wolfhounds, and should be considered in patients with acute onset of even mild respiratory signs. A complete evaluation should include examination of laryngeal function in this breed. If you see an Irish wolfhound with respiratory signs, aspiration pneumonia should be near the top of your differential list.

References:
1. Barton L. Aspiration pneumonia. In: Textbook of respiratory Disease in Dogs and Cats. Ed LG King. Saunders, St. Louis, MO, 2004: 422-430.
2. Tart MT, Babski DM, Lee JA. Potential risks, prognostic indicators and diagnostic and treatment modalities affecting survival in dogs with presumptive aspiration pneumonia: 125 cases (2005-2008). J Vet Emerg Crit Care 2010;20:319-329.
3. Kogan DA, Johnson LR, Sturges BK et al. Etiology and clinical outcome in dogs with aspiration pneumonia: 88 cases (2004-2006). J Am Vet Med Assoc 2008;233,1748-1755.
4. Greenwell CM, Brain PH. Aspiration pneumonia in the Irish wolfhound: a possible breed predisposition. J Sm Anim Prac 2014;55:515-520.

Abbreviations:
AP: aspiration pneumonia

The post Breeds predisposed to aspiration pneumonia | VETgirl Veterinary Continuing Education Podcasts appeared first on VETgirl.

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In this VETgirl online veterinary continuing education Real-Life-Rounds, Heidi Reuss-Lamky, LVT, VTS, (Anesthesia/Analgesia, Surgery), FFCP, reviews how to perform a variety of dental nerve blocks for dogs and cats. Nerve blocks are a valuable part of a multi-modal pain management plan. Local anesthetic drug selection, placement tips, contraindications and precautions will also be discussed.

NOTE: CE credit is only available for veterinary technicians for this Real-Life Rounds, based on RACE updates.

Topic: Analgesia for Blockheads: Dental Nerve Blocks for Technicians
Speaker: Heidi Reuss-Lamky, LVT, VTS (Anesthesia & Analgesia, Surgery)
Date: Sunday, July 8, 2018
Time: 8:30-9pm EST (7:30-8pm CST, 6:30-7pm MST, 5:30-6pm PST) - Need time zone help? CLICK HERE
Total RACE-approved CE credit hours: 0.5 hours
RACE Program #: 785-32863

Not a VETgirl ELITE member? VETgirl ELITE members receive 40+ hours of RACE-approved, online veterinary CE/year ($199). That way, you know that you have flexibility to view any of our webinars and listen to our podcasts when you have time.

All the webinars are recorded and can be viewed 24/7 after their release date for CE credit. If you’re watching the recording later on, don’t forget to take the CE quiz with it when you’re done to get your CE certificate!

Join HERE!

*Note: Viewing this webinar is for individual use only; VETgirl webinars are not designed nor meant to be viewed in a group setting due to RACE-CE audit purposes. Inappropriate sharing or viewing of the webinar may result in revoking of membership.

RACE-CE provider name: VETgirl, LLC
RACE Provider number: 785
RACE Program number: 32863

This program has been approved for continuing education credit in jurisdictions which recognize AAVSB RACE approval; however participants should be aware that some boards have limitations on the number of hours accepted in certain categories and/or restrictions on certain methods of delivery of continuing education. Call VETgirl (858.859.1838) for further questions.

Please contact the AAVSB RACE program if you have any comments/concerns regarding this program’s validity or relevancy to the veterinary profession.

The post July 8, 2018: Real-Life-Rounds: Analgesia for Blockheads: Dental Nerve Blocks for Technicians appeared first on VETgirl.

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Did your canine patient eat pot? About to reach for a urine drug test and not sure if it's accurate or not?

Have a dyspneic cat and not sure if you should stress out the cat for a proBNP test?

Join VETgirl as Dr. Armelle De Laforcade, DACVECC, reviews the commonly used point of care tests in the emergency setting. In this lecture, she'll review available tests such as lactate, NT-proBNP, urine drug testing, ethylene glycol testing, canine parvovirus, and C-reactive protein. Case examples of test results will be used to highlight the application of these tests.

Topic: Point-of-care (POC) diagnostics in the ER
Speaker: Armelle De Laforcade, DACVECC
Date: Thursday, July 19, 2018
Time: 8-9:30pm EST, 7-8:30pm CST, 6-7:30pm MST, 5-6:30pm PST - Need time zone help? CLICK HERE
Total RACE-approved CE credit hours: 1.5 hours
RACE Program #: 785-31998
Cost: FREE for ELITE members, otherwise $50/1.5 CE Credits

Not a VETgirl ELITE member? VETgirl ELITE members receive 40+ hours of RACE-approved, online veterinary CE/year ($199). That way, you know that you have flexibility to view any of our webinars and listen to our podcasts when you have time.

All the webinars are recorded and can be viewed 24/7 after their release date for CE credit. If you’re watching the recording later on, don’t forget to take the CE quiz with it when you’re done to get your CE certificate!

Join HERE!

*Note: Viewing this webinar is for individual use only; VETgirl webinars are not designed nor meant to be viewed in a group setting due to RACE-CE audit purposes. Inappropriate sharing or viewing of the webinar may result in revoking of membership.

RACE-CE provider name: VETgirl, LLC
RACE Provider number: 785
RACE Program number: 31998

This program has been approved for continuing education credit in jurisdictions which recognize AAVSB RACE approval; however participants should be aware that some boards have limitations on the number of hours accepted in certain categories and/or restrictions on certain methods of delivery of continuing education. Call VETgirl (858.859.1838) for further questions.

Please contact the AAVSB RACE program if you have any comments/concerns regarding this program’s validity or relevancy to the veterinary profession.

The post July 19, 2018: Point-of-care (POC) diagnostics in the ER appeared first on VETgirl.

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