Ears smell

There are no, or at the very most very very few dermatologic emergencies. Also, if we haven't given you meds for your problem in over a year, you can be pretty sure that we're going to want to see your dog again. We may not consider it a recurring problem, thus giving you your coveted discount for a "recheck" exam if we haven't seen this problem in your pet for 16 months. Please don't show up at my door on Sunday morning with a pathetic dog who has an ear infection - we're open for EMERGENCIES! Please don't request a discounted exam, particularly because last time we required an exam for your pet before dispensing meds the next note in your record is that we faxed your pets records to another clinic.

In summary, ears are gross and I will smell like ears until I can shower. Ew.
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Do you practice what you preach?

My best friend asked me an interesting question yesterday, after getting the response to the standard question "what did you do today?". She asked, "how often do you actually do what you tell your clients to do?"

Well, frankly... not often. You see, I know better. What I tell my clients is what I need to tell them to give them the best chance to get through a circumstance that I don't necessarily know the outcome to. This presumes that they don't know what an infection looks like, that they are going to let their animals go play at an off-leash dog park after major surgery, that they don't recognize subtle pain in their pets, and all sorts of things that I know that I won't do. But I don't know that you won't do them.

So yes, I neutered my cat on a whim, not fasting him the night before. My logic - he's 9 weeks old, I wouldn't have fasted him for more than an hour or two anyway due to his age. Granted, the time and situation was dictated by boredom rather than careful planning ahead, but surgery is surgery. I had time, space, material, and help while doing it, which is all I ask for.

I didn't give him as much anesthesia as I would have given a client's cat in the same circumstances. I give my patients the amount of anesthesia that they need so that I can be positive that they will not wake up during the procedure, that they won't remember it, or feel any pain. In my own cat, I gave just barely enough to finish the procedure - knowing that he would wake up faster and that I would be on hand to monitor his recovery and pain levels very closely. Is this hypocritical? Maybe. Is this something that was in Alexander's best interest? Yes, he recovered quickly, he was a known quantity to me, and I ensured that his pain was well controlled. Is this something that I should be maybe doing with all my clients' pets? Should I be using the lowest possible dose of anesthesia so that they have fast recoveries? Probably not. In this situation, I was not going to be leaving Alexander overnight at the clinic, he'd have to be awake and alert that evening at home. 99% of our surgeries stay overnight, and they are able to have a slow recovery in an enclosed area where their pain and mobility is managed. I don't think that I would *trust* most of my clients to have a pet home that night - what if the pet fell down the stairs, started bleeding, started chewing at the incision, etc. I know what to do and have the resources to deal with it - others don't.

I took Xander home the same night, letting him even play with my older cat. Again - I was able to gauge his level of alertness, and recognized if I'd gotten him in over his head. If he hadn't been able to hold his own at home, he would have been restricted to a single room or a crate to recover without interference. Would I trust my clients to make this same assessment and decision... no.

I guess what it comes down to is that I assume the lowest common denominator for my clientele. And while I've often been pleasantly surprised to find out that they are more competent, observant, or rational than the average person, as often as not I find out that people are making decisions that aren't in the best interest of their pet.

Also, I'm one of the biggest culprits for telling people to bring their pet to the veterinarian. I cannot diagnose things over the phone - god knows I've tried. In fact, yesterday I diagnosed constipation over the phone. Today, after having set up all the materials needed for the 9:30 appointment and enema... there was no stool in the colon. At all. Boy, did I feel silly. I have best guesses and gut feelings. But unless you have had the opportunity to at least hear about a possible diagnosis, if not have seen it or treated it yourself, it's very difficult for you to look at something and know that it is or isn't something that needs medical treatment.

I'm starting to realize why veterinary school is shaped the way it is. It's a fun feeling.

Alexander the Great

This is unfortunately the season of euthanasias. Some animals can't make it to the new year, some families finally have children and extended family all in the same place, some people are finally home enough to be able to make a decision. Regardless, no euthanasia is every easy for me.

I hate being with people who have spent a lifetime with a pet and now have to say goodbye. I was lucky when I first started working and had a long string of "perfect" euthanasias, where I was able to get the vein quickly and the animal died gracefully. I have since had my share of euthanasias that have not gone well, including some where the animal has had such a low blood pressure or such scarred veins from repeated treatments and diagnostics that I was ready to cry from the difficulty of doing an IV injection without even considering the circumstances.

I'm hoping that things will be better this year. I have been a vet for over 6 months now, and the very sharp learning curve of the first year is slowly starting to level out. That said, I diagnosed new things I'd never seen before even in the last week, and done surgeries that I'd never done before (removing a needle from a cat's intestines).

The most important thing that happened here in the last week though was that we have added a brand new member to our family - a 9 week old kitten named Alexander. Our apartment is about as full as we can cram it, with 2 adults and 2 cats now. We're going to have to move before we can consider getting another pet at this point.

Since Monday, we have gone through stages of hissing that today culminated in chasing one another across the apartment and wrestling with true play and enjoyment. I think Oberon (the older cat) is finally starting to come around. We hope that soon they will both hang out in bed with us on our lazy mornings and we can have a lot more purring!

Brownie Points

I frequently give out "brownie points" to my technicians (and sometimes my fellow doctors) at work. These aren't anything that I keep track of, much less remember from day to day who I've even given them too.

Sometimes it comes in the form of, "brownie points to whoever can tell me where I left this chart", or "brownie points if you come up with a good treatment plan for this patient".

Other times I give them out more as recognition that someone took the initiative to do something less than pleasant. Someone was going to have to do it anyways, but it's nice when someone does it cheerfully and quickly. For example, "you gave him a bath after he danced in diarrhea?!?! glad it wasn't me, you get brownie points!!"

Yesterday I made a big batch of oatmeal chocolate chip cookies, and today I brought them into work to share. I told everyone that if they needed an excuse to eat cookies (as many of us generally do), they could tell themselves that they were redeeming their brownie points!

Maybe next time I'll make real brownies - I even have a recipe bookmarked for one that includes ingredients I have in the house!

My First CCL

First time for everything - and today it was an cranial cruciate ligament tear in a 90-pound 5-year-old yellow Labrador Retriever.

She was the perfect candidate for the tear, and I had diagnosed her after seeing her for a mere 5 or 10 seconds in the lobby. She bounced towards me, completely non-weight bearing on her left hind leg. I asked her to sit for me like a good girl, and when she did she flipped that knee right out, refusing to put it where it belonged. Classic. I informed her that her daddy and I had a very expensive discussion to have, and invited him into the exam room.

She had all the right history, she was out hunting (her collar read "forever pheasants") on Friday, and she came up lame all of the sudden. She wanted to keep hunting. Dad kept her quiet for the weekend, but she just didn't spring back by this morning. Her knee was lax and swollen, but everything else about her looked great.

We took x-rays, I checked with my boss (the TPLO guy), and went in to deliver the damage to the poor owner. $200 for today's visit. ~$2000 to do the surgery here. ~$2800-3100 to do it at the U. He's gonna call me back to let me know where he wants to do the surgery - all he wants is for her to be able to hunt again.

I think they would both be devastated if she couldn't.

The pyo that took a month

I first saw her, S, for drinking more water. She was a 9 year old Chow crossbreed dog. She had never been spayed, but otherwise was kept well by a young man without too much money to spare. After careful interrogation, I determined that there was really nothing at all wrong with her other than she had quadrupled her water intake in the past week or so.

As any good new grad would, I looked in my brain for the most obvious things. An older intact female who was at the very least PD (polydypsic) - obviously it was a pyometra, or an infected pus-filled uterus. Other options for polydypsia included kidney disease, urinary tract infection and kidney disease. X-rays at our clinic are $150, a CBC and chemistry profile is $110, and a urinalysis plus culture is about $120. Due to the financial constraints of this situation, I had to go with the most likely causes of disease. She was acting totally normally, and her temperature was normal. She had no pain in her abdomen, no vaginal discharge and I had no reason other than instinct to order abdominal radiographs.

Her urinalysis was normal, although her specific gravity was a little lower than I would have hoped. Her urine culture was negative. I did manage to convince her owner to run bloodwork when she was just not acting well a couple of days later. Because I was still curious about pyometra, I did a vaginal swab (negative) and an abdominal tap (negative). The bloodwork came back with a mild mature neutrophilia, a mild non-regenerative anemia (anemia of chronic disease), and a completely normal profile.

I didn't treat S with anything at that time. I explained the symptoms of pyometra as a surgical emergency, gave him directions to the e-clinic and sent him on his way. I didn't hear back from him for almost a month.

She appeared back on my schedule about a month later, unexpectedly. The appointment book said that she was not eating and that she had lost some weight. When she came in, I immediately noticed a couple of things. First, she had obviously lost a significant amount of weight, about 10 pounds. Second, she smelled awful! I lifted her tail to take her temperature, and asked if she had been having any diarrhea. Her hind end was coated in fetid material. Her owner denied any abnormal stools.

I pretty much didn't give the owner a choice at this point, we were going to do some x-rays (the last thing on my original 'want list'). We took her in the back and gave her a butt bath, and clipped some of the matted fur. X-rays were pretty clear - a grossly distended uterus. I again did an abdominal tap - this time easily acquiring 3cc of bloody purulent fluid. It then clicked on what the "diarrhea" was - it was pus, resulting from an open pyometra.

An open pyo was definately preferred, as it was about 5pm and the last thing I wanted was emergency surgery. I gave him the estimate and prepped her by giving a shot of antibiotics and a liter of fluids subcutaneously. He was scheduled the next morning to drop her off for surgery.

Surgery, like almost nothing else in this case, went textbook perfect. I had a vet student with me, and she had fun scrubbing in and helping me out. She was bright, alert and eating the next morning. More than she'd eaten in a long time. She went home that afternoon on antibiotics.

A week later her owner was pleased to report that she was bright, alert and eating normally again. Success! Score one for intuition. :)

New Directions

This blog needs to change direction I guess. I graduated from vet school this past spring and am now working at a 3.5 doctor practice in a moderately affluent neighborhood.

To sum up: I received my masters in public health in september of 2007 and my doctors of veterinary medicine in may of 2008. I took 3 weeks off and started full time at this small animal practice. Another new grad started with me at the same time, and the last full-time doctor has been practicing for about 15 years. The clinic owner has been in practice for about 10 years, and splits his time pretty evenly between the two practices that he owns.

Once the first 8 or 10 weeks had passed, I started seeing very few new things. I quickly became proficient at the everyday things: vaccinations, ear infections, acute and chronic vomiting and diarrhea, kidney disease, food allergies, etc. Even the things that I have come to think of as routine can be unique and interesting depending on the client and patient. Seeing these things frequently means that I have become more adept at diagnosing them and have perfected my "speil" that I give while explaining the diagnosis and treatment process it has also enabled me to better explain to clients the specific challences and difficulties that they may face while following through with the course of treatment.

But, as usual, it's the new and different things that keeps things fun and interesting for me. Last week I did two surgeries that I had never done before, both reproductive. The first was a pyometra (infected uterus) which has a story that almost deserves its own post. The second was a cryptorchid (retained testicle) cat. Both went off without a hitch, and I'm very proud of myself.

In the meantime, I'll try to keep my eye out for fun and interesting cases and post about them more often. Also, some housekeeping around the website to update some of the blogs that I follow.

It's almost over now

And so another year has passed, and I have continued to be incapable of updating this blog on even a monthly basis. I can't decide if it's because no one actually reads it or because I'm not invested in it. I'm not sure it actually matters. Vet school will be over in 4 weeks, so this blog naturally must come to an end.

I defended my MPH in September and received my degree. My thesis was on MRSA and resident animals in a long-term care facility. I'm proud of myself for finishing it while being in vet school. It has been fun to sometimes put "MPH" at the end of my name when writing discharge letters :) I'll be able to put on the DVM in a month, so that's even more exciting.

I'm currently on Cardiology. I have radiology and emergency remaining prior to graduation. I'll try to find a fun case to write up for people to think about. But in the meantime, this is all the update I appear to be able to provide. And you wonder why I don't bother blogging - nothing interesting to write!

E.J.

His name was E.J. I never asked what it stood for... only now does it occur to me to wonder. He was a middle aged cat. A gray tabby with longer fur. He started off beautiful, but days of hospitalization, eventually with an e-collar, caused his coat to become grungy and gross.

He had bladder stones that he couldn't pass. And when he tried, they got stuck in his urethra, and he became blocked. A week ago, he presented to the emergency clinic for this problem. It was the first time it had happened to him. His owners weren't properly educated on what this meant in terms of lifestyle changes, diet changes, and survival time. Bladder stones are managable, they can be influenced by diet and water intake. They can be removed with surgery. They can be an incidental finding that will never affect the health of the animal.

But E.J. had problems from his. And each time the stones reentered his urethra, he had to be anesthetized again. He blocked 4 times in the last week. Yesterday, we did a cystotomy. That's the surgery where we go into the bladder through the abdomen and scoop out all the stones. It was like picking grains of sand out of a beach blanket. The stones were tiny, most of them. Many he could likely pass on his own. But two were larger, round stones that were small enough to enter his urethra from the bladder, and large enough to not be able to pass all the way through. We took out 30+ stones. Carefully flushing and flushing and flushing until we were convinced that the larger stones were all gone, and anything too small for us to remove would probably be able to be passed on his own.

We closed the abdomen. We took a radiograph that showed a nice bubble of air in his bladder, but no remaining stones big enough to be spotted. We placed an indwelling urinary catheter, because his urethra has been traumatized so many times in the last week that we wanted to relax it while the inflammation died down. Amy went to make some phone calls. The technicians were placing a new IV catheter, because his current one (though working well throughout surgery) had been in for 4 days and was at increased risk for infection.

They walked away for 10 seconds. Both new catheters were in, he was still on the table on anesthesia. The pulse-ox slipped off his tongue and the alarm went off. Gail went to replace it, and noticed he was very pale. Then she noticed he wasn't breathing. We located doctors, three of them.

We did CPR for almost 10 minutes. We used epi, atropine. We ventilated him at 40 times per minute, we pumped his heart as fast as we could (you try making a heart beat 150 times/minute). We watched the ekg each time we paused. He didn't make it.

A week ago, before first going to the emergency clinic because he couldn't pee, he was a healthy cat. Whatever stones may have been present were not affecting his life at all. Yesterday, he died. The owners elected a group cremation, with no ashes returned.

Ethical Dilemma

S is a 11 month old Doberman Pinscher. She is not spayed. She is purebred with papers. She has a class III malocclusion, an anterior crossbite (example in picture below), and "rostral flare" of her lower incisors.



A class I malocclusion is just when the front teeth (between the canines) don't quite meet the way they're supposed to. It is presumed to be some combination of factors including environment, congenital, genetic, and dumb luck.

A class III malocclusion is when the mandible is just a little bit too long, and rather than the top teeth fitting nicely and prettily over the bottom, instead they either meet straight on (try it, you can see how it would hurt after a while) or have the "bulldog look". Class III's are considered to be a genetic skeletal deformity, where the pre-molars and molars are involved to some degree as well as the more obvious incisors.



(For reference, a class II is when the maxilla is waaay to long, and a class IV is severe skeletal deformities like where the teeth don't even meet in the front, or one side of the mandible is longer than the other.)

Dogs that are shown are typically in the highest demand for breeding and continuing the lines of the breed. As a result, they need to be the best genetics available, and breeding dogs with cranial skeletal deformities is not in anyone's best interest.

S's owner came to the dentistry clinic when she was about 6 months old. In hand, he had an article written by the AKC for judges about how to spot (and disqualify) dogs who have had orthodontic work to correct malocclusions. The article had a picture of a dog with an expansion device, which many people I know had as children in conjunction with their braces. The expansion devices angle the teeth outward appropriately so that the skeletal abnormalities are disguised and the dog has a normal bite.

He pointed to the device in the picture and said "I want that for my dog."

After many hours of ethical discussions amongst themselves and with the owners, my clinicians ultimately decided to use the expansion device to correct S's malocclusion and crossbite. The owner desires to show this dog, and insists that "no other dogs in the line have any teeth problems".

I have several major ethical issues with treating this dog and working with this owner, which I will briefly highlight, along with some pertinent facts.

1) The dog is in no pain and has no quality of life issues with her current bite.
2) The dog is an intact female that may be bred in the future, potentially to relatives.
3) The dog is intended as a show dog, and judges are clearly *taught* to look for these changes.
4) There is no real way for us to "report" this owner to the AKC.
5) In order to become board certified in veterinary dentistry, a resident must perform and document two orthodontic device fitting and placements.

Personally, I have decided to not treat an animal when placed in this situation. While I would be happy to place the device, I would do it on contingency of spaying the dog. As a student, I abide by the choices of my attending clinicians.