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Monday, February 28, 2011

Playing It Safe

One of the most important pieces of equipment during anesthesia monitoring is the electrocardiogram (ECG or sometimes EKG).  With this tool we can not only keep track of the actual rate of the heart but also note electrical abnormalities in the heart, problems with rhythm, and issues with abnormal contraction patterns.  Not using an ECG during general anesthesia is taking a big and unnecessary risk. 

Today we had an issue with our ECG machine.  Remember that this is my first full week in the new location and I'm adjusting to the new staff and patterns.  Though I've worked with all of them before I don't know all of the ins-and-outs of the team yet.  We had induced our first procedure, a routine neuter, and had him under anesthesia.  As my assistant was connecting the monitoring equipment (ECG, blood pressure, and pulse oximeter) she noticed that the ECG wasn't reading at all.  It was strange because the graph wasn't coming up on the screen at all, yet the computer acknowledged that it had found and recognized the machine.  She tried to get it to work and went through various screens, turning it on and off, and finally rebooting the whole computer.  Nothing worked and the ECG still wouldn't read. 

Since the dog was already anesthetized and a neuter usually takes me less than seven minutes, I forged ahead and finished as quickly as I could.  We still had all of our other monitoring equipment so I wasn't without physiologic data.  The dog did fine and recovered normally.  But we still had three more anesthetic procedures, all dentals.  And we still couldn't figure out what was wrong with the ECG!  My assistant contacted tech support and they didn't know what was going on either.  They started to research it and said they'd call us back.

While waiting I made the decision not to proceed with the dental cleanings.  Those all would have taken longer than an neuter and I didn't want to take any risks of missing a serious cardiac abnormality.  So I called the owners, explained the situation, apologized for the inconvenience, and had them reschedule the cleanings.  I hated to do that as it potentially caused a problem for the client, as well as lost the revenue from the procedures.  However, my primary concern should always be to the health and safety of the pet, so I did what I thought was the right thing.  Thankfully the clients were very understanding of what happened.

In situations like this a vet should always remember that their first priority is the pet, not the client or even the business.  We shouldn't take risks that don't need to be taken, especially with anesthesia.  I've heard anesthesia described as the closest to the conditions of death we willingly take a patient.  So when we take this step we need to do it as safely as possible.  And if all of the equipment that keeps it safe isn't working as it should, we should think of the patient and consider canceling an elective procedure.

Later that afternoon we learned that a few days prior a different assistant had accidentally messed with some of the settings.  After looking into it further we discovered a setting that needed to be activated to allow the ECG pattern to display.  Somehow we had overlooked this when troubleshooting earlier, and if we had only noticed it we could have followed our original schedule.  I'm also very surprised that the tech support couldn't describe how to check that.  So our machine actually WAS working properly, but needed a single setting to be readjusted. I don't regret our decision to reschedule things, and I'm glad that everything will be in good working order for tomorrow.

Saturday, February 26, 2011

Moving On

I've probably mentioned before that the practice I work for has multiple satellite locations in our area and I manage one of them. Well, the more appropriate word is "managed".  Not to worry, it's not a bad thing.  I'm actually just switching locations.

I've been at multiple clinics over the years, and every place I've been at has been profitable and well managed.  In fact, I've developed a reputation as a successful manager and strong leader.  While this is a good reputation to have, it has led to some interesting experiences.  A few months ago I was approached with the offer of taking a new location and trying to make it successful.  The vet there is a good doctor but doesn't have the interest or ability to be a leader.  In my own location there is a doctor who was being groomed for leadership and this is a great time for her to step up and grow.  So after a little thought I accepted the offer.

Today was my last day in the old location. I've seen lots of changes there in the over two years I've managed it, and like to think that I'm leaving it on a high note.  The clientele is good, the staff pretty well managed, and the hospital is consistently operating in the black.  It's a bit of a bittersweet change, as I've made some good friends and know the people very well.  When you work in one place this long, you become comfortable with the circumstances and change can be a difficult thing.  But at the same time I like new challenges and can feel a bit stagnant after a while.  I've moved around a lot in the last 13 years, and like seeing new things and pursing new opportunities.

So Monday I begin at the new location.  I've filled in there before and know the staff, so it's not like it's a completely unknown clinic to me.  The drive is only about 10 minutes longer, so it's not significantly further for me.  In fact it's close enough that several of my regular clients are going to start coming there to see me. Hopefully the ones I'd rather not see will stay in the old clinic.  In either case the dynamics will be quite different.

New challenges await me.  The clinic I'm going to is stable but isn't living up to its potential for growth and clients.  The staff is good and experienced, but they're short-handed so we will need to hire some new people.  The other vet is skilled but apparently doesn't take change well, so we'll see how my style works there. Overall the foundation is there and I'll just need to build on that. 

Time to move on and see how things work from here on out.

Friday, February 25, 2011

Can't Heal 'Em All

Sometimes I feel so lost when I can't fix an illness.  I see the patient obviously feeling bad, maybe even vomiting, and don't know what I can do to help them.  So I have to sit and hope that they get better quickly.

Nope, I'm not talking about my role as a doctor.  I'm talking about my job as a husband and father.

In the last week illness has struck my family.  My daughter caught strep throat last week and still doesn't seem over it.  She had to switch from amoxicillin to Augmentin.  Last night my wife started feeling weak and tired and had stomach cramping and nausea.  This morning my son wasn't feeling good and I ended up having to pick him up early from school.  So right now I'm the only one out of the four of us that isn't sick.

My knowledge as a veterinarian doesn't easily translate to human illness.  I can figure out how to at least treat the symptoms of a sick pet, but I'm relatively clueless about how to treat my own family.  I know that these are all minor illnesses, viral or bacterial and either easily treated or they just have to tough through it.  But I hate seeing my wife and kids like this and not know how to help them.  They're really pitiful right now and I've been spending the day trying to take care of them as best as I can.

My one worry is that I'll be the next one to get sick.  Next week I'm the only doctor through Thursday as the others are gone to a continuing education meeting.  So if I get sick and can't come in, we're a bit up the creek without a relief vet.  So I'll be taking extra vitamins and praying that my immune system can fight it all off.

Thursday, February 24, 2011

Big Bad Spays

Many people may not realize it, but not all surgeries of a given type are the same.  Take spays as an example.

Ask a vet which routine surgery they look forward to the least, and I bet that most of them will say adult large dog spays.  I've had many of my staff say that they always figured that the big dogs would be easier because the uterus and other organs are bigger and therefore less difficult to find.  Quite the contrary, actually.  Yes, the diameter of the uterus usually is larger, but so are the intestines.  Combine all of those organs with a much larger area to search through and it can be more difficult to find things in a larger dog.  Small dog spays are usually quicker and easier.

Additionally you have larger vessels, which means more that you have to tie off and a greater risk for bleeding.  Then if you get an adult dog who has had litters in the past those vessels tend to be even bigger.  It's actually quite a lot of work and you feel pretty worn out by the time you're done.

Can you guess that I had one of the dogs today?  A very sweet yellow lab who was overweight (problem #1), over 70 pounds (problem #2), and had at one point been used for breeding (and there's our hat trick!).  From what I was told she had been used in a "puppy mill" and when her breeding days were over she was given away.  The current owners realized the risks and mess of an unspayed female, so they brought her in for surgery.

Now I fully commend the owners and think they made the right decision.  But once I saw her size and age, I knew I was in for a tough time.  All things considered, it was a routine procedure for a dog this big.  But it was a lot of work, an extra pack of suture, and more bleeding than I normally have.  None of this was concerning or life-threatening, just messy and annoying.  It made me long for the 9 pound shih-tzu spay I had done just before her.  But she did well, recovered normally, and will heal properly.  A good day's work, but one where I really earned the income.

Getting your dog spayed when they are young isn't just good for their health, it's nice for your vet's stress level!

Monday, February 21, 2011

Cons, Hair, And Droids

This weekend my family was at ConNooga, a smaller sci-fi/fantasy/anime/geek convention in Chattanooga, Tennessee.  It's one of our regular events, and we have a lot of fun there.  We go as part of a Christian fan group, Fans For Christ, and set up a table to talk to people as well as hold a church service.

But this year was special for a few reasons.  First, my wife finished her Rapunzel costume (from the recent movie Tangled) in time for the con, and it looks great!  Next she's going to work on a Flynn Rider costume for me so we can go as a pair.

The other big thing was that I finally was given permission to build my own droid.  For the last several years I've slowly gotten to know some of the guys in a local chapter of the R2 Builders Club when they were set up at the con.  These people build full-size, functional, mobile, working astromech droids like R2-D2 in the Star Wars movies.  As a huge geek, I would love to have a working R2 unit in my possession.  My son also wants to help me build it, so it could be a bonding opportunity for us.  Some fathers and sons work on cars, play football, or other things.  We'd be building a Star Wars droid.  However, my wife was worried about the cost and time, so wouldn't let me do it.  This weekend she got to know some of the guys and their wives, learning that they're really nice people.  She also learned that the cost doesn't have to be as much as some people.  While some droids can cost $20,000-40,000, others can be done for less than $2000 (such as the ones at the con this weekend which still looked great).  It all depends on the materials used and what kinds of functions you want.

The defining moment came when I was talking to one of the guys in the club.  I told him that my son wanted to make an all-blue R2.  Dan walked me over to a nearby dealer that was selling Star Wars toys and showed me an action figure for R2-B1.

This figure struck me for a couple of reason.  First, it was the blue that my son wanted.  Second, it had yellow accents.  My father is from Sweden and I'm very proud of that Swedish heritage.  This droid is the color of the Swedish flag!  Lastly, this is R2-B1, and my last name begins with the letter B.  It was meant to be!

Don't recognize him?  He's actually briefly in The Phantom Menace, as one of the droids that goes out to fix Queen Amidala's ship as they're fleeing Naboo.
This will be a long, slow process, and will probably take a few years to complete.  It will also be strange as I have minimal to no abilities with electronics and mechanical devices.  I can remove a spleen and fix a ruptured diaphragm, but I'm not even comfortable replacing the wiring in a light switch.  Still, it will be so cool to have my own R2 unit.  Periodically I'll post pictures as the process continues. 

Remember, there is much more to a veterinarian than being a vet!

Thursday, February 17, 2011

Funny Or Fearsome?

Mary asks this question...

I saw this video, and while it's funny to watch, does this dog's food aggression make him a danger to his family? What should a family do for a dog like this?

This is actually a pretty well-known video, and I believe it even won on America's Funniest Home Videos.  At first glance it's funny, watching the dog attack its own foot because its worried that the foot might somehow steal its food.  However, there is actually a real danger here.

This dog has an obviously serious problem with food protectiveness and aggression.  So much so that it doesn't even recognize its own foot as part of its body and not another animal.  If a human or even another pet in the family came close to it while eating, there is a very high risk of someone being injured.  This dog is so protective of its food that it can't properly recognize threat from non-threat.  Something like this shouldn't be taken lightly.

First, if someone has a dog like this I would strongly recommend finding a vet who is skilled in behavioral therapy or even a board-certified behavioral specialist.  A problem like this is best handled by someone who knows how to deal with complicated behavioral issues.  The risk of injury is simply too great not to find an expert in these matters.

As you wait to see the vet, be sure to avoid any competition with this dog.  Avoid any situation where it might be protective of something, and then avoid taking away a possession. Do not give a dog like this any treats that will take a while to chew.  Keep the treats limited to something small that it immediately eats and cannot protect.  Second, this dog shouldn't be allowed on the furniture.  Being on beds, couches, chairs, etc. is a sign of social dominance to a dog with these kinds of behaviors, and such positions should be reserved only for the humans in the family.  Third, this dog should be part of a "nothing for free" program. What this means is that this dog is not allowed to have or do anything at all without having to obey a command.  Need to go outside?  Obey a command.  Needs its food?  Obey a command.  And so on.  The commands can be as simple as sit, lay down, or anything the dog can do.  Using this technique helps reinforce the authority of the humans as the sole source of the dog's needs.

There is a good chance that a dog like this may need to be on behavioral medication, and this can only be done properly by someone who has had training in this area.  Pharmaceutical therapy should never be done as the only method of behavioral correction, and you need to know what to expect of the medications.  Make sure your vet works with you on correction methods other than simply giving pills.

Thanks for bringing this up, Mary! It's interesting to take a second look at situations like this.

Tuesday, February 15, 2011

Best Heartworm/Flea Preventatives?

Krissy, a veterinary student at UC Davis, sent me this question last week.

Thanks again for your insight on your blog, I really enjoy reading. Today we had a rep (a vet) from Bayer (the company that sells advantage) and they said there was this study and that only THEIR heart worm/flea preventative (Advantage Multi) was the only one that prevented heart worm in 8 out of 8 dogs. Very interesting, you can see the info just released this past month.
I understand this is a very small data sample, but of course they wanted to have to infect and kill as few dogs as possible. I also know that different products are better than others depending on the situation, like some permethrin tick preventatives are toxic to cats. I think it is difficult as a consumer to understand which product is the best on the market and most cost effective (in this economy). I have found some info on the internet, and in a clinic I worked in previously we primarily used Frontline and Revolution. But I was wondering if you would share your personal thoughts on this topic. If you would like of course! 

Krissy, you'll find that this is a complicated topic, and every pharmaceutical company can present hard data on why THEIR product is better than their competitors.  So you can't completely go by what the reps say, as their job is to convince you to use their product over all of the others.  That doesn't mean that they're wrong or deceptive.  You just have to understand their perspective and reasons for communicating.

I wasn't familiar with the data in the article so it was an interesting read.  I am very familiar with Dr. Blagburn, and have heard him lecture several times as well as have spoken to him personally at a conference.  I have a lot of respect for his opinions and research, and overall trust his judgment.  However, besides the small sample size remember that this was also a laboratory setting.  Real-world data may be different.  So while Advantage Multi may be a good product, I wouldn't use this one study to prove that it's the best product on the market.  Lastly, one of the problems facing parasitologists is the increasing data showing likely resistance of certain populations of heartworms to current preventatives.  I foresee this being a big problem within a decade or so.

Now you asked my opinion, and I'm happy to give it.  But remember that this is my personal opinion.  Yes, it's based on all of the data I've come across, as well as lectures by Dr. Blagburn and others, personal experience, and information gleaned from journal articles.  I certainly don't consider myself an expert in this area, and I'm sure my views can be contested by others.

Heartworm prevention:  Personally I really like Proheart.  Studies have shown that it's just as safe as any other prevention on the market, and it's had limited enough use that I'd be surprised at any resistance.  What I really like is the fact that it's not dependent on the client remembering to give a pill or apply a product every month.  Twice annual injections (once annual in some countries) and you're covered.  I still think the ivermectin-based preventions (Heartgard, Iverhart, etc.) are effective for most pets.  I worry that topical products like Advantage Multi and Revolution can be made less effective by frequent bathing and other factors, though admittedly those are not going to be common situations.  I haven't seen evidence that one prevention completely overwhelms the others.  In my practice we use Proheart 6, Revolution, and an oral ivermectin preventative.

Flea prevention:  There are a lot of strong opinions on this topic.  For my first choices I really like Comfortis and Vectra (sold under the brand FirstShield at Banfield Pet Hospitals....same product, different names), each for different reasons.  My views are based on discussions with Dr. Blagburn (and some pointed questions to him a few years ago) and local dermatology specialists.  I think that the Bayer products (Advantage, K9 Advantix) are still good and I do think they are worthwhile choices.  I haven't been a fan of Frontline for many years.  I also don't like Program/Sentinel, as it doesn't actually kill fleas.

Krissy, I hope this answers your questions.  As flea season is beginning soon, this is a good reminder of the importance of these products.

Monday, February 14, 2011

Love Is In The Air

Those of you who are married and have kids can probably relate to my situation.  My wife and I haven't been on a date in many months, and honestly can't remember when our last one was.  We have lunch together a few times per month, but haven't done a real honest-to-goodness date in far too long.  With this being Valentine's Day, we made a point to change that.

Because I was originally scheduled to work today (I ended up taking the day off) we made our plans for last night.  Rather than the typical dinner and a movie, I found a local place that had dancing and dining.  It was a small nightclub with a fairly intimate setting and a live band.  We dressed up in dressy clothes since we never do that and went out to spend some time together.

Honestly, it wasn't a busy, exciting evening.  We spent about 3 1/2 hours sitting, talking, listening to music, and watching people.  But it was so very nice.  We relaxed, we didn't have an agenda, and we didn't feel rushed.  The time was spent talking, holding hands, leaning close to each other, and simply having quality time together.  Though we see each other every day, there are usually so many distractions with the kids, pets, and daily life.  Having that simple time together allowed us to focus on each other and re-connect a bit.

I'm proud to say that I'm more in love with my wife now than when we first met almost 13 years ago, and that grows every day.  She is my best friend, my partner, and my forever love.  I am truly blessed to have her in my life.  Later today the kids will be home from school and we're babysitting her sister's four kids so they can have some time on Valentine's Day, so the daily grind is quickly coming back.  But the stresses of life will never fully get in the way of our love, and we enjoyed last night so much that we're already planning on our next date on March 11th, the 13th anniversary of our first date.

Yeah, when you're parents you have to plan these dates in advance.

Friday, February 11, 2011

Skewed Experiences

Once you're in medicine for any length of time it quickly becomes evident that there are a variety of opinions on any given topic.  One joke is that if you ask 10 vets their opinion on something you'll get at least 11 answers.  Why does this happen?  Part of it has to do with differences among experts, which articles someone reads, which lectures they attend, how they were trained in school, and so on.  But I believe that a lot of it has to do with their personal experiences.

Like it or not, everyone is influenced by what they have personally seen and done.  These cases and events will guide future opinions and decisions, and will sometimes result in disagreements among professionals.  For example, let's take the recent discussion on GDV ("bloat") in dogs.  I see around 100 or so pets every week (more in busy seasons), so I have around 5000 patient visits every year (yes, some of these are repeat visits).  In the last 10 years I have seen 2 cases of bloat.  Someone who works in emergency medicine may see that many cases in a month.  So my viewpoint is going to lean towards the infrequent nature of the disorder, while an emergency vet's opinion will skew in the opposite direction.

One of the things new graduates have to get used to is that the strange, weird cases they see in school don't happen often in general practice.  Veterinary schools normally run as specialty referral facilities, so the cases seen by students are not representative of the cases most of them will see once they graduate.  Common, straightforward cases never make it to a referral practice, so those students have a skewed set of cases to learn from.  When they graduate and begin working, they have to somewhat re-learn the simple, daily things that they will actually see regularly. This can be a bit of a mental transition, as their minds gravitate towards the cases that they personally saw, and the cases in private practice aren't normally that odd or difficult.

The skills of a vet are also directly related to their personal experiences.  Many years after graduating I learned that one of my former anatomy professors was doing some relief work for a practice that I occasionally worked with.  We sat down and talked one day and I discovered that she had never been in practice before.  She had gone from being a vet student to an internship to faculty.  Then she proceeded to ask me questions about exotic pet medicine.  Now that was a real shocker!  One of my old professors was asking ME questions!  Though she was an anatomy expert and had authored a text book on feline anatomy, she had never really dealt with exotics.  And even though I'm not an exotics expert, my interest and experience outweighed hers.  Because of different experiences, I was teaching one of my teachers!

These are some of the reasons why you will get different opinions from one vet to another.  It doesn't necessarily mean that one is more right than another, as studies and hard data have to be merged with what I call the "art of medicine". This is when you have the unquantifiable knowledge and feelings that go beyond the pure science.  It's still a valid influence on medical decisions, but is where you can get differences between doctors.

Wednesday, February 9, 2011

Acting Family

It looks like my family is going to be populated by actors.  Not that this is a bad thing.  My wife was a drama minor in college, and has always loved theater.  Over the last year and a half she and I have been involved in local community theater and have really enjoyed it.  In fact, if you go back in the archives of this blog you'll see some pictures of me in some of the plays.  But now it's going beyond that.

Last week my wife found out that she has been cast as the lead in the musical Kiss Me, Kate.  Though she loves drama, musical theater is her real passion, and she's always dreamed of having the lead role in a musical.  Now she gets to live that dream, and is tremendously excited.  Her only fear is that she'll have to kiss her co-star, and she's never kissed another man since we've been married.

Our kids have been involved in a few plays in the last year and based on that interest we enrolled them in acting classes taught by a local friend of ours who has done extensive theater and even movies.  Today he said that our son had really impressed him and had the potential to be a skilled actor.  He even said that Lucas had the potential to get minor roles in movies or act in commercials.  Now wouldn't that be nice!  He could make enough money to support his parents!

I don't expect Hollywood or Broadway to call anytime soon.  But it sure is a nice thing to dream of.  Until then we'll continue to do our thing in local theater.  In fact, auditions for Romeo and Juliet will be later this year, and I'm certainly going for a role in that.

Monday, February 7, 2011

Professional Disagreement

I'm often faced with clients transferring to our clinic from other vets, and this can be quite a challenge, especially if they're seeking a second opinion. There is the very human temptation to say that the other person is wrong and promote your own opinion.  But I am very strongly of the opinion that this is the wrong thing to do for numerous reasons.

Intentionally or not, clients often misrepresent what another vet says.  Maybe they misunderstood, maybe the vet didn't communicate well enough, or maybe the client just didn't personally like that vet and wants to bad-mouth them.  I've seen clients take a statement such as "I believe..." or "In my opinion..." and translate that as the gospel truth.  So as much as it may be hard for clients to understand, many veterinarians take a client's statements with a healthy grain of salt, realizing that it may not be exactly what a previous vet had intended.  I've heard clients who took my statements completely wrong, ending up telling another vet something completely different than what I had said and recommended.

I also think that even if I believe that a vet is completely wrong and off the mark, there needs to be a degree of professional courtesy.  Criticizing another doctor is a sure way to breed bad feelings among colleagues, and can often come around to bite you back.  If I was not directly involved with a case or otherwise have first-hand knowledge of it I'll generally decline to comment about the actions of another vet.  There may be details I'm not aware of that would change my opinion, and it's not a good idea to go off half-cocked to later regret it.

If I'm placed in a situation where a client is coming to me for another opinion and I agree with the previous vet, I make a point to tell the client this and support my colleague.  If I disagree with the other vet, I'm careful to talk about things only from my viewpoint and use statements like "Based on my training...", "In my opinion...", "According to lectures and articles that I've seen..." and so on.  By focusing on my own education and opinions I hopefully avoid being antagonistic towards another vet.

Why do I bring this up?  In recent discussions in the comments of this blog other vets and I have had disagreements.  This actually happens commonly, even among specialists. Ideally we should all be professional and mature enough to realize that as valid as we believe our opinions to be, they are not the only viewpoint out there.  Science actually thrives on differences, as by disagreeing with convention we explore possibilities that may not be otherwise considered.  Even in established professions (most vets aren't performing research) new therapies can come from discussions of contrary opinions.  The key is to keep it civil.  I believe that it is okay to say "I disagree" and provide your reasons.  But I don't think it's acceptable to deride someone for having a different point of view.

Thankfully, I have to say that my colleagues who comment on this blog have been such professionals.

Sunday, February 6, 2011

Grief Counseling

One of the hardest things a vet has to do is handle grieving clients.  Most of us get no training in how to handle this, as it's not emphasized in vet school.  However, we're faced with this on a regular basis as we deal with critically ill patients and euthanasias.  Some people are easier than others and every situation is unique.  Human grief is especially hard to deal with for those vets who are very introverted and don't handle people situations very well, yet we can't really get away from it.

Yesterday morning my very first case of the day was a male cat who had been straining to urinate for a day or so.  As soon as I looked at him I was able to tell that his bladder was very full, tense, and painful.  He was completely blocked and could not urinate.  This is a critical situation as the urine has nowhere to go and continues to accumulate in the bladder, eventually backing up into the kidneys.  The kidneys quickly become damaged, heart arrhythmias can happen, and a cat can die within 24-48 hours of this happening.  You need immediate hospitalization and care, as well as several days of leaving a urinary catheter in while hospitalized.  These cases can easily run $500-1000 or even higher, so it's not a simple fix.

I began to talk to the owner about this situation, and it was quickly evident that they didn't have the money for this care and wouldn't qualify for Care Credit.  (As an aside to those who feel that a vet should treat a case regardless of the owner's ability to can a veterinary practice afford to give away $1000 in services and still stay in business?)  Really the most humane option in this situation was euthanizing the cat.

That's when the drama began.  The owner was crying and upset.  She had a little boy, around 9 or 10, who also started crying.  And her daughter (around 11 or 12) began screaming.  I mean fully screaming in anguish and not simply crying.  I left the room and gave them time to talk over things.  We could hear the girl screaming out all over the clinic, and I'm sure the clients in the lobby were wondering what was going on.  We could hear the girl arguing with her mother, and at one point she ran out of the room and her mother had to go chasing after her.  I've seen a lot of grief, but I have to say this was the most severe reaction I've ever seen.  In the end the mother finally calmed her daughter down enough to be rational, and we euthanized the cat.

We certainly don't get enough training in these situations, and I'm not sure that there is enough training to cover every eventuality.  So for any prospective veterinarians, I'd encourage you to seek out information on grief counseling whether it be from a good mentor or from a course or book.  Both you and your clients will benefit.

Friday, February 4, 2011

Preventing Bloat

Stefanie asked a good question...

What is the recommendation for feeding and exercising a dog - especially for deep-chested breeds that are prone to bloat? Is it better to walk a dog first thing in the morning and then wait and hour and feed him/her or feed first, wait an hour and then exercise? 

This is a condition that I have personal experience with.  When I was 16 we had a German shepherd that had to be euthanized because he developed bloat.  We had gotten him when I was three years old, so it was hard for me as that was my friend as I grew up.

For those who aren't aware, let me describe what is commonly called "bloat" in dogs.  The proper medical name is gastric dilatation and volvulus, or GDV. In this condition the stomach twists, either rotating along it's axis or flipping 180 degrees.  In either case, the inflow and outflow of the stomach are closed off resulting in gasses building up inside the stomach.  This can cause difficulty breathing as the stomach balloons against the diaphragm, but more importantly pressure against the wall of the stomach can cut off the blood supply and lead to a rupture.  As can be imagined, this is a critical condition and dogs can die quickly once it begins.

Dogs that bloat most commonly act and look like they swallowed a large beach ball.  Their abdomen becomes large and tense, their gums can become pale, they will become suddenly lethargic, and will usually act like they are gagging or retching.   If you see your dog act like this with a bloated belly, consider this a life-or-death emergency and see a vet immediately.

Though this can theoretically happen in any dog, there are definitely certain breeds that are more prone to GDV. These breeds include English bulldogs, Weimaraners, Rottweilers, German shepherds, Great Danes, and any other large, deep-chested breed.  Though it seems like it's a genetic breed tendency, it's really more a factor of the anatomy of these breeds based on their size and shape.  Studies have looked at how to prevent it, and there is really only one thing that has been shown to significantly increase the risk--exercise after filling the stomach with food or water.  So take a dog of the right size and breed, fill their stomach with food or water, then let them run around a lot.  That's a formula for bloat.

Here are precautions to take to help prevent this deadly condition:
*  Wait at least one hour after eating or drinking before allowing exercise.  This is the main factor shown to prevent bloat.
*  Don't encourage your dog to roll over.  Though a low risk, the twisting action has been shown to lead to bloat.  In fact, some veterinarians do not rotate a dog over their back while anesthetized due to this risk.
*  Feed 2-3 meals during the day rather than one large meal.  However, be sure that you're taking the measured amount of daily food and dividing it into the meals rather than giving the once daily amount two or three times.
*  Don't allow excessive water drinking immediately before or after a meal.  Abnormal amounts of water have the potential to delay breakdown of food and lead to gas production.
*  DO NOT raise the food bowl.  While this was at one time thought to prevent bloat, a study in 2000 showed that this can actually increase the risk.
* Dogs who have had episodes of GDV are at risk for further occurrences.  A surgery can be performed to attach the outside lining of the stomach to the body wall (gastropexy).  While this doesn't completely prevent the stomach from rotating, it does lower the risk.  Some advocate having this surgery performed routinely on high-risk breeds, but personally I disagree.  Even in breeds that are prone to bloat most will never have this happen, and I don't think the benefits of the procedure (since it's not a guarantee that it will never happen) outweigh the risks.  Remember, this is only in cases of preventative surgery.  I certainly do think that it should be done in a dog who has bloated once since they show a personal tendency.

Stefanie, I hope this fully answers your question.  This is a horrible thing to happen, and I hope it never happens to one of your dogs.

Tuesday, February 1, 2011

Dealing With Burdening Loans

Evan asked this question...

My sister is currently in vet school and is very worried about paying off her student loans once she is finished.  The minimum payments appear to be close to $900/month, which a resident making $28,000/year would not be able to afford.  Do you have any advice for young veterinarians like my sister as they try to start their careers? 

Evan, this is a very common and very real problem that is changing how students live and practice after graduating. Currently in the US average starting salaries for a newly graduated vet are around $55,000-60,000.  The average student loan debt is around $80,000-100,000.  Veterinarians have the highest debt-to-income ration of any other medical profession.  That means that proportionally we go into more debt to get our education than any doctor, dentist, surgeon, or other professional.  Veterinary school really isn't horribly expensive; it's the very low comparative salaries we make that get us into trouble.

The situation is bad enough when you go straight into practice after graduation.  It's so much worse when you want to consider a residency like Evan's sister.  Since interns and residents get paid about 1/3 of what a practicing vet makes, the debt becomes untenable.  It's actually making advanced training difficult to acquire, purely because of finances.

The extreme debt is becoming a bit of a crisis in veterinary medicine here in America.  Starting salaries aren't keeping up with increasing tuition and other debt.  Eventually this reaches to the point where many younger vets can't purchase a practice because they don't have the financial resources or are too burdened by debt.  And because fewer veterinary practices are being purchased, retiring vets are having a hard time selling their clinics and leaving practice.

So what to aspiring vets do?  First, lower your expectations.  Unfortunately salaries aren't going to increase quickly, so you'll have to learn to live frugally.  You'd think that a doctor would be able to live very well, but that's not the case with new vets.  Second, get as much training as you can in personal and business finances.  Learn what it will take for you to be productive and profitable in practice, as this is the way to increase your personal salary.  By making sound financial decisions you can make your money go farther.  Third, you may have to re-think the decision to go straight into a residency program.  It may be better to work for several years and then go into a residency, simply to get yourself on more firm financial footing.  It's tempting to take out even more personal loans, but they you have to add them on top of what you already have, and this can mean that a specialist's salary is mostly going to repay the debt.

Evan, there isn't an easy answer for your sister.  Her situation is all too common, and nobody has come up with a good solution yet.  In my opinion it would be worthwhile for her to sit down with a professional financial adviser and take a hard look at her situation.  Good luck to her!