Trust me.?!

Hope you had a fantastic Thanksgiving!

Many of the people reading this know me from my previous job in veterinary general practice. Many of them I met years ago and over time and through experience, we developed a veterinarian/client relationship and they came to trust me with the health and well being of their family pets. This is of course, a huge honor for a veterinarian and for many of us it is exactly why we went into this profession in the first place.

Presently, I am working in an emergency clinic and the dynamics are considerably different. I rarely see people more than once and they have to come into this situation trusting us from the beginning and from our side of the exam table, we have to establish that trust as quickly as possible. Their pet’s life might depend on it. Sometimes that trust comes easy, people understand the situation we are all in and they go with it, sometimes it’s less easy and sometimes it’s downright impossible.  I’d like to offer anyone reading this some advice on how to make it less scary for themselves and hopefully have a better chance at a good outcome for their pet.

There are two ways a client ends up bringing their pet to an emergency clinic. The first is the more obvious one, something happens after hours and the pet requires immediate attention. In these cases, the owner may call their veterinarian and receive instructions to contact the emergency clinic or they may find the number online. The second way a pet ends up at our facility is if he/she has an illness or issue that is going to require a level of care or monitoring that the pet’s family veterinarian cannot provide. In either situation, the owner of the pet has to bring their beloved family member to someone they have likely never met before and entrust that person with their pet’s health and well being.

This can be scary for some people. Sometimes it can be a little daunting for us as well. I have a few ideas about how we can make it a little less scary for you and ultimately better for your pet.

The first step would be that you just have to try to come into the situation with a little trust in the first place. There are few if any veterinarians or veterinary staff working in an emergency clinic who don’t really want to be there. It’s long hours, you sacrifice a lot of things we all take for granted (sleep schedules for one) and you miss that connection with clients and their pets. Don’t get me wrong, there are upsides including that the emergency clinic doesn’t support veterinarians with egos or ones who want to be dishonest. There’s too many people seeing what we do or say to clients for us to be anything but transparent and honest. That alone may not make you trust an ER veterinarian or the staff but it should help.

The other thing to remember is that if your veterinarian chose to send you to a specific emergency clinic, it’s because they trust them. Usually, if there is enough business to support an emergency clinic, two pop up to fill the need. Most veterinarians will choose the clinic that treats their clients the same way they would treat their clients. Ask your veterinarian which emergency clinic they recommend, ask them why and try to ask them before you have an emergency.

The next step after determining which emergency clinic your veterinarian recommends is to call them yourself, preferably before you have an emergency and ask all of the things you might want to know. Try to call after the morning and evening busy periods, so skip 7am to 10am and 4pm to 8pm and keep in mind, anytime can be busy for an emergency clinic. So if they seem a little brusque the first time, call back again and see if maybe you just caught them at a bad time. Once you have an idea of what the culture of the practice is like it might be a little easier for you to go into an emergency situation with a little more trust.

The final point I’d like to make when it comes to trust and the emergency clinic is that the emergency clinic has to cover all their bases, every time. What I mean by this is that we not only have to answer to you, we also have to answer to your veterinarian and to each other. Any veterinarian can only work with the information provided to them and when your veterinarian or the next shift at the emergency clinic takes over your pet’s care they will want to know why they don’t have certain pieces of information. Saying that the client and the veterinarian discussed options and decided that a specific approach fit the family’s wishes better is perfectly acceptable. Telling your colleagues the case they are taking over is lacking important information because the veterinarian failed to offer certain diagnostics is never acceptable. So while it might seem like the emergency clinic is pushing a lot of testing up front, it’s because we are but not for the reasons you might think. We have a limited window to get an answer to your problem and an obligation to offer you all of the possible options within our window. There is nothing wrong with doing the less emergent diagnostics with your veterinarian after we get your pet to a more stable state, but that has to be your decision not ours and you can’t make the decision to wait on diagnostics if they aren’t even offered in the first place.

I hope your pet never ends up in an emergency clinic. But if you do find yourself needing one, I hope that you can take some of these points and make it a less stressful and smoother event than it might have been otherwise.

Thanks for reading.

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Nutrition

I talk to pet owners every single day. Even on my days off I am likely going to answer a question for a friend and I often get emails from complete strangers asking me for advice about their pets. I always take it as a compliment when someone wants my input in a decision and try to be as helpful as possible.

If nutrition isn’t the most common subject I discuss with people, it’s in the top 5. Pet owners spend a lot of time looking into what foods will be best for their pet’s needs. It makes sense, you want what’s best for your pet and nutrition is one of the easiest things to control. The problem I see people run into with their pets is the same problem I see people run into with their own diets; there are so many “experts” and so little information. Bags with claims like “human grade” “no byproducts” “grain free” “holistic” and more clog the aisles at pet food stores but don’t really have an affect on anything but the cost of the food. I usually like to start the food conversation with new people by “admitting” my dogs eat a diet with corn in it and meat is not the first ingredient on the bag. My dogs also have their health monitored pretty closely and they are lean but well muscled with the exception of our black lab who steals food from our three children, a lot. In short, my dogs are a lot healthier than the average American dog.

I wrote about this subject a while back but it was sort of more informational and less conversational at the time. I think a conversational approach to nutrition is a good idea. And I think the conversation should be centered around, what are you trying to accomplish with your pet’s nutrition?

If your goals are medically based. If you are trying to accomplish weight loss or manage a disease process like diabetes or arthritis with nutrition, then a consult with your veterinarian and ideally a veterinary nutritionist would be your best bet. They can discuss with you the advantages of using specific nutrient profiles in specific diseases and how we expect those nutrients to effect the physiology of your pet.

If your goals are athletic, your dog is sled dog or an agility dog or a dock diving dog and you want to be sure their nutrition is optimized for competition, a visit to your veterinarian is likely going to be helpful but you really want to utilize a veterinary nutritionist. Specifically one that focuses on athlete or search and rescue dogs. Veterinary nutritionists are veterinarians who have gone on and received advanced training and accomplished certification in the field of veterinary nutrition. You can find more about them here.

If your thinking about breed specific nutrition, I would recommend a consultation with your veterinarian but if your dog is a family companion and has no known medical issues, your dog will likely do just fine on any well balanced diet so long as you are paying attention to the number of calories they take in.

If you are trying to do what’s best for your pet because they are a member of your family and they are otherwise healthy, I have good news for you. Pretty much any food that meets AAFCO standards is going to be alright for your pet. Certainly, a conversation with your veterinarian won’t hurt but a healthy dog can get all of their nutritional needs met by even some of the cheaper foods that are currently on the market. I’m not saying you should necessarily reach for the cheapest food you can find but here’s a point I wish I could put on a coffee mug and give away with every puppy/kitten: If you are skipping out on preventative medical care like flea/tick prevention, oral healthcare, vaccination or annual check ups because of the cost and are feeding an expensive dog food, you are missing the point. Your attention to your pet’s well being would be far better served by focusing on preventing diseases they may encounter and ensuring appropriate oral health than by feeding them foods that aren’t providing any measurable health benefits.

If you’re trying to feed your dog a diet closer to what he/she would eat in the wild, we need to look at this realistically. There are no wild dog populations, there are feral dog populations and having visited many places that have feral dog populations the only diet I would recommend for matching the average feral dog’s is this one. That’s right, “wild” dogs eat garbage. If you are about to insist that your dog should eat like a wolf, stop. No. Your dog is not a wolf. But even if I were to humor you and agree that your dog is a wolf, you would have to concede that wolves live longer and healthier lives in captivity. Do you know what they feed wolves in captivity? Dry commercially available dog food. Don’t believe me? Here. Here. Here.

But what about cats? Feel free to substitute cat for dog above. If you have a sled or dock diving cat I would really like to meet them. And yes, feeding dry commercially available cat food is the recommended diet for small wild felids in captivity. I do prefer to see cats get at least some high quality canned food in their diets. Right now in our house, we are feeding our feline buddies Hill’s C/D stew cans, but that is subject to change based on what’s about to expire at the clinic.

So that’s my take on pet nutrition. If your pet has specific needs, please involve a veterinary nutritionist. If your really happy with your current pet food and your pet is receiving the level of preventative care that works for you, awesome! Keep it up. If you find yourself skimping on preventative care based on cost, you might benefit from switching to a less expensive commercially available dog or cat food. If you really think that your cat/dog should eat like a wild tiger/wolf, I’ll look for your angry comments below. Spelling and grammar may be enforced.

One of the best resources we have for pet nutrition is the Pet Nutrition Alliance. You can find answers to all kinds of questions and some of the reasons our recommendations are the way they are.

Thanks for reading.

Lyme Disease in Dogs

Oddly enough to those of us living in New England, Lyme disease is kind of a controversial issue in veterinary medicine. When we get onto the topic of vaccinating against Lyme disease, opinions really start to fly around and when we get to the topic of vaccinating dogs who have tested positive for Lyme disease it can get down right ugly! Which when you think about it objectively, the idea of people fighting over these kind of issues is sort of hilarious, in a sad way.

I’m not going to try to convince anyone one way or the other about whether or not Lyme vaccines are necessary or if dogs who have tested positive should be vaccinated. People can think what they want, I’ll continue to make the best decisions I can with the information available being processed by my meager mind and I expect others to do the same. If you are a veterinarian who disagrees with me or a pet owner who sees a veterinarian who disagrees with me, welcome to medicine where there is often more than one point of view. I care about what you think but more about how you got there.

My approach to preventing Lyme disease can be compared to preventing automobile deaths and for me, makes for an easier explanation of my position.

The first line of defense in preventing Lyme disease in your pet is checking for ticks every time your pet goes outside and removing them as soon as you find them. I would compare this to paying attention when you are driving as far as preventing automobile deaths is concerned. If you are looking for ticks or if you are being attentive to the environment around you while operating a motor vehicle, the chances of contracting Lyme disease or dying in a car crash are greatly reduced. Respectively of course. The best way to check for ticks is to run your hands all over your dog, going against the fur patterns on their skin. Combs and brushes may also help to remove unattached ticks or uncover attached ones. Attached ticks are best removed by grasping them down by their head and pulling straight out. I use my fingers for this. In all of the time I have been practicing veterinary medicine in tick endemic areas I have never seen a situation where leaving the head behind happened or caused any ill effects. I have never seen evidence suggesting it happens with any regularity that would elevate concerns. It would probably have similar statistical occurrence rates (though less horrible effects) to being killed in a vehicle by objects – like meteorites – falling from the sky. It happens but that’s no reason for everyone to drive an armored vehicle. So pull ticks out as soon as you find them.

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The second line of defense would be using an effective product for repelling or killing ticks when they get on your dog. You might think that I have it backwards and this should be first and checking for ticks should be second. Fine, copy and paste this into a word document, change the order around and read it that way. By having a tick preventative on your dog you are preventing the ticks from being on your dog long enough to bite and transmit Lyme. The bacteria isn’t injected into your dog immediately by the tick but if the tick is ingesting poison immediately and dying within a few minutes, transmission of Lyme is virtually impossible. Using a decent flea and tick preventative is like putting seat belts in cars and using the seat belts. Seat belts have been required in motor vehicles since 1968, as you might expect there was a lag time between requiring seat belts in cars and seeing a significant decrease in deaths per hundred thousand people in the country. The law requiring seat belts did not require everyone to buy a new car. But less than 10 years after the implementation of the law, automobile deaths had decreased by more than 20%. There are many flea and tick products on the market. I recommended a few here. I stand by those recommendations.

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Finally, Lyme vaccines are available and are effective for dogs. No vaccine is 100% effective and bacterial vaccines are particularly difficult because bacterial surface proteins are constantly evolving but studies have shown the vaccine to have an efficacy between 80 – 90%. Vaccinating against Lyme disease is like driving a car with an airbag. Airbags in vehicles were first introduced as an idea in the 1940’s but did not become prevalent n vehicles until the late 1990’s. As a result of airbag and seat belt use combined with safe driving, automobile deaths per hundred thousand citizens are the lowest they have been since 1918. Yes, that was the last time in the 20th century the Red Sox won the world series. Adding Lyme vaccines into your dog’s healthcare plan if you live in an endemic region is a very solid idea. Depending solely on the vaccine to protect your dog from Lyme disease might work but I would consider it very similar to driving a car distracted with just the airbag to prevent you. You’ll probably live through the accident but there’s also a small chance the airbag will kill you. In a similar fashion, while vaccines are typically safe and effective, there is a risk associated with stimulating the immune system and vaccine related deaths in pets do happen. So while I think every dog in endemic regions should be vaccinated for Lyme disease, I also think exactly zero pets living in non-endemic regions should be vaccinated for Lyme disease.

A side note on vaccinating, Lyme vaccines do not prevent the other diseases transmitted by ticks and this small but important fact is another reason I consider tick removal and prevention more important than vaccination.

Even with vigilant drivers who are wearing their seat belts and driving cars with airbags, there are going to be some deaths on the road every year. In a similar fashion, Lyme disease which may have been around 15 million years ago is still likely to score a few points against us despite our best efforts. But by checking for ticks every time your dog goes outside, removing them whenever you find them, using an effective flea and tick preventative and vaccinating against Lyme if you live in a Lyme endemic region, you greatly reduce your dog’s chances of being afflicted by this disease.

Thanks for reading.

Living with Each Other’s Choices

I feel like I’m sharing a well kept secret of veterinary medicine here. Except it shouldn’t be a well kept secret or a secret at all. Your pets; they belong to you. They are yours. You are the decision maker when it comes to their healthcare. Our job as veterinary professionals is to understand your problem, use our training and understanding to formulate an approach to the problem and finally, share all of that with you in the form of a recommendation.

That’s all it is. A recommendation. You are always in the driver’s seat. Sometimes, it seems like you don’t have a choice. Sometimes there are few options and sometimes decisions need to be made right away but you are always in control.

Right now I see emergencies exclusively, when I actually started this article I was doing a lot of dentistry, the parallels are very similar. When someone comes into the emergency clinic I work at right now, we often have to have difficult discussions about the problem at hand, how much it is going to cost to get a handle on the problem and the fact that we need a considerable amount of that money BEFORE we do anything with their pet. One tricky thing about quality veterinary care is that it is really expensive to provide. Our equipment, supplies and training cost just as much as the ones utilized by the health care teams who provide our own health care. The costs are essentially the same for all clinics, so if you are getting a great “deal” at your current veterinarian, I promise they’re cutting the costs somewhere. Our pets have many of the same health problems we do as their owners. And the treatments are also very similar in a lot of ways. One big difference, our patients more frequently need to be under anesthesia in order for us to do a satisfactory job. I’m not going to try to reason with a worked up house cat about, well anything really. Lacerations, porcupine quills, dentistry or even growth removals could all happen with local anesthesia in people, not so with pets. As a result, we have added costs in many areas based on the way our patients respond to care. When we are adding things like anesthesia, we are also adding risk as well, mitigating risk involves gathering additional information like blood-work, chest x rays or blood pressure measurements. This additional information also adds cost. All of it, from running blood-work to walking in the front door, is voluntary, but once we start down that path the veterinarian treating your pet has a responsibility. It is our responsibility to provide you with as thorough a plan as possible to give you the best opportunity to make an informed decision about your pet’s healthcare. What you choose to do with that plan is completely up to you.

If a person were to bring a dog having seizures to a veterinarian and task that veterinarian with figuring out why your dog is having seizures and what could be done about it, That seems like a pretty straight forward issue, make sure it’s otherwise healthy and put the dog on anti-convulsant medication and that should work, right? Maybe. I bet you would be successful most of the time with that approach. At least better than half the time, depending on the factors involved of course. If a client came to me and asked if we could just try medication, I would be willing to consider that approach so long as the client understood that we were taking a risk of missing the cause and potentially making things worse. If all I know is that you have a dog having seizures, the list of possible causes is pretty extensive; infections (viral and bacterial), parasites, toxin exposure, electrolyte abnormalities, congenital abnormalities, cancers, liver disease, kidney disease, metabolic diseases, trauma, nutritional deficiencies are just some of the causes of seizure activity in dogs. The better approach would be to fully examine the dog, discuss with them what the seizure activity looked like, how long it lasted, how often it occurred and how the dog recovered to determine first if it was truly a seizure, what kind of a seizure it was and where our diagnostic testing should start. There will be different approaches for patients in different age groups or breeds for example. Then we would present the dog’s owner with a comprehensive idea of where diagnostics should start and how we can expect things to proceed. In this situation the client can now take all of the provided information, process it and make a better informed decision. They could even take the recommendation, leave, go home, look everything up on the internet and come back with a series of questions for their veterinarian. From that conversation a diagnostic plan could be implemented and they could start down the path towards understanding their pet’s medical condition and needs but in order to get there, we need to present the owner with a complete plan.

One of my least favorite questions to answer when presenting a plan is which part of the plan is necessary. Personally, it bothers me because the idea that I would offer unnecessary testing is the same to me as asking if I’m trying to steal from you. The answer is no. Professionally, it’s a frustrating question because the only appropriate answer is, “It depends.” It depends on what you as the customer wants. Do you want to know why your dog is having seizures or do you just want to try something to see if we can reduce the number or duration of the seizures? Perhaps rather than asking how much of this is necessary, it might be better worded as, what is the minimal amount of information we need to have a reasonable chance at a positive result? Of course the answer to that is also, “It depends.” It depends on how extensive the problem is and what the solution is going to be. Sometimes, even the options available to us are incredibly limited. I still think we can have a satisfactory outcome every time just as long as we are communicating openly and understand what we are doing. Even if we chose the minimal amount of information path, if we communicated effectively,  going down a path with a lot of uncertainty surrounding our issue is alright.

Where we start to have trouble is when the communication breaks down. If we don’t have access to all of the information that makes sense for this problem then it becomes harder to come up with a treatment plan. Without a solid treatment plan we might not have the expected results, they may take longer or we may encounter complications. It’s possible everything will be completely fine but when things don’t get better or take a long time in getting better it’s also very possible that those missing pieces of information would have helped. It doesn’t mean we have to do everything recommended every time or right at the beginning. It means we have to be open and realistic about expectations. And we all have to be on the same page. And we all have to accept responsibility for our own decisions.

In no way am I typing this hoping that you start spending more money at your veterinarian’s office and I would feel awful if you took this to mean that I think you should spend more than you can afford. What I am trying to articulate is that both sides of the exam table are making decisions and as long as they are on the same page and can be frank and candid with one another, I expect every outcome to be satisfactory.

Thanks for reading.