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Friday, October 9, 2015

Veterinary Life + Tech Week = No Rest

As I've posted about several times, my whole family is involved in community theater.  It's a really fun hobby and I've been involved in everything from Shakespeare to farce comedies.  My wife and I do two to three shows per year, and are currently about to open on our latest one, The Crucible by Arthur Miller.  It's a classic story with some incredible language.  I have a relatively small role, that of Thomas Putnam.  Here's a photo of me (on the left), having grown out my beard for the show.

While acting is fun, it can be quite a stressful time when combined with my regular job.  This week we've been in "Tech Week", or as it is often called, "Hell Week".  For those of you who aren't thespians, this is the period just prior to the first performance where you rehearse every night in full costume to try and work out the kinks, lighting, sound, and so on.  It is a lot of work but it is important to get everything as perfect as possible before we have an audience.  My problem is that I've been doing it after a full day at work.

I leave for work about 8:15 in the morning so that I can get to the clinic before 9:00.  I work until 7:00 in the evening, and lately have been busy enough that I haven't been able to take much in the way of a lunch break.  Typically I'm eating lunch while writing up medical notes and calling clients.  I leave work and go directly to the rehearsal, getting there around 7:30.  The show has about a three hour run time, so with a break at intermission and discussions with the director I'm not getting home until after 11:00.  

Take a 10 hour work day, add three and a half hours of acting, throw in driving time, and all this week I've been spending a total of nearly 15 hours away from home.  By the time I get home at night I'm absolutely exhausted.  At the end of this week I will have done that for five days in a row.

I'm looking forward to Monday, which I have off work and where I won't have anything to do with the play.  I will definitely be sleeping in that day!

Saturday, October 3, 2015

Come On, Halloween! Get Anatomy Right!

It is getting close to one of my favorite times of the year.  I love Halloween!  It was always a fun event growing up, and I've always loved costumes and spooky themes.  I get really excited when the Halloween decorations start to crop up in stores, and start making regular trips to see what new things they have each year.  And don't even get me started on the fun of specialty Halloween Stores!

This year I noticed far more animal skeletons than I've ever seen before.  As a veterinarian as well as a Halloween enthusiast, this was a double bonus to me.  However, I noticed some problems.....

It starts out well enough, with some cool skeletons and skulls.

 I'd have fun displaying these all year!  But then I noticed some anatomical issues on other skeletons.

Do you see the problem?  Can anyone tell what's incorrect about the cat and rat skeletons?  It's the ears!  A skeleton is made of bone, and the ear flaps (pinnas) are cartilage.  Therefore you will never see the ears on any skeleton.

Okay, this bothered me a bit, but I understand that it is harder to quickly identify the skeleton without the ears, at least for a layperson.  So I was willing to let this slide since the rest was so cool.  But then I saw the skeleton that sent me over the edge.

Please tell me you see the problem!  Spiders don't have endoskeletons!  THEY DON'T HAVE BONES!  There are no leg bones, spine, or ribs on an arachnid!!!!  Spiders are supported by exoskeletons, which is basically their entire body.  

Here's what such a thing actually looks like.  The two left objects are shed exoskeletons, while on the right is the live spider.  

A dead spider wouldn't look like the Halloween decoration!

I know this is a minor issue to most people, and I'm probably one of the few that even notices this.  My wife has had to hear my rants every time we see the spider skeletons in stores, and she patiently lets me get my frustrations out.  But this really does bother me!  I don't expect complete scientific accuracy in a holiday decoration, but at least don't be so glaringly wrong!

Wednesday, September 30, 2015

Leptospirosis Cases Increasing. Should You Vaccinate?

I can't think of a more controversial vaccine than Leptospirosis.  Many people, especially certain breeders, think that it is dangerous and should never be given.  But the disease is potentially fatal and can be transmitted to humans.  So what should you as a pet owner do?

First, let's understand what "lepto" really is.  Here's a summary from the Centers For Disease Control website:  

Leptospirosis is a bacterial disease that affects humans and animals. It is caused by bacteria of the genus Leptospira. In humans, it can cause a wide range of symptoms, some of which may be mistaken for other diseases. Some infected persons, however, may have no symptoms at all.

Without treatment, Leptospirosis can lead to kidney damage, meningitis (inflammation of the membrane around the brain and spinal cord), liver failure, respiratory distress, and even death.

That sounds pretty serious, doesn't it?  And it really is.  While we don't see the disease often, it is very serious when it crops up.  Why don't we see it appear as frequently as it used to?  Because we've done such a good job of vaccinating against it.  But it's still out there, and in increasing numbers.

Again from the CDC's website:

The bacteria that cause leptospirosis are spread through the urine of infected animals, which can get into water or soil and can survive there for weeks to months. Many different kinds of wild and domestic animals carry the bacterium.

These can include, but are not limited to:
  • Cattle
  • Pigs
  • Horses
  • Dogs
  • Rodents
  • Wild animals
When these animals are infected, they may have no symptoms of the disease.

Infected animals may continue to excrete the bacteria into the environment continuously or every once in a while for a few months up to several years.

Humans can become infected through:
  • Contact with urine (or other body fluids, except saliva) from infected animals.
  • Contact with water, soil, or food contaminated with the urine of infected animals.
The bacteria can enter the body through skin or mucous membranes (eyes, nose, or mouth), especially if the skin is broken from a cut or scratch. Drinking contaminated water can also cause infection. Outbreaks of leptospirosis are usually caused by exposure to contaminated water, such as floodwaters. Person to person transmission is rare.

So anywhere that there are wild animals coming close to domesticated animals there is risk of lepto transmission.  If an infected wild animal urinates on the soil or in a water source, and your dog then drinks from that source or licks contaminated soil from their paws, there is a risk of infection.  And then if your dog becomes infected, it is a risk for anyone in your home to also contract the disease.

For my entire career (since 1997) there has been a perception among many pet owners and a LOT of breeders that the Leptospirosis vaccine was dangerous and should never be given.  I've even seen handouts from breeders that explicitly state that if a vet tries to give the lepto vaccine the new pet owner should find another vet.  This belief seems to stem from an impression that this particular vaccine has a significantly higher rate of serious reactions than any other vaccine.  Unfortunately these breeders are owners are very misinformed, even dangerously so.

A recent article in Veterinary Practice News highlights the increasing risk of lepto even in urban settings.  Here are some relevant quotes from that article

“Since 2013 in Florida, we have seen a 10-fold increase,” explains Carsten Bandt, DVM, Dipl. ACVECC, assistant professor of Emergency Medicine and Critical Care at the University of Florida College of Veterinary Medicine.

Although it was once most prevalent in regions with high annual rainfall and warm climates, current indications are that dogs with leptospirosis are found throughout the U.S.

“We are a tertiary center that sees two to three cases of leptospirosis a month in the warmer months,” said Julia Veir, DVM, Ph.D., of Colorado State University in Ft. Collins. “Our patients come from southern Wyoming and across the front range, the area from Denver north to Ft. Collins.”

“It is a bacterium that is spread from the urine of mammalian species like raccoons, mice and rats,” Goldstein said. “If a dog licks a puddle on a sidewalk, or walks in wet grass or in parks where wildlife would urinate, they can ingest the bacteria.”

“It is very rare to see a dog who was vaccinated get the disease,” Goldstein says. The first dose is two shots followed by one shot each year.

“The vaccination is effective against the four serovars of leptospirosis and may provide some cross protection against other serovars,” Dr. Harkin said.

It should be apparent that this is still a serious disease, and one that is actually increasing in incidence in various parts of the country.  Virtually all dogs are at risk for the disease, and there is no way to tell whether or not a pet is being exposed when they contact water or wet soil.  With this information in mind it should be easy to see the rationale for prevention.

But what about the often-touted idea of the vaccine causing horrible reactions?  Is it worth that risk?

This idea has no data to support it.  In fact, if you find anyone who states this as "fact", I challenge them to provide actual objective proof that the vaccine is more reactive than any other.  ALL vaccines carry some risk of causing a reaction, and rarely is that reaction truly life-threatening.  I've seen two different studies that have looked at vaccine reaction rates, and both of them showed no significant difference when comparing Leptospirosis vaccines to other vaccines.  "Well, I've been breeding for 25 years and I've seen plenty of bad reactions" is a subjective, anecdotal assessment, and is not actually any proof that would stand up in science or a court of law.  In order to prove a statement like "lepto vaccines are highly likely to cause bad reactions" you need to have numbers and statistics.  Not only does that data not exist, but the times it's been examined the numbers have actually shown that it is no more reactive than any other vaccine.

It's also important to note that there are several companies that make animal vaccines, and each company's vaccine is slightly different.  One company's vaccines may have a higher reaction rate than another company's.  In fact, my practice revised our vaccines in 2014, and the number one criterion we looked at was the reaction rate between manufacturers.  That data made us change the brand of some vaccines.  It's impossible to make a blanket statement "all lepto vaccines are reactive" when the rate of reaction varies depending on the brand.

So a breeder tells you never to give lepto because in their 25 years of experience this vaccine will almost always cause serious reactions.  Well, if we want to stick to subjective information, I can clearly state that I've been practicing for 18 years and in the veterinary field for 32 years, and I haven't seen lepto cause significantly more reactions than other vaccines.  I rarely seen vaccine reactions at all, and when I have it's to pretty much any vaccine on the market.  Lepto doesn't jump out to me as a dangerous vaccine.  

Now you have a choice....take the opinion of someone who has been breeding dogs for several decades, or take the opinion of someone with a medical degree and access to scientific journals who has been in the heart of veterinary medicine for the same amount of time.  Which opinion do you think is more likely to be informed and accurate?

Here's the bottom line for me.  Leptospirosis cases decreased after we started vaccinating for it.  In the last 20 years as we've seen an unfounded opinion that the vaccine is a problem, and therefore fewer pets are being vaccinated, we've seen a steady increase in lepto cases.  This is made worse as the population has expanded into previously rural areas and wild animals have adapted to suburban and urban life, bringing their diseases into closer contact with humans and our pets.  In the article above you can see that cases have increased 10-fold in just a few years.  We have a safe, effective vaccine that is no more dangerous than any other vaccine.  I strongly believe that this is an essential vaccine, and unless a dog has a significant medical reason that makes them unable to receive it, all dogs should have it included as part of their regular preventative care.  

And yes, my dogs are vaccinated for it.

Wednesday, September 23, 2015

Double-Checking A Spay

Last week I performed a routine spay on an English bulldog.  She was in heat, so the uterus was a bit bigger than normal.   Vets don't like doing surgery on dogs in estrus because the vessels and uterus are larger, increasing the risk of bleeding and other complications.  However, most of us with good surgical experience will still do it, adding a charge to account for the extra time and materials (sponges and suture) it will take.  Over my career I've spayed plenty of dogs who were in heat and never had any serious problems.  But last week's spay came close.

The surgery was routine, but nearing the end I noticed some excessive bleeding.  I extended my incision and saw that one of the pedicles (the part we remove the ovaries from) was bleeding.  This happens sometimes, even with good, experienced surgeons.  We know that this isn't a huge problem, and is just a matter of re-clamping the tissue and putting more suture around the vessels.  As scary as it may sound for a pet owner, this is a relatively routine complication and is taken care of pretty easily by the vet before closing the abdomen.

So I identified the "bleeder", finished removing the uterus, and then stood there and waited.  Whenever I have an unexpected bleeder I wait several minutes after ligating it to see if there is any further leakage that I have to fix.  I'll use gauze to remove any mild capillary seeping and check for bleeding several times.  When I am convinced that there is nothing abnormal I'll proceed to close the abdomen, as I did in this case.  Everything was routine from that point on.

Until time for her to go home.

I had finished her surgery early in the morning so I had told the client to pick up in the early afternoon.  When we got her out to remove her IV catheter and take final vital signs I noticed a decent amount of bleeding from the incision.  This can sometimes happen when a subcutaneous vessel bleeds and is rarely a concern.  Typically it will stop quickly.  Unfortunately this dog's didn't.  In fact, as I pushed on the abdomen the bleeding became heavier and faster.  It was clear to me that this didn't appear to be a simple small skin vessel, and there was a very real risk that there was more internal bleeding that was now leaking through the incision.

So I did the right thing.  When the owner came to pick up we still had three hours left in the day.  We told the client that we needed to observe her longer and I had my associate take my next few appointments.  I immediately got the dog back under anesthesia and went in to look for the bleeding.  I didn't want to have to do that for multiple reasons, such as increased anesthesia risks, a higher possibility of infection, further tissue trauma, and just the time it would take.  But this had happened because of a surgery we did, and I didn't want the pet to end up at the emergency clinic that night or even bleed to death.  I took responsibility and went back in to find what was bleeding.

Here's where I was surprised.  There was a slight amount of bleeding at the incision, likely from a subcutaneous vessel or the muscle wall.  However, inside the abdomen there was no blood.  In a case like this where a major vessel may have slipped out of the suture, I would have expected a pool of blood in the belly.  But that was not the case.  I spent some time looking around, identified the surgery locations, and verified that the sutures were all still in place and tight.  I was puzzled because there was no apparent source of the heavy bleeding I had noticed just a few minutes prior.  I triple-checked, then stood back for a full five minutes waiting for blood to accumulate.  Nothing happened.  So I finally closed her back up.

The next couple of hours were pretty standard for a second post-op recovery.  There was no further bleeding and she recovered normally.  I saw her today for a recheck, and she was doing just fine.

It was a weird case because I never identified the source of the bleeding that had worried me enough to go back in on a second surgery.  Honestly, looking back I could have just placed a pressure bandage around her abdomen and she would have been fine.  But at the time I didn't know that and I don't regret my decision one tiny bit.

Friday, September 18, 2015

A Great Old Couple

Even though I may gripe about many clients, I have some absolutely wonderful ones.  In fact, most of my clients are great, and the obnoxious ones are in the minority. If all clients were "bad" I couldn't do this job.

One of my favorite clients is an elderly couple (we'll call them Mr. and Mrs. Charming) who are in their 80s and have been married for nearly 60 years.  I've been seeing their pets for many years.  One of their dogs was a very sweet, very old Sheltie.  They took great care of her for 16 years, and loved her dearly.  We finally had to euthanize her last winter, and it was hard on them.  Not long afterwards they got a new puppy, another Sheltie.  She actually closely resembles their other dog, and is just as calm and sweet.

Recently I was talking to another regular client in the lobby, and she gave me a hug because of how much she appreciated me taking care of her dog.  Mrs. Charming happened to be up there and I didn't see her right away.  She walked over and said "Why are you hugging my doctor?" with a smile on her face.  I turned to her and said "I have enough hugs for you too," and gave her one.  

The next day she and her husband brought their puppy in for her first heartworm test and routine checkup.  While there were there I recounted to her husband my experience of the day before, then asked "Does she get that jealous with you, too?"  Mr. Charming replied "No, she actually encourages me."  He chuckled and she rolled her eyes and playfully hit his shoulder.  

That is the kind of interaction they have.  You can easily tell that they care about each other and that he likes antagonizing her, but she's used to it.  The are one of the sweetest old couples I've know, and they take great care of their dogs.  All of my staff loves when they come in and I always look forward to talking to them.  They're very entertaining to watch, but very genuine and have a quiet love of life.  You can't help but smile when you spend even a short amount of time with them.  My only problem is that I'll sometimes loose track of time talking to them and almost forget that I have other patients.

I'm glad I have clients like the Charmings.  They make the day worthwhile.  

Friday, September 11, 2015

The Best Star Wars Toy Ever?

Anyone who reads this blog for long will quickly realize what a geek I am.  And I wave my geek flag proudly!  One of my favorite fandoms is Star Wars.  I've never really gotten into the "extended universe" novels and comics that became popular over the years, but that's not a bad thing for me since the new Star Wars movies and tie-ins are pretty much ignoring that in favor of a new canon.  But I've see the movies more times than I can remember, and have bought every version on VHS and DVD.  I remember seeing the original Star Wars movie in theaters in the '70s, and ended up watching it three times, something pretty much unheard of at that time.  I've seen every new Star Wars movie in the theaters since then, including any re-releases.  I had countless Star Wars action figures, and a Millenium Falcon, Snow Speeder, and Slave 1 to go along with them.
So of course I'm really excited about Star Wars Episode VII: The Force Awakens being released in a few months.  I've watched every teaser and trailer that's been put out so far, and am especially happy about the fact that they have most of the original actors returning to reprise their roles of Luke, Han, Leia, and Chewie.  For someone of my generation, this brings back some of the best memories of our childhoods, and really taps into some of our happiest moments.  How can one of us watch a trailer like these and not get excited?

On September 4th there was a huge marketing push called "Force Friday" where all of the new product tie-ins for the upcoming movie were released on the same day.  Yes, I went by the local stores and got to see some of the new merchandise in person, and yes, I was drooling over them quite heavily.  I already have a good bit of memorabilia in my home and my son has all of my old Star Wars action figures, but I can see myself getting some of these toys in the upcoming months.

There was a standout star, however.  The new droid, BB-8, has been making the headlines among Star Wars fans, in large part because he is a real effect like R2-D2 and not just a practical effect.  I have a feeling that he'll come to become as popular as R2 has been, at least if his personality is as strong.  I would have loved to have been there when the movie makers proved to the fans that they had build a working droid that rolls like that!

On Force Friday it was revealed that a company had made a real, working replica of BB-8 as a toy.  And it looks amazing!  I've been reading some of the online reviews, and this looks to be a big leap forward in toy robot technology.  Plus, he is so cute!

Even though it has a $150 price tag, I really want this toy.  And my kids do too, so I'm thinking about this as a joint Christmas gift to each other.  That is, if we can find it!  Apparently this toy has been the hottest thing on the market and everyone has sold out almost immediately after it went on sale.  The prediction is that this will be THE toy of the holiday season, and I can see why.

Anyone want to chip in to the "Buy Dr. Bern A BB-8 Toy" fund? 

Tuesday, September 8, 2015

What Causes Ear Infections? And How Do You Treat Them?

Probably one of the top disorders that vets see on a daily basis is ear infections.  Most days I'll see at least one, and often several.  Some breeds and individuals are prone to them and we may see those patients for chronic, ongoing, or recurrent problems.  So why do some dogs get them so often?  What can a pet owner do to help?

I wish there was a simple answer, but unfortunately there isn't.  Ear infections, especially chronic ones, can be a challenge to diagnose and treat, and every case is going to be a little different.  Ongoing issues can take a lot of time and money to get under control and are usually frustrating for everyone involved.

One of the biggest reasons for ear infections is simple anatomy.  Dogs with floppy ears are more prone than dogs with upright ears because there is less air flow and moisture can't evaporate easily.  If water gets in the ear and stays there it causes irritation which can lead to an infection.  With upright ears there is good evaporation of the moisture.  But floppy ears close off the ear canal and don't allow good evaporation.  You then get a dark, warm, moist environment which can be a great breeding ground for microorganisms. 

Excessive hair in the ears is another problematic factor.  Many small, fluffy dogs have hair growing not just around the ear, but down inside the ear canal.  Common breeds include poodles, shih-tzus, bichons, Maltese, and similar dogs.  Think of the hair in the canal like hair in your sink drain.  Normal moisture and debris gets trapped and has a hard time getting out.  Just like having to clean your drain, it is often necessary to clean the canal.  This involves plucking the hair from the ears, which can be uncomfortable for the pet (about as bad as plucking your eyebrows).  Groomers will typically do this as part of their services or if asked, and vets can always do this.  Plucking the hair opens the ear canal and removes some of the blockages, allowing for more thorough cleaning and evaporation of moisture.

Dogs who frequently swim or get bathed are at a higher than normal risk for ear infections.  It goes back to the principle of excessive moisture remaining in the ears leading to an increased risk of irritation.  I will often see dogs come in with infected ears 1-2 weeks after being groomed or having go to the lake.  Dogs who have frequent water exposure or who have a tendency for infections should have their ears cleaned and dried after being in water. 

The other big cause of chronic ear problems is allergies.  In fact, recurrent ear infections can be the only symptom of an underlying allergy disorder.  The food or environmental allergy causes inflammation in the skin of the ear canals, making them irritated and susceptible to infection.  You can usually clear up the infection, but unless you address the underlying root cause you'll see the infection come back frequently.  So when your vet talks to you about doing trials of specialized foods or doing allergy testing, they really are trying to get to the bottom of the problem.  Some breeds have an increased likelihood of ear infections not just because of the ear anatomy but because these breeds are also prone to allergy disorders (such as cocker spaniels and Labrador retrievers).

The first step in treating an infection is to make the right diagnosis.  And that involves the vet looking at an ear swab under the microscope every single time.  I know it may seem like the vet is just trying to make money, but the composition of the bacteria and yeast can change from infection to infection.  Every dermatology specialist agrees that you do an ear swab and microscopic exam on every ear infection and follow-up, regardless of previous results.  Different kinds of bacteria can infect the ear and some of them may need to be treated differently.  There are also some kinds of bacteria that may have a higher likelihood of being resitant to treatment, so we need to look for those. 

If an infection just won't go away, it may be a resistant bacteria.  In these cases the vet will need to get a sterile sample and send it off for culture and sensitivity testing.  The lab will grow the organisms, identify them, and test them against various antibiotics.  I've had results come back where the bacteria is resistant to just about everything available, and these infections are particularly difficult to resolve.

Even if you treat the infection you still need to address the underlying cause if it is a recurrent situation.  For dogs with closed-off ear canals there is a surgery that can be done to open the ear canal and make it easier to treat (lateral ear canal resection).  Dogs with hair in the canals may need to have them plucked and cleaned regularly.   If there are numerous polyps or growths in the canals the pet may need surgery.  And of course the vet may talk to you about underlying allergy disorders, which can be difficult to diagnose and require life-long treatment.

If chronic ear infections are untreated they will lead to permanent damage to the ear canal.  Over time this worsens, leading to hardening of the cartilage of the ear and disruption in the normal function of the canal lining.  When an ear gets to this point it is impossible to completely resolve the infection, and the only long-term solution is to surgically remove the ear canal (total ear canal ablation, or TECA).

Chronic or recurrent ear infections are very frustrating to deal with as a pet owner and can cause significant discomfort to your pet.  Work closely with your vet in these cases, and really try to get down to the underlying cause rather than just continuing to put medications in the ears.