Friday, January 30, 2009

A Big Lump of Fat

Scooby is an older Rottweiler, and as such, had a few problems to deal with today. She has always been a little lame on her hind legs, off and on for years, attributed to likely hip dysplasia so common in the breed. Lately she has actually been holding her left hind leg up, not putting weight on it at all if she could help it. Because of her age, visions of Chloe and her bone cancer came to mind, and I sure didn't want to go there.

Scooby also had a very large mass or lump under the skin over her right shoulder. It has been there for some time, but because she is shifting so much of her weight to her front end (a normal dog will carry 70% of their body weight on their fore limbs-Scooby, with her painful hind limbs, was likely carrying 80 or 90%) this large mass was starting to inhibit the range of motion of her shoulder. It was harder for her to get up and down-and at almost 100 pounds, it would be very difficult for her owners to help her. We needed to find out what this mass was before we could decide what to do about it.

An FNA or fine needle aspirate is a test we can do right in the exam or treatment room of the hospital. It only takes a few minutes on a cooperative patient. We take a very small guage needle, thinner than those typically used to administer vaccines to pets, and aspirate or "suck" cells or fluid or other material from the mass. This material is then put on a microscope slide, it may or may not be stained, and is examined for identification of the type of tissue comprising the mass. In Scooby's case, we aspirated a thin, clear, oily material-fat. Scooby had a giant lipoma or fatty tumor.

Lipomas are very common soft, moveable, round lumps under the skin. They usually don't bother the pet-owners only notice these lumps when they are petting or grooming the pet. They are benign masses, not metastasizing or spreading to other organs in the body although it might seem like they do since pets can get many of them throughout their lives. Verbal has quite a few of these lipomas, most on her ventral or lower chest and belly, but they can occur on legs and tails and even internally in animals as well as people. They are more common in middle-age to older animals, and over-weight females may be pre-disposed to them. Cats and younger dogs can certainly get them, too. Any new lump or bump on your pet should be evaluated by your veterinarian, even if it looks and feels just like a previosly dignosed lipoma, since they can mimic more serious cancerous masses such as mast cell tumors. An FNA such as we performed on Scooby, or even a biopsy may be necessary.

Large lipomas like Scooby had can be very vascular masses, having numerous large blood vessels which make the surgery more of a challenge. It was important we knew what her metabolic status was, the functioning of her organs before anesthesia as this was likely to be a long procedure. We also wanted to know just what was going on with her hind limb lameness and whether it was a treatable or just manageable condition. It would be awful to put her through a big, traumatic (and expensive) surgery only to find she had a malignant bone tumor or something. Thankfully, that wasn't the case for Scooby. She had pretty severe degenerative joint changes in both of her stifles (knees) and both of them had excessive "drawer" motion. By now, reading this blog regularly you know what that means-Scooby had long-standing ACL or anterior cruciate ligament ruptures. Her hip, which her owners always assumed were the source of her pain, were just beautiful on those x-rays! No signs of arthrits or degenerative joint disease there, no remodeling of the femoral heads, good seating of the "ball" into the "socket," and most important, no evidence of bone cancer.

Now Scooby's owners want to do what they can to help make her comfortable but unfortunately won't be able to afford knee surgery (much less two of them) for her. They haven't tried any joint supplements or NSAIDs, let alone narcotics, so we can set her up for our "multi-modal" analgesia plan, just like I have Verbal on. This morning we did the surgery to remove the large lipoma-and it was quite a procedure. There were lots of vessels as I had suspected, but it was also very invasive in the adjacent tissues, seeming to grow into the muscle and fat layers and even right on the ribs themselves. I don't like these "infiltrative lipomas" because it is very difficult if not impossible to be sure you removed all of the abnormal tissue, thus making recurrance likely. Lipomas regrow in about 50% of these cases. It is possible to do adjunct therapy such as radiation to inhibit the regrowth, although this is very expensive. Chemotherapy is useless for infiltrative lipomas. At least we have "de-bulked" the mass, allowing for freer, more normal function of Scooby's shoulder as she puts more and more weight on her front legs. And we are left with a big lump of glistening white fat-anyone for a reverse liposuction procedure?


Thursday, January 29, 2009

Hoards of Pets

There was a recent local case of horrendous animal abuse and neglect, truly defining the words "puppy mill." It has tugged at the hearts of many of my clients who are very responsible pet owners, taking on only the amount of dogs, cats, even horses that they can actually afford to keep-understanding this means not only food (which is expensive these days!) but regular veterinary care as well. Even though it is hard to do, these types of owners also budget for the unexpected, when illness or injury befalls their pet as it did for Mikey yesterday. Yep, even I am in that category-you know I have the opportunity to acquire so many hard luck cases but practicality keeps me from doing so. When Verbal faced cancer 2 years ago, we had to juggle our finances and did just that to confer with the specialists and provide the radiation therapy that probably saved her life. I sure realize not all owners are able or even want to go to these lengths, but keeping things manageable is only fair to the pets.

Animal hoarding can actually be a form of mental illness, and as such, not being trained in counseling or therapy, we are not usually capable of effectively dealing with the people involved in these cases. You may know people who adopt every stray pet they come across, who claim to "rescue" abused animals from terrible situations, and do so over and over. They don't hesitate to offer to adopt a new animal, even several animals at once, and don't give consideration to the amount of time or expense these new additions will require. They don't ever have outside people over to their homes, and they may have windows that are papered or otherwise blocked out. It isn't uncommon for them to try medicating animals themselves with products bought at a feed or pet store before seeking veterinary care. They may have relationships with several different veterinary practices, but rarely follow through with care recommendations for pets brought in-often asking for medication for other pets that have symptoms "just like this one."

While this might not be overt animal "abuse," it can certainly be deemed "neglect," and as such, we can't ignore the situation, as tempting as that may be. An immediate call to law enforcement may be appropriate in some cases, especially if care recommendations are declined for an obviously suffering pet. Animal control officers will do the evaluation of the situation-we can feel safe in reporting suspected cases anonymously if needed, and it isn't our job to determine "guilt" or "innocence" of the charge. If the suspected hoarder is a friend or a once good client who has changed over time, working with that person may be OK.

If you decide to work with a suspected animal hoarder, you must develop a relationship with that person. It requires a slow, cautious, respectful approach and gradual building of trust. Show yourself to be trustworthy and honest, reliable and predictable to that person or they will likely shut you out. In conversation, see if this person has any concerns about their pets and if they have any plans already for constructive action. The best way to help make a plan is to see the home setting-offering to come over and establish a care plan is a good way to start. Avoid suggestions of getting rid of any animals until trust is established, but do make part of the plan "no new animals." Always demonstrate genuine concern for the pets and the person-but don't be judgmental. That sure can be hard to do.

If you just aren't able to build that kind of relationship, talk to an animal control officer for advice. They may have a history with that person, often with a different species of animal. Sometimes you can use the officer in a "good cop/bad cop" scenario-they will insist on the care conditions and you can be kind and compassionate and offer help in the plan.

There is nothing wrong with you having a big heart and wanting to help the animals in a crummy situation like this. It may mean that having an on-going relationship with this person will allow you access to the animals and ensure continued care. It could result in a big "bust" as happened with the tragic situation in the news with the hundreds of affected animals. Your big heart is fine just the way it is, open, generous and compassionate. Your eyes may be the only witness to the suffering of animals in need, and your intervention may be crucial in saving their lives. And be sure you keep your own animal family number manageable.


Wednesday, January 28, 2009

Mikey's Big Spleen

Mikey wasn't feeling well. (Isn't that usually why critters come for a visit to the vet?) His owner said he just wouldn't eat, he was restless, acting like he couldn't get comfortable, and he was kind of crab-walking-hunched up and walking almost sideways. More importantly, he was hurting somewhere-he was crying when he was touched, even just lightly petted. Being part German Shepherd, he isn't known for being an overly brave dog (oops, I'm perpetuating a stereotype here, but it is silly how those fierce-looking, big, sturdy dogs can also be the biggest wimps!) When I saw Mikey, I quickly discovered this wasn't him just being wimpy. He didn't cry when I palpated his neck or spinal muscles or examined his legs, but he cried loudly when I barely touched his ribcage and belly.

Mikey's owner was pretty sure he wasn't the kind of dog to eat something he shouldn't have like a stick or rock or something, but an intestinal or gastric (stomach) obstruction and maybe perforation certainly could cause these symptoms. Pancreatitis or inflammation of the enzyme-secreting pancreas can often be very painful and very serious. Mikey was getting to be an older dog, so neoplasia or cancer had to be considered, too. He was just too painful for me to palpate or put pressure on both sides of the abdomen and feel for abnormalities, so we decided to run some blood work and do some abdominal radiographs. I didn't see any obvious obstructions or a large volume of free fluid on the x-rays, but he was a big dog and I felt he could be hiding things pretty easily-we sent the films to the radiologist for review. Since he hadn't been drinking well, Mikey was a little dehydrated. We gave him some fluids with electrolytes under the skin to tide him over until we could get some test results back and sent him home for the night. Fluids alone often make many ill pets feel better right away. This wasn't the case for Mikey.

The next morning we had the blood results back-there was a very minor anemia and that was all. The rest of his blood work was essentially normal. This is good news, but frustrating since, when we called to check up on our patient, Mikey was even worse, and we had no real answer. I did not feel that the degree of anemia was enough to be causing his extreme symptoms, but it was leading us in the right direction. We called the radiologist and put a "STAT" on his report; we ordinarily close early on Wednesdays and didn't believe he could wait for answers. Mikey's owners were very worried, so we had them bring him back in to the hospital while we waited for test results. We wanted to start him on IV fluids and pain relief medications at the least.

Dr. Root, our radiologist, called right away. He thought there might be some loss of detail in the abdomen which can be a result of free fluid or motion from breathing efforts. He thought the spleen looked enlarged, and when he learned of Mikey's symptoms, especially the extreme pain, he thought peritonitis or infection in the abdomen was possible. Dr. Root believed Mikey was a good candidate for an exploratory laparotomy-a surgery to open up the belly and go search for the cause of the problems. I really like exploratories because along with discovering the cause, I am always hopeful that we will find a "cure" as well, something to fix or remove to alleviate the pain or the cause or source of the infection, tumor, or swallowed thread as happened to Bunny a few weeks ago. I decided to get another piece of information first-to find out if there really was fluid in the abdomen, and if so, what type. Mikey's belly felt fuller today and had a "wave" feel to it. Peritonitis can have purulent fluid, pus, bacteria and white blood cells. An enlarged spleen could be due to cancer and rupture of a tumor, therefore blood was a likely fluid. Organ dysfunction can cause clear white or straw colored fluid. We made a quick prep of Mikey's belly and a thin needle was inserted in the caudal abdomen so as to try and avoid hitting the enlarged spleen itself. There was pure blood-a lot of it. We took some quick x-rays of his chest to rule out obvious metastasis or spread of cancer to the heart or lungs, and these appeared fine. Mikey was going to surgery.

It was unlikely given his symptoms that Mikey's bleeding happened suddenly. Since his body has sort-of acclimated to it, he wasn't in immediate need of a blood transfusion from a donor dog. This could change, of course, given the type of surgery I was anticipating, a splenectomy. The spleen is a highly vascular organ, comprised of lots of winding blood vessels and packed full of blood cells. In fact, it acts as a reservoir of blood cells, there to be "squeezed" out in times of need, such as when blood is lost if a dog is hit by a car. The spleen also filters the blood, removing older red cells from circulation, ensuring only vital, healthy red cells that can carry oxygen are cycled through. The spleen also removes parasites that might be present in red cells or entire cells if they are diseased. It also acts as a lymphatic organ, draining material from local areas of the body to the regional "lymph node-like" spleen, stimulating it to react or swell along with the rest of the immune system and the antibody producing lymphocytes. Now, Mikey would also have plenty of red cells in his bone marrow-he could do just fine without his spleen if it was found to be diseased, cancerous and/or hemorrhaging. It would just be a big stress to his body to remove it, and thus the potential need for a transfusion.

When I first cut into Mikey's abdomen, I realized he had been bleeding much more over night than the x-rays taken just yesterday had shown. Blood literally flowed out of the first small incision. I attempted to hold the edges up and contain the blood and instructed my nurses to collect it in an aseptic (very clean) manner, thus allowing us to perform an autotransfusion-we were going to give the blood right back to Mikey, but we were going to put it back where it belonged-in his veins. It took numerous syringes and 2 large collection bags with anticoagulant in them, and my fingers were stressed to their limits holding his abdominal wall edges up and open to keep the blood from spilling out while we collected it. The entire time we also monitored his anesthesia levels, blood pressure and oxygen carrying capacity-he did great! The collected blood was then put through filters before it was given back to him, slowly at first to be sure there would be no reaction. His hematocrit or packed cell volume, the percentage of blood cells in relation to the fluid portion of blood, never wavered during the day-this autotransfusion seemed to be a success.

Mikey's spleen was, indeed, really big. More importantly, it was covered in purple to black, ulcerated and bleeding various sized masses all over the spleen as well as through out the omentum supporting the organ. This is a common finding when the nodules have ruptured and blood clots or cells have spread, possibly metastasized. You can't know just by looking which this is, clots or metastatic disease, but I did my best to remove all affected tissue, knowing microscopically this wasn't likely. I knew that to have a chance, Mikey had to stop actively bleeding, so removing the source was necessary. We were set up to biopsy the tissues and then consult with oncologists for further plans to combat the cancer if that was the final diagnosis. The spleen was taking up a lot of space so it was difficult to visualize the rest of the abdomen clearly; I did find a large mass on a liver lobe-not good. It was the same color and texture as the splenic nodules-and it peeled away from the liver tissue, leaving an oozing crater. I used some hemostatic "styrofoam" to plug up the hole, but advised the owner by phone of the problem and the seriousness of the likely spread of the disease. She understood the situation and elected to be as aggressive as we could be right now-it was likely the only chance to save his life.

I mentioned how vascular the spleen is inside-well, it is just as vascular on the outside. Many large, tortuous vessels supply and drain the organ and the affected omentum, so I did quite a lot of ligating. When it was removed, the abdomen looked so much happier! Apart from the single liver mass, there was no other obviously affected organs. I took samples for microscopic examination to confirm this, but with no more bleeding and no distorted, tumorous masses, Mikey's belly almost looked-normal. I sutured his abdomen closed in 3 layers and we woke him up.

Because of his good pre-operative analgesia or pain relief medications, Mikey woke up very smoothly-quiet and comfortable in his warmed blankets. He had received all of his own blood and some additional IV fluids for support, as well as some prophylactic antibiotics. We helped his owner transfer him to her car so she could take him to the 24 hour care facility; after going through such a major procedure I didn't want him spending the night by himself, even if I could look in on him frequently. I knew he would be in far better hands having a critical care doctor on hand through out the night. My staff wrapped up everything after staying late for Mikey today. They knew how important this was to Mikey and his very scared owner, and to me to be able to provide this service for them. I couldn't have done it without their dedication and kindness in giving up their only free afternoon this week. Way to go Amber, Kayla and Terra. You are awesome nurses.

We aren't out of the woods yet. Mikey needs to get eating and drinking again and we have to be sure all the bleeding has stopped. Then, of course, we have to wait on the pathology report to identify the source of the masses. It is very likely they are a hemangiosarcoma, the malignant neoplasm of blood vessels. We could get lucky and the diagnosis could be hemangioma, the benign form. We will consult with the veterinary oncologists once we have the diagnosis and work together on the next step of his treatment plan. I have said more than a few prayers for Mikey and his owners, asking that he recovers quickly and that his owner can rest well knowing she has done everything possible for her friend in a really crummy situation. He is so well loved-that, and a belly free from a big bleeding spleen, is all that he needs tonight.


Tuesday, January 27, 2009

Caution, X-Rated Blog

Yep, usually this blog is family-friendly, no more x-rated than Animal Planet or Wild Kingdom shows. But today a 115-pound Malamute named Raven came to see us with a rather embarrassing problem, one it might be a bit delicate to talk about around the dinner table.

Have you seen those commercials for ED (erectile dysfunction) treatments for men, you know the ones where they mention calling your doctor if you experience an erection lasting longer than 3 hours? Yea, right you think. Dream on. Well, it isn't as glamorous as you might think. Just ask poor Raven. No, he wasn't taking any Viagra or Cialis as far as I know, but he had the reason to call his doctor all right. OK, his owner is the one who called, frantic as she came home to find her dog miserably licking at his "private" area and noticed that his penis was extruded from the normal sheath (skin) covering and trapped outside of it, very red and swollen. This is called paraphimosis, and is different from priapism, which is a state of continuous erection due to a neurologic anomoly. Raven is a neutered male dog, so his owner wasn't expecting to see what she perceived as overt sexual behavior in him. Little did she know, boys will be boys.

Causes for this very uncomfortable condition can be excessive hair in the area, which can cause a ring around the base of the penis and subsequent constriction of the blood vessels, neurologic disease, trauma to the organs, or sexual stimulation/masturbation. Sometimes we don't know the cause, but finding a cure-quickly-is pretty darned important for the affected pet.

If the situation has just occured, there is likely little pain involved. Cleaning and some lubrication with K-Y jelly is all it takes to put things right. But if the tissues are very swollen and raw from being licked and dried out, as was the case with Raven, sedation and some good pain medication is the way to go. We gave Raven both of these right off so we could better evaluate the situation. He had traumatized the tissues and the circulation had been cut off for some time. Once he was relaxed and after some gentle cleaning and lubrication, we were able to replace the tissues fairly easily. He did have a ring of hair around the base of the penis, so this was the likely cause of the whole situation. Since he had done a fair bit of damage with his licking, we decided to put him on some antibiotics and anti-inflammatory medications for a few days, as well as make sure he stays in an e-collar to prevent further self-trauma. His owner will have to watch him for any furthur episodes, and be sure to keep him well groomed to decrease the chance of all that hair building up in the area. I also instructed her to make sure he was urinating normally.

Raven was lucky-just sedation and lubrication was all it took to put things right. Other dogs have needed surgery to correct strictures, to make room for the swollen tissues, or even to amputate damaged penile tissue, especially if the situation occurs repeatedly. I thought it best not to include pictures today, at least not of the anatomy we are discussing. I'm sure you can Google the topic if you want more information. Just think of Raven when you next see one of those ED commercials and be glad he turned out OK.


Monday, January 26, 2009

How NOT To Go Down Stairs

Elwood had a big "oops" last week-he fell down some stairs and came up lame on a hind leg. He wouldn't put any weight on it at all. His owners felt terrible seeing him like that, so brought him in to see us.
Now remember when I said that all hind limb lamenesses are due to injured cruciate ligaments until proven otherwise? In Elwood's case, we proved otherwise pretty quickly. He was so painful, that a good examination of his affected leg just wasn't possible with him awake, so we made sure he was stable, listened to his heart and lungs and checked the color of his gums and all. It appeared that all we were dealing with was that hurting leg. We quickly got some pain-relief and sedation medications into him and I proceeded to examine him more thoroughly. No thorn in his paw, no torn toe nail. I worked on up the leg, really concentrating on the stifle (knee) of course, but it was very stable and was not hot or swollen. None of the long bones felt unstable or were visibly poking through the skin-so no obvious fractures were evident. But when we got to his coxofemoral (hip) joint, it just wasn't as flexible as his opposite one was-we couldn't extend it completely. Hmmm, it was looking like that knee just wasn't the problem after all.

Next we decided to take some x-rays of his pelvis and knees to be complete and hopefully discover the cause of his coxofemoral joint decreased range of motion. The answer popped right out at us-Elwood had a luxated (dislocated) hip joint. Ouch! No wonder he wouldn't put weight on it. I was so glad we had given him a hefty dose of pain medication. He sure needed it. We called his owner and told him the story. Elwood would need to be anesthetised (sedation just wouldn't cut it) so we could reduce or replace the femoral head (ball) into the acetabulum (socket.) Of course they agreed and we proceeded to do that right away.

Elwood wasn't a large dog, thank goodness. He was a Cocker Spaniel, a little less than 30 pounds. In large dogs, reducing a hip luxation can be HARD work, and even in a 30 pound dog, I could expect to work up a little sweat. We anesthetised Elwood and placed him on a padded exam table. We then placed a cotton rope around his groin and had one of our assistants hold on to this for traction against me for when I started to pull. I didn't want him coming off the table! Another nurse held his head and endotracheal tube (breathing tube) in place.

There is a bit of an art to reducing a luxated joint. This is where the little bit of physics we learned so long ago comes in handy. It is also important to have both radiographic views of the hip to see just where the femoral head was in relation to the socket. Most luxations result in a dorsal and cranial position of the ball and this was the case with Elwood. I used one hand to put pressure on the ball (through the skin) and would attempt to guide it back where I wanted it-up and over the rim of the acetabulum (socket.) I used my other hand (and whole body, really) to rotate the femur outward and down-praying for that tell-tale "pop" when the ball happily returns to its normal position.

It took quite some time to get Elwood's muscles loosened up, but when we did, the "pop" came and the hip was back to normal. It instantly flexed and rotated normally-just like the opposite, healthy leg. We took a post-reduction x-ray just to confirm this and-nope-it wasn't in place. Rats! Sure enough, when I palpated the joint area, I could feel the ball out of the socket, plain as day. It either never went in completely and the "pop" was something else entirely, or the ball had re-luxated when we transported him to the x-ray room. Not good. This time when I made the motions to reduce the joint, I felt how easy it really did "pop" and how just as easily "popped" right back out. Double rats! This meant there was likely damage to the rim of the acetabulum, maybe even a congenital defect making the socket just too shallow to contain the femoral head with out the strong ligament attachment which had ruptured during Elwood's fall. So now what?

Elwood was going to need surgery to correct his dislocated hip. There is no wrap or sling that is strong enough or that offers enough support to keep a dog's hip joint stable for the time it would require to heal. If possible, it could be reduced and a band of heavy duty suture or wire could act as a sling internally, trapping the ball in the socket. Not all injuries can be repaired this way, especially if there is a congenital defect like a shallow acetabulum as I suspected was the case for Elwood. I recommended that Elwood have a procedure called an FHO-a femoral head and neck ostectomy. In this procedure, the femoral head and neck are actually removed, thus removing the object that is causing the bone-to-bone contact and thus the limitation of movement and the extreme pain.

Wow! That sure sounds dramatic, doesn't it? How would a dog be able to walk if his leg wasn't connected to his body? Well of course his leg is still connected-there are numerous very strong muscles in the thigh and buttocks that support the hip. The body will shortly form a sort-of false joint, one with no arthritis and no pain since there is no longer any bone-to-bone contact. My dog Verbal had this surgery done when she was quite young due to her terrible hip dysplasia in the affected limb. It is often considered a salvage procedure, but I really consider it to be a good choice for many dogs, especially young, active dogs. After recovering from the initial pain post-operatively, we encourage the clients to get those dogs moving-no cage confinement and strict rest as is the case with so many other orthopedic surgeries. We want the muscles to strengthen to support the hip, not atrophy from disuse. We will give instructions for physical therapy and get these patients started within a week or two after surgery.

I have done numerous FHO surgeries over the years and have always been happy with the outcome. A rare dog may need a second surgery if a portion of the neck remains and interferes with motion as the dog starts to bear more weight. Elwood's owners elected to have his surgery done at a veterinary surgical specialist facility since they could do the surgery that day and we would have had to schedule him for the next day. They just wanted him on the road to recovery as soon as possible. I received a report from the surgeon this morning and it sounds like Elwood's surgery went very well. He is home and his owners are pleased that he is already starting to touch his toes to the ground. What a trooper! I'll get the privilege of following up on his post-op care since the surgery facility is a much longer distance away. It is a shame this happened to poor Elwood, but he is fortunate to have devoted humans who are caring for him so well. He's already up and around, on good pain medication, and we'll have a discussion soon on how NOT to go down stairs in the future.


Friday, January 23, 2009

A New Family Member

This is exactly the kind of appointment that everyone who ever wanted to be a veterinarian thinks of-a healthy, happy brand new puppy. Snickerdoodle is a 3 month old Havanese and Poodle cross-as cute as a bug and has never met a human she didn't instantly love. It's a good thing she can't run out of kisses-she doles them out fast and furious, interspersed with some "tastes" with those needle teeth. Doodle is filling the shoes (paws) of her owners first dogs who both passed away at 16 years of age. If this is any indication, she will have herself a lifetime full of love and care-just what every new puppy needs and deserves.

When we schedule new puppy or kitten visits, we make sure the new owners have a good chunk of time, at least an hour, that they can spend with us. We want to ensure we get the opportunity to go over all the basic care instructions, especially if the humans have never had pets before or, as is the case with Snickerdoodles owners, it has been a long time since they have had a puppy to raise. Their geriatric dogs just didn't have nearly the level of energy and "got things to do" as this new family member does. As is often the case, every staff member plays a part in a new puppy or kitten exam.

Receptionists of course get to book the first appointment and greet the proud new owners. They find out where the puppy or kitten was found or purchased as there can be certain issues that crop up as a result of coming from a shelter or a pet store for example. "Back yard breeder" or puppy mill dogs also have their own types of challenges to over come, and knowing their source is important for their management. Receptionists will also give the owners some information on the puppy or kitten "plan" we offer which bundles together all the early exams, vaccines, deworming and other getting started procedures. Clients who opt for one of these plans also receive a discount on their pet's spay or neuter when the time for that surgery comes around.

An assistant or technician will usher the family into an exam room and start by getting a weight on the pet. It will be important to monitor their weight as they are growing up, ensuring they aren't too thin and possibly parasitized or undernourished nor getting too fat and possibly stressing those growing joints. The assistant or technician takes 20 to 30 minutes thoroughly discussing everything from potty training-a very important subject!-to feeding and nutrition. They will talk about the various diseases we want to vaccinate against and when we will do so, explaining immunity, booster vaccines, etc. Deworming and flea control, along with zoonoses or diseases humans, especially children if they are present in the family, can pick up from the pet are mentioned and then often the first doses of preventatives are given. Basic vital signs are taken and any health problems are noted.

The puppy or kitten may be taken in the back to collect a sample of feces, do a skin scraping or microscopic exam of ear debris if indicated, or draw blood for viral testing. Our hospital attendants help restrain the wiggly critters, ensuring this is a gentle procedure with lots of treats and reassuring. We sure don't want them remembering this place as bad or scary-they will be coming to see us throughout their lives and we want to start them off right.

Next comes the veterinarian's part of the visit-that would be me. I will introduce myself to new owners and/or congratulate others on the new family member. I will do a thorough health exam on the puppy or kitten, eating up the wiggly kisses or purrs. I am so glad I can get my "fix" at work and don't have to take everything home. I try to fill out a health report card so owners have a record of the exam and any notes of problems or issues we discussed. Sometimes there will be an umbilical hernia for example-we will note this and plan to repair it at the time of the spay or neuter. I do my best to answer any questions that come up, often referring owners to web sites I trust or trainers we work with. Finally we pop in those icky vaccines and discuss what to watch for in case the pet has an adverse reaction to them.

The assistants or technicians then wrap up the appointment, making sure the owner's have had their questions answered, have all of their samples and literature to refer to later, and be sure they know how to reach us if other questions arise. Receptionists will take care of the money part (yep, I have to pay my staff and suppliers, too) and arrange for booster vaccine appointments. I always make sure owners know to stop on in anytime they are out and about with their pets, just coming by for a social visit-cookies and kisses-so they won't associate us with just thermometers and shots and all the "bad" things. We want our patients to love coming to see us, and most of them really do. Then the new family is good to go.

New puppy and kitten visits are highlights of the day, making up for emotional euthanasia appointments or crummy diagnoses of cancer and all. Happy, busy puppies and kittens just don't have time to be sad. They live for the moment-and if they are lucky like Snickerdoodle, that moment is always wonderful.


Thursday, January 22, 2009

A Wealth of Knowledge

Yesterday's blog about specialists was pretty timely. One of those local specialists, Dr. Sullivan, who is a veterinary ophthalmologist, very graciously took the time tonight to share with a room full of general practitioners some pearls of wisdom from his field. He talked about some of the more common eye conditions we might see in practice and those that warrant referral. There are some newer medications and surgical procedures available, and the videos he showed of some of those procedures were pretty darned cool. Little endoscopic instruments inside a dog's eye, repositioning a detached retina-absolutely amazing. Eye surgery isn't just for your Grandma anymore.

I am very fortunate to have had the opportunity to hear Dr. Sullivan talk tonight. Things change rapidly in the veterinary medicine field, so I welcome the chance to learn whenever I can. Did you realize that continuing education is actually a requirement of the licensure of veterinarians in our state? It isn't much-40 hours of classes every 2 years-and a veterinarian is required to keep their own records of those classes. I know that there are certainly ways to skirt around the requirements for those who are too busy or don't believe in the necessity of those requirements. But I believe it is an attempt by the licensing board to ensure that its doctors remain as current as is possible in their knowledge and skills. I, for one, am glad of the requirements and routinely acquire several times the required number of credits for my benefit and for the sake of my clients and patients. I cherish every opportunity to learn and better myself, and encourage that attitude in all of my staff members as well.

Opportunities for CE come in many forms. Drug companies and suppliers often sponsor them by arranging a dinner and providing the speaker as was done for Dr. Sullivan tonight. We often schedule "lunch and learn" sessions in our hospital on specific topics like flea control or prescription diets. Large conferences where numerous lectures and laboratories are offered are held in various locations all over the world, literally. Attendees might combine learning with skiing in Colorado or snorkeling in Hawaii for example. Oh, that snorkeling sure sounds good about now, doesn't it?

Even though it isn't required for them, continuing education helps every staff member in their respective jobs. It adds interest for them, increases their personal skills and knowledge, opportunities for advancement, and supports the rest of the team. Since not everyone can go to every available class, nor has the interest to do so, we usually ask those who have recently attended a class or seminar to share the information with the others at a staff meeting or through handouts they might put together. I really believe in sharing the wealth of knowledge-it does wonders for our team spirit, and can only benefit our patients.


Wednesday, January 21, 2009

Those "Special" Cases

Wow. None of my blogs have received the kind of response I've gotten as yesterday's "Loser Humans" entry did. Well, maybe the one when we learned that Lucy was killed, but Sunshine's story hit a nerve with my readers and I got quite a few calls and emails today asking about her. You know I wouldn't have euthanized her unless she was terminally ill, or sent her away to be killed. But I really don't want it to get back to those heartless people who abandoned her just what did happen with her. I know, I know, they COULD have left her on the streets to fend for her self. They COULD have taken her to the pound. They must in their heart of hearts want a better life for her. Fine. I just HATE being used this way, when anyone who knows me KNOWS I would have helped if just asked. Thank you to every body who is asking after her and thanking my staff and me for her sake. She is a sweetheart and although scared to death yesterday, has really come around today with just a little tender loving care.

Veterinary medicine is wonderful in that general practitioner veterinarians like me (somewhat similar to family practice MDs-they are just limited to a single species!) are able to see and handle a wide variety of patients and cases-limited really just by their interests and experiences. It allows for a wide variety of situations-there is rarely a dull moment around our hospital as you just don't know what might come about when that phone rings. I love being able to examine a patient, do any necessary tests right in my own hospital, and often do major surgery or dental work, manage infections, control pain, provide behavior consultations-"all in a day's work" as I've written about before. Since the knowledge base is so huge-and seems to get larger every year-there is always talk of "tracking" veterinary students, limiting their training to large or small animal species for example. But I continue to support the type of training I received-"all creatures great and small." I may not do as much large animal work these days-the small animal work takes up a lot of time-but my time working on cows and horses and all gave me confidence and experience-and lots of stories!-which will follow me throughout my career.

As you have been reading along in these blogs, you have likely noted when a patient requires attention above and beyond what a general practitioner (me) is able to provide. There are many veterinarians who elected not to concentrate on a certain species, only seeing cats or birds for example, but rather specialized in a given area of medicine or surgery. Most of these specialties require additional years of study or internships, then the passing of difficult tests or boards, thus the term "board-certified" in describing a specialist. We are fortunate to live near a large metropolitan area and have many of these board-certified specialists available for our patients without having to travel great distances. Of course, the additional training and equipment specialists and their teams require come at a cost-referral or consultation services can be expensive, and some of our clients may not be able to afford this option. If this is the case, I will provide the care that I have been trained to do, often with the advice of experts I consult online. Although clients are made aware that specialists are often more qualified for given procedures, I will do the next best thing for the pet when their are cost or other limiting factors. I happen to enjoy surgery and other challenging medical cases, so these situations add excitement to the day, allowing me to stretch out my skills and keep my team hopping.

I believe we have specialists from every board represented in our area. Dr. Matson is a veterinary dental specialist: Eastside Veterinary Dentistry
Dr. DuPont is at Shoreline Veterinary Dental Clinic. Dr. Karri Meleo is a veterinary oncologist or cancer specialist. Dr. Sullivan and Dr. Landry are ophthalmologists or veterinary eye doctors. Dr. Duclos specializes in dermatology or skin and allergy problems: Animal Skin and Allergy Clinic
Dr. Mison is a boarded surgeon: Seattle Veterinary Specialists
Dr. Wackerbath is at the feline hyperthyroid treatment center: Feline HTC
Dr. Woodfield is a board-certified cardiologist or heart doctor.
Dr. Sung is a veterinary behavior specialist. These are just examples of the many wonderful doctors we work with regularly-and are fortunate to do so.

Some of the specialists that supply their services to our clients and pets on a regular basis work in large group or specialty centers. They are often associated with critical care and/or emergency facilities, offering state-of-the-art veterinary medicine and surgical procedures. It is very handy to refer the very ill patients to these large centers as so many of them have more than one issue or problem. Having the ability to do an ultrasound, a specialized diagnostic imaging test, for example, interpret that test, do a biopsy, and continue on to surgery if indicated makes it much easier on the patient and client-not having to transport an ill and/or stressed pet, securing records and test results-everything is at hand and the whole team can work together for that pet. Two centers or facilities we commonly refer to can be learned about here:



Pet lovers are more and more demanding higher levels of care for their furry family members. With veterinary specialists at the standby, our pets have never been in better hands.


Tuesday, January 20, 2009

Loser Humans

I am really hesitant to write about the dog pictured here today-my staff is calling her Sunshine, but no one knows her real name. I am so angry about the situation that brought her to our hospital and me even mentioning her here just gives attention to the loser humans associated with her. Yes, I am being harsh with them and that just isn't usually my nature. But when it comes to the welfare of animals, I go a little ballistic.

When we came back from lunch yesterday, we found Sunshine tied to the picnic bench outside our back door. There was no note, no tags or microchip identified her-nothing. I know that times are tough, her so-called owners could have lost their jobs or have medical problems of their own. Did their property flood recently and they are now homeless? Maybe Sunshine has health issues too costly for them to deal with. She might not get along with cats and they have a beloved Persian or something. But how would we know any of this? If they had called and asked, we could have sent them to rescue groups (she appears to be a purebred Basset Hound) for help and advice. We could have utilized some of our Flake's Angel Fund money if they had made it known they were destitute. You know by now how my staff and I will go out of our way to work with people to find solutions to problems like these. But this act of abandonment, so passive aggressive and manipulative is the lowest form of human behavior. At this point I don't care what their "story" is. Can you tell this makes me just a bit crazy? Sorry. I guess I'm in a mood today.

Stories like this are unfortunately becoming more and more common in this terrible economy. We've seen a box full of kittens on the door stop in the morning or a new "client" claiming they forgot their checkbook after an appointment, running home to get it, only to never show up again, all phone numbers left as contacts being bogus. I've seen news stories about even bigger problems, people unable to afford their horses, can't sell them or even give them away. There are no longer any slaughter facilities in this country for horses (another story for another time and debate....) so people have actually turned their pets loose on government land, hoping they will be able to fend for themselves. So scary for those poor horses-just what are people thinking?

People must believe that leaving a once beloved pet (we hope Sunshine was loved at one time) at a veterinary hospital will result in a happy ending; veterinary staff love animals after all. But I have asked my staff to be responsible pet owners-that means not having more pets than they can afford to take care of and therefore are good examples to our clients. Personally, I have to do that as well. I can't take in every stray or unwanted critter as much as my heart tugs me to-I have pets of my own to care for, have a home with a mortgage, a business and employees I am responsible for. Drugs and supplies, food, utilities- everything is more expensive these days, and my suppliers aren't giving me any breaks; how can I be expected to?

I'm not going to tell "the rest of the story" about Sunshine simply because I don't want those humans to feel justified in leaving her here with us. They abandoned her, and don't deserve to know if she was euthanized, taken to the pound, or given to a family with 19 kids and loving humans who will care for her all the days of her life. They should have big tattoos across their foreheads that state they are no longer allowed to own pets, ever, because they can't be trusted to provide basic care for them. I know it can be embarrassing to ask for help when you are down on your luck-believe me, I've been there. But if it is for the sake of a friend, especially one who relies on you so completely as a pet does, well, you swallow your pride and just ask. Anyone who knows me and my staff knows we wouldn't judge the people who come to us and sincerely want to find a solution to a crummy situation. But you can bet we are "judging" these people....rightly or wrongly. Being judgmental isn't a great character trait to admit to having, but there you go. My dog still loves me :)


Monday, January 19, 2009

Max's "Drawer Motion"

Little Max is a lucky dog. He and his buddy, Ewoki, get to go on walks and to the dog park all the time with their human and have a wonderful time doing that. This weekend, though, he over did it and came up lame on a hind leg-ouch! He was holding his leg up, not wanting to put any weight on it at all yesterday. He is a bit better today, touching his toes to the ground, but you can see that he is off his game a bit and so his owner brought him in to see us.

Do you remember reading about Charlie and his hind leg lameness on New Year's Eve? I said that when dogs are lame in the hind end, there are numerous things that could be wrong-anything from a thorn in the paw (wouldn't it be nice if they all were that simple?) to hip dysplasia (an inherited condition where the hip joint never formed correctly, resulting in a progressive, painful degenerative condition.) But there is one problem that is so common that we tend to say all hind leg lame dogs have this until proven otherwise. The problem is called ACL or CCL rupture-anterior (or cranial) cruciate ligament rupture or tear.

The ACL's "job" is to connect the top bone (femur) and bottom bone (tiba) and to stabilize the motion of the joint, keeping it from moving in abnormal ways. We know a knee joint should flex back and forth, but if the ligament is injured, the joint may have what we call "drawer" motion; the lower tibia will move forward as if you are pulling a drawer out of a desk or dresser. Drawer motion is abnormal and when it is present during an exam (done under sedation or anesthesia due to the pain of manipulation and because the strong muscles of the leg will hold the joint together in an awake animal) confirms the diagnosis of ACL rupture. Max had definite drawer motion in his affected stifle and no abnormal motion at all in his good leg. We then took radiographs during his sedation so we could see if there was any other problem like fractures or even neoplasia (cancer) that would affect the outcome of repair and recovery.

Once damage to the ACL was confirmed, we had to talk about repair-that meant surgery. For bigger dogs like Charlie, a trip to the surgery specialist is warranted to have a procedure called a TPLO or tibial plateau leveling osteotomy (see why we call it a TPLO?) Max only weighs about 13 pounds, so he could be a candidate for a different surgery, one we do at our hospital routinely, called a lateral imbrication procedure. In this surgery, heavy suture material, almost like fishing line, is laced along the side or sides of the stifle joint and mimics the function of the cruciate ligaments, stabilizing the motion of the joint. There should be no drawer motion remaining after these lateral imbrication sutures are placed. It is a good procedure, costs significantly less than a TPLO, and should have Max back to good weight bearing in a month or so.

We did get some x-rays of Max's stifle and saw a little piece of bone in the center of the joint. This is common in ACL ruptures as bone can come off from the point of attachment of the ligament and the joint surface. The radiologist will review the films, but the diagnosis is clear.

Max and his owner will go visit the veterinary surgery specialist for a consultation and get their recommendation for the repair of his injury. At his age (10 years) this is less likly to be a conformational issue and more a primary injury-I doubt he will have his opposite leg affected but since he is putting almost all his weight on that opposite leg, it is vulnerable to that possibility. He will be rested and put on anti-inflammatory and pain relief medications before and after his surgery. I said at the start that he is a lucky dog and I really believe that. He has a wonderful owner who is willing to take care of him, he has a good buddy, Ewoki, who watches out for him. And he has a great personality, seeming to realize that his veterinary team is trying to help him feel better-it sure makes us love our jobs all the more and want us to go out of our way to do what he and his owner need. In this case it means closing that "drawer."


Friday, January 16, 2009

"Just Say Cheese"

I admit it. I don't like going to the dentist. I was "lucky" enough to inherit my Mom and Dad's crummy teeth, so a trip to the dentist usually results in the diagnosis of cavities, broken old fillings or worse. The staff at my dentist's office are nice and always try to make the visit pleasant, but it is usually painful and expensive-what's to like? I do make myself go regularly-I know that the preventive care will help ward off even worse dental conditions and possible systemic diseases.

Our pets are no different when it comes to the need for preventive orodontal care. Most people realize that unhealthy teeth or gums can be a source of pain or infection in a body, but few realize they can lead to problems with the over all health of the pet. Bacteria can enter the bloodstream of inflamed gums or through the roots of abscessed teeth and "seed" the filtering organs such as the kidneys and liver, resulting in significant damage and loss of function. This can certainly shorten lifespans, which we've already mentioned are much too short as it is. We want to do all we can to extend these lives, and good dental hygiene is a step in the right direction.

You really should be examining your pet's mouth once a month if they will let you do so safely. This is especially important in dogs who like to chew on hard things (we know rocks are a big "no-no", but some dogs do it anyway) and in older animals. We offer a free dental evaluation by one of our technicians or assistants and encourage clients to make a brief appointment for this important service if they have any questions about their pet's oral health. Start by smelling the breath-"dog breath" is never yummy (except for puppy breath, who can resist that?) but it shouldn't be really foul. This could be coming from accumulating food or periodontal or gum disease. Periodontal disease is very common in pets, caused by bacteria accumulating at the gum line around the tooth and can result in red, swollen or bleeding gums, the breakdown of the bone that holds the teeth in place, loose teeth and and ultimately in the loss of teeth. Periodontal disease can be prevented, but daily brushing is required to remove the offending bacteria. Anti-bacterial and/or enzymatic treats, pastes and rinses can also be used-but something has to be used every day to do any good.

When you are checking the mouth out, look for signs of broken or loose teeth-these may look irregular compared to the same ones on the opposite side or may be painful to the touch. The pet may be drooling excessively or may be pawing at their face. Some may get swellings of the cheek or even protrusion of the eye over the affected tooth. An empty spot where a tooth used to be may have been broken off and roots left behind. These are important to be assessed by your veterinarian as retained root fragments are often sources of pain and infection and much more difficult to remove the longer they remain. You may see a red or brown spot in the center of a broken or chipped tooth-this is the pulp or root canal-living tissue that once exposed, can be quite painful and possibly lead to infection.

Noting any masses or growths in the mouth or on the lips or tongue is an important part of the oral exam. These could be benign growths called an epulis, really just overgrowth of gum tissue, but only microscopic examination by a pathologist can tell for sure. Malignant or cancerous growths in the mouth are often very aggressive and early treatment/removal is essential for their management. Ulcers or wounds here may be symptoms of a systemic disease process.

Your veterinarian or technician will chart the mouth and every individual tooth will be identified just as our dentists do for ours. A probe is used to measure pockets of detachment of the gums
all around a tooth. This needs to be done under general anesthesia as part of the complete dental ATP-Assessment, Treatment, and Prevention plan. It is the only way to be safe and thorough-even the most well-behaved critter doesn't say "ahhhh" and let us poke around their mouth. Radiographs or x-rays, again just like they do for us, are taken (in hospitals that have the equipment to do so) and evaluated for the health of tooth roots and adjacent bony tissue. These are essential in determining the best treatment plan for the teeth or the need for extraction if the tooth cannot be saved (or restoration procedures are too costly.) As hard as it is to believe, most pets do pretty darned well without their teeth. Many don't even chew their food (as is evident when mine puke up their food on my carpet....) I'd probably have a few less scars on my hands and arms if some of my more aggressive patients lost a few of their "weapons."

It may be recommended that your pet visits a veterinary dental specialist if one or more dental conditions warrant it. They will have the equipment and training needed to provide the best care for your beloved friend. However it is provided, by you at home, your general veterinary practitioner or the dental specialist, it is simply important that we work together to ensure our patients are smiling for their next family photo-"Just Say Cheese!"


Thursday, January 15, 2009

Goodbye, Little Friend

Our feathered and furry friends live lives that are far too short for most of us; we are greedy and want them with us forever and ever. Even when they reach their senior years and die of natural causes, we sometimes feel ripped off, and when we are talking about our typical "pocket pets," guinea pigs, hamsters and such, that is particularly true. Little Tiki was a cute, chunky, squeaking ball of joy- a guinea pig who shared her life with one of my dear friends, Happy. Happy sent me an email today to let me know that Tiki had passed away, surrounded by her loving family. I know she had a great life, even though we might feel it was far too short. Her wonderful humans gave her just the right care and she had the essential companionship for a happy piggie with her buddy, Kona, and two Labradors (yes, the big dogs!) Opal and Meile. In fact, Opal and Meile gave her big sloppy wet kisses as she passed from this world. Tiki is at peace now, buried in a small, open area in her backyard where the sunshine can warm her from above. Such a little life can make a huge impact on the lives they leave behind.

The average guinea pig only lives about 4 to 7 years. While they are classified as rodents, these "cavies" are more closely related to porcupines and chinchillas than to rats and mice. Since they are generally very sweet-tempered, (rarely biting or scratching) relatively inexpensive to buy and maintain, and easy to take care of if you know the basics, guinea pigs make excellent pets. They are, however, one of the most allergenic animals-children or people with asthma or other severe allergies probably should avoid them. We commonly find short-haired or the English variety as well as the shaggy, rough coated Abyssinian (whose hair is often in a spiral or rosette pattern) and the longer haired Peruvian breeds-all in an abundance of colors and patterns.

These little piggies (no, they are NOT related to pigs or hogs) are not inclined to climb, so housing them in open-top cages with sides at least 10 inches high is fine, as long as there are no predators (hungry or curious kitty cats or dogs) with access to them. They do need room for exercise, though, so the cage should be at least 8 square feet per adult animal. Solid flooring is safest with wood or paper shavings for bedding. They shouldn't be in drafty areas, or in direct sunlight and room temperatures should be about 65 to 75 degrees F.

Solid, heavy crocks for food dishes are best so they can't be tipped over or chewed and result in sharp edges as plastic can. Free choice grass hay should be available, as well as fresh, clean water, usually via a water bottle. They tend to "back-wash" food particles into the tip of the bottle, so they need it cleaned and changed daily. Guinea pigs are known for their inability to manufacture their own vitamin C, so require a daily source of this in their diet. It is not enough to give it to them in their pellets as these quickly oxidize or age and can't be relied upon to provide the levels our pigs require. Pellets alone also make for very fat little pigs-a common problem of our house pets. Fresh veggies and fruits are the best sources of vitamin C, but vitamin supplements can also be given. I don't generally like to add things to their water for fear it will make them drink less than they should.

Guinea pigs live in groups in the wild-they are very social little guys. They do best if they are kept in pairs, preferably two females to decrease the tendency to fight, especially if the owner is away for long periods during the day. They really bond to their humans, often learning their voices and squeak excitedly when they come home.

It is possible to breed guinea pigs, but females must be bred about the age of 3 to 5 months. This allows for a 59 to 70 day length gestation and birth before the pubic symphisis or pelvis joint fuses. If bred for the first time as an older animal, (females are referred to as "sows" and males are "boars") the pelvis can't expand during delivery and dystocia or difficult birth results, usually requiring a c-section. Baby guinea pigs have what we call "precocious" development-they are born fully haired with their eyes open. They can walk and eat solid food within a few hours. They can reach puberty as early as 4 weeks, so young males and females should be separated so they don't breed too early.

Like most pocket pets, most of the more common guinea pig ailments are related to husbandry or management issues. Scurvy results when they aren't provided with enough vitamin C, and can develop rapidly. They can get distended joints, act achy, unthrifty, get diarrhea and not eat or move. Pigs get pododermatitis or bumblefoot, sores on the undersides of the feet, developing most commonly when housed on wire-meshed flooring, especially if the wire is rusted or soiled.

Alopecia or hair loss occurs will occur over the flanks and back in all sows in late pregnancy, and thinning of the hair over all will occur near the time of weaning. It can be a pathology when associated with stressful conditions, such as when the pigs are housed in very noisy area of the home, or when they are "watched" or teased by cats or dogs or other perceived predators. Poor diet, even "over nutrition", is a stressor, too. Guinea pigs will "barber" their hair or chew it off themselves or their cage mates. You can generally tell if it is self-inflicted or done by the other pigs due to the location of hair loss on the body-can the pig actually reach that area on their own? Skin mites can be transmitted through bedding materials or by contact with infested animals. These can be contagious to other animals, even humans.

Ptylism or excessive drooling is often referred to as "slobbers." It occurs most often due to malocclusion or malalignment or overgrowth of the teeth which grow continuously through the guinea pig's life. These need to be monitored and trimmed or floated (filed) as needed as it can lead to pain in the mouth, abscesses, anorexia and weight loss.

Guinea pigs are great little pets-Tiki was a prime example. We know her humans will miss her a lot, but are comforted in knowing she was a very fortunate little girl, loved and cared for and never knowing a moment of fear or pain or hunger. That is saying a lot in what can be a big scary world. Our sympathies go to her family, animal and human.


Wednesday, January 14, 2009

The Right Fit

The wonderful doctor I had for myself for over 10 years had the nerve to go and retire on me. I was so bummed. I had what I felt was the right fit with her- I had trust and confidence in her medical skills, she respected me and my knowledge, she made herself available and was extremely compassionate. I felt she genuinely cared for me as a person. It didn't surprise me when I learned she was going to enter the seminary. Even though I will have to go through the process of finding a new doctor, (darn it) I sure wish her the best in her new career.

Finding a veterinarian for your pet can be just as much of a challenge as finding an MD for yourself. We are "The Other Family Doctor" after all. It is a good idea to have a veterinarian picked out even before you have the pet picked out-and hopefully before there is an emergency.
Many people may just pick their veterinarian based on location or through the yellow page ads. These are rapidly becoming obsolete and internet resources such as websites are becoming better marketing tools. It can be helpful to contact neighbors or friends for their recommendations, as well as local pet groups, breeders, veterinary associations, schools, and animal shelters.

If you have your choice narrowed down, you may want to ask some questions before your first appointment. Since this "interview" could take some time, it would be courteous to fax or e-mail your questions to the hospital ahead of time and have the staff review them-you may not need to talk directly to the doctor. Some potential questions you might consider asking are:
-What species does the practice see?
-Does the doctor have any specialty training or interests?
-What organizations does the doctor belong to?
-Does the doctor and/or staff pursue continuing education courses?
-How are after-hours emergencies handled?
-Does the doctor routinely refer complicated or difficult cases to board certified specialists?
-Does the doctor or hospital work with any shelters or rescue organizations?
-Does the practice have a website or printed brochure they can give you/refer you to?
-Can I briefly meet the doctor and/or get a quick tour of the hospital before my first visit? (This is usually honored but respect the veterinarian's time and realize this is to be a BRIEF visit/tour.)

If you do visit the hospital, you'll want to make some first impressions:

-How clean does the hospital look/smell, including the exam rooms, the reception area, and are the staff members themselves dressed professionally?
-Is the staff able and willing to answer your questions or get answers for you if they don't know answers themselves?
-Are printed materials available on your pet species?
-Does the staff show skill in handling your type of pet?

There are some common characteristics of a health professional that you will likely deem important in your new veterinarian and the support staff as well:

-handles your pet with care/respect
-interested/knowledgeable about your species of pet(s)
-is a good listener
-is willing to answer your questions
-is interested in client education and encourages research on your part
-is willing to admit when they don't know the answer, but will search out an answer for you
-is flexible in developing a treatment plan based on medical and financial constraints for an individual pet
-is not offended when a second opinion is sought-works as a team member for the benefit of the pet

You may want to know if a particular doctor will allow you to be with your pet for all aspects of a veterinary visit. Sometimes clients will want to assist their veterinarians by holding or restraining their pets during exams or procedures. Veterinarians are all advised by their malpractice insurance providers not to allow this since owners often are not trained to do so and could become injured. You need to respect this difficult position. Doctors may need a high level of focus when performing certain procedures and it can be distracting to have an owner there that may be asking a lot of questions or who may be nervous. Sometimes animals actually pick up on the nerves of a worried owner and do a bit better away from their owners. If a veterinarian or staff member suggests taking your pet to a separate treatment area, don't be worried or offended-they are just looking out for the pet's best interests. Ultimately it will be the result of the relationship you establish with your veterinarian that will determine in what capacity you will be allowed to be present with your pet during treatments or diagnostics.

As a pet owner, you have the ultimate responsibility to be educated, be prepared, and to ask questions if you don't understand something. This will be a continuous process throughout your pet's lifetime. If a problem ever arises during a veterinary visit, be sure you let the doctor or office manager know about it right away. Most will want to know about them so they can resolve the issue and prevent them from happening again. The relationship between an owner, his or her pet and their veterinarian can be a wonderful, life-long, team effort. With a little bit of homework and a touch of luck, you will find that "right fit" for all of you.


Tuesday, January 13, 2009

Helicopter Head

I've been pretty surprised lately how many clients will have questions or concerns about things I have just recently blogged about. I guess it shows how common some of these issues are. Grass eating, medicating your pet with human medicines, anal glands, separation anxiety and weight issues were all brought up again just today! It was fun to be able to refer those concerned owners to the link for my blog-I'm oh so computer savvy.

A very common medical problem, one that we see at least daily if not multiple times each day, is an ear infection in dogs. Cats get them, too, but we see dogs much more often, especially those dogs with floppy ears-Labs, Golden Retrievers, Poodles, Shih Tzus, and most notably, Cocker Spaniels. An owner of an affected dog might notice the pet scratching at the ears, might smell a bad odor about the head, or could see or hear the tell-tale flapping of the ears against the head that my husband calls "helicopter head." It sure does sound like the beating of the blades of a rotating helicopter-you can imagine how uncomfortable a poor dog is if they are doing this constantly.

Otitis externa, or infection in the outer ear canal, can be caused by inflammation from allergies, bacteria, yeast or fungus, or by tiny insects called mites. It is essential to know which is present in an affected ear because the treatments are very different for each condition. Your veterinarian will perform a microscopic examination of the debris that comes out of the ear canal to make the diagnosis. Some dogs will have mixed infections; it is not uncommon for them to scratch ear mite-infested ears and cause secondary bacterial infections from the dirt under their toenails. Bacterial infections can challenge the immune system, causing the natural balance of organisms you would usually find in an ear to be interrupted, resulting in a yeast invasion.

There are some traits of the different problems that may be apparent on the physical exam. Mite infestations do not usually cause an odor, but they are accompanied by a lot of dark, dry, crumbly debris, almost like coffee grounds. They are severely pruritic, (itchy) often resulting in scabs or alopecia (loss of hair) behind the ears or on the pinna (ear flap.) When they shake or scratch so dramatically and get "helicopter head," an aural hematoma or giant blood-filled pocket can form from ruptured blood vessels between the skin and cartilage of the pinna. This can add to the discomfort and must also be treated.

"Allergic" ears are often inflamed-very red and swollen deep down into the canal. There may or may not be debris associated with the inflammation.

Bacterial infections often are accompanied by white blood cells which are trying to phagocytose or eat up the invaders and then become overwhelmed. This becomes pus, and can have a thick, creamy appearance with or without a strong odor.

Yeast or fungal infections often have a sickening "sweet" sort of smell-kind of like fermenting organisms. They will often have a dark, brown, moist debris-but not always. The most common yeast found in dog ears and skin is Malassezia, and can often be caused by exposure to water-baths or swims. When a dog with floppy ears gets water in its ear, it has a hard time drying out. Malassezia loves that dark, moist, and warm environment. That is why it is important to use an ear cleaner that also dries out the canal after any bath or swim.

Most ear infections, after being diagnosed correctly, and getting to the underlying cause, (such as food allergies, particularly common in breeds such as Golden Retrievers) can be cleared up after a good ear cleaning and a course of medication. Oral medications rarely reach therapeutic levels in the ears, thus topical preparations are utilized. Medications may be prescribed for owners to apply once or twice a day to the affected ears, often containing an antimicrobial (antibiotic or antifungal) and an anti-inflammatory medication to help calm the itching. We have been using a kind of "timed-released" plug of medication, instilled into the infected ear(s.) Owners love this treatment because they don't have to do anything except show up for a recheck in 2 weeks to see if the infection is cleared up completely. No chasing the dog around, pinning him down, fighting and making your buddy cringe at the sight of you and the bottle of medication. Some dogs may need an e-collar or cone around the head to protect their ears from themselves;self trauma from scratching or rubbing can wipe away medication and delay healing.

Speaking of the recheck, this is an essential part of the treatment of otitis due to any cause; if we stop medicating before all the organisms are gone, the infection may rear its ugly head soon after we stop treatment. This can lead to a more aggressive, chronic disease and medication resistance may develop. We may need to culture the debris if the infection just isn't clearing up. We will discuss allergies at this time if the patient seems to be getting frequent infections, or they are accompanied by other symptoms of food allergies such as chewing at the feet or rubbing the face. If all is well and the infection is gone, we certainly go over preventive measures-using ear drying solutions in our floppy-eared dogs after any bath or swim to wick moisture from the canal and make it a less hospitable environment for microorganisms to survive. Keeping hair plucked out of the canals may decrease the chance of debris hanging up there and will allow it to "air out."

There are some dogs that develop such severe infections that they can not be controlled with medication and diet alone. Deafness can occur. In these extreme cases, surgery may be needed to open the vertical ear canal, enabling it to "breathe" better and stay free of debris. If it really becomes scarred down, ablation of the entire ear canal can be performed, usually by a veterinary surgeon. Abnormal tissue is removed, allowing for the growth of healthy new tissue.

As common as ear infections are, they are not "routine"- any more than spays or neuters are routine procedures to the individual animal experiencing the surgery. Each patient must be evaluated for all potential causes of the infection, treated for the underlying and overt causes, and counseled on means of prevention. The lucky ones have observant owners who see those ears flapping or smell the sweet-ish odor and get them to their veterinarian right away. The helicopters never get a chance to get airborne.


Monday, January 12, 2009

Q and A

One of my friends, Heidi, asked if I'd answer a few veterinary-related questions for her. She has a delightful, fluffy white dog named MC, the joy of her life. Some of Heidi's questions might be of interest to other readers, so thought I'd share them today.

Instead of automatically vaccinating MC every year, Heidi elects to have her veterinarian test MC's vaccine "titers." These are the antibodies that circulate in the blood of anyone who has ever been given a vaccine (or been exposed to the disease.) Antibodies develop in response to the stimulation of the immune system, and are what protect the individual from contracting the specific disease at hand. Immunologists calculate what level of these antibodies are considered protective, and anything less than this would require re-vaccination to further stimulate the immune system to develop a higher titer.

There are problems with running titers instead of just giving vaccines, as good as the medicine is behind running titers. You certainly don't want to give un-needed vaccines or drugs of any kind if there are safer alternatives. Titers are very expensive tests. You need to run a seperate test for each disease that we vaccinate against-just because a titer is deemed protective for one does not mean the patient is covered for all other diseases. Some tests are run so infrequently that local labs may have to send out the test, resulting in long waits to get results and furthur visits if we find the levels to be inadequate. If a dog happens to be going to a groomer or boarding facility in a few days and needs "proof" of vaccination, titers may not be readily available. Planning ahead is always the best course.

Heidi also asked about dewclaws in dogs. She wanted to know why some dogs had them and others were removed by breeders at very young ages. Dewclaws correspond to human "thumbs," the 1st digit on the legs of dogs, and can be found on the front and hind limbs. Some dogs are born without them and others have all four-or even more! The front dewclaws are often attached securely to the leg as our thumbs are, and many dogs really seem to use these digits, especially when manipulating a tasty bone or other chew toy. Dewclaws on the hind legs are often very loose or "dangly," and as a result, can become caught on things like heavy brush or sticks or woodsy vegetation, especially so in hunting dogs. This is why many breeders have them removed in puppies at approximately 3 to 5 days of age. Some breeds like a long, "clean" appearance to the front legs as well, especially in a show ring, so will also have the front dewclaws removed. There are breeds like Great Pyrenees dogs where there are multiple dewclaws, each with their own toe nails, and they are not to be removed in these dogs.

One other question had to do with senior diets. Heidi asked why older dogs should be changed to one. It's no surprise that our senior pets (senior humans, for that matter) start to slow down a bit. Less exercise can often lead to weight gain, and excessive weight is harder to carry for all of us, but particularly so on those older joints that might have a touch of arthritis. Senior foods address this problem by having less fat in their formulas and thus less calories per serving. They may have less sodium for blood pressure issues, and will often help those mobility issues by having a touch of glucosamine for joint support. The glucosamine won't likely be enough to be at a therapeutic level, so supplementation will likely be necessary if a pet does develop degenerative joint disease or osteoarthritis.

There are other benefits to senior diets including more antioxidants to help with the immune system and slow cell oxidation (degradation.) They have less quantity of protein but higher quality, as well as low phosphorus to help maintain good kidney function while maintaining strong bones and muscles. Fatty acids help in the proper function of nervous and immune systems as well as making a shiny coat and healthy skin. Diets for mature dogs will balance vitamins and minerals for dogs in this age range-feeding an older pet is not the same as feeding a youngster or even an adult pet. Those "one-size-fits-all diets that say they are "formulated to meet the requirements of all life stages" just aren't acceptable. They generally provide too much nutrition for our senior friends-and this is just as dangerous as feeding too little.

I hope that answered some of your questions, Heidi. Thank you for helping me educate my readers-they were good topics and I hope others learned a thing or two due to your curiosity. Give MC a sloppy kiss from Verbal and me.


Friday, January 9, 2009

Tied Up in Knots

We saw Bunny yesterday-she had been vomiting and not eating very well for about 2 weeks. No, bunny isn't a rabbit-she is a darling little wisp of a kitty, about 10 months old and ordinarily rambunctious and in to EVERYTHING as all good kittens are. She was sleeping a lot and wouldn't play with her beloved toys. Ordinarily a tiny cat, she was losing weight (and doesn't have it to lose.) In getting her history, we found out she was particularly fond of the Christmas tree and all the pretty packages with the shiny ribbons and all. More than once her owner had to take chewed up ribbons and strings away from her, but was very concerned she didn't catch her at some time and that she might have a piece of string, or maybe a toy or who knows what stuck inside her. Looking at how sick this cute kitten was, it sure was possible.

We took radiographs of her abdomen and ran some blood work. While there wasn't an obvious toy or piece of "something" present on the x-ray film, there was a distinctive "bunching" of the small intestinal loops that often happens when animals eat strings or ribbons or fishing line. Some gas was building up on either side of these bunched up gut loops, but there was, thankfully, no evidence of free fluid in her abdomen as there would be if she had large perforations or tears in her gastrointestinal organs. We sent the films to our radiologist for review, just like they would if they took x-rays of us.

Bunny's blood work came back this morning and it showed that she was low in her total protein, no surprise since she hadn't eaten in so long. Most concerning, however, was the elevation of her white blood cell count. Normal values are about 6 to 14,000-Bunny's were over 43,000! WBCs come about in times of infection or inflammation-perforation of the gut walls was looking more likely. The radiologist called this morning (he usually just sends a faxed report in the afternoon but knew there was a need for a "STAT" report in Bunny's case) and he concurred that she had evidence of a linear foreign body. He suggested giving her some contrast medium, barium, and follow it with multiple x-rays through out the day to see if it was obstructed in the region where we saw the bunching of intestines. When I told him about the elevated WBCs, he said doing an exploratory enterotomy (doing abdominal surgery to find out what was going on in there) was a smart choice, especially since it was a Friday and we are closed for the weekend. Why do animals always who have been sick for WEEKS get ready to die hours before we close for a holiday or weekend?

Linear foreign bodies (strings, fishing line, ribbons, etc.) are very attractive to cats-anyone who has tried to knit or crochet with cats in the house knows how "helpful" they can be, batting at your yarn, chewing on the end and making your project all spitt-y. My Stella has been incredibly lucky so far because she is obsessed about these things and I really have to string-proof the house. I have had to pull ribbon away from her on numerous occasions. What a brat.

The reason they are so dangerous is they often snag or get hung up at one end, the other end continues to travel through the GI tract, and this is what literally causes the bunching up of the intestinal loops. It can cut through the mesenteric border or the top edge where the connective tissue is located, making small perforations difficult to see, but causing leakage of intestinal contents into the abdominal cavity. This sets the cat up for peritonitis, a potentially deadly infection. We treated Bunny with two broad spectrum antibiotics, pain medications and placed an IV catheter for fluid support. Then we took her to surgery.

The first thing we did when we got her in surgery was to look under her tongue. Yes, her tongue. What in the world was I thinking? Well, cats who swallow string foreign bodies often hook the string under their tongue-that is why it catches and won't pass through the intestines in the first place. It cuts into the delicate tissue there and becomes buried, very difficult to see in an awake cat. Bunny wouldn't let me see under her tongue during her exam, either because she didn't like being messed with or because it hurt-and sure enough, there was a necrotic ring around the base of her tongue! We had our diagnosis, darn it. We dissected into this tissue and pulled out the thinnest, see-through thread you have ever seen. I have used thread like this, I think they actually call it "invisible thread" on sewing projects in the past. If we hadn't seen what the string foreign body looked like there, I don't know how we would have found it buried in those intestines.

I made an incision into her stomach and after a lot of searching, found the micro-thin thread, and put gentle traction on it. The mouth ends of the string came right out, but the end leading into the small intestine had too much tension and I was afraid that by pulling on it, I could pull it through the fragile tissues and cause a perforation. I sewed up this incision and made another one a few inches along the small intestine. I was able to get the stomach end out, but again, there was more tension where there was obviously more string in the bunched up intestines. I made a third cut into the small intestine and was finally able to remove what I hope is all of the offending string. I followed all of the intestinal tract a final time, looking for tears and any remaining bunching and none remained. There were many areas of small hemorrhages or bleeds where the mesentary or connective tissues join with the intestinal walls, but no overt leaking. We went ahead and spayed Bunny since she hadn't yet had this done, flushed out her abdomen and closed her up.

Bunny's recovery was surprisingly quick and uneventful-that is a good thing. Her body temperature never fell very low as it certainly could have due to the length of the surgery and the fact that her abdomen was wide open to the elements for a while. She had good pain medication before and after her procedure, so she didn't thrash around or act painful or scared. We will send her to a 24 hour hospital for monitoring over night and they will discharge her if there are no complications and she is eating OK. She is a young, healthy kitten and should do well, but this was a major procedure and you can't be too careful.

Bunny's owner will have to Bunny-proof her home all over again. All her sewing things will have to go up or into cabinets. It was a good thing there was no needle attached to the thread this time-I have seen that happen in other cats. Not good. Her owner has a toddler in the home and thought baby-proofing equaled kitten-proofing. Bunny has proven this isn't necessarily the case. We hope she has learned her lesson about strings, and tieing her intestines up in knots.