Tag Archives: veterinary medicine

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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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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I Couldn’t Live Without: Cerenia

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I’ve decided to start a new category, “What I Couldn’t Live Without,” and I’d like to post a product or useful device that makes my life as a small animal veterinarian easier on a daily basis. Today’s can’t-live-without item is Cerenia.

Cerenia, or maropitant, is a wonderful anti-emetic. It comes in two forms: oral tablets and injectable solution. I feel safe and confident using it in many of my vomiting cases. In fact, that’s one way I know something is seriously wrong–I gave them cerenia and they’re still vomiting. Of course, xrays/ultrasound are important for investigating causes of vomiting, but I don’t see any reason why a patient shouldn’t get a Cerenia injection if they’re feeling nauseated.

VIN (the Veterinary Information Network) had a Rounds discussion not so long ago on this very topic, entitled, “Cerenia: Is It The New Anti-Inflammatory, Anti-Allergy, Analgesic, Anti-Emetic, Anti-Obesity, And Antidepressant Wonder Drug?” (if you’re a VIN subscriber, you can access that link; if you’re not a VIN subscriber, then I ask you, “Why not???“).

A summary of the Rounds is as follows:

  • Cerenia (maropitant) is a tachykinin antagonist which acts by inhibiting the binding of substance P.
  • Cerenia is labeled only for treatment of nausea and vomiting, but can potentially be used extra-label for pain, inflammation, GI disturbances, allergies and immune diseases, bladder inflammation, CNS and spinal cord injury, and mast cell diseases.
  • Treatment schedules should be 5 days on, 2 days off or every other day as continuous dosing depletes substance P which leads to tremors.

With all these benefits, why wouldn’t it be one of my favorite drugs? The VIN discussion includes a lot of other really useful and interesting information (way more than I ever thought I wanted to know about Cerenia but am now glad to know!), and I encourage you to read it over.

Cerenia is labeled for dogs, but it can be used in cats too. In fact, I gave it to two different cats in one day recently. It’s also touted as a useful aid for motion sickness in dogs. It doesn’t cause drowsiness, unlike Dramamine, which I’ve also suggested for dogs who get sick while riding in the car.

Practice Tip: Cerenia stings, but it stings less if cold–so wee keep the bottle in the refrigerator! We’ll also give it with SC fluids (when indicated) to help reduce the sting.

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