My daughters will not be bossy

I have three daughters. Three young girls who are everything to me at this point in my life. Like any parent I spend a fair amount of time reflecting, thinking, and planning how to best go about setting the right examples, teaching the right lessons, and encouraging the right behaviors. Over the past seven years or so I have learned that conventional wisdom, while being very conventional is seldom wisdom. I have also learned that most frequently, when humans realize our conventional wisdom is wrong the response is to try to re-frame the outcome rather than trying to change the input.

Recently, we were introduced to the double standard of girls being called ‘bossy’ while little boys might be called ‘leaders’ for similar behavior. The idea stemmed from one of our daughters asserting herself and letting the rest of her group know that she had the answer and she was the one that was going to get the problem solved. And she was called ‘bossy’ for it. At first I was angry about name calling a seven year old. Then I considered the reasoning behind it. She was being bossy. I don’t like it but I don’t think I would like it from anyone. Which lead to my next thought. Is that the type of behavior we would call a boy a leader for displaying?

That’s not leadership. Assertiveness might be part of leadership but it’s not the only part. Authority might be granted to a leader but not every authority is a leader. And so to me, the question is not why are my daughters’ being admonished for behavior we would admire if they were boys. The question to me is why do we consider this leadership when it comes from anyone? Why do we accept this kind of behavior from anyone?

So I looked a little deeper into what about being called bossy is bad and why maybe having qualities that might get you called bossy is a good thing.

If I am understanding everything I am reading on the subject correctly, “bossy” people who are actually good leaders:

Aren’t afraid to say what they want.

Have a natural sense of authority.

Have a lot of self confidence.

Don’t take ‘no’ for an answer.

Aren’t afraid to tell you when you’re wrong.

Are never ashamed of anything they do.

Tell it like it is.

These aren’t the qualities of a leader. These are the qualities of an asshole (sorry Grandma). Sure, plenty of men and women have achieved high levels of success while demonstrating these character qualities but that doesn’t make them good leaders. And if we are to believe any of the science looking at leadership, motivation, or similar fields of study over the last century, these people would have been far more effective and likely a fair bit more successful if they had not demonstrated the traits listed above. Because that is not leadership. We shouldn’t be encouraging any young person to demonstrate this behavior. We should be recognizing that these young people have an ability to demonstrate some leadership qualities and then as their guides and role models we should be explaining to them that their actions and attitudes towards the people they are working with are undermining their abilities as leaders.

Good leaders follow a dichotomy that takes the better part of a lifetime to master and takes a lot of humility and self reflection to even begin. A good leader is confident but not arrogant, they are ready to lead and to follow at the same time. Good leadership means that you have a plan but maintain the distance from that plan to see when it is not going well and you need to make a change. Good leaders understand that they are responsible for everything that happens within their sphere of influence and they step up to take the blame when there is blame to be taken but are willing to hand out the credit when things go right.

If they find themselves in a leadership position on a bad team, we should be there to explain to them – gently in the beginning – that it’s their fault. Because there are no bad teams, only bad leaders and almost every problem in any organization can be traced back to poor leadership. It’s that important.

So please, please, I beg of you do not tell my daughters that it is acceptable to be bossy. And don’t be surprised if I start telling your sons that it’s not alright for them to be bossy either. Instead of lowering the standard to remove a double standard, let’s raise the bar entirely and develop a generation of actual leaders.

Thank you for reading.

 

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Does it Hurt?

The best doctor in the world is the veterinarian. He can’t ask his patients what is the matter-he’s got to just know. – Will Rogers

I spend a considerable amount of time trying to explain to pet owners that their pet’s conditions are painful. The disconnect is not in their understanding or their level of concern for their pet. The problem is usually in the way we are communicating about pain. Pain for us affects the way we act, feel and go about our daily business. Sort of. I think all of us have experienced pain that came on subtly and we adapted so well we didn’t realize it was there until it was gone. Many headaches and sinus infections have pain like this.

The most common pain for me to be discussing with people is dental pain. I always aim to provide the best care possible for the situation I am dealing with (every veterinarian does this) and dental care is no exception. This includes paying close attention to pain management before, during and after the event. For those who see the need, understand the course of the disease or just take my word for it I will almost always (90% or better) hear from them at their one week check up that their pet is acting years younger or that they did not realize how much pain he or she was in before it was addressed. For those who have never had to endure my talk about why chronic or progressive pain often goes unnoticed, here it is.

Physiologically and anatomically speaking: All other mammals have exactly the same mechanisms feeling and reacting to pain as humans do. There is no reason to assume that something that is painful for us is not at least equally painful for them. Most of the really acute pain from fractures, lacerations or burns is fairly easy for people to relate to. The slower onset, chronic pain situations like arthritis or dental disease are a lot harder to understand.

Dogs are pack animals, they live in cooperative societies that also involve a fair amount of competition. A dog at the top of the heap is going to want to stay there. Dogs a little further down will want to at least maintain their position and may try to rise up and become top dog if the opportunity arises. Dogs at the bottom of the pack will be looking for any opportunity to make an advancement. Dogs at the bottom of the pack are also at risk for being removed from the pack if they are seen as a burden or a liability. For these reasons it is more advantageous to the dogs who have an endurable amount of pain to go on acting healthy and lively. That’s why when they have dental pain they will continue to eat, continue to play and may even continue to chew on their chew toys. The changes that have occurred are going to have come on so subtly that you will most likely not notice that they are there until they have been treated.

Cats are certainly not pack animals. They may form friendships and may even develop a pride mentality if you have enough of them but it is not a pack. They are however, prey items for larger animals. Predators are going to look for the easiest possible meal and an animal that is showing weakness and vulnerability is going to be targeted over an animal that might put up a decent fight. Cats in pain have no incentive to show any pain, they don’t know that you are going to help them. In many natural situations a predator that lives with you when you are healthy, read hyenas, jackals and piranhas,are likely to eat you as soon as you are weak. As far as Cuddles’ instincts go she doesn’t know you aren’t going to eat her if she gets sick. It is for this reason that many cats are doing “just fine” until they fall down dead. Their instincts have been telling them that if they act weak they are going to die and then when they are going to die anyway there is no point in hiding their pain/sickness anymore.

Another aspect of this is to consider how many issues your pet would choose to live with. If your dog or cat has a painful mouth or hips even if that pain is excruciating they still really only have one issue. If they then decide that they are not going to get up to go to the bathroom or they are not going to eat anymore, well then, they have two issues. Remember that your pet does not know or understand that you are there to solve their problems, especially when they are hurting, it is simply not in the pet’s best interest to give themselves more problems. Keeping that in mind, this next thought is aimed at runners, skiers really anyone doing strenuous exercise or work. Do you run, ski or work when you’re hurt just a little bit, maybe a sore knee, hip, or shoulder? Chances are you do. Dogs are at least as fanatical about their running or chewing and are going to “play through the pain” just like you and I do.

The other important aspect in this is the idea of suffering. Living with a certain amount of pain is not the same as suffering. Would it be better if the pain were gone? Yes, of course it would. But that does not mean that the pain is so bad that it is negatively affecting the quality of life. There might be times where you have to choose between paying your bills and treating one of these situations. I promise you that not only do I understand why you might be making the choice you are making but that more importantly, I consider your pet one lucky dog or cat to have you in their lives.

Thank you for reading.

Rules of Engagement

Everywhere we go in life, rules are set in place to guide how we behave. When you get to the bank, you know to walk into the lines that eventually lead you to a teller, you know to wait until the teller calls to you and you know how to communicate with them to successfully accomplish any of the transactions you have to complete that day. With us it’s not really any different on the basic level.

However, with us, there is much more to our relationship than just a transaction. I’ve come up with a list of 11 agreements I am willing to make with any of my clients. I’m  betting any other veterinarian would be willing to make the same arrangements.

1. We have to be honest with each other. Sometimes I make mistakes or put things off and you won’t hear from me as quickly as you think you should. You’re not wrong; I drop the ball sometimes and I don’t mind being called out on it. Sometimes things happen at home that you might not be too proud of either. Maybe you decided to not give a medication I prescribed and didn’t want to tell me. Maybe you spaced on an appointment and feel guilty: it’s ok. Sometimes it’s more serious than that. Dogs and cats sometimes get themselves into trouble and the reason they are in trouble can be embarrassing. Sometimes dogs eat your pot, sometimes they drink too much beer. Sometimes they eat things that are embarrassing to talk about. That’s ok. I don’t judge people. I fix sick pets. You can be 100% honest with me and I promise to never judge you or report you to some sort of authority. Ever. Unless you’re abusing animals.

2. I promise that every time you see me you will get 100% of my attention and 100% of my abilities. But I’m only a human being with a very narrow window of expertise. There are some things I just can’t tell you using only my eyes, ears, nose and hands. I’m more than willing to involve as many other people as possible to help to resolve any problems your pet is having. If I recommend that you see a specialist because your pet’s problem is more complicated than something a general practioner should be dealing with, please at at least give it some consideration. The other general practioners in our practice or our area, while highly skilled, do not qualify as specialists and do not tend to have abilities or skills that differ greatly from one general practioner to another. Second opinions are always a good idea, but when I recommend a specialist it’s because I can see some of the problems your pet is having and have a very good idea of what the specialist is going to find but don’t have the skill set it takes to properly diagnose and treat that particular problem.

3. Somedays I probably seem a little off: maybe I look like I haven’t slept in a week or eaten in a few days. I’m ok, I promise. And I will do my best to be as happy and outgoing as I can be but there are parts of our job that are very stressful. We deal with death almost every day. Many times it’s in the middle of the day and I might very well be stepping from an end of life appointment into a new puppy appointment. If I seem like I’ve been trampled on a particular day, please be patient with me. I’ll be my normal happy-go-lucky self the next time we meet.

4. Part of the veterinarian’s oath involves the continual improvement of my skills. If I am not constantly improving, I will be retiring. Even then, I’m willing to bet I’ll still want to be learning the new things going on in this profession. I spend an immense amount of my time getting better at providing veterinary services to you and your pets. Please respect that. If I make a recommendation or give you directions, I’m not making this stuff up on the fly, I’m relying on all of the research and work that goes into this profession. Believe me, there is a lot! If I’m making a recommendation that doesn’t make sense to you, ask me about it. If I couldn’t explain it in easy to understand terms and words, then I wouldn’t understand it enough to feel comfortable recommending it.

5. We need to work together. Most of the work that goes into keeping your pet healthy or making them better when they aren’t feeling well is done by you. I only examine, diagnose and set up treatment plans. In reality, I do very little of the nursing care even when your pet is hospitalized. If your pet is to become sick I will likely be giving you a specific set of recommendations. These recommendations are the best way I know of to deal with the problem your pet is having and stay within whatever budget we have established. There are no guarantees in this profession but if I give you specific recommendations and you make the decision not to follow them, I can guarantee that the results we get will be different than the results I expected to get. Please don’t get frustrated with us should this happen. I promise I’m not asking you to put eye drops in your cat’s eyes three times a day because I think it’s funny to picture you giving them, it’s because that is how often it needs to happen.

6. I will never duck you in public and if I don’t remember your name, I won’t try to fake it. Please feel free to treat me in the same manner. We only go through this life once: if you recognize me in public but can’t place me, say “hi.” It’ll all come together eventually. You may not remember this advice if you don’t remember me, so do this with everyone you recgonize. It’ll make you a lot happier. Unless you borrow money a lot.

7. I get that this stuff is expensive. I try to do my best to work with any budget but we have to pay the laboratory, we have to pay for biopsy results, we have to buy the equiment and supplies in advance. My job is to let you know everything that is available to us to help us in diagnosing your pet’s problem and then treating it appropriately. It is only fair that I also apprise you of how much of your money I am recommending you invest in your pet’s healthcare. Don’t take the money stuff personally and don’t try to make it personal. I spend enough time feeling guilty about how little I see my family. And frankly, we’re pretty reasonable, you might be surprised to learn that part of the recommended work up for a chronically sneezing cat is a Cat Scan (CT) and deep tissue biopsies. I will bring this up with you if you bring me a cat that has been sneezing for a long time but I have never had anyone ask me to refer them for this. And I understand why.

8. We can’t tell you what’s wrong or treat your pet over the phone, via email and definitely not via facebook. That doesn’t mean I don’t want you to call me, email or me or find me on facebook. I love when clients have questions and reach out and contact me. I love talking about what I do. I love helping people. I want to answer all the questions ever asked of me but if I tell you I need to see your pet, I expect to see you and your pet in the hospital as soon as you can get them there.

9. Sometimes emergencies happen and the thing about them is that they always hapen at unexpected times. Sometimes it’s right in the middle of a busy day with a full appointment schedule. Someday I might have to ask you to wait a few minutes while I am dealing with something that can not wait. If you promise to be patient, I promise to drop everything I’m doing if your pet ever needs me. Also, this is probably going to be one of those days where deal number 3 applies.

10. I promise to explain everything I can to the best of my ability but I also have other patients who need my attention. If a lot of people have a vested interest in how your pet is doing, please pick one of them to be the contact person between our hospital and the rest of your pet’s family. I don’t mind talking to large groups of people at the same time. But spending a lot of time on the phone or in person answering the same questions from multiple household members takes away from other patients who need my attention. Please try to have everyone who will be asking questions either in the clinic or on the phone at the same time.

11. Sometimes some words of encouragement and my professional opinion that things are going to be ok is all you need. But if I say something is serious, it’s serious. I won’t ever blow things out of proportion or try to work up unnecessary problems. I have a lot on my plate right now as it is and promise to never try to make an issue into more than it is. If I’m worried about your pet’s health please take my concerns seriously. For example, if you call me in the middle of the night with a concern and I tell you that I think your pet needs to be seen, it’s not because I want to leave my cozy bed, drive to work in the middle of the night and risk missing breakfast with my family. It’s because I am genuinely worried about your pet and don’t think it can wait until morning.

These are 11 promises and requests I have for my clients that I think will make our relationship better in the long run.

Thank you for reading.

Hold On There…

One of the toughest things I encounter on a daily basis is the realization of how much a lot of my patients really don’t like me. In fact I often tell people looking to become veterinarians that if their major motivator is a love for animals, they should think about owning a boarding facility or being zookeepers. I say that because more often than not the animals we are dealing with want nothing to do with us in the exam room. Even my own cat will hiss and get his fur on end in one of our exam rooms and at home he’s an absolute love.

Pets aren’t in my office, however, for me to pet and love on them. They’re there because I have a very specialized set of skills. A set of skills that allow me in less than half an hour to use my ears, hands, eyes and often nose to tell you whether or not your pet is healthy. Unfortunately, even for the most skilled veterinarian the examination part of that half hour requires the patient to be restrained. Restraint is often the most difficult part of the visit for pet owners to deal with. Many times they will try to comfort their pet during restraint or some owners will even try to do the restraining themselves. Over the next few short paragraphs I will try to explain why restraint is important and why you should step back and let us do what we’re trained to do.

It’s dangerous for you. Hospital and court documents are full of stories of well intentioned owners whose pet’s would have never bit them otherwise who were injured while trying to comfort or restrain their pets and subsequently had to sue their veterinarian. Notice I said had to sue their vet. A single cat bite in an otherwise healthy person can lead to an infection that requires a hospital stay and intravenous antibiotics. It’s not unusual for treatment like this to cost tens of thousands of dollars. If you have insurance, they will sue me. If you don’t, you will have to sue me just to cover your medical bills. I understand that and wouldn’t blame you but if I can prevent it simply by not having you hold your pet or touch it while it is being restrained, I will. The last thing I want is for you to get hurt and possibly seriously ill from something I could have prevented by being a little more assertive.

It’s dangerous for your pet. You know your dog or cat better than anyone. I never forget that, in fact it’s why I ask you to bring them in every year and not have someone else do it for you. To me, you are the most important source of information about how your pet is doing. What you might not know about your pet is how they are going to respond when I inject them with a vaccine or apply gentle pressure to that really painful loop of intestine I found on physical exam. I have seen owners “have to” hold their cats by one leg as they tried to jump off the exam table, needless to say that is not good for the cat and possibly not very good for the owner either. The bottom line there is, you aren’t trained in animal restraint, my staff is. Allowing them to do their jobs makes the exam go faster and allows it to be more thorough. Fortunately, I have never seen an injury to a pet during an exam but much like the paragraph above, if my telling you that I can’t allow you to restrain your pet during my physical exam is what it takes to prevent an injury, that’s what I’m going to do.

It’s dangerous for me. I make a living with my hands. I need them to do my job. The number one place I’m going to be bitten by a pet is on the hand. If I get a bad enough bite or an infection from a bite that costs me the use of one of my hands, my career is over. You might know your pet inside and out but you don’t know what I’m going to do next. My staff does. On any given day we will examine between fifteen and thirty pets together. For safety and to offer your pet the best care we have to get it right every time. To do that, we practice together. We don’t practice until we get it right, we practice until we can’t get it wrong. If I’m having someone I haven’t worked and practiced with hold a pet during an exam, there are things that aren’t are going to happen. The most important is that the pet is not going to get as thorough an exam as it deserves and there are certain things that I will not even attempt such as a full ocular exam, a complete oral exam and I may not look as thoroughly at the ears. I will probably not be doing a rectal exam and in some cases will have to even skip the temperature. That’s not great medicine. Oddly enough, we don’t have a charge built in for an exam limited by having the owner hold the pet. You’re still going to pay for the full exam I would have performed if my staff was holding your pet. You just won’t get that exam.

Furthermore, it is below the standard of care for a veterinarian to have you restrain your pet during a physical exam. This is actually one fairly universally defined standard. If something happens in an exam room and a pet or owner is injured while the owner is restraining the pet, that is my fault because allowing an owner to restrain the pet for examination or treatment is below the standard of care. I try to never practice below the standard of care, that is a commitment I have made to myself and to your pet and you. Often that is difficult and the standard of care is open to interpretation. When I have a set standard that I can adhere to, I will.

Most importantly to me, it is less stressful for your pet. You don’t hold pets still for examinations everyday. You don’t even do it a few times a year. Our staff do it everyday. They are confident and comfortable holding your pet and your pet can sense that. In a similar fashion they sense your unease and inexperience and it stresses them out. If you are truly confident that you can hold your pet, save that attitude for the gym, I’m not getting ego bit for you.

Many of the people who read this blog have been in situations where I might have let you hold your pet for something, I’m not perfect but maybe you’ll be more understanding now when I ask you to give us a little more room to do our jobs better.

Thank you for reading.

 

Leaky Dog

It usually happens to older female dogs. They have their favorite spots to lie around and when they get up it looks like those spots are wet. Then they get up on the couch with you one evening and you know for sure. Your dog is leaking urine, in the house, on the couch, on your lap. This is not good. Fifty or sixty years ago it was common for dogs to live outside. They might come in during a particularly terrible storm or a really cold night but for the most part they lived outside. If they leaked urine, no one noticed. Now dogs sleep in our beds, I’m not exactly sure how that transition occurred but it would be an interesting sociological study. When your dog, who sleeps in your bed, leaks urine, you notice.

Diagnosing the incontinent dog is fairly straight forward. The first thing you want to be certain of is that your pup is not urinating on purpose. If they are this is not incontinence and we can move on from there. Once we have determined that your pup is leaking urine involuntarily we will want to perform a complete physical exam. Feeling for bladder tone, trying to express a bit of urine manually and getting an impression of your dog’s overall health is a good place to start diagnostically speaking. Once we have an idea about the possible problems your pup is facing we will most likely recommend two laboratory tests in addition to our exam and conversation, a blood panel and a urinalysis with a urine culture. These tests combined with exam findings and our clinical judgement will rule in or out nearly 90% of the causes of incontinence. If these come back with no abnormalities that would explain the issue we can comfortably start talking about a weak bladder sphincter. Weak bladder sphincter is a common problem for female dogs affecting up to 20% of the population. In these cases the muscle that holds urine in is weakened and when Fluffy relaxes, her muscles also relax and small (or in bad cases large) amounts of urine leak out of her.

There are several physiological and anatomic factors that are implicated in the mechanism behind this form of incontinence in dogs. Ultimately however, we do not have a complete understanding of how this works. If we did we would probably be better at preventing it. Fortunately, we are fairly good at treating weak bladder sphincter incontinence.

We will typically start these patients on a drug called phenylpropanolamine (PPA). This drug directly stimulates receptors in the urethra and it causes the release of norepinepherine. Both of these actions help to increase sphincter tone. Side effects of this drug include restlessness, anorexia, irritability and hypertension. We often recommend monitoring blood pressure while on this medication and dropping the dose back a bit if we start to see changes in the blood pressure measurements.

Sometimes PPA doesn’t work, sometimes it works for a little while but then doesn’t seem to cut it anymore. In those cases we will often add or substitute in Diethylstilbestrol (DES). DES is a synthetic non steroidal estrogen. It is used at a loading dose and then tapered to the lowest effective dose to control incontinence. If you are familiar with pharmacological history in the United States you might have heard of DES. DES was used in human medicine up until the 1980’s for estrogen replacement therapy and to deal with inflammatory conditions associated with the female urogenital tract. It was discontinued in human medicine after some very serious adverse health links were found. Fortunately, we have not been able to document the same health links in our canine or feline patients.

Males with urinary incontinence are typically given testosterone to treat urinary incontinence when PPA is not working. Testosterone also has a synthetic non steroidal oral form but the injectable steroid form is much more effective.

When all else fails or if you are not getting 100% resolution with medication alone there are surgical options. These include tacking the bladder and/or urethra to the body wall or other organs to increase the pressure on the urethra. There are also collagen or other bulking agent injections that can be given using a long scope to increase resistance and decrease incontinence. No surgical approach is going to offer life long resolution but may help lower doses of medications.

There are lots of reasons a dog could be leaking urine and getting to the bottom of incontinence is a lot like any other medical problem in our pets. The answer starts with a good physical exam by your veterinarian.

Thank you for reading.

Fun with “D” words.

Burn out. Substance abuse. Suicide. Mental illness. These things don’t sound like behind the scenes issues at your friendly family veterinarian’s office anymore than they seem like behind the scene issues at the dentist or pediatrician’s office. But they are. They might even be behind the scene issues at your place of work, or in your personal life.

I might have ideas about why as a society we are seeing more – or in my opinion have more time, money and changing social views to deal with – issues of mental health, substance abuse and the relationship our working environment plays in them. But I am not a sociologist, I am a veterinarian and this is a veterinary blog. Though I do sometimes dabble in other topics I consider to be; fun Hooch Heart of Bixi, important Philosophy Sacrifice Communication communication Optimism Parenting, or even sometimes a little existential I don’t HAVE a body. I AM a body I typically approach most things here as a veterinarian, which ties into what I want to write about today. It would be easy for me to state here that being a veterinarian is who I am but in reality, being a veterinarian is what I do. If somehow, I couldn’t be a veterinarian anymore, I would still be me but would have to do something else to pay my bills. And that would be alright. Not great. Alright.

 

In veterinary medicine – as in probably any other profession – stress levels can be high. The emotional toll it takes can be immense and the burnout rate is getting higher as more brilliant doctors are graduating unprepared for a high-paced, service oriented profession.

My own career path has danced dangerously close to the edge of burnout more than once. In full disclosure, I struggle with Major Depressive Disorder which was diagnosed and a successful treatment/management plan was instituted while I was in college. That does not mean I am immune to relapse. While this has not helped me deal with professional stress directly, learning how to deal with depression has helped me realize how much I was getting in my own way when it comes to dealing with professional stress.

 

I have broken down the steps I have taken into topics that I was able to use to limit the professional stress I experience at work and ultimately allow myself to enjoy what I do in spite of myself sometimes. Because it worked out this way and because it was fun, I used words starting with the letter “D” to describe these steps. Hence the title of this post.

 

Decision: Before I could make any changes to my professional life I had to decide that a change was necessary. That was the hard part: deciding what areas were the most important ones to change. This meant looking at myself and my situations in an objective and critical light and determining what changes were going to bring the most satisfying and positive changes. This is the hardest part, as it involved taking a serious life inventory and acknowledging that at the end of the day, I was the person most responsible for my own happiness and my own misery.

 

Detachment: This was the most important part. If I was going to avoid burning out and giving up, I was going to have to step back to see this from outside my own head. Detachment was probably the best thing I was able to do for myself as it allowed me to recognize how much I was taking personally and why. I realized I didn’t want to get better, I wasn’t looking to improve and I definitely didn’t want to actually avoid burning out. I wanted to focus on my strengths and act elitist about stuff that matters to maybe 0.1% of the population. I wanted people to recognize that veterinarians- and me, by association- had it really hard and this job was really stressful. I wanted other people to validate me and my greatness. I wanted people to recognize how compassionate I was, how much I understood about medicine and science. I wanted people to understand how much we had to deal with. Ultimately, I wanted this to be about me. It turns out, when I detached and looked at that, it looked as bad as it does in black and white above.

Holy ego Batman! What is wrong with this person? In reality, nothing. It was simply that I had so much of my personal identity tied up in my profession that it was impossible for me to separate the two. This unsurprisingly led to me taking every criticism and obstacle as a personal reflection of who I was and how good I was. This is a formula certain to stunt professional growth as well as personal development.

 

Once I was able to step back and look at the situation instead of my response to the situation, I was able to see how much my perspective was limiting my ability to get better. I also saw how destructive it was to continue to see what I do as who I was and how ultimately that could lead to some pretty dark and destructive behavior on my part.

 

Then I had to institute a plan that could be executed daily. The first thing I needed was to recognize that this wasn’t about me. How people choose to approach their pet’s health care, how they feed their pets, whether or not they choose to utilize the preventative measures I recommend had little if anything to do with me. They were coming to me for the service I provide, true enough. But it is about them and their pet and has nothing to do with me, at least personally. Taking this position allows me to focus on how to be better professionally without allowing it to reflect on me as a person. Putting my ego in the backseat allowed me to learn more from a greater variety of people. No longer was someone who knew more about something in my field “better” than me. Instead, they were more interesting to discuss things with and conversations stopped being about being right or the best and started being about learning everything I could from everyone around me.

 

Discipline: Any plan is only as good as your willingness to execute it daily. For that, I have developed other daily habits that seem unrelated to my goals but ultimately keep me focused and consistent.

 

Deadlifts: I considered skipping this one but it is important. A huge part of what keeps my head on straight and helps me keep the darkness from pouring in and taking over my day to day is that I routinely go to the same place and lift heavy things until I am dog tired. This stress, success, consistency and ability to monitor progress helps immensely and might be the most important thing I do for myself. Turns out I am not making this up:

 

https://www.unm.edu/~lkravitz/Article%20folder/RTandMentalHealth.html

 

Ultimately, the take away from this is: whatever you do in this life for work may be a big part of your life, but it’s not who you are. If somehow your profession was ripped away from you, you would not cease to be who you are. The sooner we decide to detach from our professions more and discipline ourselves to stay detached, the better protected we will be from burnout, compassion fatigue and the burdens that follow.

Thank you for reading.

 

Kitty Colds

You just adopted a kitten from the local shelter. She had sneezed a few times at the shelter but you hadn’t given it a lot of thought. When you got her home and she stopped eating, started with mucus from both nostrils and eyes and sprayed the room with her sneezes every few minutes you started to wonder whether or not she was a good idea. You put your new kitty in the cardboard carrier you brought her home in and rush her into the vet’s office. They tell you that she has a complex of diseases she was most likely exposed to as a kitten and that this condition was exacerbated by the stress of being in the shelter. Before you start to think it was the shelter’s fault however, let’s quickly get into what your cat has going on and why.

The major contributor to Feline Upper Respiratory Complex are viruses that your new kitten was most likely exposed to long before she arrived at the shelter. Because many of the cats that are surrendered to shelters, or the cats that are dropped there by animal control, have a herpes infection that is not currently causing disease it is not necessarily something that even the best disease prevention program can address. The shelter situation, no matter how well done, is going to be stressful for the feline participants. There is a lot of shuffling between cages to clean and keep angry neighbors apart. There are also a lot of sexually intact cats that come through the front doors of any busy shelter and their attitudes do not help in lowering the stressful conditions. This stress causes a drop in the immune systems ability to respond to disease. When this happens, the viral infection that your kitty was keeping in check has a chance to rise to the surface. The most common offender is the feline herpes-virus. It will manifest itself first as runny, watery eyes, light sneezing and maybe a bit of conjunctivitis.

Ok so maybe that’s why your new kitty is sneezing but what can we do to help her? Here is where many vets are going to differ a bit. This is yet another one of those times I feel compelled to inform you that this blog contains my opinions (professional though they may be they are opinions) about best medicine and current therapies. The following is what I would consider to be the best course of treatement for an owned cat with an upper respiratory issue.

I start with hydration, keeping your new kitten well hydrated is an important part of treatment. It makes the mucus secretions less viscous and allows for better expectoration of particles. It also helps in keeping inflammation at a minimum. If your new kitty is eating well and only sneezing a bit I may give her a small amount of fluids under her skin and ask you to place her in a room with a humidifier running when you go to bed. Sometimes that is all it takes.

If the sneezing has been going on for awhile, is getting worse or if she is breathing with her mouth open or not eating I will get a bit more aggressive. Treatment for these cats will include the fluids and humidifier but we will now add in some decongestants. Oral and nasal decongestants are available. I tend to use a lot of diphenhydramine but there are many available. If there is conjunctivitis present I will also add in some eye drops. Many of the drugs I would reach for here are available over the counter and will not require a prescription nor will they be terribly expensive. Not eating for a young cat is a big deal however, and I have started adding in an antiviral drug at this point. This is not an over the counter and will require a prescription. It will also require you to get a pill into your kitty. Good luck.

If stage 2 treatment plans are not making in a dent in your kitty’s upper respiratory disease we will start to have a conversation about further diagnostics. I probably won’t be too pushy at this point but I will at least put it on your radar. A cat should really be getting better by now. Here I am going to start to actively address some of the other issues with your cat’s respiratory system. Anti-inflammatories may make an appearance in this case. A brand of drugs called leukotriene receptor antagonists are useful in controlling the inflammation involved in the disease process as well. It is typically here that people start to ask about antibiotics. I am not huge on just prescribing out antibiotics for, well anything really. I like to know that there is a bacterial component to the disease I am trying to treat and I really like to know what the bacteria is and what kills it before prescribing an antibiotic. If the discharge has changed in consistency or color or if there is a fever present I may be convinced to add in an antibiotic at this point. If I am going to add in an antibiotic I try to choose ones that will also mediate the immune system and help to control inflammation at the same time.

If we are still having a problem now it’s been well over a month and it is time to get a bit more serious. Here I may start recommending sending in a culture for bacteria and funguses. I will definitely recommend retesting for feline leukemia and feline immunodeficiency viruses. If we are talking about an older cat (not a kitten) I might even recommend biopsies of the nasal passage. With more information comes a much more tailored medical approach and discussion of what we might find would carry us well over the thousand word limit I typically set for myself each week.

In closing, don’t hate the shelters for adopting out a sneezing cat, it’s not their fault and they do a job many of us wouldn’t be strong enough to handle. Make sure you get your sneezing cat to the vet early on and be wary of vets that just reach for antibiotics in these cases. It won’t help and will end up costing you more than it has to.

This Generation’s Reckoning

Right now, it appears as though the United States is going through a reckoning about how people are expected to behave in the workplace. Society has turned around in what appears to be- it isn’t, but it appears to be- a short period of time, and individuals from all walks of life are paying the price for behavior that never should have been considered acceptable. Yet it was still accepted. In many ways it was the price a woman- or in some rare cases, a man- would have to pay in order to advance a career, to even have a career to advance in the first place. I am writing of course about sexual harassment in the workplace.

 

While we have not yet resurrected the tradition of tarring and feathering the perpetrators of workplace sexual harassment (nor should we seriously consider tarring and feathering, google that before running such an idea up the flagpole), we appear to be very comfortable bringing up instances that are years or even decades old. It appears that we are witnessing a watershed moment in American culture. This is good. But it is also a little bit scary.

 

It is scary for me mostly because I am guilty too. And admitting that and facing it in my own life and my own head is scary. Scary not because I am afraid that how I acted in the past will have reprisals. Even if my actions in the past came back and cost me my job, influence, or friends, that wouldn’t be the worst part. It is scary because I want to believe I am better than that. I want to believe I treat everyone as an equal and consider others’ feelings with my actions. But I don’t. At least I haven’t always. And sometimes, I still don’t live up to the standards I set for myself.  

 

In fact, I’ve been pretty terrible about not recognizing the line where it stops being funny and starts making people uncomfortable.

 

In fact, I’ve been terrible about using the little power I have in the world to get what I want. Maybe never sexually, but definitely in a lot of other ways.

 

In fact, if we want to talk about social situations outside of the work force there are some stories that would make me blush even a decade and a half later. 

 

In fact, up until I was 25 years old, this behavior seemed totally normal to me. Boys will boys and all.

 

I don’t know what changed at 25 but a lot of things in my life and the way I viewed life changed. Maybe my brain finally developed enough to have a more complete understanding of the way I interacted with my environment. Maybe it was entering a profession where I often find myself the only male in any group of individuals. Maybe it was having to interact with women who would not tolerate that type of behavior.

 

Whatever it was, it’s not like I got better overnight. It’s not like I am 100% better now. I still find myself glancing in the wrong directions, thinking in the wrong words, and sometimes speaking in ways that my wife and three daughters would be ashamed of if they knew. I’m not there yet. I might never be. But I am working at it. I will continue to work at it until I get it right.

 

Recently, when I come across questionable thoughts in my own mind or I find myself in situations where my actions or words could become questionable, I apply a thought exercise I have been working on for awhile now. I ask myself if I was someone else and the woman I was interacting with was my wife, would I be alright with the way I was acting? If the answer to that question is no, I need to explain that to myself and correct it. I’m not always there yet. I might never be. But I am working on it.

 

How often does it happen that I have to correct my thought pattern? More than I want it to. I’m not perfect, behavior is hard to fix, and like a lot of men I thought my behavior was normal until I grew up and started thinking differently about the people I interact with daily. So this behavior is ingrained. But also like a lot of men, I am working on changing and I won’t stop working on it until I get it right. Don’t give up on me (us) yet.

 

Thank you for reading.

No poop.

You didn’t realize that you haven’t noticed any stool in Fluffy’s litter box until the veterinarian asked. By the way the vet was holding Fluffy’s belly you’re suddenly putting it all together. Fluffy has been yowling in the litter box for a few days now. You knew that he could urinate and he was passing those small, wet, slimy stools and you figured he had some diarrhea. Then he stopped eating, started vomiting and you got really worried and forgot all about what you had thought was diarrhea. Then in this room with this strange person squeezing your cat’s abdomen it all comes back to you.

There are plenty of reasons a cat could become constipated. It happens to dogs as well but cats really seem to know how to do it right. In fact, cats are much more commonly represented in the small population of pets that suffer from megacolon as a result of chronic blockage and subsequent loss of function of the colonic muscles.

Straining to defecate is the most commonly seen symptom with constipated cats. This seems straight forward enough but straining to defecate can be confused with straining to urinate. Feline Urinary Obstruction Straining to defecate is also the most commonly noted sign in pets with large intestinal diarrhea so even if we know they are trying to poop but aren’t getting anything out we can’t really be sure it’s constipation. A physical exam will give me some clues about whether or not your pet is constipated but to rule out obstipation or the serious megacolon we need an x ray. X rays of obstipated cats are pretty easy to read, you look at the x ray and instantly your mind says, “That cat can not poop that out.”

Here is a small fact about veterinary medicine; cats do not enjoy enemas. How constipated a cat is determines how extensive the enema needs to be. Some cats only need a little bit of help and a simple warm water or lubrication enema will do the trick. I say simple because I don’t have to do a lot of math or monitoring. I do not mean simple as in, you should try this at home if you think your cat is constipated. For more advanced cases a lot of enema fluid is going to be introduced and this typically requires a bit of sedation as it is going to be very uncomfortable. These cases generally haven’t been eating for a few days and will require some hydration as well. We like to keep these guys overnight if we can to be sure they are going to eat and are done vomiting once the obstruction is removed. The most difficult cases require not only an enema but a good deal of manual evacuation as well. These guys go under general anesthesia and a good amount of effort is put into cleaning them out. The cat who receives an enema requiring general anesthesia is definitely going to be groggy and definitely going to leak. It may want to have a sleep over. These poor patients tend to not want to eat right away and may take several days even a week to start having bowel movements again.

That last point leads into a bit of a tangent. The colon’s main job is to store feces. It can store weeks of fecal material at a time, this is why we may not seem terribly excited when your dog or cat hasn’t had a bowel movement for a day or two.

After we have removed the offending fecal material we will want to think about ways we can avoid this in the future. If this was the first time your cat has been constipated and it was fixed with a simple enema we might tell you to add a little more canned food or pick up a fountain to try to increase water intake.

Even if it was the first time, if your cat was really constipated we will probably recommend you change his diet around a bit. There are two ways we can go with this. We can try a diet that is high in fiber and will make more bulky stools that are easier to pass because they contain more water. This can be achieved with a commercially prepared diet or by adding fiber to the diet your cat normally eats. The other direction we can take this is to feed what is called a low residue diet, this means that the diet is highly digestible and may actually produce less stool which in turn means less work for the colon.

If your cat is a chronic offender we may add in certain medications to help the colon work a little harder or to lubricate the stool and make it pass easier or both. These cats are also going to be on special diets as well.

In extreme cases we might recommend that a small section of the colon be removed so that there is not room to store large amounts of feces. These are called subtotal colectomy surgeries. In these cases you can expect your cat to always have slightly loose stool. While cats tend to do very well after surgery and the loose stool is not typically an issue we do like to save surgery as a last resort.

Thank you for reading.

Declawing

Also known as onychetomy, declawing is the removal of the distal phalanges (third knuckle) of a cat’s front paws. Typically just the front paws anyway. There are some cats out there that have been declawed in the front and back limbs but most cats have only the front removed. This is typically to prevent scratching furniture, clawing people with health concerns and I have seen cats declawed to match the situation of the other cat(s) in the house and therefore ensure a safe level playing field for all involved. No matter the reason, the procedure is the same, it is the amputation of the last bone on each digit being declawed.

Typically this is done with very good pain control including general and local anesthesia, preoperative and post operative pain control and usually the cats will be hospitalized until the incisions have at least begun to heal.  It is done by extending the claw , placing a blade in the grove between the second and third knuckles on the digit, cutting through the tendons of the extensor muscles and continuing the incision in a slightly curved fashion to get around the curved end of the flexor tubercle of the distal phalanx and disconnect the tendon of the deep digital flexor muscle. This removes the distal phalanx along with the unguicular crest and unguicular process and as a result, stops the cat from producing claws.

Cats are digitigrade animals meaning they walk on the tips of their toes, you might think that cutting the tips off the toes and then asking the cats to walk around might be asking for complications. For the most part they seem to adapt but there are some who have to live with chronic pain following the procedure. Sometimes this pain doesn’t show up for months or even years.

If you follow animal health at all you know that declawing cats is a big hot button topic here in the United States. It doesn’t tend to be as big a deal in other developed countries because by and large they just don’t do it. The big issue is we are performing a procedure on a cat who can not give consent, this procedure provides no medical benefit for the patient, provides no benefit for the population of cats as a whole, is a relatively invasive/painful procedure and carries the potential to create a chronically painful situation.

In the interest of full disclosure, I have declawed many cats. Well, more than 20 but less than 1000. While I have never had a patient experience an immediate post operative complication, I can not tell you whether or not any are going to experience chronic pain from the procedure as that can develop years later and the vast majority of cats I have declawed are still under 10 years of age.

Here’s my thoughts on declawing, I don’t like it, at all. I think in most cases it’s a harsh reaction to an otherwise minimal problem. Yes they’ll destroy furniture, wood work and other things, but that behavior can be modified through training and working with them consistently. Yes, you can make a case that immunocompromised people are at an increased risk of infection from cat scratches but I have had more clients undergoing chemotherapy or treatment for HIV who had cats with claws than I have had clients who had their cats declawed. Total.

Why would I do it then? I could give you a story about how we control pain better and if people are going to have their cat declawed they are going to have it done regardless of whether I did it or not and I would rather they have it done right. Or I could be honest and tell you that the answer is easier than that. If I explain to someone how a declaw procedure happens, show them in a text book how we do it and prepare them for the possibility of having to aggressively deal with chronic pain for the remainder of the cat’s life and the owner still wants the cat declawed; I do it. I do it because if that is the cost of a cat having an indoor home with shelter, food, love and medical care provided then to me, the risks are worth the rewards. I do it because I would rather take that risk than see a cat go back through the gauntlet of shelter living and hoping to get adopted. I do it because from where I sit it is the better of the two options. I take heart in knowing that I will have to do it less and less as my career advances.

Thank you for reading.

 

Homestyle…

This week might seem a bit strange for folks who know me well or deal with me frequently. I am typically not an advocate of many things that people might consider to be “alternative.” This is usually because in medicine the word alternative typically precedes something that is decidedly not medicine. Home cooked, balanced diets are not only good for pets but in many cases they are also excellent medicine.   

If you’ve read a few of the posts I’ve put up about pet foods it might surprise you that I think home cooking is a good idea.

There are several foods on the market that are produced by companies that employ veterinariary nutritionists, actually perform digestion studies and are really setting the standards for pet foods. These are also the same companies that produce the diets we use to manage diseases that respond to nutritional management. I know that these foods are well balanced and nutritious and I choose to feed them to my own pets.

Whatever commercially prepared food you use, however, the ingredients are not going to be fresh by the time you feed them. They are properly preserved but surely nothing is better than a home cooked meal. The trick is balancing that meal. There are all kinds of websites that offer up home cooked recipes for dogs and cats. Over the six month period before writing this I have evaluated several dozen of them. Only two of them offer diets that I would consider to be balanced and healthy. Not surprisingly these two sites are managed by diplomates of the American College of Veterinary Nutrition. A board certified veterinary nutritionist is a fully trained veterinarian who has gone on to receive advanced training in animal nutrition. They then have to sit for a board exam and must maintain a certain number of hours of continuing education every year in nutrition to hold onto their diplomate status. You can learn more about veterinary nutritionists here: ACVN

These two websites are also pay sites. You are getting specific information from a highly trained specialist, it is going to cost money. The diet you pay for, however, is yours and will never go bad or out of style. In my eyes it is a sound investment.

Those sites are: Pet Diets and Balance It

I typically tell people to cook a week’s worth of food at a time, freeze it in individual meals and then heat it in the microwave when it is chow time. Not only will you be offering your pet a healthy well balanced alternative to kibble but you will also get the satisfaction that comes with helping your pet live a healthy life.

A quick word about raw diets. While it seems wonderful to feed your dog a “natural” or “wild” diet I think it is important to point out two things. One is that wolves supplement their diets in the wild with fruit and vegetables so a meat only diet is not only inappropriate it is not “natural.” The second thing I would point out is that “natural” canids live only long enough to pass on their genes and then they die. This typically takes about 8 years. In captivity they live 15 – 20 years. In captivity they also typically receive commercially prepared cooked diets. Dogs are also not wild animals, I’ve written about this. They have lived with humans for at least 15,000 years (probably a lot longer than that) and have evolved to eat with us and depend on us for survival. Comparing them to wolves is equivalent to comparing our children to chimpanzees. The ACVN addresses the idea of raw diets and many other subjects in their FAQ page. FAQ

Thanks for reading.

Stuff.

This is a tough thing to talk about when I have to let alone write about when I really don’t. I’m just going to lay it out there, I don’t think about the financial aspect of what I do when I am coming up with a treatment plan for your pet. For the next five hundred words or so I’m going to try to convince you that you don’t want me to be thinking about money either.

I am trained extensively in the diagnosis, treatment and prevention of animal diseases. When you bring an animal to me for a problem or even for an annual examination my job is to formulate a problem list and then come up with the least invasive manner to properly identify and address the source of each problem. There is often a difference between the least invasive manner of diagnosing something compared to the least expensive.

The other major aspect of my job that I feel is lost somewhere in the conversation is that I make recommendations. If I make a recommendation based on a finding during a physical exam and you choose to ignore it, that’s ok. It is your pet and ultimately your decision and I understand that there are a lot of factors that go into deciding on a treatment plan for your pet. Some of them are often personal beliefs about treatments, many owners are not willing to put a pet through chemotherapy for example. Other decisions are going to based on finances. If you are having to decide on treating your pet and paying your mortgage, that isn’t much of a decision is it? It does your pet no good to diagnose an illness and treat it if there is no home to return to when they are well!

There are two problems that happen when your vet starts thinking about the cost of things when he/she is coming up with a treatment plan. The first is kind of obvious to us, if your veterinarian’s salary is directly tied into how much they produce for the practice (many of them are) they may include things that are unnecessary to try to “pad” the bill and increase the amount they will make. I’ve heard of veterinarians that will “pad” a bill but I’ve never actually met one. They are the alligators in the sewer of veterinary medicine.  I have met many veterinarians that claim to work for one or have worked with one but I’ve never seen one! The opposite is far more common and most of us often fall into patterns where we are guilty of being too conservative and trying to fix things inexpensively without offering all options. To illustrate what I mean I will share one of my more recent short comings.

One of my favorite patients is a small young canine belonging to an older woman. The dog was brought in to me early in the week because she had vomited a few times and was having bloody diarrhea in the house. Physical exam was fairly straight forward and I ran a small amount of blood work and was able to determine that the dog more than likely had a fair amount of gastroenteritis with a secondary low grade pancreatitis. This is where I dropped the ball. I should have offered my client the option of hospitalizing her pet for several days with intense fluid therapy, pain management and tailored nutritional and pharmaceutical therapy possibly including antibiotics. Instead I treated her in the same manner we often end up treating these patients when the first treatment plan we offer is rejected. I went straight to plan B medicine without giving the owner the option of plan A. I did it in an attempt to keep her bill low without asking her if she needed me to do that. Her dog did ok and in the end fully recovered but needed several out patient treatments and spent longer than was necessary feeling lousy. In the end the treatment plan worked but my patient and my client could have been feeling better sooner and could have healed with less complication, weight loss and damage to the intestinal tract or carpets, had we been more aggressive.

Ultimately I owe it to you and your pet to make you aware of the best treatment options my expertise will allow. You owe it to your pet and yourself to elect a treatment plan that fits your lifestyle and your relationship with your pet. We owe it to each other to keep those lines of communication as open as possible.

Thanks for reading.

The Daily Juggle

My job is inherently emotional. It goes without saying that when you are treating sick pets, things can (and often do) get intense in one direction or another. Sometimes the emotions run hot and we catch the blunt end of the anger stage of grieving. Sometimes emotions run in the sunny direction, often surprisingly. It will never cease to amaze me how frequently we get thank you cards and gifts from clients after their pet does not survive a serious illness or accident. Not that I expect them to be unhappy with us; we show up everyday- sometimes at night- and give one hundred percent of ourselves for one hundred percent of the time we are servicing our clients and their pets. This often includes stepping from one appointment with a seriously ill patient into a vaccine appointment with a new client and their puppy or kitten.

Actors practice their art by transforming themselves into different characters to tell a story on stage or screen. It is an art form that involves controlling and expressing human emotion in a believable and realistic manner. The daily life of a veterinarian is not unlike that of an actor. Allow me to tell you about a day I had in what now feels like a past life. It wasn’t a whole day; in fact, just a few hours of one day.

Seeing appointments is a juggling act; not only because you see multiple different kinds of appointments in the same day, but also because you will often come across things in appointments that cannot wait to be treated. Wounds can be especially like this; not that they can’t be stabilized and wait but if we are going to treat them and get them home in a timely fashion we will often work wound treatment into our day. This is a very perfectly balanced game of beat the clock. Depending on the wounds, I will sometimes tell people their pet absolutely has to spend the night. More often than not, it will be treated and return home that afternoon. On the particular day in question we saw a pet with a fairly extensive (but not terribly difficult to treat) wound on its side. It would be a straight forward task to explore the wound, remove and dead or infected tissue, flush the wound and then close it. And it went exactly like that: the pet’s wound was extensive and had a large amount of infected tissue associated with it but everything was going great. We were able to clean the entire wound out, flush it and were getting ready to close the wound. We wouldn’t even be running late for the next appointment. Then the pet died. Out of the blue. No changes noted on our monitoring equipment before hand, good strong heart beats and good deep regular breaths and then nothing. Silence. We fall back on our training in moments like this: commence resuscitation, get the client on the phone, explain the situation, continue resuscitation. In this case we were unable to bring the pet back. We lost. Anyone who has ever experienced this will tell you that if you were to offer them the choice of this situation and the feeling that comes with it or being sucker punched in the gut as hard as possible, they would ask you what the difference would be. The only real difference is you don’t replay a sucker punch a thousand times wondering how you could have dealt with it differently. A sucker punch doesn’t make you want to quit. A sucker punch just hurts for a little while.

I had to walk away from that situation and into an appointment that did end up having to wait for me because I was now running about forty-five minutes behind schedule. Of course the waiting client wasn’t happy about waiting and while they might have understood if I had explained everything to them, they didn’t need to have that heavy material laid on them at that moment. As it was, their pet wasn’t feeling well and they wanted to be reassured that it was going to be alright. It was going to be fine but it was going to have to go see a specialist for its problem. While I was working that out over the phone, the owners of the first pet arrived. I spoke with them and answered as many questions as I could, and then went into my next appointment- a recheck appointment and suture removal for a wound treatment I had performed a little over a week previously. This pet had healed wonderfully and was doing very well. As I was talking to them at the check out desk about scheduling a grooming appointment for their pet now that the sutures were out, a very large dog with a very large wound came through the front door leaving a very large trail of blood behind it. This day was going to last longer than we wanted it to…

On a typical day, we deal with and experience a complete range of emotions. We knew what we were getting into before we stood in that hall and took the veterinary oath. That doesn’t mean that some days don’t absolutely devastate us. But we look forward to each and every day we get to go through these experiences with you and your pet. Thank you for giving us the opportunity.

Thanks for reading.

 

It’s a New Year!

My New Year’s resolution for pet owner’s is going to be to get as many of my patients on pet health insurance as possible. It’s not that I like to spend your money. It’s that I really enjoy practicing high quality veterinary medicine whenever I can. This happens more when finances aren’t the major governing factor. With pet insurance you as the owner have already been making small payments towards Fluffy’s serious illness so after paying a small deductible we can be assured that while good veterinary care is expensive you have already offset the bulk of that expense.

Veterinary health insurance is nothing like human health insurance. There is no haggling over bills, there is none of that getting the bill from us if your insurance refuses to cover services. It is a lot more like having dental insurance. You pay your bill at the time services are rendered (or put it on a credit card or make arrangements with your veterinarian), your veterinarian fills out a form and you submit the form to the insurance company. They then cut you a check for the amount they are going to cover. All you have to do is bring the form to the vet with you and then mail it out when they have filled it out.

Most insurance companies pay a portion of the bill. This ranges between 80-90%. Meaning if your pet is struck by a vehicle and needs multiple long bone fracture repairs, for example, the bill may quickly approach $4,000-5,000 but your responsibility would be between $400-600.00 still a hefty bill but certainly more manageable.

All of the insurance programs available to dogs and cats offer packages that include vaccines, dental care, routine fecals and heart worm testing. For some of these companies this is an extra cost and some companies include them in their base cost. Most of these policies are handled by nationally recognized insurance companies and may be handled by insurance agents in your town, often we find they are handled by insurance agents our clients are already working with. This puts a friendly local face on the policy and makes it that much more personal.

There is a lot of information out there (online) about pet insurance. Much of it has a lot of wording that makes sense to me when I read them but often involves things that I do and use everyday. I always recommend that before you sign onto a policy you bring it in to your veterinarian and have them review it and see if it is worth what you are spending on it. I will often enter in all of the routine, preventative care that a policy covers and then compare the total yearly benefits with the total yearly cost. You are not going to save money on preventative care with pet insurance. You might end up spending an extra hundred or so dollars over the course of a year. This is all worth it, however, if Fluffy is ever to have a serious accident or contract a serious illness.

I’m not going to promote one veterinary insurance program over another. The American Animal Hospital Association doesn’t do that anymore and neither should I.

Less than 1% of my clients have pet health insurance on their pets. It makes a world of difference when something serious comes up. Look at the links, call the company and see if it might work for you. If it does print out the plan you are thinking of and take it to your veterinarian. If they think it is a good fit for you bring it to an insurance agent that deals with the carrier and see what they can do for you. It might actually give your veterinarian the power to save your pet’s life someday.

Have a great year everyone!

Thanks for reading!

This Christmas give Your Heart

To a kitten or puppy!

If you search on the internet for “Kittens (or puppies) for Christmas” you are bound to find a lot of opinionated articles about why pets make terrible holiday or birthday presents. While I agree with that statement on the surface, I don’t typically like making blanket statements that would make otherwise responsible pet owners feel like they are doing something wrong.

If you are thinking about purchasing/adopting a kitten or puppy for a family member as a gift based on the reaction they will have to seeing the cute little bundle of fluff with a bow on its head you probably have the wrong idea. I will concede that kittens and puppies are cute but they also live a relatively long time. It would not be surprising for a kitten or puppy purchased as a gift for a six year old child to still be alive when they graduate from college. That is sixteen years, eight hundred and thirty two weeks or almost six thousand days of feeding, walking, scooping the litter box or cleaning the yard. If you’re looking for an impulse buy get them an ipad, it’s cheaper in the long run and won’t last nearly as long. Also, electronics don’t do any worse if they are not cared for after a child becomes bored with them.

There are people out there who already know all of the information in the above paragraph and might still want to get a loved one a kitten or puppy for Christmas. If you were going to get a puppy or kitten anyway and think that it would make a fun gift or would enhance the morning gift opening session there are a few things to think about first. If you are planning to have a lot of people at your house this Christmas, you might think about taking a slightly different approach to bringing a pet into your home. Instead of getting the puppy or kitten on the big day have your gift recipient open the food dishes, leashes, litter box and other pet accessories with a photo of the soon to be adopted pet. That way the young animal isn’t stressed by the activity of the house during the holidays but the recipient still gets the joy and anticipation of the new pet.

If it is going to be just your family at home this holiday season then the time between Christmas and New Year’s might actually be one of the best times all year to welcome a new pet. Typically, people are home more during this period and can spend the time it takes to get the new pet adjusted. Children have off from school during this period and may have more time to get used to the responsibility that accompanies a new pet.

Be sure to pick up all of the accessories necessary for a new pet. If you are a motivated pet owner and want to get an idea about the total costs and responsibilities that you will face in the first year book an appointment with a veterinarian just for a consult. This time of year our schedules are typically clear enough for us to view this type of an appointment as an enjoyable and productive use of our down time and I would be surprised if a veterinarian charged very much if anything at all for such a visit. I know we would be happy to give a potential or current client 15 – 20 minutes to ask a few questions and get an idea of what they could expect. We would even be willing to print you out an idea of what type of visits and what type of expense you would be looking at for the first year.

There is a responsible way to get a pet as a gift during the holiday season. If you are thinking of adding a furry family member to your home this year adding them during the holiday season can be just as responsible and perhaps a bit more memorable than other times of the year.

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Remember you can always follow me on facebook or twitter. I often will post other blogger’s articles and small notes throughout the week. So you get a little more than just the blog.

Hope your holidays are safe and fun.

Thanks for reading.

Prevention

I’ve dealt with this subject before. Prevention is way better than treatment, almost always.

The end of summer/middle of Autumn is the season of the itchy dog. We see several everyday at our clinic and while we treat each problem and each pet a little differently there is one that always evokes a similar response from me. The flea infested dog. Here are a few funny things about fleas. They are really small, you might not see them even if you’re looking. They breed really fast, so by the time we do see a few adults there are probably thousands in your house. They make pupae just like caterpillars and those pupae are immune to every treatment short of burning down your house. This is why the following exchanges evoke a little bit of frustration in me.

A client brings in an itchy dog and I ask, “So you’re keeping Cuddles on a flea preventative, right?” I am giving them the chance to absolutely make my day with this question. Unfortunately, I usually get one of the following responses, “I haven’t seen any fleas,” “We’ve never had a problem with fleas before,” “We don’t get fleas in our house,” and my personal favorite, “I’ve looked, there aren’t any fleas.”

In my head there is this little sarcastic jerk who constantly needs to be silenced. I resist the urge to explain to people that if we wait until we see the problem we are trying to prevent to start prevention, we can’t rightly call that prevention anymore. I would much rather prevent fleas on your pet than treat them. Just as I would much rather prevent fleas from being in my house than treat them.

Warning: there is a wild tangent coming up.

It does a person’s pet no good to point those petty facts out to them and it turns out it doesn’t make my day any better either. My job is to recognize that they have an itchy pet, this pet is uncomfortable, this pet owner feels badly for their pet and I have the knowledge and tools available to me to make this situation better. Not just that, but this owner took the time, effort and is going to pay the money to come and visit me out of all of the vets they could be seeing right now. How dare I make them feel silly for not completely understanding the life cycle of the flea! So I have started to try to teach people more about the why behind the how of veterinary medicine. Some people are interested, some people aren’t. On a good day I can handle both types of people with ease, on a bad day… well, I’m a human being too.

How this leads me into holistic medicine is a bit of a stretch unless you know me well. I suppose the easy answer is that while I know there are all kinds of “natural” and “holistic” and “homeopathic” remedies for fleas, ticks and just about any other ailment you’ll find, I don’t recommend them because they either don’t work or don’t work as well as something else. People pay me to do what is best for their pet utilizing all of the available information we have. It bothers me to no end that someone who chooses to include within their “treatment” armamentarium a procedure, drug (all substances given with the intention to produce an effect are drugs regardless of what they are made of) or dietary change that has yet to be validated or has been invalidated by scientific methodology would be considered to be treating the whole animal more than I am.

My personal professional ethics dictate to me that treatments- whether preventative or palliative or curative- must have been exposed to criticism via the scientific method. I do this for two reasons. The first is obvious: if it survives the critical objective eye of good science it will work better for my patient than something that hasn’t. The second reason is that if all of my plans, treatments and recommendations are based on scientific evidence then I will be less likely to resist changing them when something better comes along.

And it will. Because that is how science works, better ideas come along and we either adopt those ideas or we are left behind in our field. Look at what happened with the idea of “junk dna.” We originally thought a huge percentage of dna served no purpose. Now we realize that it not only serves a purpose but is instrumental in carrying out multiple biochemical functions. Science accepted its idea was wrong, adopted the new paradigm and there will be a multitude of valuable therapies developed over the next few decades all stemming from that small change in thinking.

Back to the fleas, with an active infestation we can stop the itching, stop the biting and start a really good preventative. Following that we can typically control future infestations and hopefully kill off the population that is living in the client’s house.

Thanks for reading!

 

When it isn’t good.

This was a hard blog to write. I love my profession and I feel very strongly that the vast majority of veterinarians practice their craft with their hearts and minds in it one hundred percent. There will be times, however, when even the best of veterinarians drop the ball or come up short. This week the main message I want you to take away from this is that you have the right to hold us accountable when we do this. Let us know when you’re not happy and I promise you any decent veterinarian will try to make it right.

Complaints.

All of my clients love their pets. The way they show their love may differ but it is indisputable that all of my clients love their pets. It is because of this love that things can become emotional at times. This week I’m writing to say, “That is ok.” If you don’t understand a diagnosis or a treatment plan, ask a question and don’t hear from one of us, it is understandable to be upset. If the outcome of a case upsets you or you experience a loss and become upset, blame us or say some things you didn’t mean; that happens. We really won’t hold it against you. This is not a license to act the fool every time you get a bit upset but we are all human and we understand that sometimes emotions get the better of us. If you have ever studied neurology you might call this an amygdala hijack.

There will be times, even if I’m your veterinarian, where your veterinarian does something that is just plain wrong. Maybe it’s something simple like forgetting to call you back or maybe it’s something more serious. When these things occur there are multiple ways that you can voice your concerns and, if need be, take action. While you are legally a consumer of a service we provide, we would prefer it if you felt like a member of your pet’s medical team.

No one likes to hear that they’ve done a bad job or that a client is unhappy with the medical care they’ve provided for their pet. In many cases we take it very personally when there is a negative outcome or a patient’s owners aren’t pleased but in every case that comes to mind, the owner that complained directly to us pushed us to make changes to improve the quality of our veterinary care. So while you might not want to seem like a rude person or you might not want to hurt our feelings, please understand that if you are not pleased with any aspect of your experience with us, we want to know right away. More often than not a simple conversation will leave you feeling better and will open our eyes to something we might never have thought of before. I understand not wanting to make a fuss, I’m like that almost all the time, but if you don’t tell us you’re not happy then we won’t ever know and if we never know we won’t ever try to do it better. From another perspective I can tell you that most of us would much rather have a conversation with someone who doesn’t want to be rude or hurt anyone’s feelings than with someone who doesn’t care about those things.

It might happen- I really hope it doesn’t- but it might. You might find yourself in a situation where you don’t think the veterinarian treating your pet has your family’s best interests at heart. It’s times like these where I would recommend that you need to have a conversation with this veterinarian and let them know just how you feel. If they can’t explain themselves or they aren’t willing to have that conversation with you huge red flags should be raised in the back of your mind. No matter what kind of service you receive at a veterinary clinic, restaurant or human hospital you can be sure of one thing, it is probably similar to the level of service everyone else receives as well. That is great when you receive really good care, follow up and follow through. In those cases you may wonder just how they do it and you might call all of your friends and let them know. We certainly hope you do! It’s less great when the service is lacking and the professional providing the service is less than professional and you can be sure if someone is less than straight with you then that is most likely their standard operating procedure and you are not alone. In these cases after having that conversation with the veterinarian (or accountant or real estate broker or tattoo artist) and not reaching any resolution you might want to consider filing a formal complaint. A formal complaint is a legal complaint with your state’s professional licensing board. This sort of thing is serious business and should not be entered into lightly, that being said there are a multitude of check points along the way to opening an investigation that prevent petty and dishonest license claims from clogging up our boards. A license claim is just that, it is an investigation into a professional’s license and their ability to adequately perform within their vocation. You can find more information on the complaint process by visiting the website of your home state’s office of professional regulation.

Every veterinarian I know- and I know a lot of veterinarians- is deeply committed to their work. For the four years of eduction and then most of our careers we have had it ingrained in us that this is a way of life- not just a job. That being said, I don’t know a single perfect veterinarian. We all make mistakes, we could all stand to get a little better at what we do and a big part of getting better is recognizing what we’re doing wrong. If you’re not happy with your experience please let us know; it might be hard to take but it will ultimately allow us to offer you, and everyone else we care for, better veterinary medicine in the long run.

Have a safe and happy Halloween!

Thanks for reading.

 

That gotta go feeling…

Cats are hardy little survival machines. They tolerate us a lot more than they require us. There are few times when Cuddles needs you to come to his rescue. This is one of them.

Your cat has been going to his litter box every few minutes, maybe he hasn’t left it for a few hours. He’s crying out in what sounds like pain and you haven’t noticed any urination. If he does come out of his box he might drop down and lick at his private areas but still no urine comes out. Please call a veterinarian at this point. If left untreated a blocked cat will build up toxins and will die from changes in their blood chemistry in 3-6 days. It is a fairly painful and treatable condition.

Male cats block for a number of reasons. They may form plugs made of crystals, mucus and/or tiny bladder stones. They may have severe urethral spasms due to stress. They may have a combination of both plus additional factors. The end result is that they can not void urine from their bladders. This causes the kidneys to stop producing urine and the toxins that the kidneys filter from the blood end up building up. These toxins can make your cat very sick. Vomiting is not uncommon and life threatening heart arrhythmias can also occur.

What are we going to do about it? Treatment depends on just how sick your cat is when you bring him in. If he is alert and manageable we might sedate him before we go any further. If he is very down and out and we are concerned that sedating him might be dangerous we may start to check for electrolyte abnormalities and begin treating those before we sedate for catheter placement.

Sedation almost always accompanies the treatment phase. We will place an intravenous catheter for the post obstruction part of this disease often before we even begin to unblock you cat. When Cuddles is sedated we will pass a urinary catheter up his urethra and into the bladder. This can be one of the most frustrating tasks in veterinary medicine though I feel like I’ve really found the most hassle free and gentle means of placing a catheter in male cats. Once we get urine flow through our catheter we immediately start them on intravenous fluids. The kidneys are going to do the bulk of the work from here on out and we simply collect and measure urine to be sure everything is going as expected. Once the removal of the obstruction is complete the kidneys will begin working overtime to make up for the accumulation of toxins that occurred during their brief hiatus. This is potentially very dangerous for your cat as it can rapidly dehydrate him and lead to serious health risks.

We typically will keep an unblocked cat on iv fluids and maintain a urinary catheter until the urine is clear of all visible blood and debris. We will then pull the catheter and be certain they are urinating on their own. Sometimes this can take up to three days. As a result blocked cat’s veterinary visits tend to get very expensive very quickly. It is not unusual for a blocked cat to go home with a dent in his owner’s checkbook to the tune of $2,000.00!

After your cat goes home they are still at an increased risk for re-blocking for a few weeks. During this convalescing period we will institute a number of treatments to prevent the blockage from reoccurring. This will often include diet changes and enhancement of his at home environment. Sometimes it may also include behavior modifying medications. In rare cases, we may have to resort to dealing with the issue surgically. A perineal urethrostomy involves the surgical removal of the penis and urethra up as close to the bladder as possible. This shortens the urethra and places the opening in an area where the urethra is at its widest. By doing this we prevent future blocking as the cat is able to pass larger plugs and there is less urethra to spasm. Personally, I consider this surgery a last resort for cats that repeatedly block and will do almost anything to avoid it. The way I see it as long as you haven’t done it yet any surgery is still an option, once you cut you really can’t take that back.

Unfortunately finances are the demise of many of our patients and I think that obstructed male cats are probably over represented in this category. There are always options available and if you find yourself in this position with your cat please don’t assume you have to make a choice between a huge bill or the loss of a furry friend. I’m not going to get into the “budget” style treatments for unblocking as I would consider them to be less than best medicine but if that’s what it comes to then that’s what it comes to. I would prefer to at least try something than to make a final decision based solely on the finances.

Thanks for reading!

When it’s not the moon…

That hits your eye that is.

Everything was fine when you went to bed last night. You woke up this morning and Cuddles’ eye was bright red, she was squinting and pawing at the eye as well. You called and the veterinarian had an opening so you rushed Cuddles right in. There was some testing, the veterinarian drew a picture, told you it was a “corneal ulcer” and then precribed medication that has to be applied 3 times a day. You get in the car, drive home and when you get there your family asks, “So what happened?” And you have no idea.

Bright red eyes are a fairly common problem in veterinary medcine. There are several reasons an eye, or both eyes for that matter, can turn red. If it is only one eye and it seemed to go from perfectly normal to a bright, angry red, I start to think about corneal ulcer or corneal erosion. A corneal ulcer or erosion is a disruption in the clear protective layer of the eye. When this layer becomes damaged for any reason it is extremely painful and will disrupt the architecture of the cornea. This will cause the surrounding tissues to turn that angry red color and they may even swell up a little bit.

Diagnosing a corneal ulcer is fairly straight forward and one of the more interesting things we get to do in routine exams. First the eye is examined thoroughly visually and then again using the ophthlamascope. We will then typically measure the eye’s tear production as a condition called dry eye may lead to corneal ulcers. Dry Eye Once the tear production has been measured we will place a small amount of a brightly colored stain in the eye, rinse the extra out, turn out the lights and look at the cornea using an ultraviolet light. This allows us to measure two things the first being the quality of tears produced and the second being whether or not there is an ulcer present. For the sake of this week’s post, you guessed it, there’s an ulcer. The stain will “stick” to the edges of the ulcer and may even stick to the bottom of the ulcer as well.

Treatment of an ulcer can be straight forward as well. The cells want to get to the right place and help to fill in the gap left by the ulcer. Utilizing a lubricating topical medication helps the cells do what they are supposed to do. We typically will prescribe an antibioitc eye ointment that will prevent subsequent infection (or treat a present infection) while allowing the cells that are laying down new cornea to migrate freely. The best way to use a medication like is is to apply it at least four times a day, preferably more. It is the very rare owner that has the time to apply medication to their pet’s eyes four times daily and it is an even more rare pet that tolerates this. For that reason we typically have to make due with three times daily. We also want to treat the pain associated with corneal ulcers. These things are really painful. Most of the pain is caused by the spasming of the iris, the colored part of the eye, in reaction to the inflammation associated with the ulcer. We stop this by paralyzing the iris with atropine. This causes the pupils to dilate so you might be careful about taking Cuddles out in the bright sun. This might also cause a cat to drool a bit after application, this is normal and will only last a few minutes. The pain relief on the other hand lasts for hours.

An Elizabethan collar (cone of shame) may be necessary to keep Cuddles from pawing at his eye while it is healing. If Cuddles has been pawing the eye or you are worried he might, a collar is a good way to get some piece of mind.

It is important that you have the eye rechecked every week or two until the ulcer is resolved. If the ulcer is not healing or the inflammation starts to spread we might have to be more aggressive with it. Some may even require surgery to protect the area of the cornea while the ulcer heals. Typically if an ulcer is not healing the way we think it should be, I start to talk about involving an ophthalmologist. Before we go down a long path of trying to make something work and potentially end up frustrated and with months worth of time and money invested, when the “usual” line of treatments don’t work, involving someone who has dedicated their entire profession to treating eyes is the most cost effective and efficient move.

Thanks for reading!

Chimera

A disease that strikes at young cats. A disease that has no definitive diagnostic tests. A disease that is nearly 100% fatal. A disease that has no effective treatment. A disease that is infectious but is not contagious. Cat owners know and fear the diagnosis. FIP is the feline practitioners chimera. A poorly understood untreatable and deadly disease that offers no warning that it might be on the horizon.  

From what we currently understand, FIP is an inflammatory reaction to infection with the feline enteric coronavirus. The feline enteric coronavirus is not involved in SARS which is caused by a different species of coronavirus. The majority of cats infected with coronavirus typically encountered the virus in infected feces (litter box) and this typically occurs in environments where multiple cats are housed together. They will exhibit flu like symptoms for a few weeks maybe a few months and depending on the number of cats in the house they may or may not clear the virus. Homes with 5 or fewer cats seem to spontaneously clear the virus eventually but houses with more than 5 cats will almost never clear the virus. Cats that are exposed to and infected with coronavirus and cleared it are still susceptible to reinfection. They can easily pick up the virus again and again.

As long as the virus sticks to your cats gastrointestinal system your cat will not develop FIP and will most likely clear the virus, unless you have a lot of cats. There are multiple theories about how FIP occurs and how it spreads in the body. Today, in 2016, I can give you the most recent understanding we have and the most recent ideas being proposed about FIP.

It is currently thought that FIP is the body reacting to a mutated version of the Corona virus. We can’t cause transmission of FIP by putting a cat with FIP into a densely packed cat environment. We can cause transmission by taking fluid from one cat and injecting it into another cat. This supports the disease being infectious (fulfills Koch’s Postulates) but not actively contagious.

Assuming that we are correct about the virus that causes FIP being a mutated strain we can then make some inferences about how it causes disease. When the body is dealing with a virus it utilizes a particular cell called a macrophage. Macrophage means “big eater” in Greek and that is exactly what these cells do. The engulf cellular debris, foreign material, bacteria and viruses and package it into little sacks called phagostomes. The macrophage then joins forces with a cell called a lysome to form a phagocyte. This phagolysome fills the sack containing the invader with digestive enzymes and peroxides. Once the macrophage has ingested a foreign invader it will display a piece of the invader’s surface on the outside of its cell. This encourages the body to create antibodies and allows for a sort of seek and destroy mission to commence within the body. This is where FIP becomes a problem.

In FIP the mutated virus is immune to the degradation activity of the macrophage. So the body still goes through the action of creating more and more antibodies and macrophages but they don’t do anything and the virus continues to replicate. Increased numbers of viral particles cause an increase in the production of macrophages. These useless macrophages start to coalesce in the internal organs into tumors called pyogranulomas. FIP is the infiltration of these pyogranulomas into internal organs.

Diagnosing FIP is difficult to say the least. It typically is a rule out diagnosis meaning that even if that is what we are suspecting from the beginning, we still need to rule out just about everything else before we can be comfortable telling you your cat had FIP. This means blood work, sampling fluid from the abdomen and if possible taking a surgical biopsy. There are few diseases that cause the spread of pyogranulomas through the body and if we already suspect FIP for other reasons that would make me comfortable with the diagnosis.

Once we have a diagnosis treatment is limited or non existent. Because the pyogranulomas and inflammation are caused by the body’s immune system the mainstay of therapy for a long time was suppressing the immune system. Immunosuppression will slow the progression of the disease but because FIP is also a viral infection immunosuppression is not going to be a cure. In cases where there is a lot of abdominal effusion or fluid removing the fluid may help to lessen the symptoms and may also slow the progression of the disease.

Right now research is looking into different anti-viral therapies to treat FIP, people are also working on breeding cats that are more resistant to FIP. Currently neither of these approaches have been successful yet. FIP continues to be a fatal disease for the affected cats.

Sorry to be so glum during the fun Summer months! Hope you are enjoying the weather.

Thanks for reading.

Full tilt

Do a handstand and your body knows that it is upside down. When you fall your body instinctively knows how to try to right itself. Not that it always succeeds but it knows how to try. It does this using a pair of organs located in the middle ear. This is called your vestibular apparatus.

The vestibular apparatus is made up of three semicircular canals filled with a fluid. There are sensory hairs in this fluid that detect the movement of the fluid and inform the brain about rotational movement and the body’s position in space. Within the cochlea of the ear there is a saccule containing a gelatinous material. Within this material are little bony structures called otoliths. These move up and down in the gelatin and  trigger small hairs that are attached to sensory nerves. This informs your brain of up and down motion of the body.

If the vestibular apparatus is disrupted by injury or disease we see changes in the way our patients understand their position relative to the outside world. Of the things that can disrupt the vestibular system we can classify them into three broad categories. These are; infections of the middle ear, lesions on the brain and the third category is called idiopathic meaning we do not know the cause.

A dog or cat with vestibular disease will stumble and stagger when they try to walk. They may circle to one side and may get motion sickness. They may also have rapid uncontrolled eye movements and they almost always have a head tilt to one side.

Brain lesions are typically accompanied by other signs that indicate that the problem is affecting more than just the peripheral nerves. Sometimes it can be difficult to preform a complete neurological examination but there will be some subtle clues such as changes in other nerves associated with the head (cranial nerves) on the opposite side of the head tilt that indicate there is something going on in the brain. Many people take these central lesions to be “strokes” and while vascular accidents do occur in our patients they are not terribly common. Typically we recommend advanced imaging of the brain using MRI or contrast CT if MRI is not available to get a better understanding of the problem.

Infections of the middle ear are a bit more common than central brain lesions. Sometimes they will accompany an infection of the external ear or sometimes they come on their own. The best way to diagnose a middle ear infection in general practice is by taking x rays of the middle ear. It is impossible to see the middle ear with an otoscope although sometimes we can infer that there is an infection in the middle ear based on our examination of the external ear canal. Middle ear infections require antibiotics for around 6 -8 weeks and sometimes will not resolve with out surgery to open and clear the middle ear.

The most common cause of vestibular disease in cats and dogs is idiopathic or unknown. These typically show up suddenly and will show signs of improvement over the following three days. It usually takes around 1 to 2 weeks to see complete resolution and it is not uncommon for a slight head tilt to persist. If an infection is not detected and a brain lesion is not suspected it is a good idea to look at tick titers especially in dogs living in areas where tick borne illnesses are common. Fungal titers are also a good idea and ruling out hypothyroidism should also be on the diagnostic list. In fact ruling out hypothyroidism, getting base line blood and urine, taking chest radiographs and (if everything looks ok) waiting three days is our current standard approach to these cases.

After arriving at a diagnosis or ruling everything out and going with an idiopathic diagnosis the best treatment we currently have is to treat and prevent nausea and keep our patients relaxed and calm. This allows them to be comfortable while the condition runs its course.

Thanks for reading.

 

FATE

Most of the time when I’m writing these I’m thinking of diseases, conditions or situations where we can really make a positive difference or there is some way to prevent or manage the problem. This week is about one of those terrible situations for which there is really little we can do and little warning about what may be happening. Fortunately they are not terribly common. Statistics, however, do little to console those few owners who have something like this happen to a beloved family pet.

When cats develop heart disease they tend to do it a little differently than dogs. They will overgrow or thicken their ventricle walls, the ventricle is the part of the heart that pushes the blood into the aorta or pulmonary vein and move it into the circulation. If the ventricle wall becomes thicker the ventricle will have difficulty relaxing and filling with blood. The ventricle also has difficulty filling because the space is smaller. This can lead to sudden decreases in cardiac output that occur at times when the cat needs the blood the most (during dog chases for example) and this can lead to sudden death. Blood needs to flow in a specific pattern through the body. It flows in layers and we call this a lamellar flow pattern. If these layers are disturbed during flow by a heart murmur or pushing the blood through a narrowed space the factors that affect clotting can be activated and a clot can form. This clot is pushed out into the aorta and a moving clot in the blood stream is called an embolus. Technically, it is called a thromboembolus as it is made of a blood clot (thrombo = blood clot).

The embolus will move down the bloodstream until it encounters a vessel too small for it to pass through. There it will lodge and occlude blood flow. In cats, this typically occurs at the end of the aorta where the major vessel splits into the supporting arteries of the pelvic limbs. (These are the iliac arteries, this will be important in a minute.) This blockage is very painful, sudden and often causes a complete loss of blood flow to the affected limb or both limbs. These cats instantly lose their ability to walk, vocalize with pain and will have cold to the touch feet that do not respond to stimulus.

Treatment for a thromboembolism is available but it is very expensive, there are cases where cats do die during administration of the drugs involved and there is a very high recurrence rate of thromboembolisms in cats with heart disease. As a result, many people do not go for clot lysing treatment. Most commonly we will manage these cats with supportive care for 72 hours. During that time we try to facilitate clot breakdown, manage the cat’s pain and dilate the vessels a little bit. If we can get the clot to move down the iliac arteries there is collateral circulation, the deep circumferential iliac and theinternal iliac vessels branch from the external iliac which is the major large vessel in the pelvic limb. If we can open flow to these vessels the collateral circulation can start to feed the muscles and we can prevent serious, irreversible damage. This may buy us enough time for the body to break down the rest of the clot and over time the cat may regain its ability to walk.

There is approximately a 50% chance that the cat will recover with supportive care. After that there is a very good chance that it will happen again in the next few months or even weeks. For this reason, many of these cats are euthanized when they throw clots rather than treated. If we are successful and the cat doesn’t throw a clot in the following months we recommend a complete cardiac examination including echocardiography to evaluate for heart failure. Cats with hypertrophic cardiomyopathy, the most common heart disease in cats, with evidence of heart failure will typically succumb to well treated heart disease 12 to 18 months after the diagnosis. If there is not evidence of heart failure our course of treatment involves lowering the heart rate and relaxing the heart muscle. We will also start a clot preventing therapy using aspirin or sometimes plavix. While these treatments work anecdotally, there is little clinically supported evidence for thier use.

While we all have a few really good success stories to drag out and show off regarding thromboembolisms in cats, ultimately the realistic expectation we should be giving owners is that this probably isn’t going to get better. These cats can have their pain managed for a few days and we can give them a chance, if the owners want to try break down the clot and treat the heart disease I am all for it. In cases like this, however, it is very important to me that we all go in with both eyes open and understanding that even our best efforts may not be enough to overcome the disease we are dealing with.

The one area where prevention might be possible is if you have a breed of cat predisposed to heart disease or if your veterinarian has heard a murmur, it might be useful to have an echocardiogram performed and if there are signs of heart disease, putting your cat on anticoagulant medication can help prevent the formation of thromboembolisms. They also prevent the normal clotting that keeps us from bleeding excessively from small wounds so treatment/prevention is not without risk.

Thanks for reading.

Shots.

This is one of those blogs that I feel should be written and shared with everyone who vaccinates their pets but is also possibly going to upset some of my colleagues. So, I’ll start this one off with another reminder that this blog projects the opinions of a single veterinarian (me) and while my opinion is shaped by my understanding of the evidence available, my opinion is not necessarily shared by every other veterinarian. Nor am I certain that my interpretation is necessarily the correct one, it is the one that makes the most sense to me with what I understand. Should my understanding change, so will my opinion.

Nearly every pet is brought to the vet’s office annually for “shots”. This is done so routinely that many times people might not think about what is in the “shots” we are giving and what the consequences might be. Today I will try to address that. I will do my best to keep this species neutral but vaccine reactions do tend to be more of a dog problem.

A vaccine is meant to stimulate the immune system to produce antibodies to a specific infectious disease. As a result, vaccines contain either killed or attenuated infectious organisms. These organisms are the same organisms that cause diseases like Parvovirus, Distemper and Rabies. This stimulation of the immune system is naturally an inflammatory process. The muscle aches and soreness associated with illnesses like influenza are a good example of this inflammation. An allergic reaction is an individual inflammatory reaction to specific proteins. In the case of vaccines one of two reactions is possible. A type I reaction is immediate and usually occurs before the patient has even left the building. A type IV reaction, on the other hand is also called a delayed hypersensitivity reaction and can occur anytime in the 48 hours following vaccination. Vaccine reactions can include nausea, hives or facial swelling. In extreme cases they can include anaphylaxis and possibly death.

A study performed by the American Veterinary Medical Association in 2005 showed that vaccine reactions occur in 1 out of every 250 pets receiving vaccines. It turns out that small breed neutered male dogs were more likely than others to have reactions and that smaller dogs have more reactions than larger dogs. This may make a person think that giving smaller doses of vaccines to smaller dogs might be the way to go with this issue. Vaccines are not dose dependent, there are a particular number of antigen or disease particles that have to be present in order to stimulate a proper immune response and protect your pet regardless of size. If only half of these particles are given, for example, then it is possible and likely that your pet is not protected against the disease we are trying to prevent. In the case of Rabies this is a very serious matter.

It also turns out that giving more vaccines in a single visit increases the chances of causing a vaccine reaction.

After a vaccine visit some soreness, lethargy and even mild swelling at the injection sites is to be expected. This is the body’s natural reaction to being exposed to diseases and as unpleasant as it is, this is what we are trying to accomplish. If we can get your pet’s body to “believe” that it has been exposed to Rabies, for example, then it will make antibodies against the disease. With these antibodies in place the body can then fight off the Rabies virus should it ever be encountered. This saves not just animal but also human lives.

If your pet is having a reaction you can expect to see some or all of the following. Vomiting, hives, swelling of the face and complete collapse/unconsciousness. Notify your veterinarian even if you think that the vomiting might have been due to car sickness from the ride home. We will want to make a record of it and may consider taking preventative measures in the future. If your pet is showing signs of facial swelling or loses consciousness do not call your vet, bring your pet to them quickly!

Once your pet has had a vaccine reaction you will most likely not take any comfort in knowing that your pet is in less than 1/2 of 1 percent of the pet population. If they have had a severe or life threatening reaction they are even more rare. In the future you will want to take some preventative measures to be sure that this doesn’t happen again. There are 4 major things we can do to help to prevent vaccine reactions from repeating themselves in the future. The first thing we can plan on is adding in a preventative dose of an antihistamine before vaccination from now on. This will have the added benefit of helping to prevent motion/car sickness of the ride home. We might also put off that car ride home and keep your pet for observation for the following few hours. This will mean making vaccine appointments in the morning and picking Fluffy up in the evening. This means more expense and time from your part but it is well worth the money and effort. The second thing we can do to help to prevent vaccine reactions is to not give more than one vaccine at a time. Because giving vaccines within two weeks of each other can interfere with each other and the immune system we will never split up vaccines and give them less than two weeks apart. This would run the risk of your pet not being properly protected against the diseases we are trying to prevent. The third line in prevention would be to remember to tell us if your pet has reacted to vaccines in the past. This is especially important when changing veterinarians and in pets who travel and may see more than one vet. The fourth and final preventative measure is more a word of caution. If your pet has ever had a reaction to a vaccine, never have them vaccinated at a vaccine clinic. These busy and high paced events are typically not properly equipped to handle a vaccine reaction.

As an aside, a vaccine clinic is not the same as a low cost clinic. Vaccine clinics are those high number events that do not typically occur at a veterinary clinic and are aimed at increasing the total number of vaccinated pets. Low cost spay/neuter and vaccine clinics are typically veterinary practices that offer the basic preventative care for people who may not be able to afford typical veterinary care. The aim in these clinics is to increase access of veterinary care to pets that may not otherwise receive it.

Another aside, a quick word about cats. If your cat received an injectable vaccine and has a lump at the injection site that is either greater than one inch in diameter or has persisted for more than 3 months then it should be surgically biopsied and submitted to a laboratory for analysis. Some cats have a genetic mutation that causes them to overreact to any type of injection with unregulated inflammation. This inflammation lowers their natural safeguards against cancer and injection site tumors can occur.

If your pet has had a severe vaccine reaction and we know the culprit, we will typically cut that vaccine out of your pet’s schedule. If we do not know the culprit splitting up the vaccines and observing your pet post vaccination is the best way to determine which vaccine was the offender. If your dog is an adult that has finished a puppy series and started reacting to vaccines later in life, we may opt out of all vaccines except for Rabies (State law). In these cases your pet will still require an annual check up. In fact all pets should be examined by their veterinarian yearly regardless of health status with the exception of older patients who should be seen twice a year. While vaccine reactions are a scary and unfortunate complication to preventative care the rarity of adverse events combined with the prevalence and severity of the diseases they prevent keep vaccines a staple in responsible pet ownership.

Thanks for reading.

Pancreatitis Summer article

Summertime is coming and for most of us that means long days, grilling more meals outdoors and cookouts with family and friends. It also means that all the fatty foods we’ve been avoiding for the past few months so we look good in our swimsuits are about to make a strong comeback! There are a few dogs out there that are definitely, without a doubt going to get into some post barbecue garbage sometime this summer. One of them lives in my house. Most of the time these guys may have some stomach upset, even a few days of diarrhea but that should pass. A few of them, though will end up in serious trouble. Foreign bodies, ulcers and pancreatitis are all on the list. Today we’re going to talk about pancreatitis.There are some cases of mild pancreatitis that are treated less aggressively. I will not really be getting into those cases.

First we should have some idea of what the pancreas is and what it does. The pancreas is a small pink organ that is attached to the stomach and the beginning of the intestines. It has two major jobs. It secretes te hormones involved in regulating blood sugars, insulin and glucagon. It also secretes the enzymes used to break down proteins, starches and fats that we eat.

The enzymes used to break down the things we eat are typically safely stored in granules that need to be activated by a catalyst for them to begin digestion. When the pancreas becomes inflamed this integrity is lost and the enzymes are activated inappropriately. They begin to digest the pancreas itself. This leads to more inflammation in the pancreas and more leakage of enzymes. Eventually the enzymes start to leak out of the pancreas and into the abdomen where they can do serious damage.

Frequently we never find out why a dog has pancreatitis but one of the major causes we know about occurs when the contents of the intestines is refluxed back into the duct that releases the pancreatic enzymes. This is a problem because once in the intestines the pancreatic enzymes are mixed with the activating enzymes. If you move a fluid containing these activating enzymes into the pancreatic duct it will prematurely activate the enzymes within the pancreas. This reflux can happen after a dog ingests a very fatty meal. Similar to heart burn in humans.

Diagnosing pancreatitis is fairly difficult in the dog and cat. The major clinical signs (symptoms) are not eating, vomiting, lethargy, abdominal pain and diarrhea. Those are also the major clinical signs for just about every disease that occurs within the abdomen. Often the leaking pancreatic enzymes will affect other organs as well including the liver, kidneys, intestines and gall bladder. It can also cause problems with the heart, blood vessels and lungs if the enzymes make it into the blood stream. Often a pancreatitis is diagnosed during an exploratory surgery.

There are some blood work and imaging indicators of pancreatitis. In veterinary medicine we look at tests in terms of how well they avoid false negative and false positives. This is called sensitivity and specificity respectively. If a test is very sensitive it is good for ruling diseases out because a negative is a negative. In terms of ruling out pancreatitis in dogs the best blood test we have available to us right now is called a cPLI and it has a sensitivity of about 80%. This means that out of every 10 patients that truly had pancreatitis this test would incorrectly tell us that 2 of them did not have pancreatitis. Ultrasound examination of the pancreas yields similar sensitivity. (If this seems really confusing you are not alone. I guarantee I will get a few emails from veterinarians this week telling me I have this backwards.) My point is that diagnosing pancreatitis 100% is very difficult.

So if we can’t be certain that it is pancreatitis what do we do? Unfortunately there is not a specific treatment for pancreatitis and we are left providing supportive care. In other words we treat what we know we have. This means treating aggressively for pain. Replacing the fluids and electrolytes lost from vomiting, diarrhea and not eating. We will also often give drugs to stop vomiting and keep them from being nauseous. All of my patients with intestinal issues are started on drugs to prevent or treat stomach ulcers. The most important aspect of therapy is fluid therapy, hydrating dogs and cats and keeping their systems “flushing” helps to clear the inflammatory mediators and allow the pancreas a chance to calm down and heal. Dogs and cats, especially cats, will not drink enough to accomplish this feat. This often means they will have to be hospitalized and will get their hydration through intravenous administration.

Pancreatitis is a serious disease with life threatening consequences. Many dogs and cats with pancreatitis do not recover fully and it is not uncommon to lose a patient with pancreatitis even in the face of aggressive therapy. Your vet sees these cases fairly regularly and avoiding this outcome drives them to recommend rapid diagnosis and aggressive treatment.

This is also one of the diseases we see where early diagnosis, intervention and aggressive treatment will be a deciding factor in how things turn out. So please do not ignore it if your normal chow hound of a dog or cat suddenly loses their interest in eating. This is one of those times where being overly cautious is well worth it.

Thanks for reading.

 

Rat Bait

We receive these phone calls year round. A dog (rarely a cat) has ingested poison left out for mice or rats. The owner is often frantic and usually wants to be seen right away. I am not generally in the habit of turning away people who are upset, scared and want me to look at their pet right away but this is one of the cases where I might encourage them to wait depending on when the poison was ingested and what i am going to be able to do for them.

While are several types of rodenticides available for home use the majority of poisons being used in our area are anticoagulants. They kill mice and rats by causing them to bleed to death. In order to understand how these poisons work we should first do a brief overview of clotting.

Everyday we suffer minor injuries that cause damage to the small blood vessels in our bodies. These small breaks in the vessel do not cause any harm because we have a mechanism set up to control blood loss. When a vessel is ruptured it spasms and constricts to minimize the blood lost. When the outside of the blood vessel comes into contact with blood it attracts platelets. Platelets are always circulating and they begin to accumulate at the site of injury. In order for the platelets to stick together and make a clot they need to produce a substance called fibrin. The formation of fibrin involves the activation of one of two clotting pathways. These pathways involve proteins called serine proteases that facilitate several reactions that eventually lead to fibrin formation. As long as vitamin K is available these serine proteases can do their job.

Anticoagulant rodenticides block the body’s ability to produce and utilize vitamin K. That means that once the vitamin K stores in the body are depleted clotting can not take place. If clotting can not take place then the bleeding that occurs everyday but typically goes unnoticed takes on a life threatening importance.

It takes a bit of time for the vitamin K stores to be depleted and most dogs don’t show any signs of toxicity until several days after ingesting the poison. This is why I typically don’t have my clients rush the dog right into the clinic. Especially if the dog eats the poison in front of the owner on a Saturday or Sunday evening. Most people can look up how to induce vomiting on the internet and can try this at home if they like. I always recommend that we induce vomiting as there are certain risks associated with inducing vomiting, including but not limited to breathing in vomit and setting up a terrible pneumonia. If it has been more than few hours since the dog ate the poison, our chances of getting it up with vomiting are pretty small. We can try but it is not likely to happen.

Treatment of anticoagulant rodenticide toxicity involves replacing the vitamin K. This is usually started with an injection of vitamin K given under the skin in the clinic. The injection is followed with oral vitamin K supplementation for several weeks. It is important to be using vitamin K1 (phylloquinone) and the use of vitamin K3 (menadione) as a substitute can be fatal. After two or three weeks the vitamin K is discontinued. 48 hours later we will test your dog’s ability to clot by performing a specific blood test called a Prothrombin Time (PT). If the PT is abnormal we can assume there is still rodenticide in the system and we will continue vitamin K for a few more weeks.

There are newer rodenticides on the market but if you are thinking about fixing your mouse problem with poison I recommend an anicoagulant as there is an antidote available to us should your pet accidentally get into it.

While it is possible for a pet to become poisoned by eating poisoned mice, it requires either the mouse to eat a lot of poison or the pet needs to eat a lot of poisoned mice. These are both possible in theory and have been seen, mostly in barn cats, but it is very unlikely.

Thanks for reading!

Idle Chatter

When you call your veterinarian with a problem the response you are most likely to hear is, “We think Fluffy should probably come in for an examination.” We offer everyone an opportunity to come in and have an exam because we figure if it was important enough for you to pick up the phone and call it is important enough for us to take the time and have a look. So you load Fluffy into the car and drive all the way into the veterinary clinic and we perform a physical exam but we also put you through a barrage of questions. You didn’t know this was going to be a pop quiz! And an oral exam at that!

We call that line of questioning you receive in the exam room taking a history. In veterinary school they teach us that a thorough physical exam and good history lend 80% of the diagnosis. The testing and diagnostics that we recommend typically just help us confirm or distinguish between a few very similar illnesses. Our job is to ask the right questions to get to that diagnosis without having to rely too heavily on testing and diagnostics.

History taking is also the big reason we recommend that you bring your pets to the veterinarian every year. A good physical exam combined with a decent conversation about how your pet has been over the past year can catch a lot of illnesses before they become unmanageable. Often heart disease in dogs and kidney disease in cats are noticed first on routine examinations. It’s the questions in these diseases that get to the diagnosis and help determine the level of work up required.

Your job in the exam room is to answer our questions as completely as possible. If Fluffy has been vomiting for a few days there are going to be a lot of things on my list. If you also noticed that Fluffy has been drinking and peeing a lot more over the past few months, well that changes things. Another important aspect of the exam room conversation is that there are no wrong answers. I am asking questions to get a general sense of your pet’s health and well being. Your answers may encourage recommendations but they are never the wrong answers.

The basic questions to know when you are preparing for a veterinary visit when your pet is not sick are fairly straight forward. What type of food does your pet eat? How much and how often do they eat? Is their water intake increased, decreased or the same? Activity levels, are they also the same or have they changed? We want to know about any changes and anything that seems odd to you since the last time we spoke. This history combined with a good physical exam this should help us to determine that there is nothing to worry about this year as far as Fluffy’s health is concerned.

If you’ve come in for a sick visit there will be a different set of questions. We will want to know as much as possible about Fluffy’s medical history. This is where jumping around to different veterinarians can be detrimental to your pet’s health. If you have been coming to me since your pet was a kitten or puppy I can look through his record and get a sense of specific needs, ongoing illnesses or things we should be watching for. Otherwise, we have to try to piece records together with another vet and your memory and we can miss things like elevated liver enzymes six months ago or changes in thyroid activity. At the sick visit we will want to know about the changes as well but this time we want more specific information regarding this particular problem. How long has it been going on? Has it gotten better, worse or stayed the same? Have you done anything to treat it? Does it happen at a specific time of day? The answers to these questions can go a long way in diagnosing an illness and selecting the appropriate treatment.

So the next time you take a pet to the vet or have to make a phone call concerning a problem you’re having with a pet. Please try to remember we are not trying to quiz you but because Fluffy can’t talk we need as much information as you can possibly give us. In the long run it will save us time, save you money and possibly save Fluffy’s life.

Thanks for reading!

It’s a gas

Where I work we anesthetize nearly 20 cases a week. Most of these are young and healthy patients but some of these are elderly or extremely ill patients. Of those 20 or so patients I may explain the anesthesia process to 1 or 2 clients. It’s not that I don’t enjoy explaining things, I do, it’s just that the majority of people don’t ask and I often manage my time poorly and don’t have enough of it to take the time every time to explain really important things. It’s disappointing.

So here is my explanation of anesthesia in pets. Keep in mind that we are constantly improving our anesthesia so while the information I am about to lay out may be true for today but will most likely not be true for 6 months from now and will definitely not be true for a year from now.

So what we will do is walk through the basic anesthesia process and I will do my best to explain what happens and why along the way.

Patients that are undergoing scheduled anesthesia events are fasted overnight. This helps to prevent vomiting during anesthesia. Animals and people who are under anesthesia will not cough if they accidentally inhale a small amount of vomit. This vomit can then end up in the lungs where it can cause a life threatening pneumonia.

We have most patients dropped off to us at or before 8 am they are not typically picked up before 5 pm. This gives time to prepare them for anesthesia in the morning and gives the patients the entire afternoon to recover from anesthesia.

Every patient is examined that morning to help us develop the best possible anesthesia protocol for them on that specific day. Each patient is given a numerical rating based on how critical the patient is and how dangerous anesthesia will be for them. This is one of the reasons we often request that patients also have some blood work run. Patients will need red blood cells to transport oxygen during the procedure and to wake up well. They will also respond to anesthesia differently if they have an ongoing infection or a compromised immune system.  The drugs we use are going to be bound to proteins in the plasma during anesthesia. They will also be metabolized by the liver and excreted by the kidneys. Some routine blood work can give us the information we need to make changes to our patients anesthesia protocols and avoid a bad anesthesia experience.

Every anesthesia protocol is made up of 4 basic components. There is a premedication, induction, maintenance (also called peri operative) and post operative component to each anesthesia protocol used at any hospital.

As soon as we have our blood work available and the physical exam is complete we premedicate our patients. Our premedication drugs are almost always a combination of a sedative and a pain medication. The premedication calms the patient, dulls the body’s ability to register pain and makes the remainder of the process easier on the animal. It also allows for smoother induction of and recovery from anesthesia. Using good premedication allows us to use less of the drugs we use to induce anesthesia; these drugs typically have more profound effects on the cardiovascular system so using less is always preferred.

After the premedication has sufficiently taken its affect we are able to move to the next phase of anesthesia. With the exception of very quick procedures we place intravenous catheters in every patient undergoing anesthesia. This allows us to administer the induction drugs IV. Having IV access allows us to give fluids during the procedure and in the event that anything goes wrong we have access to the circulatory system and can respond immediately.

Once the IV catheter is in place we do a quick systems check to be sure we are all completely ready to do our job. As soon as we are all prepared and ready we induce our patients with an injectable anesthetic or a combination of several different anesthetics. We always induce intravenously as it is more rapid, smoother and controllable. Every patient, again with the exception of very quick procedures, is intubated for anesthesia. This means that we place a small plastic tube with an inflatable cuff directly in their trachea. This allows us to administer oxygen during the procedure. We also routinely use inhalant anesthesia as our maintenance anesthetic. If something were to go wrong in anesthesia having control of the airway is one of the most important parts of a good outcome.

As soon as a patient is induced and intubated our goal is to get them ready for the procedure and in the surgery suite as soon as possible. Once in the surgery suite they are immediately connected to oxygen and inhalant anesthesia. If the patient is a critical case (heart failure for example) or the procedure is going to be painful we often augment the inhalant anesthesia with controlled rate infusions (CRI) of injectable anesthetics as well as pain medications. This allows us to use less inhalant and we are able to manage pain better during the procedure. We also immediately connect patients to fluids given at a surgical rate. All anesthetic drugs will alter the cardiovascular system but by giving them fluids we are able to offset those effects and maintain good blood flow to organs that may have been compromised without fluid therapy. It also offsets the amount of fluid that is lost during surgery by having a body cavity opened and exposed to the outside as well as fluid lost to breathing with the anesthesia machine.This set up moves us to the third phase of anesthesia, maintenance or peri operative anesthesia.

As soon as the patient has entered the third phase of anesthesia we attach our monitoring equipment. The reason this happens here is because between phase 1 and 2 we are monitoring from a distance, allowing the drugs to do their job. It’s typically not until the patient has been induced that they start to undergo serious cardiovascular changes. For a reference, the total time between induction and being completely set up for surgery, including monitoring equipment, at our hospital is less than five minutes. In our hospital the monitoring of anesthesia is taken very seriously. A single veterinary technician is assigned to the job.  Each patient is attached to an ECG to monitor the electrical activity of the heart. This allows us to see and hear that the nerves that control the heart are conducting. If we want to hear the physical pulse during surgery we will also connect an ultrasound device called Doppler to actually hear the pulses. We often use Doppler with critical cases or patients with severe heart murmurs.  We also monitor the patient’s temperature, blood pressure and respiratory rate during anesthesia. A system called pulse oximetry gives us a measurement of the amount of oxygen being carried by the patient’s blood. In addition to that the technician assigned to monitoring anesthesia takes note of several of the indicators we use to assess the patients level of anesthesia at specific intervals throughout the procedure. As a general rule, the person monitoring anesthesia is expected to place hands on the patient every 5 minutes or so but in reality there are often anesthetic episodes where the technician has hands on the patient almost the entire time.

As soon as the procedure is finished the inhalant anesthesia or the CRI is turned off. Every patient receives at least an additional 5 minutes of 100% oxygen and is then moved out of the surgery suite and we enter the post operative phase of anesthesia. Here we may supply external heat if the patient’s body temperature has become low during the procedure. We also formulate the medications we will want to continue to keep this patient on while they are healing from the procedure. A different veterinary technician then takes over the post operative monitoring and brings any issues to the attention of the doctor. Monitoring of anesthesia ends when the patient is able to hold itself up unassisted, the temperature is above 99.5 degrees and they respond to having their name called or to being stimulated in another way.

The majority of our anesthesia patients go home the same day. This is mainly due to us using highly specified protocols for each patient and adjusting them to fit each patient’s needs.  We are always looking to improve and add in new protocols and increase our monitoring capability so next time your pet is going under anesthesia ask if we have anything new. We’d love to explain it to you.

Thanks for reading!

 

Dentistry

You’ve heard it from your veterinarian plenty of times. “Your dog or cat has tartar on its teeth.” “You should brush your pet’s teeth.” “We should get your pet started on some dental chews.” “We should think about getting Cuddles in for some dental work.” We mean it but at some point we just fail to really push the importance of keeping good dental care as a priority for your pet. Your pet’s mouth is the major way they communicate with the world around them. They use their mouth when they play, for defense, when they are exploring new objects and when they are eating. An animal with a painful mouth is not going to have the same quality of life as they would if that mouth were pain free. I think everyone can agree with that assessment when it comes to dental care in pets. Where the major disconnect in communication seems to be lately is in the understanding of what happens during a “dental” in the veterinary hospital setting.

The term dental can mean a lot of different things. In the case of an animal with a healthy mouth that needs some scaling and polishing this would be called a “prophy.” Short for prophylactic this procedures is a preemptive strike against periodontal disease. If we were to go in and clean and polish the teeth and then realize that there were some questionable teeth that may need to be removed this becomes a surgical procedure. The difference between the two can be measured in hours of time spent working in the mouth and in hundreds of dollars.

Every pet having dental care at our hospital is going to be placed under anesthesia. This is for three major reasons. The first is fairly straightforward, your pet can not understand what is happening to them and will not hold still to allow us to perform a technically difficult procedure inside their mouth. Without anesthesia the dental work being performed is going to be sub par and in most cases will do more long term harm then good. The second reason we use anesthesia is because of the nature of tartar in a pet’s mouth. Dental calculus is a calcium composite produced by bacteria in the mouth. When the teeth are scaled this bacteria is taken off the teeth and ends up in the mouth, on the table and in the air. When a patient is anesthetized they have an endotracheal (inside the trachea) tube that delivers the anesthetic gas mixed with oxygen. This tube has a small cuff that inflates to provide a gentle but airtight seal. The cuff prevents any of that bacteria from entering the airway and setting up a potentially life threatening pneumonia. The third reason we place animals under anesthesia for dental care is because it hurts! The calculus is most abundant at the base where the gums meet the tooth. In attempt to prevent further build up and a life threatening infection the gums become inflamed and bring blood and the bacteria fighting cells in the blood to the area. When we go in to physically clean the tartar off the teeth we have to clean above the gum line. Moving a scaler above inflamed gums is very painful and doing this in a patient that was not anesthetized and did not understand the procedure would be unfair.

Let’s walk through a dental procedure that includes several extractions. Each patient’s mouth is examined while they are still awake. Sometimes we will then call the owner and let them know what we expect to find. This is especially true if we have never seen the patient before or if we expect there to be a lot of extractions. It can be tricky giving the owner a first assessment because there can be a huge difference between the mouth a dog will show you awake and the mouth you find under anesthesia. The patient is then anesthetized and placed on their side. An overview of the mouth is performed and an initial treatment plan is formulated. The calculus or tartar is de-bulked using an instrument that looks similar to the crackers used on crab or lobster claws. Once the bulk of the tartar has been removed a new plan is formulated. The teeth are cleaned with an ultrasonic scaler and hand scaling until there is no visible tartar. They are also scaled above the gum line (60% of dental disease occurs above the gum line) and at this time the teeth are evaluated for pockets and loss of attachment. Once the teeth are completely scaled a dental probe is used to evaluate the teeth and gums and to determine whether or not we need to move to the next step, extraction. If the mouth is healthy this is where we would stop, polish and wake the patient. This would be a “prophy.”

If the mouth is not healthy we need to make some decisions. The best way to decide whether or not a tooth needs to be taken out is use the evaluation arrived at with the scaler and probe and compare that to a dental  x-ray. Remember I said 60% of the disease occurs above the gum line where we can’t see. Sometimes there will be bone infection and loss of jaw bone present in otherwise healthy teeth visible on x-rays that we might have missed otherwise. With the information from the x ray we can then decide which teeth need to be removed and which teeth should be left alone. The technique used in removing teeth varies depending on the tooth that requires extraction. For our example, let’s pretend we are removing a Canine tooth (on of the 4 long thin teeth towards the front of the mouth) and a Carnassial tooth (one of the big scissor like teeth in the back of the mouth.) To remove the canine tooth we use instruments that resemble chisels known as elevators to gently pull the gingiva (gum tissue) away from the tooth on all sides. Often times a scalpel will be used first to incise the periodontal ligament and ease the elevation of gingiva. Once all the gingiva has been properly elevated we sometimes make two small incisions into the gingiva on either side of the tooth. Sometimes we make one incision and often we try not to make any incisions. This flap of tissue is pulled back to reveal the tooth to the root. The tooth is then gently removed from its socket using the elevators. To remove the Carnassial tooth we will also elevate the gingiva away from the tooth and sometimes make a gingival flap by making incisions into the gingiva but in these cases we often need to cut the tooth into segments before we remove it. This is done using a dental drill. We typically split the tooth between each of the three roots and then using the elevators we will remove the tooth from the socket one root at a time. The socket is thoroughly cleaned and reevaluated and any bleeding is topped. The patient will now have a second dental x ray taken to be sure that we did not leave any bits of teeth behind as left behind pieces of tooth root may cause a problem in the future. As long as the x ray is clear we can close the holes we left behind using the gingival flaps we made. In the Canine sockets I typically pack a bone matrix into the hole left behind to accelerate healing and minimize bone loss (which causes loss of structural integrity) for the jaw. In the Carnassial tooth socket I will actually clip some of the bone away before packing the site with bone matrix. I then suture the gingival flaps over the extraction sites. The remaining teeth are then polished and the patient is recovered from anesthesia.This is not a “prophy” but would be considered dental surgery. The next dental this dog or cat has may in fact be a prophy so long as it is done in a timely manner.

Most dogs do better after removal of offending teeth. They are less painful and return to life as normal within a few days. The exception being full mouth extractions, these dogs and cats (usually cats) may take a few extra days to recover but when they do their lives are much improved. Unexpectedly, the majority of patients who have had all of their teeth removed prefer to eat kibble over canned food.

Thanks for reading!

Diagnostics

When a sick pet comes to see me there are a few things I can diagnose and treat based only on physical exam and the history I receive from the owner. Most illnesses, especially serious ones that appear rapidly require diagnostic testing to appropriately diagnose and treat. Even more frustrating for many pet owners are the illnesses that require more than one round of testing to reach an answer and an appropriate treatment plan. As veterinarians we sometimes become discouraged by this and fall into not pushing for the best diagnostics because we know how frustrating it can be for owners. This doesn’t do our patients any favors and in some cases it can lead us into treating the wrong diseases or it could extend the treatment of a disease costing our clients more in the long run than if we had just pushed for the more appropriate course of action in the first place.

For illustrative purposes we will pretend a dog is brought in to see us because the owner has noticed recently that the dog has lost some hair. The owner will stand quietly for a few minutes while I go over the dog and look at the skin showing through the sparse hair. As soon as I look up from the patient clients will often ask, “So what is it?” I understand the desire to know what the problem is but if it is just hair loss with no other clinical signs there are over 200 possible illnesses that can cause hair loss. Many of these are rare but the list is extensive.

If the dog is also itching at itself we can narrow our list of possible illnesses down to just under 100. So we’ve already ruled out over 100 illnesses before we do any diagnostic testing at all. Not too bad. If we add in just two more clinical signs we can narrow it down even further. Let’s say that the dog also has crusts and scabs in the areas of hair loss and that those areas have increased pigmentation. We can now narrow our list down to just over 25 illnesses. Now we’re talking! So we’ve gone from over 200 to around 25 and so far all the client has to pay for is the exam. This is going great.

It’s sort of going great. Now we have 25 different illnesses that we have to rule out before we begin treatment. This is where the job becomes challenging. I need to come up with the best diagnostic value for the client’s money. In this case we would start with scraping the skin to look for external parasites. We would also place tape on the areas of hair loss to look for fungi and bacteria. Total cost right now for the client is still pretty low. If those come back negative that means we don’t have a diagnosis or treatment plan yet but it also means we can narrow our list down even further. Now we have to think again about where we want to go next diagnostically.

My next step for this patient would be complete blood work including electrolytes and a urinalysis. Now we are spending money. We just likely doubled our bill and this still may come back as a big list of rule outs. In our line of work, however, rule outs are occasionally more important than diagnoses. If this dog has disseminated Mast Cell Tumor for example we are going to have some very difficult decisions ahead of us. It’s still entirely possible that this dog only has allergies.

Let’s say that the blood work came back with mild to moderate elevations in a few liver enzymes and a mild anemia. Well this narrows it down considerably but while it seems like it makes things easier our next step is going to be more specific. Many of our next steps will be costly and will only be ruling in or out a single disease. Here we choose to play the numbers and rely heavily on the owner’s history being very accurate. We recommend a skin biopsy. We have now increased the total cost to the client to over $600 and we still might end up with only allergies as a diagnosis.

The other road to go would be to just treat the dog for allergies and see what happens. This is leaves an uncomfortable amount of uncertainty and in some cases can end disastrously but every case is different. There have been plenty of cases where I have chosen to treat dogs for just allergies based on the history and physical exam and there have been a few cases where I have gone all the way to biopsy and then treated for allergies. There have also been cases where I considered treating for allergies, looked a little deeper and discovered diseases that might have been exacerbated by treating the dog as an allergic dermatitis. No two cases present exactly the same and some of the allergic dogs present exactly like dogs with some other more specific and serious illnesses. Unfortunately we aren’t able to attach our patients to a computer and have it spit out a diagnosis.

Please remember that we are often as frustrated as you are as we go down these diagnostic paths and sometimes maybe we take a wrong turn or two. I can say with complete certainty that I have never recommended a diagnostic test that I did not believe was necessary. That doesn’t mean I wouldn’t do a few things differently on a lot of cases if I got the opportunity. Hindsight is like that but as long as hindsight helps guide future decisions, it’s all part of the game.

Thanks for reading!

 

Capitalizing on Nature

My intention in approaching topics like this isn’t so much to push peoples’ buttons as it is to get them thinking in a more critical manner about what they take at face value. If I told you I didn’t smirk at some of the angry comments I received however, I would be lying.

Recently, a friend of mine posted an “article” about how sodium bicarbonate or baking soda cures cancer and how drug companies don’t want us to know about it because they make so much money off chemotherapy. I could not resist pointing out that drug companies do in fact manufacture and sell sodium bicarbonate in injection form and for what hospitals pay for it on a per gram basis, they are making quite a bit more on sodium bicarbonate than the grocery store is. Hospitals of course also mark it up a bit when we give it via injection and while I couldn’t tell you off the top of my head how much the hospital I work for charges for an injection, I can tell you that if I were using it to treat cancer, I’d make more than enough to maintain my current lifestyle. And I’d also be recommending that we monitor things like blood pH and white cell counts so I’d still do alright on the monitoring end of things as well. My point being, if sodium bicarbonate was in fact a reasonable treatment for cancer – and if cancer was some sort of single disease that responded to one form of treatment – not only would drug companies recommend it and health care providers use it to the result of everyone making money on it, no new production of medical grade sodium bicarbonate would occur because drug companies already make it, health care providers already use it and they all make money on it. Just not for cancer.

In the weeks that followed I saw roughly a dozen other articles touting some natural cure that drug companies don’t want you to know about because then they couldn’t make money on them. I do not currently have any friends or acquaintances working at the executive level in any research and design department in any pharmaceutical company so I do not know that the following activity occurs but I like to think it does. An executive level research scientist for a major drug company is sitting at her desk after getting off the phone with the financial department about budgetary issues and needs to decompress before going back out into the laboratory to whip the post docs back to work. She clicks on social media for some mindless internet surfing and comes across an “article” touting celery as the anti-hypertensive secret the drug companies don’t want consumers to know about.

“This is ridiculous,” she thinks to herself as she opens a separate tab and starts combing through the scientific literature for any studies on the effect of celery on hypertension. “If there were even a reasonable amount of evidence that celery contained an effective treatment for hypertension, of course we could isolate it, purify it and make money on it. We built an entire brand around the extract of White Willow bark for goodness sake.”

And of course, she would be correct. An early form of aspirin was isolated from Willow bark in Hippocrates time and the compound was isolated in 1763. It still remains a reasonable treatment for mild pain, fever and as an anti-thrombotic in people at risk for strokes or heart attacks. And Bayer still makes money selling it. Somewhere between 1803 and 1805 a German pharmacist isolated a compound from the Poppy plant that became morphine and pain control became a lucrative and slightly dodgy industry. Still is. Later in the 19th century a plant metabolic product known as Gamma-Aminobutyric Acid was synthesized in the laboratory. Nearly 60 years later it was discovered to be part of the mammalian central nervous system and a hundred years after it was first synthesized it was found to be very useful in the treatment of nerve pain and seizure activity. Analogues of this natural product are used to treat nerve pain associated with diabetes today.

And that’s just a few pain treatments that are natural in origin. Less than 100 years ago, Alexander Fleming noticed that the Pencillium notatum mold, if grown on the right substrate would inhibit and even kill bacteria. A few years later the world was forever changed by a new ability to combat infectious disease. The fungus Acremonium eventually gave us Cephalosporin drugs and these two classes of drugs, penicillins and cephalosporins,  are still among the most commonly used antibiotics we have available to us.

But what about cancer drugs? Those are poisons. True but like a lot of other pharmaceuticals, many chemotherapy drugs have a natural origin. Vincristine is listed among the WHO’s list of essential medicines for a health care system to have access to. It is also derived from the Madagascar periwinkle, a pretty purple flower. The bacteria E. Coli gave us an enzyme called Asparaginase that is used in the treatment of lymphatic cancers as well as some Mast Cell Tumor protocols.

This is by no means an extensive list of the products that have been developed by people having recognized them in nature as effective, isolated the compound having the desired effect and found a way to make it safer and more readily available to the public. It’s just a series of examples of where a naturally occurring treatment or cure existed and people found a way to bring it to market. If lemon juice or sodium bicarbonate or Himalayan rock salt had healing properties, you can bet that someone would have or would be working on isolating what those properties were, finding a way to mass produce it and get it out into your hands.

The fact that drug companies aren’t pushing the sodium bicarbonate or any other natural product they are likely to be already manufacturing as a treatment for cancer speaks more to the lack of efficacy of any one of these products as a cancer treatment than it does as proof of some global conspiracy to hide the healing power of natural ingredients in a greedy quest for profits.

Thanks for reading.

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.