Category Archives: General medicine

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 13th.

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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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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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Parvo positive?

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"Please, not the pink stuff." (Photo Credit: West Hills Animal Hospital)

Last night, about 5:30pm, my receptionist said a new client (someone we’d never seen before) called because her puppy was just diagnosed with parvo and she wanted to have it euthanized. Would I be willing to do it? I said yes, and agreed to stay late, for the puppy would be arriving about a half hour past closing time.

I dreaded her arrival and doing what I had already agreed to do. But when the owner arrived, things went quite differently than I had expected. She was upset, understandably, and during her hour-long drive to come see us, she started thinking about alternatives to euthanasia. She was especially upset because the vet who provided the diagnosis gave her no information and no options for treatment. “Is there anything I can do for her?” she asked.

It’s not exactly something to be proud of, but our hospital does have a lot of experience treating parvo, and we have (what I feel is) a pretty good protocol in place. We even have a 3-day “initial treatment of parvo” treatment plan already made up in our computer system. I reviewed this with her, along with key information all owners should know about parvo:

  • It’s a highly contagious virus, and puppies and unvaccinated dogs are at greatest risk
  • The virus attacks the neutrophils, the type of white blood cells responsible for fighting infections
  • It also causes breakdown of the lining of the intestines (I don’t see value in explaining the important role of the villi and how they’re destroyed, even though I find it interesting and relevant–there’s just not enough time to cover all that), leading to severe diarrhea and absorption of “bad” bacteria into the bloodstream, eventually leading to sepsis
  • Dogs/puppies with parvo tend to shed the virus for about 7-10 days, so patients are often treated for a full week
  • We usually know within the first 3 days whether or not the patient is going to survive

The puppy’s presenting complaint at the other vet was related to an episode of bloody diarrhea. She had just bought the puppy on Sunday, and the puppy had diarrhea on a Monday. The other vet performed (I assume) a parvo snap test using a swab of fecal matter. Naturally, the owner wondered if it’s possible to have a false positive, and I said yes, it’s possible. “When was she last vaccinated for parvo?” I asked. Apparently, the breeder had given the vaccines herself, “shortly before” the puppy came home. (We don’t know if that means hours before or days before.)

Normally, I place an IV catheter and get started on fluids and antibiotics right away for these puppies, but “normally”, parvo puppies don’t have much appetite and this puppy wolfed down some Critical Care food I set out for her. (Thankfully, she didn’t throw it up either, which I would have expected a sick puppy to do!) When my initial blood work revealed a normal CBC and no significant changes in the chemistries, and my recheck parvo test was negative (admittedly it didn’t have a lot of stool sample on it, so I couldn’t get too excited yet), I started to doubt whether she was truly sick.

But when I checked on her the next morning, and she was clearly feeling very good (especially those strong vocal cords!), I tried retesting her parvo test again, with a better sample. Weakly positive.

We continued to monitor her throughout the day (and had her on prophylactic metronidazole and clavamox) in our isolation ward, but when she passed a very normal-looking stool in the afternoon, and a recheck CBC was still normal, I pronounced her as normal, with a false-positive parvo test.

And to think, we came soooo close to euthanizing this perfectly healthy baby! Thank God the owner trusted her gut that euthanasia was not the right answer, and was willing to spend $1000+ to treat (the final total was far less than that, of course, but my initial treatment plan was in that ballpark, and we had no idea how things were going to play out). She thanked me again today, as I sent the puppy home, for providing me with the information and options that the other vet had not delivered.

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