That's No Moon. It's An E-collar!

Most pets HATE "the cone of shame", or Elizabethan collars (e-collars) as they are more properly called.  They are a very necessary part of veterinary care, used to prevent a pet from licking or chewing at a certain area.  In a few decades of working in the veterinary field, I haven't seen clients get very creative with these unfortunate devices.

Until now.

As a veterinarian, geek, and major Star Wars fan, I grinned when I saw this online.  "Now witness the firepower of this fully ARMED and OPERATIONAL battle collar!"

The Surprising Truth Behind Bully Sticks

Most of you have wandered in the chew toy aisles of pet stores and have seen the large variety of treats, rawhides, and other objects for your dogs to chew on.  A very common one is "bully sticks".  These look like long, tubular rawhide and are mixed in among the other chews.  Some of them are very long, some have been twisted into a spiral, and some have been cut into shorter lengths.  They're quite common and I bet that many readers have given them to their own pets.

But do you know what they are?  The first time I saw one in a pet store I was a bit shocked, and it still causes me to smile when I see them, especially if someone is buying a pack.  If more people knew what they were, I think sales would drop.  So what are they?

Bull penis.

Yes, that's right.  Bully sticks are dried and preserved bull penis, hence the name.  I've even been able to identify the different sections of the penis and the urethra and have a complete anatomy lesson right there in the store.  The long ones are the full length penis, while the shorter ones are the penis cut into pieces.

Yes, I know some of you men are crossing your legs and cringing.  And you women are probably dying to read this to one of the men in your life to see their reaction.

As strange as this may seem, it's purely psychological.  There is nothing bad about rawhide penis and the dogs certainly don't know the difference.  In essence, there is no real difference between bully sticks and more traditional rawhide treats.  Both are cow tissue dried and preserved and both are safe to chew.  You can also find dried liver and lungs as treats.

But I have to admit that while I give rawhides to my own dogs, I've never given them bully sticks and don't think I would.  There's just something about the fact that it's penis that weirds me out a bit.

Now all of you know the truth.  Be sure to tell all of your friends!

Home-Made Kidney Diet

Sarah sent the following scenario....

My aunt has a  22 lb female beagle mix that is somewhere between 12-14 years old. She seems to be in about stage 2 of chronic kidney disease. Her family vet had her switch to Hills K/d, but her dog has stopped eating it. My aunt did some basic research and found a recipe for a home made diet that is supposed to be appropriate kidney disease. Her own vet had little to say about the diet, so my aunt went ahead and fed it. I believe the diet consists of white rice, white bread, sometimes carrots or green beans, a potato starch, and either a lean mean or hard boiled egg.  I was hoping that you might be able to point me in the right direction to find a reliable recipe for a canine kidney diet. She has also been supplementing calcium in the form of Tums tablets to bind the phosphorous. I have some understanding that it is advised to supplement calcium, but I am wondering what the most efficient way of doing this is.

I'm not a nutritional specialist, but I can see some problems with this diet, depending on the amounts used.  Making a nutritionally balanced home-made diet is always difficult, but the problems are compounded when you are making it for a medical condition.  In many disorders the correct nutrition can make or break the case, and this is certainly true with kidney disease.

Here's a recipe for a fully balanced diet that will help with kidney disease.  This comes from Small Animal Clinical Nutrition, 4th Edition (a veterinary nutrition textbook).

Daily food as fed formulation for an 18kg (40lb) dog.  Change the amounts based on the size of the dog.  Food can be weighed with a regular cooking scale or other gram scale.

Cooked white rice (may substitute rice baby cereal and flavor with meat broth during cooking)--237g

Cooked regular beef (retain the fat)--78g

Large boiled egg--20g

White bread--50g

Vegetable oil--3g

Calcium carbonate--1.5g

Iodized salt--0.5g

1 human multivitamin

For a 4.5g (10lb) cat you can use the following recipe for daily amounts.

Cooked chicken liver--21g

Cooked white rice (may substitute rice baby cereal and flavor with meat broth during cooking)--98g

Cooked white chicken--21g

Vegetable oil--7g

Calcium carbonate--0.7g

Iodized salt--0.5g

Salt substitute (KCl)--0.5g

1/2 human multivitamin

1 to 1/2 taurine tablet (500mg/tablet)

Obviously, making a balanced diet at home can be difficult and a lot of work.  But it can be done.  Using these recipes you'll meet all nutritional needs for kidney disease, as well as the calcium. 

Let's say a word about phosphorus here.  In advanced kidney disease the phosphorous level will become very high.  To keep the phosphorous low, you need it in reduced amounts in the diet (which the above diets take into account) and often with additional medications to "bind" the phosphorous in the diet, preventing the patient from absorbing it.  First, your aunt needs to talk to her vet about the phosphorous level.  If it's not elevated, there is nothing other than diet that should be done to keep the levels low.  Calcium by itself does not bind phosphorous well and is not normally used.  The two most common binders recommended are aluminum hydroxide or aluminum carbonate.  Calcium acetate may also be used, but can cause the calcium levels to be too hight.  The aluminum compounds are actually commonly found in over-the-counter antacids, as well as in specialized forms that can be easily obtained from human pharmacies. 

Sarah, I hope this helps.  Above all, have her keep in close contact with her vet and follow the recommendations about further testing and monitoring.

Do We Need Another Vet School?

A few weeks ago I read an article that discussed a new veterinary college that is being planned in Arizona.  The decision to open a new school stems from a perceived shortage of vets in the state. 

Arizona has one veterinarian per 4,100 animals, while the national average is one per 3,500. Greenlee, La Paz and Yuma counties have no veterinarians, according to Midwestern spokeswoman Stacy Pearson.

While on the surface this seems to speak of a need, it turns out that the real shortage is in large animal vets.  The deficit of veterinarians practicing in this field is nation-wide, hitting rural and agricultural areas hardest.  However, I have doubts that a new vet school is going to meet this particular need, as a vet pointed out in the article.

Gary Thrasher, a "food-animal" veterinarian who has treated large animals all over the state for 41 years, said he and many other large-animal vets are getting older.
"A lot are retiring or dying off, and it has left a vacuum," he said.
Few young people who graduate from veterinary school want to live his life, Thrasher added. A typical call could mean a drive of 80 miles or more. Hours are long, and urban cat and dog clinics can pay more and offer better conditions. In addition, horses tend to be companion animals that are found nearer cities.
"My only concern about a veterinarian-teaching hospital is that a ton of people want to become veterinarians but few want to become large-animal veterinarians, and the few that do don't stay in it very long," Thrasher said.

I completely agree with Dr. Thrasher.  I firmly believe that the US shortage of food- and large-animal vets has nothing to do with the number of vets who graduate every year.  As our population has shifted from rural backgrounds to suburban and urban, fewer and fewer people have the background that would give them an interest in this area of medicine.  Honestly, I'm not sure how to meet this need and change interests, but Dr. Thrasher is spot-on in saying that most new graduates now want the lifestyle of being in small animal medicine.

I keep reading articles in journals talking about how the unemployment rate among vets is the highest in recent memory (though still far lower than the national average), new graduates are taking longer than ever before until they can find a job, student debt is at record highs, and vet schools are having to cut back on programs and faculties because of budget cuts.  With all of these things in mind, should we really be opening a new vet school?  Personally, I don't think it's wise. 

I bet that most of the graduates from this new vet school will end up in small animal medicine.  They may see a slight increase in the numbers of large animal vets, but I don't think it will be enough to help.  States like this need to look at debt-forgiveness programs and other methods to entice people to move there and be vets in the agricultural industries.  I'm concerned that opening another vet school now will increase the difficulties for new graduates to find well-paying jobs.  With current concerns in personal and educational finances, I worry that the people involved are being too short-sighted and relying on hope that this will change the situation.

How To Solve A Problem And Get Praise

Last month I started seeing comments on several of my blog posts that didn't always seem to fit with the topic.  All of these contained links to a specific veterinary referral practice in Austin Texas.  I sent a few emails to them asking them to stop the spam, but the comments continued and were becoming annoying.  I deleted the comments that weren't caught by the spam filter on Blogger, but I still preferred they not happen at all.

So I called the practice and ended up speaking to the doctor in charge of it as well as the practice manager.  He was surprised about this, as it apparently had also happened to at least a few other veterinary blogs.  He was very personable and sincere, apologized for the problem, and promised to get to the bottom of the situation.  It was certainly not the impression they wanted to give.  I emailed him one of the comments which was passed on to the hospital director along with their apologies.

Today I received an email from them with the explanation.  A search engine optimization company they had hired went out of business.  Last month one of the former partners in that SEO business picked up the contract and started working on it without the practice's knowledge.  They have since contacted this company and asked them to stop, to which the company agreed.

I must say that I have been extremely impressed by the friendliness, concern, and professionalism of the staff and doctors at Austin Veterinary Diagnostic Hospital over the last month.  They were very open and sincere, and followed through exactly as they said they would.  They have handled this situation beyond what I wanted and expected, and I am truly grateful for their diligence.  

To me the most important part of any business is developing relationships and interpersonal skills.  Many businesses provide great services or products, but fail in the area of customer service.  I have always believed that businesses are run by people and people are only human and can make mistakes.  I don't usually get upset at the mistake itself, but rather how it is handled afterwards.  I have had many businesses that I have continued to patronize and recommend because of how they settled their own mistake to my satisfaction.  Austin Veterinary Diagnostic Hospital certainly falls into this category.

Because of how they handled this problem I am posting my recommendation for them.  Though I don't practice in the Austin, Texas area, if I did I would most certainly recommend clients to this practice.  If they treat their clients half as well as they have treated me and my tiny corner of the Internet, they are worthy of respect and people should utilize their services.  They should also be an example to any business of how to conduct yourself.  Because of their sincerity, professionalism, and communication ability, they have turned this situation from one of frustration to one of glowing praise. 

Exam Vs. Vaccine?

I'm on a roll this week so let's kick the hornet's nest a little more.

Most of my discussions this week have centered around a need to change the business models of veterinary practice.  I've stated recently as well as many times in the past that the physical exam is actually the most important part of the veterinary visit.  But is it important enough to supersede the vaccines themselves?

As I've mentioned, there are many, many things that can be caught early on a routine physical exam.  A short list includes heart murmurs, tumors, cataracts, ear infections, periodontal disease, fleas, bladder stones and various endocrine disorders.  A good doctor is going to be able to find these problems or hints that lead to more diagonses by just a thorough exam.  No matter what the disease or disorder, it is always better to treat in the early stages than waiting until later.  So it's only beneficial to the patient if we are examining them regularly.   It has been common for me to notice a problem on the exam that the owner was never aware of (yes, including bladder stones).

Here's a little known concept about vaccinating animals.  It's often more important for population health than it is for individual health.  I have only seen three cases of canine distemper in my 15 year career (so far).  I have never seen a case of rabies.  Yet go back about 30 years and these diseases were much more common.  Though parvo is still common, it's not as rampant as it used to be.  All of this is because we have done such a good job of convincing people to vaccinate their pets and livestock.  The vaccinated ones not only are protected as individuals, they also slow or stop further spread of these infections.  Sometimes indivual pets may not be able to receive vaccines because of other illness or severe allergic reactions.  The chances of these pets contracting preventable diseases is low.  Now this isn't a license to stop vaccinating your pets.  You ARE protecting the individual, but realize that it's also to protect the population as a whole (human and animal).  And if we stop vaccinating we'll most certainly see a resurgence in these illnesses.

In my personal experience (no hard data here, folks) I believe that the average dog is more likely to develop a heart murmur than it is distemper.  And your typical cat is more likely to have cancer than feline leukemia.  I deal with problems I notice on physical exams more than I deal with infections preventable by vaccines.  Again, this is because overall we do such a good job of vaccinating.

Now some may say that people with low income may not be able to afford care for murmurs, dental disease, and so on.  But don't they have the right to know?  Isn't there a responsiblity we have to inform them of their pet's true health status and then let them make the decisions?  Shouldn't we tell them their options and not pre-judge based on a perceived income level?

So that brings up the question.  Which is most important to a pet's health?  An annual exam, or vaccinations?  I would argue that the exam is marginally more important than the vaccines because of the numerous health issues that we could detect and prevent.  To a population the vaccine is more important because of the contagious nature.  But to the individual the exam may actually be more important.

Again, please don't misunderstand me.  I am a huge advocate of preventative immunization in humans and pets, firmly believe that we have saved countless lives because of vaccines, and am completely aware that if we reduced vaccination we are going to see a return to the epidemics of now-rare diseases.  I am sincerely pro-vaccination and make sure that my pets and my family are immunized.  I also realize that often the only reason we get to examine the pet is because they came in for vaccines.  My point comes from my belief that we as a profession have historically seemed to emphasize vaccines over the exam.  For decades veterinarians have devalued the exam itself, and clients now have the wrong idea about the visit.  And this is a viewpoint that needs to change. 

Thankfully, I do see signs of such in the profession as consultants and new graduates are changing the way we think about ourselves and our patients.  I hope this trend continues, educating owners along the way about what they really need to do for life-long care of their pets.

Shot Clinics: Good Or Bad?

I stirred the pot a bit yesterday with my discussion on the poor business model veterinarians have related to prescription medications.  Today let me stoke the fire a bit and see if I can really get it boiling.

I believe that another bad business decision is related to vaccines.  When I was growing up working for a vet, the standard practice was that there was no office visit charged when a pet received vaccines.  So the clients came in and paid for the immunizations but not the exam.  Most vets charged this way back then and many still do.  While it seems to be an incentive for owners to come in for vaccines, it also places the emphasis on the wrong aspect of the visit.  The clients think they just need the shots.  In reality we need to do the exam and will happen to give the shots if everything looks good.  The most important part of the visit is a thorough exam by the vet.  Unfortunately, we now have 1-2 generations of pet owners who are used to this older model and are put off by vets who actually charge for exams.  Once again, poor business models by vets are hurting the profession as a whole and are making it difficult to change client perceptions.

Which brings me to "shot clinics".  These happen all over the country, sometimes in store parking lots, sometimes inside pet stores, or sometimes through mobile facilities.  Clients bring their pets for vaccines, minimal to no exam is performed, and the clinic charges minimal price for the injections.  This is another poor business model that harms the profession.

So why do I feel this way?  It goes back to my earlier comments about emphasizing the wrong thing.  The vets and technicians in these clinics often will not do a thorough exam, simply giving the shots and moving on.  Many things can be missed this way, such as periodontal disease, heart murmurs, tumors, and many other problems that the owner may not have noticed.  These clients likely won't go to a vet for a separate annual exam, which means that disorders can go missed for years, sometimes becoming very advanced where it may be more difficult to treat.  Once again the emphasis is on the vaccine, not on the exam, which is the wrong message to send to people.

"But what about poor people?  What about those who can't afford a regular vet?  Don't their pets need shots also?"  I'm going to be a bit harsh for a moment, but this is nothing I haven't said many times in the past.  If you cannot afford basic, proper care for a pet, you shouldn't have a pet at all.  If someone doesn't have the money for regular vet visits and preventative care, then they should get a hamster or guinea pig, not a dog or cat.  Pet ownership is not a right.  And doing annual vaccines alone is NOT sufficient for proper health care!  I simply can't emphasize that point enough.  Full physical exams are a necessity and can prevent more serious problems later on.

However, I do recognize that people fall on hard times.  I feel that shelters and discount vaccine clinics should have a means testing procedure.  Someone making $20,000 a year certainly would benefit from these clinics (though I'd argue they shouldn't have a pet at all).  Someone making $100,000 annually should be excluded from shot clinics.  There needs to be a way for people to prove income to justify getting discounted services. 

But all of this takes a change in the mindset of both veterinarians and consumers.  We have a lot of bad business practices to overcome.  It took a couple of generations to develop these bad habits, and it will take at least as many to break them.  Once we do so the profession will be in a better situation and the pets will be healthier.

Getting Rid Of Prescriptions

I have to admit that vets haven't done a good job of structuring their business model.  For several generations we have relied on product and prescription sales as a large part of our revenue.  In the past this has been great for business.  But in recent years many products have become over-the-counter (Advantage, Frontline, and others) and human pharmacies have been selling very cheap generic prescriptions.  Veterinary practices haven't kept up with changes in medications and business and are hurting from this.

Today I received an email from our state veterinary medical association about a recent article from consumer advocate Clark Howard.  He suggests getting a written prescription from the vet and having it filled cheaper at a large pharmacy.  The VMA appeared to go into panic mode, making some bold comments to members:  

Pet owner cautions-
•    Studies show that pet owners who leave the veterinary clinic with their prescription are more likely to follow the treatment recommended by the veterinarian.
•    Animal pharmacology has many complicated aspects for which human pharmacists are not trained:

o    Many drugs have side effects that might be particular to a breed
o    Drug interactions vary from animal to humans
o    Generics often do not have the same efficacy on animals as humans. Your veterinarian knows what works best for your pets, but a drug store pharmacist most likely will not know this and offer the generic to the consumer.

•    Prescription medications, including heartworm and many flea and tick products, are available only by a prescription from your veterinarian. Pharmacies or retail stores that sell these products directly to consumers are in violation of the law.

When your pets' prescriptions are filled at the clinic-
•    They are guaranteed to be the specific medication and dosage prescribed
•    The veterinarian can forewarn pet owners about side effects -- and if necessary to stop dosage
•    The veterinarian can know what other medications your pet is taking to avoid any potentially harmful drug interactions
•    Refills - the veterinarian is the best resource to determine if the prescribed medications are in fact working or if it is necessary to readjust and/or switch medications

While several of those points may be valid, I also think that this is an attempt to protect the business of veterinarians rather than looking out for the best interest of the client and pet. And I really can't agree with that attitude.

Please don't get me wrong, here.  I manage a business and am all about making a profit.  I also want to make sure that my clients get the best and appropriate medication.  I agree that human pharmacists don't have enough training in the effects of medications on animals.  I don't apologize for our mark-ups on medications because we have considerable overhead that human pharmacies don't.  But I think this is an unfortunate attempt to save an outdated business model.

Human doctors perform exams, interpret lab results, make diagnoses, perform surgery and other medical procedures, and write prescriptions.  The doctors don't actually sell the medications themselves, and so can concentrate only on the actual medical procedures.  Veterinarians, on the other hand, have built a considerable part of their practices on products rather than medical services.  As these products have become cheaper and easier to get from sources other than the vet, they have seen revenues fall.  I certainly saw a big drop in my clinic when the Bayer flea products officially went over-the-counter. Vets have also seen a drop because of cheaper medications available through internet pharmacies.  And many vets have fought tooth-and-nail to keep these prescriptions in-house, either matching prices or refusing to write the prescriptions.

There are some medications that simply aren't available in human pharmacies because they are veterinary-only drugs and have no human equivalent.  Often times dosages are quite different, such as levothyroxine (a thyroid supplement) only being up to 0.2mg for humans, which only treats a 20 pound dog.  These things will always need to be available through vets simply because they can't get them anywhere else.

But vets really need to change how they practice.  Cheap prescriptions and internet pharmacies are not going away, despite the wishes of some of my colleagues.  We need to get rid of things that people can get easily and more cheaply somewhere else.  I've started phasing out medications like cephalexin and amoxicillin where I simply can't compete with the prices of large chain pharmacies.  Basically, anything that someone can get by going to Wal-Mart, CVS, or Walgreens I try not to carry.  I'm also happy to write a prescription when the client asks for one, as that's certainly their right and by honoring the request I help build trust.  The focus should be on the true medicine and surgery, things that they can't get anywhere else.  We need clients to see us as actual doctors and not people who want to push a given product on them.  Though I don't agree with every aspect of the structure of the business of human medicine, I do think this is one area where we can learn from them.

Cautious Or Hypochondriac?

Erin made this comment on another entry and I thought it was worthy of discussion.

If my dog is acting "off" and there's not a logical reason (such as just receiving shots, or a change in diet), I pack him up and take him off to the vet. He gets to go to the vet more often than most because he has allergies and likes to try and scratch his eyes out of his skull sometimes. I always fear though that my vet is like, "Oh no, it's them again." Am I just being overly self-conscious about things, or do vets prefer caution to people that just "hope it gets better?" Any advice for how I can develop my discretion regarding when to visit? 

Personally, I'd rather see a patient in the early stages of a disease than the late stages.  I always tell my clients that I'd rather them come in and me say it's nothing to worry about than them waiting until it may be too late to do anything.  I will never make fun of them for this, and have many times each week where my recommendation is to watch the pet for a little longer.

Yes, I do see clients who come in for every little thing.  And sometimes it does get a bit annoying.  But even in these cases I'd still rather have the client come in.  As frustrating as some people can be, there is nothing worse than someone coming in almost too late.  The ones that really get to us are the people who have their pet in serious shape for days or weeks and then expect us to work miracles.  That's not fair to us, as even the best doctor is not a miracle worker.  It's also not fair to the pet, who should have been much sooner.

My first and best advice to you, Erin, and all of my clients is this:  if you're worried enough to call the vet and ask a question, it's worthwhile bringing the pet in.  If you have a concern, then we should examine it and determine if there really is a serious problem.  Want more specifics?  Unfortunately that's hard to do.  Generally I'll say that if vomiting is happening every few hours continuously or goes on for more than 24 hours, come in.  If diarrhea is going on for 2-3 days, come in.  If you see blood, consider letting us look at the problem (though obviously a small scratch or cut likely doesn't need treatment).  If there is sudden collapse, seizures, or neurological signs, come in right away.

Chronic disorders may be a bit different.  A problem like allergy disorders isn't life-threatening and doesn't need to be seen as an emergency.  However, it certainly needs treatment, and we vets know that these patients are going to need to be seen more frequently than your average pet.  Again, we'd rather you come in when scratching starts rather than waiting until the skin is chewed bloody.

Hope this helps a bit for Erin and anyone else wondering if you should take your pet to the vet.

Bring The Poison In, Too

Vets commonly get cases of known or suspected exposure to various toxins and poisons.  A couple of months ago I saw a case where a dog ate rat poison.  Today I saw a dog who at the cap off some weed killer.  Thankfully neither case was serious and we were able to quickly and successfully treat the pets.  However, the owner unknowingly made the proper treatment more difficult.  How?  They didn't bring the poison in with the pet.

This is actually a very important point, and one that most pet owners don't realize.  There is not one type of rodenticide, herbicide, or pesticide, and different chemicals can cause significantly different symptoms.  For example, let's look at common rat poisons.  Historically most rodenticides have been based off anticoagulants.  The rat/mouse/etc. eats the poison which interferes with the blood's ability to clot, and the animal hemorrhages to death from simple movement and bruises.  In recent years the rodenticides have changed to where they cause death from brain swelling and other problems unrelated to blood clotting.  Anymore we can't assume that a rat killer is an anticoagulant, and the treatment for the various poisons is very different.  If we don't know which kind it is and make the wrong guess on treatment, the pet could easily die.

Weed killers are similar.  Some of them have a very low potential for toxicity, some cause gastrointestinal problems, and some will cause fluid to accumulate in the lungs.  There is no single treatment for "poison", as it all depends on what chemicals the pet was exposed to.

And this is why it is very important that we can identify the specific toxin.  Without knowing exactly what the pet swallowed we won't know what symptoms to look for and what treatment to give.  Thankfully, active ingredients must be clearly printed on the package and are easy to identify.  The names are often long and difficult to remember, so if you are in a situation like this in the future, be sure to bring the package or label to your vet when you take your pet in for an exam and treatment.  If we can read the active ingredients we can tell what treatment we need to do.

This is also a good time to plug the ASPCA Poison Control Center (here in the US); 1-888-426-4435.  They are staffed 24/7/365 and will take calls of suspected or known toxin exposure.  There is normally a charge for the call, but they should be able to tell you how serious the problem might be, how quickly you need to see a vet, and what you might be able to do before going to the vet.  However, they will need to know the specific chemical or ingredient, so have that handy before you call.

Not Your Typical Grandmother

This morning I saw a very sweet elderly woman, the epitomy of a grandmother.  She was probably in her 80s, soft-spoken, with white hair, wrinkles, tasteful jewelry, a pink jumpsuit, and a warm smile.  Her cat was having some hair loss around the eyes, prompting her to bring the kitty in.  Her tone of voice was quiet and slow and she made easy small-talk, smiling the whole time.  Overall a very pleasant woman, edging towards being quite talkative.

As I was looking the cat over, she cautioned me that she might pee on me.  I get this warning frequently (though probably not frequently enough considering how many times I am urinated on without advance notice), so I smiled and laughed it off.  "Wouldn't be the first time," I said, "and I'm sure it wouldn't be the last."  The woman began talking about some other things and honestly I was only half paying attention because it wasn't really relevant to anything we were doing.  I knew she was speaking about the cat having previously urinated on her.  Then she said that she had to wipe her kitty's tw*t.

Yes, that's right.  This very sweet, grandmotherly woman casually dropped a rather vulgar slang term for a woman's genitalia.  If I had been drinking something I probably would have done a comedic spit-take.  Instead I pretended like I never heard it or hear these things every day and continued with my exam and recommendations.  Of course, as soon as I left the room I shared this rather shocking phrase with my staff and associate.

What was so surprising was not the actual word.  I've heard clients use worse language than that.  The shock came from the juxtaposition of her appearance with such vulgarity.  I would have expected someone looking like her to use a cutsey slang such as boo-boo, pee-pee, or even va-jay-jay (a common phrase here in Georgia).  I certainly was not expecting to hear her drop the "t-word" and then move on like nothing happened.

I know you can't always judge a book by its cover, and this was a rather shocking reminder of this adage.

Poop Connoisseurs

I have learned not to be self-conscious about many things I do in my profession.  One of them is close examination of animal feces.  I'm sure you've seen vets do this (or have done it yourself if you're in the profession).  The client brings in a stool sample for a sick pet or the pet eliminates in the exam room.  Since the disorder is related to the digestive tract, we want that poop!  The vet gets the sample and then starts turning it around, looking closely at it and perhaps poking and prodding to investigate what is inside the little log.  We might even bring it closer to our face to get a really good look at it.

"Eeewwwww!  Gross! You're playing with poo!"

Well, yes, I am. But there is a reason for it.  I'm completely aware of how strange it looks and that it's a rather disgusting substance to be examining that closely.  But there is a lot of information we can learn from a close look at poop.  We check to see if there is any blood, foreign objects (bone pieces, grass, thread, crayon, etc.), obvious parasites, and other things that shouldn't be there.  Additionally the color and consistency can tell us a lot about the case.  In fact, scientists have actually made rather objective charts to score the fecal consistency!  No, I'm not kidding.  Since it's rather disgusting to those unused to looking at such things I won't copy the picture here, but just Google "fecal scoring system" (or click on this link) and you'll see a nice chart that Purina made for us vets (yes, I have one in my clinic).  Most of us tend to use rather "descriptive" terms, such as referring to the stool as having a consistency like "cow patties" or "soft-serve ice-cream."  As unscientific as such descriptions are, we all know what they mean.  Still, somebody went and quantified it, hence the chart.

Let me give you an example of how much information we can get from poop.  Mrs. Cowpie brings her dog, Squirt, to the clinic with a complaint of diarrhea.  Squirt lives up to his name and provides a sample right there on the exam room floor.  I bend down and look at it, noticing that it's of the same consistency as partially melted ice-cream (okay, okay, it's a Score 6 feces), there are some streaks of blood, and a good bit of mucus.  Squirt is also straining a bit to get the last few drops out and seems a bit uncomfortable. I can tell by these clues that the dog has lower bowel diarrhea, also called colitis. Why?  Frank (red) blood comes from the lower intestine, while digested blood is from the upper intestine and looks like coffee grounds.  Mucus in the stool indicates colitis, as you won't have mucus production in the small intestine.  Straining also indicates a colon issue.  So I've already identified what part of the digestive tract is causing the diarrhea, which limits the number of diagnoses possible.  Just by bending down and getting a good view of the poo I have a short list of my top two or three likely diagnoses, as well a treatment protocol for each.  I'll do an exam, some tests, and get a good history to try and confirm my suspicions, but the feces alone has given me a direction in which to proceed.

The next time your vet oogles your pet's poop, realize that we really are connoisseurs, and like someone examining a fine wine we can tell a lot by the appearance and smell. 

Dr. Google

The Internet is now a part of daily life and is virtually a necessity rather than an option.  It's not going anywhere and in fact has greatly expanded its impact on our lives and culture over the last 10 years.  However, such easy access to information across the world can be a hindrance more than a help, especially to doctors.

When you or your pet is sick, what do you do? Older people will call their doctor.  People of my generation and younger will likely first turn to an internet search, trying to research the problem and potentially make a self diagnosis.  This situation has come to be called "Dr. Google" among vets and physicians and can be a source of concern.  I will readily admit that I've done the same thing, consulting Web MD and other sites when I couldn't get in touch with my own doctor.

There are a number of reasons why clients need to be cautious about doing so.  First of all, there is an art to diagnostics and a good doctor can take symptoms and make a conclusion of a certain disease.  When you read a list of symptoms on a web site it can be quite scary, as some of them can make you think your pet is dying or needs emergency care.  If a vet saw the pet, they may conclude that it's something very minor.  There is a lot of training and practical experience that goes into diagnosing diseases, which a layperson usually isn't able to do.  For example, bloody diarrhea can indicate something as severe as an ulcer or parvo virus, or something as simple as having eaten a piece of ham.  Believe me, I've been concerned about my own symptoms when reading them off the Internet!  You have to take all of that with a grain of salt.

Another reason for being cautious is that you may not always know the source of the information since anyone can post anything on the internet without any editorial review.  I could just say that I'm a vet and most of you wouldn't know any different, especially if what I said makes sense.  For all you know I just play a vet on TV!  Of course, that's not true and there are ways to find out (such as checking a state's veterinary board site and searching to see if the name is a licensed doctor).  But you have to be especially cautious with posts on forums and discussion boards, especially those not coming from a vet.  Medicine is both an art and a science and there are sometimes disagreements even among specialists.  If you don't have extensive training and education, you're simply not qualified to make a final decision as to which opinion is valid.

Now I don't think that everything you find on the Web is junk.  There are plenty of good, reliable sources of information (such as this blog!).  But even if you have a good source, you need to have an open discussion with your vet.  Most of us have learned that clients will sometimes come in with pages of information they printed from web sites, and realize that this is not a transient phenomenon.  Sometimes this is very valid data, and I'm glad that clients are doing their own research and homework.  I'll even sometimes write down the name of a particular disease so people can look it up on their own.  However, be open to your vet disagreeing with that info, including what you find on my own site.  Again, there are several opinions on most medical problems.  Have the discussion and honestly listen to your vet.  They may have an viewpoint contrary to what you read on the Web, but likely have legitimate reasons for how they feel.  Personally I welcom a client wants to talk about my diagnosis and testing based on their own research and aren't just out to prove me wrong.

I'm sure my astute readers will notice considerable irony in my comments today.  "Wait a minute!  Don't you give advice on the internet?  Aren't people coming to you rather than their own vet?"  This situation has obviously not escaped my notice, and I admit a certain guilt in furthering the "Dr. Google" situation.  However, my disclaimer clearly states (for anyone who actually reads it) that any advice here doesn't take the place of a vet visit and I can't properly diagnose a problem over the internet.  Long-term readers will have noticed that I usually refer people back to their own vet for further discussion and advice.  I've also received plenty of emails from clients where I don't even discuss it in the blog but simply tell them to go to their vet.

So yes, check the internet, but never believe what you find here without first talking to your own veterinarian.

Missing Testicles

Many people don't realize it, but testicles don't always end up where they are supposed to.  No, get your head out of the gutter!  This is strictly a medical discussion.

In a fetus the testicle develops in the abdomen near the kidneys. As the fetus and eventually the baby grows, the testicles move lower in the abdomen, migrate through the inguinal ring (in the groin), then under the skin and finally into the scrotum.  At any point along that journey one or both testicles can stop.  This condition is called "cryptorchidism" ("crypt-" meaning hidden and "-orchid" referring to the gonads).  Though it's not common, I see several cryptorchid patients every year.

Normally by the time a puppy or kitten is two months old we should be able to feel both testicles.  Sometimes they can be delayed in descending, but they certainly should be in the scrotum by four months old.  We always check the testicles at each visit to make sure they are where they should be.  If a testicle is retained, it can be under the skin next to the penis, under the skin in the groin, or within the abdomen.  If it's under the skin it's simply a matter of making a second skin incision and removing it.  If the testicle is in the abdomen we have to make an incision in and explore the abdomen.  Sometimes the testicle is sitting near the incision in the middle of the abdomen and it's simple to grab it, tie off vessels, and remove it.  However, there have been situations where the cryptorchid testicle is really hidden and difficult to find.  In one case early in my career I had a testicle simply not develop.  I found the vessels, vas deferens, and other associated structures, but gonad itself wasn't there.  I've had testicles stuck in the inguinal ring, and one situation where I pushed it through the inguinal ring while I was exploring the abdomen and then had to remove it from under the skin after closing the belly.

Why is this necessary?  A retained testicle will function relatively normally, producing testosterone and sperm.  Cryptorchid pets will act like any intact male and can potentially even reproduce (though this isn't recommended since this is a genetic tendency).  The biggest concern is that eventually the retained testicle may turn cancerous, especially within the abdomen.  Testicles in most mammals are not designed to be constantly at normal body temperature, which is why they hang slightly outside of the body.

Yes, I had one of these cases today, and realized that I can't remember blogging about it before.  The patient today was an Australian shepherd, and the surgery was pretty quick and easy.  With an experienced vet most of these cases are fairly straight-forward and no more invasive than a spay.  If you have a situation like this, talk to your vet and have your pet neutered.

The Causes Of Sarcomas

One of the scariest types of cancer that a pet can get is a sarcoma.  These are aggressive and highly invasive tumors that can grow very quickly.  Cat owners are likely more aware of this cancer because of the fear of it being caused by vaccines.  Within the last 20 years there have been numerous studies trying to determine why sarcomas happen after vaccines, potentially implicating certain chemicals in the vaccines.  However, much of this fear is based on old data and is unfounded.  When I graduated vet school they were called "vaccine-induced" sarcomas.  Now they are more properly named "injection site" sarcomas.

The latest issue of the NAVC Clinician's Brief has two separate discussions on this subject.  The current thinking is that certain cats are genetically predisposed to developing cancer when they have focal subcutaneous inflammation.  So basically whenever anything punctures the skin a small percentage of cats have a high likelihood of the inflammation turning into a tumor.  Sarcomas have been associated with a wide range of causes:

vaccines

microchips

Meloxicam (an analgesic)

animal bites

steroid injections

antibiotic injections

injectable Program (lufenuron)

and many other things.  Vaccines just happen to be the most common injections we give to cats, and therefore became associated with sarcomas until further research showed other factors.

I certainly don't want to make people afraid to get their cat injected or vaccinated.  This was just on my mind after reading the journal, and I wanted to bring it up to debunk the idea that vaccines are likely to cause cancer.  If there was a way to screen cats for the genes that lead to sarcomas we could avoid injections in these patients.  Unfortunately there is currently no such test, so we are left with playing the odds.  Thankfully this is a rare situation, and the huge majority of cats have no problems whatsoever.  Until new technology is developed (Star Trek hyposprays, anyone?) we can't avoid injections from time to time.  I still vaccinate my cats and will readily give them any injection they need.  They are also microchipped.  

So don't be afraid to let your cat receive vaccines or other injections.  But whenever a lump under the skin doesn't go away, be sure to have a vet check it quickly.

Earrings And Tattoos....On Pets?

Fifteen years of practice and I still see new things.  Today I saw a dog come in with earrings.  Yes, I'm serious.  Real honest-to-goodness earrings in pierced ears.  It was a chihuahua puppy with a piercing and stud in each of its rather large ears.  I was a little taken aback but was professional enough to not show much reaction to the client.  Apparently this is something popular in Columbia, where the client is originally from, and she did the piercing herself.  The dog was healthy and didn't seem to notice the piercings, but I still have to wonder about the whole thing.

A few times over the years I've had clients ask about this as well as tattooing their pets.  And I'm not talking about ID tattoos, but artistic ones.  I've never understood wanting to do such body modifications on pets, though I don't have a problem with people doing such things.  People can choose whether or not they want their ear, tongue, or other body parts pierced, and what kind of image they want permanently etched on their body.  Pets aren't involved in the decision and can't understand why they have to go through the discomfort of these procedures, just because the owners want them to look this way.  And unless you have a very short-haired or hairless dog, the tattoo isn't going to be visible anyway.

Honestly, I'm against any purely cosmetic procedures on pets other than grooming.  Anything invasive that could cause pain or complications shouldn't be done unless there is a valid medical reason to do so.  Now, I don't get bent out of shape if someone has their cat declawed, or a dog's ears cropped, dewclaws removed, or tail docked.  I don't do any of these procedures myself and am overall against them, but I'm not going to come down hard on someone who does it.  If I did, I'd be getting mad at far too many people and maybe after this long as a vet I've realized that those battles aren't worth fighting and that I never win them.  I try to convince people not do to them if they ask my opinion, but once it's done, it's done.

So while I don't like the idea that this woman pierced her dog's ears, I can't do much about it now.  I just hope that it doesn't start a trend!

Vet Or Tech?

Here's a question from Nicole....

I am a student struggling to find which career to pursue. I know I want to be in the Vet field but I cant determine if my calling is to be a vet tech or a veterinarian. Any advice to help guide me in the right direction? What scares me to become a veterinarian is the debt as well as that I really would love to start my career within the next 3-5 years, is it possible to get a vet tech degree and then later continue on to become a veterinarian?

Let's start with the last part first.  It is certainly possible to work as a licensed veterinary technician and then go on to vet school afterwards.  I've known several people who have done so and being a tech doesn't eliminate the possibility of being a full vet one day.

The debt-load of getting a veterinary doctorate is indeed an issue, and it's only getting worse.  Each year the amount of debt increases, worsening the challenges and burdens of paying it back.  From everything I've seen this is becoming a real crisis and there doesn't seem to be any solution on the horizon.  Anyone wanting to become a veterinarian needs to take a long, hard look at the cold reality of their finances once they graduate.  You can't simply have a great desire and figure that you're going to worry about it at another time.  Simply put, it's getting harder and harder to pay back the debt of a veterinary education and make a decent living.

There are some other factors in this decision.  I currently have one of my staff who is going through school to get her technician certification, and she's been asked by friends and family why she isn't going to be a doctor.  She says that the idea of being the final decision-maker is intimidating.  I can tell you from personal experience that it's very stressful to have a pet's health and life be dependent on your medical and surgical skills.  Not everyone wants that weighing on their minds and like the idea of being able to let other people make those hard choices.  And though technician school isn't easy, vet school is even harder.  My assistant is taking a clinical pathology course and is going through identifying parasite eggs.  She has one class on clin path that includes many topics.  I had one semester of parasitology and two semesters of pathology.  Lots more detail!  So you will have less stress and less time in school by going the technician route.  

And lastly, it depends on what you like about the veterinary field.  If it's mainly the technical aspects of placing catheters, running lab tests, educating clients, and handling pets, then a vet tech degree is likely your best choice.  Technicians usually do more of this than the vets do.  If you really like the idea of performing surgery, diagnosing challenging cases, and delving into the hard science of medicine, consider becoming a vet.

Best of luck with your decision, Nicole!