Corneal Pseudomonas infection in a goshawk

The Northern goshawk (Accipiter gentilis) is found throughout North America and Eurasia. One of my clients is a falconer and owns this bird legally. This case is reported with the owner’s permission in the hopes that it could help other veterinarians or falconers faced with a similar situation.

Left eye prior to treatment

At the time of presentation, the bird was 22 months old and weighed about 780 gm. The owner noticed a cloudy appearance in the bird’s left eye. It’s not unusual for this bird to dive into dense vegetation in the pursuit of rabbits and it’s thought that he may have scratched his eye.

Initial diagnostics included corneal cytology and a swab of the cornea for culture and sensitivity. When preliminary results became available five days later, the corneal lesion had progressed significantly. Thankfully, fungal infection was ruled out.

The culture grew Pseudomonas aeruginosa, a particularly nasty type of bacterial infection. It was sensitive to tobramycin, which I had at our hospital, so I prescribed some for topical use while I reached out to additional raptor specialists for advice.

Initial culture and sensitivity results for corneal swab

After hearing back from a veterinary ophthalmologist who works with wildlife, I changed the course of treatment. We stopped tobramycin and switched to topical moxifloxacin (available through regular human pharmacies) and oral doxycycline (25 mg orally every 12 hours for 14 days). The moxifloxacin needed to be applied to the eye six times per day for the first five days, then five times per day until resolved.

How does one apply eye drops to a wild bird?

I obtained the following guidance, which I hope will be of use to others:

Eye medication

1. 1. Approach and retreat techniques (negative reinforcement in the realm of operant conditioning) were used to begin the training process for applying eye medications unrestrained in the bird’s enclosure.
   2. The bird is slowly approached with the eye medication bottle until visible signs of stress are observed = the bird’s fear threshold
      1. Signs of stress include wings out, fanned tail, and increased respiratory rate.
      2. Wait in the same location where the signs of stress were observed until you see one small sign of improvement
      3. Tucking of the wings or tail will come first, a calm respiratory rate will be the last sign of stress to resolve
   3. When the bird relaxes, slowly move your hand back a few inches and wait there for ~30 seconds as the release or reward – by moving away from the bird, which is what the bird ultimately wants, we are teaching the bird that if they stand calmly on their perch with their wings tucked we will go away.
   4. Retreat slowly – this bird tends to get nervous when you move away, especially quickly. In some cases, we have used maintaining the same distance for 30 seconds – 1 minute as a reward
   5. Then gradually approach again until signs of stress/the fear threshold is reached and pause as above
   6. Approaching slowly in a stepwise fashion, allowing the bird to relax after each step, has worked well for this individual to facilitate administration of eye medications within 3 mins or less twice daily

Not sure if these links will work, but you can try them:

• https://drive.google.com/file/d/1M7YSmtVb0v5LX7v_7jlpkMnfr3TxkaUp/view
• https://drive.google.com/file/d/1DVO0G31J4WA8DU9U_1371qoD13ABvaP8/view
• https://drive.google.com/file/d/0Bzoo8FqXt1bAczd4NFBENVFJSEE/view

After 7 days of treatment

Thankfully, the client was able to get the moxifloxacin drops into the left eye as directed, and after seven days of treatment, improvement was evident.

Approximately 16 days after beginning treatment, the owner noted that his eyelid was looking a little irritated and he was keeping the eye closed, only opening it in low light or when extremely curious. We decided to discontinue topical treatment until I could perform a medical progress exam.

At the recheck exam–one month after initiating treatment and two weeks since discontinuing treatment–the cornea was completely clear except for one thread of neovascularization extending from 12 o’clock to the center of the cornea. He was consistently holding his eye open and looked comfortable. I expect his vision to remain excellent, although it will likely take another month or more for the neovascularization to retreat and a small scar is possible.

A repeat culture and sensitivity was negative for Pseudomonas!

Side view of the left eye, showing the small strand of neovascularization which is aiding the healing process.

One month after initiating treatment, healed!

Dusting off

Dust If You Must

by Rose Milligan

Dust if you must, but wouldn’t it be better
To paint a picture, or write a letter,
Bake a cake, or plant a seed;
Ponder the difference between want and need?

Dust if you must, but there’s not much time,
With rivers to swim, and mountains to climb;
Music to hear, and books to read;
Friends to cherish, and life to lead.

Dust if you must, but the world’s out there
With the sun in your eyes, and the wind in your hair;
A flutter of snow, a shower of rain,
This day will not come around again.

Dust if you must, but bear in mind,
Old age will come and it’s not kind.
And when you go (and go you must)
You, yourself, will make more dust.

 

The quiescence of this blog has been on my mind recently. I didn’t want to immediately dive into my thoughts and experiences regarding the current state of the COVID19 pandemic without first giving this site a gentle re-awakening.

Welcome back, followers. Thanks for not removing your bookmarks quite yet (although I’m sure some of you have). I look forward to sharing what life has been like in my little corner of the world.

Still kicking–sort of

Visitors to this blog might wonder if the author has given up on it. Blog writing takes time and effort, and I confess I have not devoted much of either to this project over the past year. I’m definitely not ready to throw in the towel, however. I believe in TLV and want to keep it alive. But I won’t proclaim grand plans to reinvigorate this blog in 2014, either. I’m taking a “realistic” approach with my commitments. Outside of family, which of course is my highest priority and always will be, I am fully dedicated to helping the practice I joined a little over a year ago flourish. I also want to continue to nurture my relationship with Clinician’s Brief, which has also lasted in its current form just over a year.

Last year at this time, I chose three words to guide me in 2013: Listen. Organize. Energize.

Here’s the truth: I think I failed on all three fronts. I couldn’t even remember what my three words were until I looked at them just moments ago. Part of me thinks perhaps I should not choose three words for next year, but what if that’s the beginning of the end? Does it mean I’m giving up?

Even with a reduction in my total number of commitments (e.g. stepping down as president of the non-profit I started), my kids getting a little older and slightly more independent (my youngest turned 2; she’s still in diapers but hopefully not by the end of 2014), I have felt myself slip into a strange and unfamiliar void. I’m not as excited about things that usually get me energized, such as going to work, making progress/accomplishments at work, organizing things, writing, taking pictures, etc. I usually have so many ideas about the types of things I want to do, I’ve wished for a way to turn them off. Not so now. I still have a good level of energy, and feel pleased and even happy about where I’m at in life, but I don’t feel the same excitement and passion that I used to consider innate qualities. Is it just that I’m getting older? Or am I becoming complacent? I fear complacency, and this comes back to my original point that I don’t want to give up.

If I want to choose three words for 2014, I could do:

• Don’t give up.
• Give my best.
• Keep it going.

These sound a bit defeatist, and while there’s an element of accuracy in terms of how I feel at this time, I’d like to instill a bit more optimism. I think I’ll go with a quote that I see from time to time, and it resonated with me when I saw it recently:

Trust the process.

Ok, 2014: I’m going to keep walking along the path(s) I believe in. Just need to trust myself and the path. And if I do that, I can’t fail.

Reflecting on the past year and choosing my three words for next year

Each year, instead of a New Year’s Resolution, I choose three words to help guide my decisions and how I live my life. Last year at this time, I was holding a brand new baby in my arms, and the words I chose to guide the oncoming year reflected my deep sense of commitment to her and my family: Nurture the future.

Now, here I am a year later, and my baby is a year old, and her big brother is 4.5 years old. My sense of commitment to my family is no less, but a lot has happened in the past 12 months, and the coming of a New Year brings with it a special opportunity to reaffirm one’s goals and direction.

So let’s see…here are some of the big changes that have occurred in my life in the past year:

• After 8 years practicing at the only hospital I’ve ever worked as a veterinarian, I parted ways and took a leap of faith into a new practice.
• My good, old dog, Monty, crossed the rainbow bridge. His age was unknown, but I estimated 12-15 years old.
• My working relationship with the veterinary publication, Clinician’s Brief, has molded itself into yet another adventure. I accepted a position as Medical Contributor, which means I help select content to post on their Facebook page and e-newsletters and write some of the copy for those elements.
• I announced my plans to step down as president of a non-profit organization that I started in 2008. It is in a good financial situation and has great leadership in the wings. I hope I’m leaving it in good shape for a great, promising future.

The risks associated with my employment changes has brought some tension in my personal life, and while sparing this blog of the gory details, suffice to say I believe with all my heart that I’m making the right move and I am working really hard to make sure other loved ones in my life will see that these changes will have a positive impact on all of us.

With that in mind, I have given tremendous consideration to the words I chose for 2013. One “challenge” I faced with my previous three words (“Nurture the future”) was my relentless sense of needing to accomplish things—whether it’s the laundry, a blog post, or an agenda for an upcoming board meeting of which I’m president.  So while I want to spend time with my family—and have been spending nearly every night on the couch watching TV with my husband after the kids are tucked in—I need to run the laundry, read and write more, and make impressive contributions to my new practice, where I hope to someday be a partner.  Most nights that I sit on the couch and watch reruns (thanks, Netflix!) of Magnum, P.I. and Mythbusters, I enjoy my time taking it easy, but there is a little voice in my head reminding me that I have obligations, and I’m making things more difficult for myself by putting them off.

In 2013, I want to listen to that little voice. I want to accomplish the things I know I can accomplish, which requires that I take the time to be organized. I want this leap of faith transition to ‘wow’ those around me—because I know I can do it.

Here they are, my three words for 2013:

Listen. Organize. Energize.

 

Friday the 13th

Some days, it feels like nothing goes as planned.  Friday the 13th was one of those days.

My schedule included two prophys, a dog and a cat. I also agreed to radiograph two raptors for Operation Wildlife. I thought I might actually have some time to catch up on some projects.

The phone call from one of our technicians informing us that she was too sick to come in was our first clue that today would present some challenges. Then I was told our in-house blood analyzer was out of diluent and we couldn’t run the CBC on one of my prophys (we require preanesthetic bloodwork). The chemistries weren’t working right either, but someone was “working on it”.

The next surprise was the devastating news that a cat belonging to one of our former employees died suddenly and unexpectedly—he was found that morning under the bed, deceased. A complete mystery, upon which a necropsy shed only a glimmer of light, and hopefully histopathology will be more revealing.

By 9:30am, it was clear that an emergency surgery (gastric foreign body) needed to be worked in. My associate planned to do the surgery. My technician was finishing up taking full-mouth radiographs on my first patient, a 4-year old sheltie undergoing her first prophy. She was missing at least seven teeth, and radiographs proved that they were truly missing. But a surprise finding came up—as they tend to do with full-mouth radiographs—and I found myself looking at an unerupted supernumerary tooth. Removing it was no big deal, but between the extra time on the phone with the client and the extra time performing the extraction, my technician was delayed in getting started on the emergency surgery.  We postponed the second prophy for the afternoon.

While my associate, technician and an assistant were in the surgery suite, I decided I could radiograph one of the raptors waiting for me. I weighed my options between the two—a barn owl used as an education bird that recently seemed to be holding his wing funny, and a Mississippi Kite with a fractured wing. I chose the barn owl, hoping to find something simple that didn’t need surgery.  He was never going to be released to the wild, afterall—what kind of injury could he have that would need surgery? A transverse, displaced proximal ulnar fracture, that’s what. Reluctantly, I rebandaged the wing and made arrangements for the bird to come back next week to surgically stabilize the injury.

Just when I thought I should go to lunch, we had an urgent care exam walk in: a 10 lb Pomeranian that had been picked up (literally) by a much larger dog. I was delighted to see the dog wagging happily and breathing normally. But that wound on her back worried me—how far did the gap between the skin and underlying muscle reach? We agreed to keep her for further evaluation under anesthesia.

A hurried lunch later, we surveyed the path of destruction that appeared to have swept through our treatment area. The blood work for the cat (my second prophy) was done, so my technician predmedicated and began working on her. My associate, eager to help after utilizing the majority of our staff for the last several hours, helped me anesthetize and treat the wounds of my injured Pomeranian. The wounds turned out to be far worse than I expected. Her entire dorsum was separated from the underlying muscle.  I placed two drains, gave her a Convenia injection, a Baytril injection, and a Metacam injection.  She woke up smoothly (still wagging her tail, bless her heart). I sent her home with oral Baytril, Metacam, and tramadol, and I’ll see her back early next week.

The cat prophy was uneventful, and full mouth radiographs revealed no surprises. I wished desperately that I could help my staff clean up, but I would more likely create greater chaos and confusion by putting things in the wrong place. So I headed back to radiology to x-ray the Mississippi Kite, fully prepared to see another injury in need of surgery or worse.

Then I experienced my first good surprise of the day: the figure-8 bandage was doing an excellent job of stabilizing the fractured ulna! Not only did the bird not need surgery, but he stood an excellent chance of making a full recovery and returning to the wild! I shouted the good news to my technician. She shared in my rejoicing, then made a poignant observation as I carefully held the bird waking up from its anesthesia.

“Grace’s surgery went well and she feels a whole lot better now, too. And two pets have better mouths now, thanks to us.”
“And Rosie won’t slough off her entire back now—hopefully,” I added.

We thought the day was chaotic and would never end. But at the end of the day, we realized everything we’d done, including all the mess we’d made, was for a good cause. We were doing our jobs, and doing them well.

We survived Friday the 13^th.

The best laid plans…

Excited to practice my new communication skills (see my recent post about the FRANK Communication Workshop I attended), I picked up the phone to dial my 4:30 consultation about some rabbits. The client lived far away and had questions regarding her “herd” of about 100 rabbits (started as a 4-H project). The staff had warned me this would be a challenging conversation.

An hour later, I sighed as I hung up the phone, having barely used ANY of my newly honed skills. In fact, I barely got a word in edgewise.

Luckily, we pre-arranged payment by credit card at a rate of $25 per 15 minutes, because apparently it was not possible to spend less than 20 minutes on the phone with her. And she had a LOT of questions.

Wisely, I opened a blank Word document to take notes during our call. Trying to keep up with what could most aptly be described as “verbal diarrhea” was nearly impossible. I thought my notes would be helpful for practicing my reflective listening–ha! I could have set the phone down, walked away for 5-10 minutes, come back, and she still would have been talking. I literally had to interrupt numerous times to clarify important details or make what I hoped was a useful contribution to the discussion. I’m pretty sure I never asked an open-ended question and lord knows I never had a chance to pause!!

To my pleasant surprise, I could hear her trying to wrap things up as the clock ticked closer to 60 minutes. I asked if the conversation had been helpful for her, and she said yes.

In fact, she will try to bring a couple of her rabbits to come see me some time. I wonder what that will be like?

FRANK Communication training

A dream of mine came true today: I attended the first day of the Pfizer FRANK Communication workshop!

A little background about FRANK: it’s a veterinarian-client communication workshop designed to help practicing veterinarians and their staff communicate better and more effectively with their clients and team members. I first learned about it when our Pfizer Technical Services veterinarian, Dr. Joe Holzhauer, presented several “pieces” of the workshop at our hospital a few years ago. Ever since then I knew I wanted to take the full workshop, taught by Dr. Jane Shaw and colleagues, based in Fort Collins, Colorado, at the Colorado State University Veterinary Teaching Hospital.

It’s a 1.5 day workshop, and today was Day 1. Somehow, I missed the advance reading assignment, so I was worried I would feel behind. Fortunately, the Frank presentation Dr. Holzhauer had brought to our hospital had prepared me well, and I’m interested enough in this stuff that I had already read one book (Exam Room Communication for Veterinarians by Dr. Jon Klingborg) and started another (Skills for Communicating with Patients by Silverman, Kurtz & Draper) on the subject of communicating effectively with clients.

We spent the first part of the morning learning some of the science behind improved communication skills. Not surprisingly, veterinarians who take the time to listen to their clients’ concerns can enjoy better compliance with their recommendations and achieve better patient care. The clients have an increased sense of satisfaction and have a better understanding of the recommendations being made. Studies in human medicine show that improved communication from the doctor yield improved clinical outcomes and decreases complaints and malpractice litigation.

We also discussed two main approaches to communication: the “shot-put” method and the “Frisbee” approach. As you can imagine, “shot-put” is one-way and can be overwhelming to clients due to the amount of information being dumped on the client. With the “Frisbee” approach, you have a two-way dialog with the client, listening to their needs and concerns, and shaping your recommendations to fit the situation. There has been a paradigm shift in veterinary medicine, getting away from the veterinarian-centered conversation (“I’m the doctor and I know best”) and moving towards “relationship-centered” communication where the dialogue is guided by feedback from the client. An important distinction to make: we do not practice consumerism, where the client says, “This is what I want,” and is not willing to have a back-and-forth dialogue.

In the afternoon, we practiced the communication skills we learned about in what was basically a wet lab setting! CSU has these exam rooms designed for the sole purpose of improving communication skills. A group of students can sit on one side of a one-way mirror, with headphones on, and listen to the conversation occurring in the exam room on the other side of the wall. Wow, how cool is that? There were six people in our group, and we each took turns interacting with a professional actor who portrayed a client in a pre-determined scenario. After our allotted time of 15 minutes, we all discussed how the interview went (what went well, what would be even better).  I have no doubt that we all learned a ton from this!

An added benefit was when Dr. Shaw stopped by our room for a visit. Dr. Shaw is like the guru/goddess of veterinary communication training. Someone asked what are we supposed to do when a client with a sick parvo puppy gets mad at us because she doesn’t have the money to pay for treatment? She skillfully took on the role of an angry client, and I watched one of the members of our group struggle with what to say to her as she got angrier and angrier. Then we paused, discussed what could be done differently, and tried again. I watched with amazement as one of our group members skillfully employed empathy statements and long pauses to let the owner vent her frustrations. Eventually the anger gave way to just sadness, and seeing this transition—although it was really just acting—gave me confidence and peace of mind in knowing that it’s ok to just agree with a client about the sucky situation and just let them talk. You can’t make a bad situation not suck, but you can be there as a human being and listen to them.  Sad, but touching. And instead of making the client angry that you didn’t help them, they will remember your compassion (and hopefully not write nasty reviews about you on Google!).

Tomorrow, we will do more communication lab work. The actors were fantastic, and the scenarios forced us to not worry so much about the medical/technical side of things so much as focus our attention on our communication skills.

I’m already looking forward to bringing these skills back to work with me, as I know I will be able to employ them immediately!!

Treat the patient, not the numbers

Photo Credit: Lewis Cole

I remember in vet school, one of the clinical instructors said, “Treat the patient, not the numbers.” One of our patients was a miniature schnauzer with pure red cell aplasia–her bone marrow wasn’t making red blood cells. Her hematocrit hovered around 8%!! Yet, besides tiring easily, she seemed perky and continued to eat well. We were discussing when to do a blood transfusion, and someone asked how low does the hematocrit have to be before you would transfuse her. But there is no absolute number–it depends on the patient.  Her anemia progressed slowly over time, so her body had time to compensate for the decrease in systemic oxygen delivery. (Side note: this is also the patient I will never forget because–sad part warning–she died mid-venipuncture to collect a tiny sample of blood. She literally couldn’t part with another drop of blood! Her final hematocrit was 5%.)

Another version of this saying goes, “Treat the patient, not the disease.” I can especially see how this rings true in human medicine. You go to the cardiologist for your heart. You see the ear/nose/throat doctor for your sinuses. You talk to a urologist about cystitis. You can end up on so many medications for this and that, with none of the doctors seeing the big picture: the person as a whole.

I try hard to not get too carried away with numbers, but I’m sure there are times when I could do a better job. For example, don’t we get all up in arms about elevated Alk Phos levels? I mean, how many clinically normal patients do you see with an Alk Phos greater than 800 and otherwise normal blood work? For me, it’s probably once a month or so? I do think further testing is warranted, to check for disease that is not yet clinical but may become so.

Going back to my first example of gradual-onset anemia. Take the flip-side. If you were presented with a patient who was white as a sheet and lethargic with a history of possible rat bait exposure, and the hematocrit was 20%, would you recommend a transfusion?

What I Learned This Week

Here’s a sampling of what I learned this week:

• Chameleons can’t convert beta-carotene to vitamin A
• There’s some kind of freeze-dried diet of cactus fruit for tortoises–cool!
• Necropsy on a 5-year old guinea pig revealed a large tumor inside her uterus–never seen something quite like that before
• Necropsy on a 3-year old budgie revealed one of the largest renal adenocarcinomas I’ve seen. The bird had demonstrated the predictable loss of use of its leg, mimicking a broken leg in the owner’s eyes.
• Over the past several weeks, I’ve had a crash-course in Mycoplasma infections in rats. Usually, when I see respiratory problems in rats, they’re on an individual case-by-case basis. A rat-owning client of mine recently acquired two female rats, not knowing they were pregnant, until they delivered 20 babies (between the two of them) three weeks later. All of them have been plagued with respiratory difficulties since then, and two have died. This week, I came across this article, which helped shed some much-needed light on the subject for me: “Mycoplasma pulmonis in Rats,” by Drs. Jennifer Graham and Trenton Schoeb, Journal of Exotic Pet Medicine, Volume 20, Issue 4 , Pages 270-276, October 2011.
• Palpated my first trigger point (see videos in my previous post)–wow, was it painful for the poor dog!!
• Evaluated behavior of a young but socially mature English bulldog with unusual, but severe aggression. He was adopted from an area shelter last November. He doesn’t seem anxious or fearful like most of my aggressive patients, but we’re pretty sure he has hearing loss. His behavior seems totally appropriate, and he’s very social. But if he becomes over-stimulated, it’s like a switch goes off and he gets a “crazed look” in his eyes. He has attacked the owner herself and the owner’s mother, sending the mother to the ER with serious injuries of her arm. The owner realizes that euthanasia is appropriate, and may ultimately be necessary. We are going to try an 8-week course of fluoxetine to see if that helps even out his excitability (in addition to strict environmental management). If it does, he will need to stay on it for life. I’ve never encountered a dog with aggression quite like this before–it will be an interesting road that we walk together.

It was a pretty good week, one in which I was able to help people and beloved animals. I don’t feel like I had any “do-overs” this week.

Videos related to pain management

When I come across an online resource of veterinary information that I find interesting and think others would find useful, I like to share it here! This week, I came across some videos on Vimeo that demonstrate some important concepts in veterinary pain management. Here they are:

1. From Dr. Rick Wall: m. psoas major examination & treatment – As the veterinarian palpates the affected muscle belly (psoas major), you can clearly see from the dog’s reaction that the area is painful and needs treatment. Two patients are demonstrated in this video, a black dog and a boxer with short haircoat/lean figure. Dry-needling is also demonstrated, both with and without sedation. Be sure to watch the whole thing!

2. From Dr. Rick Wall: Feline Hyperesthesia Syndrome – This cat is extremely agitated and uncomfortable due to fleas. You can see by the convulsing that his response is far more intense than one would expect in a typical cat. The veterinarian gave him gabapentin, which modifies how the central nervous system perceives the pain signal, and you can see in the video that his agitation is less severe after receiving it.  [I had trouble embedding the video–click this link to see the video on vimeo.]

3. From Dr. Mark Hocking: Canine pelvic quadrant trigger point examination – Helpful narration explains what is being done and you can clearly see the dog’s response where he’s painful.

If you’re interested in learning more about trigger point examination and pain management in general, I highly recommend you join the IVAPM (International Veterinary Academy of Pain Management)–you will learn so much!!

Another resource I found recently (and it’s free!) is the Yahoo! group: triggerpointvet – you must be a veterinary professional to join, as membership/access is limited.

Do you know of other valuable pain management-related resources others might find helpful? Share them in comments below!