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Friday, July 31, 2015

Caring For Veterinarians

I seem to be coming across a number of other veterinary bloggers recently.  A friend of my (who is also a vet) posted the following link on his Facebook page, and I found it extremely truthful and entertaining.  Written for someone who has newly acquired a veterinarian, it discusses how to handle and take care of that vet.  While very humorous and firmly tongue-in-cheek, it also is incredibly accurate about common characteristics and tendencies among those of my profession.  I present it here as an entertaining but accurate read.

The Husbandry And Feeding Of Veterinarians (for new owners)

Tuesday, July 28, 2015

Math And The Veterinarian's Day

Here is part of an email that Paula sent me....

 I graduate high school next year. I score an A in science and a B in math. Getting that B was very hard as I struggle a bit at math. I just want your opinion. If you wanted to be a vet but struggled at math, would you have continued to pursue your dream or switched to a career less intense? I can promise you work doesn't scare me. 

Let me be honest in saying that math was always a struggle for me as well.  I got mostly B's and occasional A's in math, and I had to work hard for those.  Math wasn't something that has ever come easy or natural for me and it has always required a lot of effort.  Most of my basic and even advanced math skills are rusty to say the least, and I've forgotten a lot of it.  I took calculus in college as a requirement for vet school, but I've never used it since those classes, couldn't tell you what in the world calculus is used for, and have no idea why it was a pre-veterinary requirement.

So the short answer is yes, you can still be a successful vet when math doesn't come easy.

That being said, basic math skills are essential and are used daily, especially algebra.  There isn't a day that goes by that I don't use some form of math in my job.  I have to calculate drug dosages, convert one unit to another, figure out dilutions of medications for my exotics patients, determine fluid rates, and many, many other things.  If I didn't have basic math abilities I wouldn't be able to perform my job, and couldn't even prescribe drugs appropriately.  If my calculations are wrong, it could prevent effective treatment or potentially cause severe side effects.  My success at math often determines my success as a doctor.

But you don't have to be a math whiz to be successful.  I can do a lot of math in my head, but I keep a calculator in my pocket to make basic addition, subtraction, multiplication, and division easier.  Most of our fluids are given with an electric pump, which prevents having to calculate the drips per minute for a given hourly rate.  In modern times there are plenty of apps and programs where you can plug in a given set of values and have the end results determined for you.  And really you only need basic math skills and algebra for almost all of your calculations.

It is impossible to be involved in science and medicine without some skill in math.  But you don't have to be an expert to be a veterinarian.

Saturday, July 25, 2015

Maggots, Wounds, And Summertime

***WARNING:  Graphic images in this entry!  Proceed at your own risk!  Seriously gross stuff ahead!***

Heat and humidity are never good when you're dealing with skin irritation and wounds.  Here in the southeastern US there are certain things we can just about count on in the Summer because of the kind of climate we have.  Maggots are one of those things.

I've dealt with these situations countless times over my career, and the scenario is always similar.  The dog or cat spends a lot of time outside and isn't examined closely by the owners.  In some cases the pet is severely matted and skin irritation develops under the mats.  In other cases a wound is caused by a bite, puncture, or other source.  In either situation there is exposed, damaged, open tissue.  This kind of environment draws the attention of flies, who lay their eggs on the diseased tissue.  The eggs hatch and the larval flies (maggots) begin feeding on the dead tissue.  

In one way, this isn't a bad thing as this kind of maggot only eats dead or diseased tissue, thus leaving healthy tissue behind.  However, that doesn't clear up the infection, and as long as the condition progresses there will be more and more necrotic tissue on which the maggots can feed.

One of my first maggot cases was back in my first year of practice.  A heavily matted mixed breed dog came in and there was a strong odor from its back.  We realized that there was heavy skin infection under a thick layer of mats and so we began to trim the matted fur away.  As we did so we quickly saw a writhing mass of maggots.  This was about a 30 pound dog and the entire back of the dog's fur came off as one giant mat.  Underneath the skin had become infected, and since the dog was kept mostly outside it developed a horrible case of maggots.

Here's the gross part of that of the staff was named Earl.  He was a really nice guy, very good with the animals, incredibly caring and fun, and pretty much immune to the things that happen in a vet clinic.  Earl took the dog to the back to bathe it and wash off the maggots and diseased tissue.  A minute or two after he went to the tub area we heard a horrible scream.  All of us rushed back there to see Earl retching and spitting onto the floor.  Apparently he had put the water sprayer on high, and when he first started washing the dog the spray hit the maggots at just the right angle and force to cause them to fly up into his face.  And his mouth was open!  He got a big faceful and mouthful of maggots!  I will never forget that moment.

More recently a family brought in their elderly, outdoor cat for lethargy and diarrhea.  At least, they had assumed it was diarrhea because of the wetness and horrible odor from around the cat's hind end.  When I took a look at it I quickly noticed the moisture was to one side of the rectum, more on the thigh.  And then I lifted up a matted area of fur, revealing a deep, gaping wound filled with maggots.

That was definitely not what I expected to see when they brought the cat in for "diarrhea", but it didn't surprise me considering the heat and humidity of a Georgia summer.  If you look closely at the top photo you'll notice that some of the maggots were crawling out of the rectum.

Here are a few pictures with better lighting, where you can better see the maggots and extent of the wound.

I almost took a short video to show just how disgusting this really is.  All of those maggots were moving and writhing, obviously enjoying their meal.

I suspected that this was caused by a bite wound that went undetected under the cat's long fur and mats.  As I mentioned previously, the wound was a great location for flies to lay eggs, and because there hadn't been treatment the infection had destroyed a significant amount of tissue.  While there was a decent chance of eventually curing this cat, it would have involved an incredible amount of treatment, including major reconstructive surgery.  The total treatment would have easily run into several thousand dollars, mostly due to the necessity of surgery, skin grafts and so on.  Because of the amount of treatment needed, the owners elected euthanasia.

Since this cat spent most of her time outside and was difficult for the owners to catch, they didn't realize the problem was this bad.  So I don't blame them for letting this go so long.  But this is a cautionary tale for pet owners with pets who stay outside.  Be very observant of your pets, as this could have potentially been caught earlier with a daily brief exam.

Wednesday, July 22, 2015

Medical Advice From The Tire Shop

Some things you just can't make up.

Our clinic has been seeing a 10 year old Boston Terrier.  He has had some hair loss and skin issues, so we started working up the case.  His overall blood tests were good, but his thyroid level was low.  We started him on a supplement and brought the thyroid level within normal range, but his skin didn't get much better.  We had already ruled out bacterial and fungal diseases and he wasn't itchy so we didn't think that allergies were a likely cause.  I had become a bit stumped and had recommended that they take him to a local veterinary dermatology specialist. 

That was back in early May.

Today the wife comes in and asks about whether or not the disorder could be mange.  For those non-vets reading this, let me explain a few things.  There are two kinds of mange we commonly see in dogs:  Demodex and Sarcoptes ("Scabies").  Sarcoptes can affect any dog at any time and causes significant itchiness.  Demodex occurs when the immune system is immature or suppressed and we almost exclusively see it in dogs less than a year old.  An adult dog shouldn't have Demodex unless there was a real problem with their immune system and other signs of illness.  This particular dog wasn't itchy, didn't have the signs of scabies, and was overall healthy.  Could it have been Demodex?  Actually, yes.  However, that was certainly not our first thought in a 10 year old dog with confirmed hypothyroidism and no other signs of illness.

So why did the client ask about mange?  When my receptionist, Christina, was asking me about it my first thought was that the client consulted "Dr. Google" in an internet search.  But Christina said "oh, it gets better."  I cringed.  "She was talking to the guy at the tire shop where she was getting new tires, and he said that he had a dog with mange that looked exactly the same.  So she was asking if it could be mange."

We had to spend some time explaining that mange in a dog that age was extremely unlikely, that we had absolutely confirmed hypothyroidism, and that there were no other signs of health problems to suggest an immune system disorder.  Even so, I don't know that she was completely convinced that I was right and the tire guy was wrong.

I don't mind my clients looking things up online.  It often stimulates good conversations and I like clients to be well educated.  However, I always ask my clients to discuss things with me before taking "Dr. Google" as the ultimate source.  Heck, I always tell you readers to check with your own vet!  Any vet on the internet is handicapped by not being able to see and examine a patient, and you should never rely on such advice as the sole voice of diagnosis and treatment.  If you're merely searching by symptoms you don't have the clinical judgement and ability to take a list of findings and appropriately tie them to a proper diagnosis.

But you should never listen to a non-veterinarian over a vet.

Sure, talk to friends, co-workers, and random people to see what they might suggest about your pet's illness.  But when you then talk to your vet, realize that they have the training, knowledge, and skills to make a proper diagnosis.  When it comes down to who you believe, give your vet the edge.

Sunday, July 19, 2015

Are Snake Bites Really Deadly?

Every year I see several cases of dogs being bit by snakes.  So the inevitable question comes up, "are snake bites really deadly?"  Here's my typical somewhat tongue-in-cheek reply...."It depends".

The "depends" relies heavily on the type of snake.  Even among venomous snakes some are much more deadly than others.  Thankfully in my area we only really have to worry about copperheads and cottonmouths (water moccasins).  Neither of these is particularly deadly with a single bite.  However, there are several snakes in the US that can cause fatality (especially coral snakes and some rattlesnakes), and you should always take them seriously.  If you have any questions about the lethality of venomous snakes in your area, check with your vet (especially those of you in Australia....from everything I've read your country is out to kill you!).

Most of what people seem to know about snake bites originates in Hollywood myth and hype.  If a snake bites you need to put a tourniquet on and suck the venom out of the wound!  You need to elevate the limb!  You have minutes to get to a doctor and be given antivenin or YOU WILL DIE!  Thankfully none of that is true, and while a known or suspected snake bite is absolutely an urgent case most pet owners aren't in areas with truly lethal snakes.  Those of you who are.....ignore the rest of this blog!

So what do you do if your pet is bit by a snake?  The first thing you do is stay calm.  Don't panic as that can make the situation worse.  The next thing you do is call a vet and get your pet seen immediately.  If you live in an area with highly venomous snakes the veterinary staff will be able to tell you exactly what you need to do, even if that may be going to a local emergency clinics.  Most snake bites don't require antivenin to treat, so few vets carry it.  Local human hospitals and veterinary emergency clinics will stock antivenin if there is risk in the area, so your primary doctor may refer you to an veterinary ER rather than coming to them first.  For most other snake bites it would be considered urgent enough to go to an emergency clinic if your vet is closed, but not an immediate life or death situation.

Don't try to put a tourniquet on the wound, suck the wound, or anything else you've seen in movies.  Leave it alone and get your dog to a vet right away.

Most bites that I've seen have been from copperheads, simply because they are the most common venomous snake in the areas I've lived.  Typically with this kind of snake there will be an intense local reaction with inflammation, tissue damage, and secondary infection.  The area around the bite looks really bad, but the dog is overall okay.  There is a risk of clotting disorders due to the body's reaction to the venom so a vet typically runs blood tests as part of the treatment and will instruct the owner to watch for unusual bleeding, bruising, and so on.  But a single bite shouldn't be fatal unless the dog has an anaphylactic reaction.  I've seen Yorkshire terriers bit in the face who still survived and just had a bad localized problem.

Here are photos from a dog I recently saw who was bit on the paw.  Most snake bites are on the paws or the face, because the dog is either stepping on a snake it doesn't see or is putting its muzzle close to examine the animal.  You can clearly see that the dog's left leg is significantly swollen as a reaction from the bite.

Both legs next to each other for comparison.

A closer look at the normal leg.

The leg that was bit.

The wound itself was minimal and the dog was acting normal other than a little sore in that leg.  All blood tests were normal and we treated with antibiotics and pain medication.  The leg healed well and the dog will be fine.  In cases of severe local reactions there could be a need to surgically remove damaged tissue, but this isn't common.

Again, please understand that I'm talking about mildly venomous snakes and my comments shouldn't be extended towards every kind of snake bite.  There are significant variations in the kind and strength of venoms, so you should always take a bite seriously and seek immediate veterinary care.

As I've never actually treated a patient for a potentially lethal snake bite, I'd love to have comments from vets who have done so!

Thursday, July 16, 2015

A Really Bad Break

Recently I saw a small dog who had been unable to walk for a few days.  When I talked to the client it came out that her husband had backed his truck into their dog.  Why they didn't come right in, I'll never understand.  However, that wouldn't have changed the outcome of the case.

The dog was a surprisingly well behaved Chihuahua who couldn't stand up on his hind legs.  His left hind leg was out to the side at an odd angle, and worst of all he didn't seem to have any sensation or movement in his legs.  Normally this kind of deficit indicates a spinal injury, and when there is no deep pain sensation there isn't much that we can do.  

In order to assess the extent of the injuries and see if there was anything we might be able to do, we took some x-rays of the dog.  Here is your radiology lesson for the day!  See if you can figure out the problems this dog has.  Go on, I'll give you some time.

My veterinary readers have probably started picking up on the multiple problems.  But for the laypeople looking at this let me give you a hand.  First, let's start with the side view.

Look at the vertebrae in the green oval.  Notice that there is virtually no space between them, and if you look at the intervertebral space in front of them (to the left), you'll see what it should look like.  The whole back (caudal) half of the lumbar spinal column is significantly compressed.  This likely indicates that the discs between the vertebrae have slipped out of place and are pushing against the spinal cord.  

Then look at the yellow circle.  This is a sharp projection of the pelvis that simply shouldn't be there.  This is an indication of a fracture and dislocation of part of the pelvis.  We'll see this injury better in the next view.

Look at the right hand side of the image.  The yellow line goes from the upper edge of the pelvis to the hip joint itself.  The green circle is the "head" of the femur, which is the ball part of the joint.  That right side (actually the dog's left side) is normal.  Compare that to the opposite side (the left side of the image, which is the right side of the dog).  Notice that the yellow line is at a much different angle and doesn't cross of the the femoral head.  If you look at the structure just "above" (towards the top of the image) of the femur on that side, you'll see a striking difference.  The pelvis is fractured in that area and significantly displaced.  Observant readers will also notice a fracture in the middle of the pubic area of the pelvis.

Let's summarize.  First of all the dog has significant spinal compression and herniated discs, leading to pressure on the spinal cord and complete paralysis.  Even with immediate surgery this dog has less than a 10% chance of recovery and ever walking again.  Additionally there is a bad pelvic fracture that would require surgery to correct.  Either of these injuries is bad by itself, but together they paint a very bleak picture.  This dog needs at least $6000 in surgery and probably an additional couple of thousand dollars in post-operative care, all with no guarantee whatsoever of being normal.

In the end the owners elected euthanasia, and frankly I can't blame them.  They simply didn't have the money to do the treatment this dog needed, and even if they had it the dog was unlikely to walk again.  Really they made the best decision, tragic though it was.

Monday, July 13, 2015

A Day In The Life Of A Veterinarian....The Harsh Reality

This will be a short post today, as I want to direct my readers to another vet's blog.  Earlier this year she wrote a thorough, eye-opening, and all too truthful post about what a veterinarian's day is really like.  I just found out about it recently (thanks, Fi!).  I think this is something that all pet owners and people aspiring to the profession need to read and understand.  She said it much better than I ever have.  Seriously, take some time from reading my blog and go to hers.  Here's the link:

The Harsh Reality of Vet Med...What The World Needs to Understand