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Tuesday, January 29, 2013

Bulging Chameleon Eyes

Chameleons are really interesting animals.  Their tongues are the most classic part of them but the rest of their anatomy is equally interesting.  My favorite part is their eyes, being able to move and focus independently.  The eyes are normally prominent, so it was unusual to see a patient with them bulging.

The client drove a good while to get to me since I'm one of the few vets in my area that will see exotic pets.  When I heard that the lizard had bulbous eyes I immediately started thinking about an abscess or vitamin A deficiency, both of which can cause swelling of or behind the eyes.  But when I examined him I started to realize that the appearance didn't fit with either problem.

This had been going on for about a month, gradually getting worse, and was suspected to have started after falling from his foliage.  As it worsened the chameleon's appetite decreased, likely in part because of pressure and discomfort behind the eye as well as difficulty moving the eyes to see the food.

The swelling appeared to be behind the eye itself, within the socket.  I carefully lanced the swelling and was surprised to get a large amount of blood from the puncture.  Even more shocking was that the swelling reduced behind both eyes, even though I only lanced one side.  This meant that there was an injury behind the sockets in the space between the eyes.  However, I couldn't figure out why the blood was still liquid rather than clotted and how he had been bleeding to some degree for so long without getting even worse.

Never having seen anything like this I made a couple of phone calls.  One was to a local exotics specialty practice to speak to the lead doctor there.  He had never heard of this before even though all he did was non-traditional pets.  My next call was to a vet friend of mine in Oklahoma who has extensive practical experience with reptiles.  I managed to stump him as well.  Neither of these experts could figure out what might be going on, and more importantly how to fix it.

This is one of those situations where we elected to do nothing because we couldn't figure out something safe to do.  If we kept draining the swelling we could cause anemia or infection and surgery at that location would be highly risky.  The owner could hand-feed him and elected to do so, hoping for the best.

I really hate not being able to figure out a problem!  Thankfully the client was very understanding about the unique problem and the fact that three vets had no idea what was going on.  

Veterinary medicine is not an exact science.

Wednesday, January 23, 2013

A Variety Of Veterinary Specialties

Alexandra asks this...

I was wondering what you can specialize in as a veterinarian. Did you specialize? Would you recommend specializing? 

Most veterinarians are generalists, meaning that we do a little bit of everything.  In our daily work we do surgery, work up internal medicine cases, fix skin problems, look at eyes, and so on.  We really do tend to be "Jacks (or Jills) of all trades and masters of none".  But specialties are certainly possible.

Off the top of my head veterinary specialties include internal medicine, dermatology, neurology, cardiology, oncology, surgery, ophthalmology, anesthesiology, epidemiology, nutrition, toxicology, theriogenology, radiology, avian medicine, dentistry, pharmacology, and pathology.  But there are actually even more than this.  For a full list click here and here.

Specializing is very difficult.  In order to become a board-certified specialist you usually complete a year of internship and then 3-5 years of a residency program, all after having completed veterinary school.  So a specialist has around 8-10 years of veterinary education!  But once you've done all of that it's not over.  In order to be able to call yourself "boarded" and a "specialist", you must pass an exam in that field of specialty, which is extremely difficult.  I've heard that for surgery only about 40% of candidates pass, and there is a 20% pass rate for pathology.  This means that the odds are great that someone seeking a specialty designation will need to take the test more than once.

Once you achieve this designation you spend the rest of your career focusing on a particular aspect of medicine to the exclusion of others.  For example, someone specialized in internal medicine doesn't perform surgery, and someone specialized in ophthalmology isn't going to worry about reproductive disorders.  Obviously, you need to really love what you do and want to do that all of the time.

The financial rewards are debatable.  While a specialist makes a good bit more than a general practitioner, during the training they make considerably less.  So lifetime earnings may not be any more for a specialist than a generalist and there may be more accumulated debt.

I did consider surgery as a specialty but after spending two weeks working for a surgical practice during vet school I decided against it.  In part I didn't want to do orthopedic surgery, which is a large part of that job.  I also didn't want to spend more time in school.  Lastly, I learned that I like seeing a variety of cases and clients and wanted to deal with well pets along with sick ones.

Friday, January 18, 2013

Human Or Veterinary Medicine?

Nick emailed me....

I was wondering what advice or insight you could give to a student who is currently trying to decide between veterinary or human medicine as a profession. I currently work as a biomedical engineer in an academic research setting; I'm planning to go back to school in the next few years. I had always planned to practice human medicine, but I really love animals and it would make me very happy to be around them and help them for my work. 

Snarky answer:  
Do you want to make good money and have a decent quality of life?  Choose human medicine.  Do you want to barely survive and have a hard time paying back overwhelming debt?  Choose veterinary medicine.

Real answer:
Don't choose veterinary medicine just because you love animals.  You will be faced with many difficult situations on a daily basis where you are unable to help the pets because the client can't afford it or decided not to do anything.  You'll have your hands tied by clients when you know you could do more.  And you're going to see animals suffer.  It's not easy, but neither is human medicine.  At least in human medicine you don't typically have as many limits on your diagnostics and treatments.  

In veterinary medicine you will have patients biting and scratching at you every day, and will routinely get feces, pus, blood, urine, and other random bodily fluids on you.  We don't have to worry as much about transmission of disease to us from our patients, which is a big concern with human doctors.  But it's still not pleasant and I don't think the human medical professionals have to worry as much about bodily injury in routine work.

Despite my attempt at humor, the financial prospects are much better for human doctors than veterinarians.  Take a scan through the past six months of my blog and you'll see lots of discussions on this topic, most of which will be disheartening for those wanting to enter the profession.

Really it boils down to what interests you the most and where your passions lie.  I could never do human medicine as I find it rather gross and repulsive.  Strange, right?  All of the things I see and do every day would make me sick if I saw it on a person.  I'll even pass out if I have to have my own blood collected!  So you may find yourself in a similar situation, finding one aspect less appealing than another.

Also keep in mind that you can be a human doctor and still work around animals.  You can volunteer at an animal shelter, support a rescue organization, or even help with programs that allow pets to come in hospitals as part of therapy.  You won't be a doctor for them, but you can still help them and continue that love.

Best of luck, Nick!

Wednesday, January 16, 2013

Test For Cancer?

Recently a client was mildly upset about some lab tests.  Rather, she was bothered by was wasn't found.  Her dog was sick and she wanted us to test for cancer.  When we ran basic blood tests everything was normal and she wanted to know about the "cancer test".  One of my assistants ended up talking to her and eventually explained that there was no such test and we had to look for cancer by other methods.

This is an example of where a little information and a lot of extrapolation can get people into trouble.  In human medicine there are blood tests that can help identify cancer, such as the PSA test for prostate cancer. However, these are always specific tests and they are only available for a very small number of cancers.  There is no such thing as a general cancer test.  Cancer is detected by looking at its affects on the body (decreased kidney function, liver enzyme elevation, etc.), feeling masses, or discovering abnormal lumps on x-rays and ultrasound.  

In veterinary medicine we run into the same problems of being able to find cancer.  We still have to look for its influence on the body, but we don't have any of the tests available for human doctors.  For example, prostate cancer is normally detected through a rectal exam and ultrasound, as we don't have the PSA test for dogs and cats.  We often have to do more investigation and educated guessing than in human medicine.

Sometimes cancer must be inferred rather than definitively diagnosed.  We're currently treating an elderly cat who is losing weight.  All of the blood chemistries are normal, ruling out kidney disease, liver disease, and diabetes.  The thyroid level was normal, ruling out hyperthyroidism.  The only blood panel abnormality was a slightly elevated globulin level, indicating immune stimulation.  The white blood cell count was elevated, and remained so after two weeks on antibiotics.  The cat is continuing to lose weight and doesn't want to eat, but there really aren't significant clues in his lab tests.  Elevated globulin levels and a white cell count suggests either a viral infection or cancer.  Since a virus would normally improve in a couple of weeks and it hasn't, that leaves cancer.

This is where a "cancer test" would be very helpful.  In human medicine we'd be delving further and likely be going to imaging such as x-rays and CT scans.  But that's not realistic for most clients.  So by process of elimination we're suspecting the cat has cancer, though we can't identify where or what kind.  Currently we're trying appetite stimulants and trying to buy some time, but the prognosis is poor.

Cancer is a horrible disease and it's not always easy to find.  And there isn't a test for it.  Have some patience with your veterinary team as they try to help figure out what's wrong with your pet.

Monday, January 14, 2013

Lice: Humans Vs. Animals

We discovered a rather annoying problem last night.  My daughter has head lice.  Apparently one of her neighborhood friends had it and the lice transferred.  Thankfully this is more of an annoying problem than a really serious one, and I think we caught it early before it spread to the rest of the family.  But my wife is completely freaked out by this.  

Being a veterinarian I have a very different perspective than she does.  When my daughter plucked a "bug" from her hair and my wife wanted me to look at it I calmly shrugged and said "It's lice."  She asked me if I was sure and I started giving a lesson on how it was bigger than animal lice but had the same body shape and structure, even to the naked eye.  Not what she wanted to hear!

Shortly after that she drove to the pharmacy and picked up some anti-lice shampoo.  She also had me wash our daughter's bedding, put her stuffed animals in airtight bags, and check everyone else for lice and nits (the eggs).  Since then my wife has been constantly fretting, talking about the lice, and being paranoid every time she or anyone else scratches an itch on their head.

Are lice a concern?  Sure.  They legitimately cause irritation and can be tricky to get rid of in some cases.  But most cases are very straight-forward and relatively easy to treat.  Lice also don't cause a serious health problem.  Maybe I'm being a bit too nonchalant, but it doesn't worry me.  I recognize that we need to treat the infestation and take measures to prevent spread, but to me it's pretty simple and I'm not upset.

I've seen lice plenty of times in animals, including just in the last couple of weeks.  Lice are visible to the naked eye, even though they are small.  We classify them as "biting" lice, who live off skin, and "sucking" lice who drink blood.  Regardless of the kind they can be irritating to the skin and result in itching.  Diagnosis is as simple as looking closely over the pet, confirming the diagnosis by putting a likely louse (singular) under low power on a microscope.  

Treatment is typically just as easy.  Depending on the degree of infestation and likelihood of spreading to other pets we may do a series of injections of ivermectin (an antiparasitic) or special medicated dips.  Two treatments is usually sufficient, though I've had a few cases in guinea pigs that have been rather stubborn.

Thankfully lice are species specific, so my daughter's lice won't transfer to our pets.  Conversely if you have a pet with lice it won't spread to the humans or even other pets of different species.  Of course, I had to explain this a couple of times to my wife who was envisioning every mammal in the house crawling with little critters.  Other than which species the louse affects, they behave remarkably alike.

So now we just have to wait it out.  And my family wasn't too keen on me giving my daughter a shot of ivermectin.

Saturday, January 12, 2013

Zoo Medicine

I just received this email from David....

I am interested to hear what you might know about zoo veterinarians. What might the outlook be for this career path as far as salary/competition/availability goes? I am a junior currently majoring in biology and have wanted a career in animals since I was in kindergarten but recently took a shine to veterinary school about 6 or so years ago. I have been discouraged by a lot of what you have talked about as far as the job outlooks go for large and small animal vets, but I am hoping for a ray of hope before I give up on this dream, haha.

When I was young my dream was to become a zoo veterinarian.  I loved the idea of working on exotic animals and being around animals that few ever handled.  From an early age I thought about this route and planned for it.  I even had the opportunity to be around some exotic animals at the veterinary practice I grew up working for, as the owner did some work with privately owned large cats.

My eyes were opened when I spent the summer of 1990 working at the Yerkes Primate Research Center in Lawrenceville, Georgia.  I was there doing a behavioral internship as I developed my interest in animal behavior.  The facility had large colonies of rhesus macaques, sooty mangabeys, and similar primates.  Though I mainly helped with collecting lab samples and doing my own project, I was able to spend some time with the veterinarian there.  It wasn't as cool and interesting as I had expected.  The patients were always fully sedated and it was more about treating wounds and other injuries.

When I went to graduate school for my Master's degree I ended up doing a research project on ermine and spent the summer of '92 at the Minnesota Zoo in Apple Valley, Minnesota.  I had daily access behind the scenes as I was studying neonatal and maternal behaviors of the weasels.  I did have a few opportunities to spend a little time with the vet at the zoo and it was even more eye-opening than my time at Yerkes.  Between the keepers and the vet I learned how incredibly political zoos could be.  Though the animals were well taken care of, many decisions were made because of a desire to get people through the gates rather than for the benefit of the exhibits or workers.  There was a constant balance and battle between making money, pleasing patrons, and letting the animals be healthy and happy.  As a vet you're dealing with administrators, not clients, and it's not all warm and fuzzy.

I also learned that becoming a zoo vet is probably the hardest field of veterinary medicine.  The animals in zoos are often rare, difficult to care for, and sometimes little is known about the specifics of their physiology and nutrition.  If I make a mistake on a patient it's tragic because it's a family member.  If a zoo vet makes a mistake they may be hurting one of the few animals of that type in captivity.  In a zoo you are working on pretty much every kind of animal known to man:  insects, reptiles, amphibians, fish, ruminants, carnivores, birds of all kinds, and so on.  A zoo vet has to know more about different species than pretty much any other vet.

That training is hard to come by.  There are few zoo medicine residency programs in the US and practical experience can be few and far between.  Because there are so few openings, competition for those residencies is fierce and only the absolute best make it in.

Competition for veterinary positions is also tough.  Because there are limited numbers of zoos and so many people want to be a vet in them, often you'll have a couple of dozen vets who apply for any opening.  And since so many applicants are available the zoos don't have to pay as high of a salary as you might think.  That's not to say that zoo vets are poor, but the pay isn't as high as someone with such expertise might be expected to make.

These were only some of the reasons why I decided not to pursue this aspect of veterinary medicine.  I discovered that I liked interacting with clients and enjoyed the personal bonds with pets, which you're not going to get in a zoo.  I get my exotics "fix" by working with non-traditional pets.  Just today I saw a turtle, chameleon, two guinea pigs, a hamster, and a rat!

David, I know this may burst your bubble a bit.  Being a zoo veterinarian is one of the most specialized aspects of veterinary medicine and therefore one of the most difficult to enter.  It's not impossible, but it will be even harder than being a general practitioner. 

Man, I'm being a real downer with those wanting to be a vet!  I honestly wish the prospects were better.

Wednesday, January 9, 2013

Traveler's Travails


This case is actually from last summer, but I'm just now getting around to posting it.  The dog was Traveler, named after Confederate general Robert E. Lee's horse.  He was a very sweet white German shepherd that came to me for a large, painful wound near his rectum.  

The owners had no idea how it happened, just that it suddenly appeared.  When I tried to examine him he was very nice, except when I went to look under his tail.  He turned around and tried to bite, then returned to being sweet.  It was obviously extremely painful and he was trying to protect it.  With a muzzle, good restraint, and a light touch I was able to get a good enough look to tell that it was large and deep and something we would need to sedate him to examine further. I didn't know what I was going to find, but I knew we couldn't just put him on medications and hope for the best.  Thankfully the owners agreed to our treatment plan.

Ready for the grossness?  I hope your stomach is strong.

Here is what we found once he was heavily sedated and we could get a good look at things.

This looks bad on the surface, but it was worse as I explored it and got some light into it.  This was not a simple wound, ruptured anal sac, or anything similar.  As I put my finger in I was amazed at how deep the wound went.  I could feel the outside of the rectal wall!

I was concerned that there was a puncture through the rectum or lower colon which would require major surgery to correct.  I had no idea what caused damage but knew we needed to fix it.  With some exploration I began to feel that this wasn't the case and took the chance that we might be able to manage it more conservatively, especially since he was so stable otherwise.

I flushed the wound with chlorhexidine (a disinfectant), placed a drain tube, and closed the hole.

We sent him home with antibiotics and pain medication.  I hoped that would be the end of the major problem, though I warned the owner that this could still fall apart and go bad, potentially even requiring surgery by a specialist.  And it did indeed start to fail.  

A few days later I had him scheduled to come back and remove the drain.  The skin had pulled through most of the stitches and the wound had opened up again, though not quite as much as on the original visit.

However, Traveler was feeling much, much better and was no longer painful.  He was defecating normally and in good spirits, all of which was very encouraging.  We decided to manage it more as an open wound rather than going back in for further surgery.  We kept him on antibiotics and started using Granulex spray, designed to help wounds heal.  

Believe it or not, this worked!  A couple of days later we had a slight improvement in the size of the wound, and more importantly I could see that the deeper tissues were closing up.

We checked him after a few days, continued to see improvement, and then went to weekly rechecks.  Here's a picture of Traveler's rectal area about two weeks later.

Incredible healing!  Go back and compare it to the top photo and you'll see how dramatic this was.  

Traveler made a complete recovery and had no long-term damage to his rectum or muscles.  I still have no idea what caused the wound, but in the end (pun intended) it all turned out well.  I love stories like this!

Thursday, January 3, 2013

Vet Vs. Vet? Making Sense Of Differening Findings

Last weekend I saw a dog for a very unusual fluid accumulation around the hind end and legs that had started a couple of months ago.  Neither myself nor my associate had ever seen anything quite like this, and that's about 35+ years of combined experience looking at the pet.  It was certainly a strange case!

I collected fluid from the swelling, placed a urinary catheter, collected urine, and took some x-rays of the abdomen.  The fluid looked similar to urine, but when comparing certain values to what came directly from the bladder there were some significant differences.  The x-rays and catheter also showed that there didn't appear to be any obvious communication from the bladder to the fluid swelling, so I concluded that the bladder wasn't involved and something else was going on, perhaps a serum-secreting tumor.  The dog's exam was otherwise normal and he was acting perfectly fine at home.  The tests we performed were routine and minimally invasive, things we do virtually every day without consequence.

Two days later he was euthanized at an emergency clinic.

When I came to work Tuesday I was shocked to see the report from the ER.  He had been doing great just three days before and though I had referred them to a specialist for further diagnostics, I didn't have any immediate concerns.  The lab tests they ran showed extreme blood and infection in his urine, elevated kidney and liver values, and an extremely low white blood cell count.  In essence he had a very aggressive systemic infection that was causing organ failure.  Chances for survival were very low so the client elected euthanasia.  None of that was evident on his exam and tests Saturday.  I was stumped and concerned as I hadn't seen any of this coming.  I tried to call the doctor at the emergency clinic but had no luck as I work 9am to 7pm and she works 8pm to 8am.

Since I'm human and care about my patients and clients I've fretted over this case for a few days.  I've reviewed the x-rays and gone over what we did to see if I missed anything or did anything wrong.  Obviously there was some unexpected complication after seeing him, but I couldn't find anything inappropriate with what we did or found.

Today the owner's mother called me, upset about what happened.  According to her the emergency vet had told her that the dog did have what I said he didn't have.  Basically we had contradictory stories, with me saying one thing and the other vet saying the opposite.  With such conflicting information I can certainly see why the client would be distraught and confused.

There are a few good lessons in this story, as tragic as it turned out.

First, clients and even vets need to understand that an exam and lab tests are like a photograph rather than a movie.  When we look at a pet and do diagnostics we are looking at a particular frame of time.  That picture may change if we look earlier or later.  In this case I didn't see the things the other vet did because they weren't there at the point that I did my exam.  Something happened between my exam and the other vet's that caused a difference.  So I didn't "miss" something because there wasn't something easily detected.

Second, when dealing with a situation like this the emergency vet and I don't have a complete picture of what happened at each place.  She could only go by what the owner told her and didn't have access to my lab tests and medical records.  I could never talk to her and her handwriting was almost illegible so I didn't completely know what happened there.  Here's a hint to all vets or future careful when contradicting a colleague's findings or conclusions.  You may not know everything that happened before and should give the first vet the benefit of the doubt in most cases.  Owners aren't going to be deliberately deceptive (well, most of them won't) but may not have fully understood what happened initially and may not be able to accurately explain that to the second vet.  I've had owners tell another vet that I said something when I absolutely know that I didn't.  Call and talk to the other vet and speak doctor-to-doctor to make sure everything is clear. 

Third, even the simplest of things can go wrong sometimes.  This was a strange case anyway, and I must have punctured a tumor, abscess, or something else that led to the serious complications.  Yet there was no evidence of this at the time and I still can't see an obvious issue when reviewing the x-rays.  There are cases that go wrong even with the best care, and situations that simply can't be predicted.  These are always tragic, perhaps moreso because they are unexpected, but you can't predict or avoid something you can't detect.

Sometimes lessons are hard.  But there often is a reason why vets may find different things and both be right.

Wednesday, January 2, 2013

Let The Doctor Know

My wife has been on a medication that we're hoping will help with some non-serious but annoying problems she's been having.  Unfortunately she is having some common side-effects which are bothering her.  Tonight she said that she's thinking about stopping the medication because of how it's making her feel.  While I certainly understand her concerns I imagined how I would feel if one of my clients did this.  I insisted that she call her doctor, talk about it, and at least let him know what she was doing.

This afternoon at work I saw a dog that had been seen by my associate back in October for an eye problem.  She had started him on a medication and scheduled a follow-up for five days later.  That was over two months ago.  The medication didn't help and the problem got worse. It was initially in one eye and now is affecting both, as well as worsening.  What was initially likely inflammation of the eye is developing into glaucoma in one of them.  It may not have reached this point if the client had come in for the follow-up or at least called to talk about it.

Communication with your doctor is very important.  Whether the treatment is for yourself or your pet, always keep your doctor in the loop.  Changing dosages without first talking to your vet or physician can lead to side-effects, serious consequences, or lack of improvement.  Drugs have durations, intervals, and dosages are all done for specific reasons and changing any of that could be a real issue.  

There are few things more frustrating that having a patient come in and finding out that they stopped a medication without consultation, or altered the dosage.  Sometimes it is appropriate to do so because of side-effects or lack of response, so we as doctors may agree with you.  But if we don't know about these things we may make inappropriate recommendations for care or even misdiagnose something because we assumed a treatment that wasn't actually happening.

Most doctors will actually pay attention to what you say.  I've had to alter medications many times due to client-reported problems and am always glad that they've informed me about it.  That's how a client-doctor relationship is supposed to work.

So please, let your doctor know what's going on with your pet.  Is the medicine causing side-effects?  Is it not working?  Did it work well?  All of these things are important for the vet to know as they can help us plan for future situations with that pet.  

Keep your vet informed.