Monthly Archives: May 2012

Treat the patient, not the numbers

Dog Silhouette

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?

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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.

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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!

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How veterinary medicine is like pediatric medicine…and how it’s not

Almost daily, I hear pet owners justify their behavior towards their beloved pet by saying, “She’s like my child,” or “He’s my baby!” Does this mean the person thinks their four-legged animal is equivalent to a human child?

I can’t answer that–partly because every situation and relationship is a little different. What I do find intriguing is how similar my job is to that of a pediatrician–with some important differences.

Top 5 List of How Veterinary Medicine is Like Pediatric Medicine

  1. Our patients can’t talk. Both pediatricians and veterinarians must rely on their history-taking and diagnostic skills to achieve a diagnosis. The parents need to be able to give us the information we’re looking for, and they can’t always answer our questions. (Although a pediatrician probably doesn’t hear, “I don’t know, he goes in the backyard” when asked if a child has been having loose stools!)
  2. Our patients don’t understand what we’re saying.  This is hard to accept, but it’s a reality that our patients may be scared out of their mind, and we can’t explain what’s happening to them, or why we have to get a blood sample, or what to expect with a particular test or treatment.
  3. Our patients require a caregiver. Unlike an adult human patient, who you can give instructions to, our patients rely on someone else to follow the doctor’s instructions. Some parents follow the doctor’s instructions to a T
  4. Parents–of any kind–just want reassurance that their baby will be ok. I was reminded blatantly of this when I took my three-month old daughter to the pediatrician with RSV. The nurse practitioner was talking fast about a bunch of stuff that I didn’t fully understand, and all I really wanted to hear was, “She’ll be ok.” I try to remember this when faced with a similarly-anxious pet parent: talk slow and be reassuring (when possible).
  5. As the doctor, be prepared for an interrogation of sorts regarding the why’s, what-if’s, and how-t0’s. Because of all the reasons I just listed above, the parent feels a huge responsibility and wants to be sure he/she understands the situation well enough to do right by their little one.

…and how it’s not:

  1. Due to completely different rules regarding insurance, pet parents are required to pay in full, at the time that services are rendered, which can vary from hundreds to thousands of dollars. That is a hard pill to swallow for the average American family that already has their own health care to pay for.
  2. Ultimately, pets are NOT humans, so no matter how strong the human-animal bond is, there will be some unavoidable differences between a relationship with a pet and owner versus a child and parent. We know the life expectancy when we bring an animal into our lives–we may want it to live as long as we do, but we know that it won’t. We also can’t take the pet with us everywhere we go (usually), like we would a child.
  3. We can’t even begin to compete with the federal assistance programs (social welfare) that are in place to help children in troubled homes. Although many non-profit organizations exist to support the welfare of animals, they are not federally mandated or funded, nor should they be. Animals will always be lower on the totem pole in our society, so it’s an inescapable truth that pets (in a general sense) will never receive the full spectrum of care and support that humans do. But it is thanks to those non-profits that some pets can receive help and support.
  4. Veterinarians see patients through the pets’ entire lifespans, not just the pediatric stage, so we see a wide spectrum of age-related illnesses. Pediatric doctors obviously just see people during their early life stage.

Of course, there are many more reasons and ways that veterinary medicine differs from pediatric medicine. Can you list some?

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It’s never a good time for an emergency…

At vets

Photo credit tamurray5 (flickr)

…but you can make time to prepare for one!

I’m a firm believer that planning for emergencies is one of the most important things anyone can do, for any type of situation! Perhaps I say this because I’m the founder and president of the Johnson County Animal Response Team (JoCART), and have climbed a steep learning curve to understand the ins and outs of disaster preparedness. Or maybe there’s an element of Murphy’s Law at work–if you’re prepared for a worst-case scenario, then it won’t happen!

Regardless, I felt a voice calling me to action this morning after reading a Clinician’s Brief article, Lessons Learned: Breathing Difficulty in a “Well” Cat (April 2012).  (A side note–I really love these Lessons Learned articles that spotlight a case gone wrong and what could have been done differently for a possibly better outcome. What a way to turn a negative into a positive and help others learn!) The article describes how a cat who presented for a wellness visit developed severe dyspnea, became cyanotic, and was euthanized due to a rapidly deteriorating condition. It was truly frightening to read and, like most veterinarians, I found myself wondering, “What would I have done in that situation?”

And with that, I announced to the staff that we would take advantage of this particularly slow morning we were having by running through an emergency scenario.

A short time later, one of the receptionists charged into treatment carrying a cardboard box with a lifeless toy dog inside.

“He’s not breathing!” she said.

“Here,” I said, taking the box from her and setting it on a treatment table. From there, three technicians swooped in and began assisting–one held the lifeless patient in her hands, another wheeled the anesthesia cart over and began administering pure oxygen via face mask, and another started retrieving and recording the items I was requesting. I told the receptionist to escort the imaginary distraught client to our comfort room so we could get to work.

It was hard not to feel at least a little silly “intubating” a stuffed animal, but everyone agreed that going through the motions and thinking through the different possibilities was very valuable. I loved seeing the great team work of our staff in action.

We know that emergencies come in all kinds of varieties, and they never show up at a convenient time, but I am truly grateful that this “Lessons Learned” article spurred us into action on an otherwise sleepy Tuesday morning. The cat featured in the article I read may not have survived, but thanks to the impromptu emergency response training it inspired today, perhaps we will be more ready to save a life tomorrow.

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