Translate This Blog

Tuesday, February 26, 2013

Too Long Dog Nails

Stefanie asked me the following question, and it's one I get from time to time in my clinic.

I have a question on how to keep a dog's nails trimmed naturally.  I walk and/or hike with my dog at least 6 times a week.  The hikes/walks typically last from an hour to two hours.  However, her nails are pretty long.  For a few months - I tried taking her to the vet for a nail trim every 3 weeks to try and get the quicks filed down.  It wasn't working.  My vet suggested maybe putting her under an anesthetic to file her nails down better with a Dremel or even going so far as to putting her under and cutting the quicks back (a choice even my vet felt would be quite painful and something to be used only as a last resort).  

am doing my best to use a regular (human) nail file on my dog's nails and there is a little bit of resistance but I am hoping that eventually (with lots of treats) she will learn to tolerate it more.  

Do you have any other suggestions for how I can get her quicks under control so she can get a proper nail trim?  We live in Arizona so the hiking surfaces are pretty hard so I don't understand why her nails aren't being worn down naturally.   

My first question would be whether or not the nails are actually long.  I have many clients who complain about how long their dog's nails are, yet they seem perfectly normal to me.  Dogs are supposed to have prominent nails which serve a function similar to cleats on athletes' shoes.  The nails give traction when running over uneven surfaces.  Cheetahs are the only cats with nails that don't retract, again for the same reason of traction.  So a dog's nails are supposed to extend to the end of the naturally growing quick and make contact with the ground.  It's actually abnormal for a dog's nails to be small nubs and too short to reach the ground.

Routine nail trimming and walking on hard or abrasive surfaces are the best ways to keep the nails at a normal length.  Rough surfaces naturally wear the nails down, and it sounds like you're doing that, Stefanie.  However, this will only keep the nails back to the quick and may recede the quick only a little bit.  At some point normal anatomy takes over and the quick won't go back any further.  In these cases natural genetics determine the length of the quick and you can't easily overcome that.  If regular nail trimming, nail filing, and hard surfaces several times per week are being done, the nails are already as short as they should be according to her genes.  Trying to make them shorter will require some unnatural methods.

Some vets will advocate cutting the nails and quicks back under anesthesia, as you describe.  They may also offer cauterization.  However, I'm not personally convinced that this will actually work.  It's like if you tore off one of your own fingernails, the nail would try to grow back, even if it had an abnormal appearance.  When I was very young I got one of my fingers caught in a heavy door and it almost removed the tip of the finger.  It healed and the nail regrew, but it looks a little different from the rest of my fingers.  Even though it is a bit abnormal, it still grows at the same rate and length as my other nails.  A dog's nails will try do to the same thing.  Also, it is quite painful, just as if you tore your own fingernails into the quick.

Stefanie, this may be the best it's going to get.  I know that's not a satisfying answer, but I think it's important to know that.  

Sunday, February 24, 2013

Types & Frequency Of Surgery

J Bob left this as a comment on a recent entry of mine.

I was wondering how often you get emergency surgeries vs. how often you get routine ones (such as spays)? 

Also, is most of your time spent doing surgery or doing other things such as check-ups?

First let me say that I'm a surgeon at heart.  I have consistently found that virtually every vet falls into one of two categories: surgery or medicine.  Some do surgery because they have to and really thrive on dealing with the diagnostic challenges of medical cases.  Others love surgery, often repeating the adage "A chance to cut is a chance to cure."  I definitely fall into the latter category and would be happy spending the majority of my day in the surgery suite.  I considered going into surgical specialty, but I was tired of school by the time I graduated and don't like orthopedic surgery, so opted for general practice.

That being said, I spend far more time on things other than surgery.  It's the nature of a general veterinary practice.  On average a spay will take me around 15-20 minutes of actual surgery time, but there is pre-surgical preparation and post-operative recovery, all of which extends the turnaround time in the single surgery room we have.  Some surgeries will take shorter (I average 60 seconds for a cat neuter and 7 minutes for a dog neuter), while others take longer.  I see around 20-25 pets per day, and in the time it takes to do a few surgeries I could see 3-5 patients in rooms.  Take all of that together and I will do an average of 3-4 anesthetic procedures per day.  This number includes dental cleanings as well as routine surgeries.  In order to accommodate all of the patients who need to come in I have to minimize the surgical procedures.  In a surgical specialty practice the surgeries are far more complicated and lengthy, which means that a specialist may only do 3-5 surgeries, but take the majority of the day doing so.

Routine surgeries (spays and neuters) are by far the most common ones.  I'll do at least one of these procedures every working day, and often more than one.  Non-urgent, non-routine surgeries such as mass removals, bladder stone extractions, and so on happen maybe once or twice per week and it's not uncommon to go a few weeks without doing something like this.  A true "drop everything" emergency surgery happens only a few times per year, probably no more often than once per month at the most.  Between all of that are urgent but minor surgical procedures such as wound repairs.  These usually need to be done the same day, but are short enough that they can be worked into the regular schedule.

To me surgery is the most fun and interesting part of my job.  I wish that I could get to do more of it.

Saturday, February 23, 2013

The Limits Of X-Rays

I'm back from vacation, so it's back to regular posting!

Here's a follow-up from my last post about Danica.

Since this email xray were taken Danica has calcium between her C3&C4 vertebra she is on tramidol for 14 days and methocarbonal and Prednisone for 30 days. Strict kennel confinement. I take her out to use the bathroom. The xray didnt show any bulging or no herniated disc. She is also on cod liver oil 1/4 tsp a day on her good.I would appreciate you feedback since the xrays

It's important to realize what radiographs can and cannot do.  The are great at analyzing bone and other dense objects.  They are great at looking at air patterns in the lungs.  They're pretty good at soft tissue structures and outlines.  Mineral and metal show up very well.  But they won't see everything.  

Some gastrointestinal foreign bodies have a similar "density" (we call it "radiopacity") to the surrounding tissues.  If we're suspecting something like cloth obstructing the stomach or intestines we typically won't see the object itself on the image because it blends in with the tissues.  So we have to look for other patterns, do a barium series, or have an ultrasound performed.

Intervertebral discs are another situation that doesn't show up well on a regular x-ray.  The discs themselves are not dense enough to view their borders.  Like in many cases we look for other signs that suggest a problem, such as a narrowing of the space between the vertebrae.  However, a normal intervertebral space doesn't necessarily mean that the disc isn't bulging or herniated.  It's possible to have a disc that is displaced enough to cause a problem, but not so displaced that it narrows the space.  These are tricky to diagnose because they simply don't show up on the image.  The only way to truly diagnose these cases is with a procedure called a myelogram, where a radiopaque dye is injected into the space around the spinal cord, outlining the cord and vertebrae and allowing detection of subtle narrowing.  Because this is a tricky procedure, it's normally done under anesthesia and by a specialist.

It sounds like Danica is on an appropriate treatment plan for now based on what you're saying.  Like I mentioned above, x-rays can't completely rule out a partially herniated disc, but the treatment for that is what she's already on, so in the end it may come out the same.  Continue to consult with your vet on this case.

Thursday, February 14, 2013

Stopping Treatment Too Soon

Here's an email from Sandy....

Hello Dr Bren, I have a 7 year old doxin. DANICA she holds her neck head down. I noticed when turning to the right it's like there is a catch or a musle spasm. I have had her on prednisone 2.5 once a day and metocarbol and tramidol. She showed great progress with in 4 weeks. Gave her some freedom. And now we are back to square one. I have kept her in the  kennel the whold time. She is red dappel named Danica I am asking for our take on this. My vet says we may have prematurely let out of the kennel. Could this be neurological? Disc? I would appreciate any feed back.

Okay, first let me get my anal retentive personality out of the way....It's Dr. BERN, and the breed is DACHSHUND   I normally don't correct or edit emails, but for some reason this one bothered me a bit.


I can only speculate based on this brief email, but based on the limited symptoms mentioned I would suspect a partially slipped disc in the neck or back, or a pulled muscle.  A x-ray should be performed in cases like this to rule out a potentially serious disc displacement, though it should be understood that mild displacement and muscle injuries won't show up.  If there was nothing obvious on the radiographs I would agree with a plan of antinflammatories (prednisone), muscle relaxants (methocarbamol), and pain medication (tramadol).

Injuries like this should be kept on restricted activity for a minimum of four weeks, though honestly it can take six to eight weeks for such injuries to fully heal.  It is entirely possible that she was given too much exercise too quickly.  In fact, this is the most common reason for re-injury or a failure of resolution of symptoms.

Let me pause here and mention that one of the most frustrating things for a vet is to find out that a client stopped treatment too soon.  There are specific medical reasons why we treat for a certain period of time.  If you stop giving medication or otherwise following the directions before the recommended time is up, you could see a relapse of the problem.  Antibiotics take time to work, and we normally want to keep them up for a period of time after complete resolution.  Tissues take time to heal and just because a pet starts to act better doesn't mean that they are completely healed.  Our knowledge and training lets us know how long to continue treatment.  Stopping therapy earlier than this without consulting with your vet can lead to problems. Listen to your vet and consult with them before making therapeutic decisions.

If Danica is still affected, definitely talk to your vet.  Treatment may need to be continued for a longer period of time, especially the exercise restriction.  If this doesn't fix the problem you need to expect the potential of specialized tests, especially a myelogram (where they inject dye around the spinal cord to make it show up better on radiographs).  Again, talk to your vet.

Wednesday, February 13, 2013

Picking Veterinary Journals

Ashley sends this in....

I have an interview at the University of Glasgow in a few weeks and have been told by previous interviewees that brushing up on current issues in vet medicine is a must.  Can you recommend any journals that you find to be particular helpful?  Also, do you know of any that are easy for a lay person to understand? I was reading the Veterinary Journal but had to stop every four sentences to look up the meaning of scientific terminology!

If you're in Scotland I may not be able to help because I'm only familiar with American journals.  But I'll give it a try anyway.  

If they are wanting "current issues" they likely mean some of the current discussions such as vaccine duration, allergy treatment, rising student debt load, and so on.  You're not going to find much on these topics in the hard-core scientific journals.  Also, if you're not yet a veterinary student (as I gather from your email) the language can be pretty intimidating even for an experienced vet.

There are many purely scientific journals such as the Journal of the American Veterinary Medical Association, Journal of Veterinary Science, and Veterinary Record.  As a practitioner I actually don't like those publications because most of the articles are on rare diseases, uncommon procedures, or minutia of physiology that have little to no application in day-to-day veterinary practice.  In fact I dropped my membership in the AVMA in large part because I found no value whatsoever in the journal and couldn't really apply it in my practice.

I like journals that combine practical medicine and surgery with new developments in the field and human interest stories.  These include Veterinary Forum, Veterinary Practice News, and DVM 360 (formerly DVM Newsmagazine).  A great one to understand the business side of veterinary medicine is Veterinary Economics. If you want more details on medical and surgical cases, check out Veterinary Medicine.  Keep in mind that this is all based on my personal experiences and opinions and I have no stake in any of these publications.  Several of these are available free on the Internet, and I've provided links above.  That way you can check them out even outside of the US!

I would love to hear of other suggestions for journals from my readers, especially those outside of the US.

Best of luck with the interview, Ashley!

Tuesday, February 12, 2013

Too Old For Vet School?

I'm at a conference this week, so I won't have good daily practice experiences to share.  Anticipating this event, I've saved up some emails to answer this week.  The first one is from Jeff....

I have wanted to be a veterinarian every since I can remember even before I knew what a vet did.  I also have taken some detours along the way and now at 36 yo I want to start the journey of becoming one. I do not like working in an office at a computer.  I do import/export for a Customs Broker/Freight Forwarder.  
I know I have a long road ahead of me but I can think of nothing else that I want to do with my life.  I have talked to other vets who discouraged me from doing it because of my age but damn them. I can do this.
Do you think it is worth it?  And no, it is not just because I love animals. There is much more to it than that.
Thoughts, concerns, ideas.  I know I need to get a lot more animal experience, shadowing experience, etc. LOL. 

Jeff, I'm a firm believer that it's never too late to follow a dream.  I know of at least 10 people in my own veterinary class who were over 30 and had previous careers before entering vet school.  One was in the Air Force, one a school teacher, and one worked for IBM.  While 36 is not a traditional age, I certainly don't think that you're too old.

However, you're going to face challenges that your younger classmates might not.  First is a big financial burden.  Even if you're not making much money now you're not going to be able to continue that job in school and will have to survive on a fraction of your current salary.  You'll likely have some pretty intimidating debt loads upon graduation, and a starting salary isn't a great one in this profession, at least considering the amount of debt we rack up.  If you have a family to support, this might not be a viable option.

You'll also have to look at your retirement goals.  At 36 you have less time to build a retirement than at 26, but that also depends on how diligent you have been up to this point.  But you'll also have to worry about your loans, so that is less money to save for retirement.  Those 10 years can make a big difference.

I would peruse this blog for discussions on the current state of the veterinary profession and the financial outlooks.  It's not pretty, and no matter how much you may love it, it's becoming increasingly difficult for new graduates to simply make ends meet.

Lastly, you absolutely need to get some experience working in the veterinary field.  Most clients have no idea what the daily life of a vet is like, which is one of the reasons I started this blog several years ago.  But reading my blog is still no replacement for practical experience.  You may work for a vet and decide that it's not the right option for you after all.  Or you might discover a greater passion.  One of my most recently hired employees has realized that he wants to make a career in this field, even though he is currently a receptionist.  He is learning the realities of the profession and still loves it.  Currently he's planning on gaining some more experience and then working to become a licensed technician.  So working for a vet can help you decide if it's really what you want to do.

Best of luck, Jeff!

Sunday, February 10, 2013

The Toughest Cases Aren't Because Of Pets

My last case of the day yesterday was one that hit me hard.  The health problem with the pet was sad, but what really hit me was the situation with the owner.

The puppy was a 19 week old shih-tzu.  The owner had taking him to be groomed and the groomer noted odor and discharge around the eyes.  So she came to us to have the puppy checked out.  I immediately noticed several serious problems.  The puppy's skull was large and asymmetrical, with a large open fontanelle on the right side.  The eyes were bulging and pointing down and to the sides.  He didn't seem to blink much and seemed to have some difficulties seeing.  When walking he would often start circling in one direction.  It was quickly obvious to me that this puppy had hydrocephalus.

This is a very serious condition where the fluid within the brain accumulates and starts to expand.  Over time the fluid starts to push outward, compressing the brain tissue against the inside of the skull and causing pressure against the eyes and bones.  This is a picture of a very advanced case in a dog.

The central black areas are where the fluid is and the thin tissue around it is the brain.  As you can likely imagine, this can lead to severe brain damage.  Unfortunately, treatments are limited and usually involve expensive and risky surgery to put a permanent drain.

This was the worst case of hydrocephalus I have ever seen, as well as the most obvious.  I could see early neurological signs which gives a very poor prognosis.  So I began to explain this to the owner.

That's when the case gets bad.

The owner has a 16 year-old daughter who has been struggling with an eating disorder and who has cut on herself in the past.  They wanted to try having her around a therapy horse, but her daughter is afraid of horses.  So they got a puppy and her daughter immediately fell in love.  The owner is a single mom and has been struggling with her daughter's problem.  There have been successes and relapses, and now I had to tell her that the puppy had a life-threatening problem.

The owner herself is a teacher who had a $15,000 pay cut last year.  She teaches both day and night classes to try and make ends meet.  So her life isn't exactly easy.

To top it off, she started telling me that one of her friends was on a parade float in another state several months ago when a train came through, hitting the float.  People were killed and her friend lost a leg and has been in an area hospital since then.

Here I have a puppy with a severe congenital defect that was likely going to cause severe neurological problems and even death.  This puppy was meant to help out a girl with significant psychological problems.  The owner had virtually no money and had tragedy all around her.

Oh, and then I found out that one of my assistants had a sister with an eating disorder, so she started having a hard time as she could relate to the owner's situation.  There I am getting teary-eyed right along with my assistant, all while the owner is in the exam room crying over what she knows she has to do.

We ended up euthanizing the puppy and the owner had to go home and tell her daughter, who had no idea what had happened.  I simply can't imagine how that went.

In vet school we're taught how to diagnose and treat disease.  We learn how to recognize symptoms, calculate drug dosages, and perform surgery.  We're not taught human psychology and don't get training in how to handle rough situations like this.  Most of us pick up some things with practice and experience but it's still never easy.  We go into this profession because we like dealing with medicine and surgery on animals, not because we enjoy the human side of the equation.  But for every pet that comes in there's at least one human associated with them.  It's something that you learn you can't ignore.

I honestly wish the woman and her daughter the best and will keep her in my prayers.

Tuesday, February 5, 2013

A New Toy....D-Rad!

Radiographs are an interesting thing.  Taking one is essentially like taking a photograph, but instead of light exposing the film, x-rays are.  This has been the case for well over 100 years, but like cameras have made the transition from film to digital, x-ray machines have also.

And I now have one!

First, a quick lesson with traditional x-ray films.  The film is kept in a special cartridge that is placed with the patient between the x-ray emitter and the film.  X-rays move through the patient or object with denser materials blocking more of the rays.  The top of the cartridge has special minerals that glow when hit by x-rays.  The more rays hit an area, the stronger the glow. The light exposes the film in the same way that it happens in older cameras.  The film then has to be developed in a darkroom just like camera film.  The developed film is what we're used to seeing as a radiograph.

The first practice I worked in as a vet had tanks where you had to dip the film in the developer to bring out the image and then a fixer to keep it from developing further when exposed to light.  This was back in 1997 and even then a hand-dip system was outdated.  Automatic processors had been around for a long time.  You put an exposed film in one end and it would do the developing, fixing, and rinsing in a couple of minutes, with a finished film emerging from the other end.  I simply could not convince the practice owner that an automatic processor was a huge time saver and gave less error than processing by hand.

Over my career digital x-ray equipment has become more common in veterinary and human medicine.  I was envious every time I saw digital radiography ("D-rad").  It solved so many of the problems seen with traditional film.  And while you can still get a great image with traditional radiology films, d-rad has significant advantages.

First, you get the image right away.  This is important because when you take a film you might have to adjust the patient's position or change the exposure settings.  With film you have to take it, wait several minutes to develop it, and then potentially get the patient back out and re-take it.  That makes taking radiographs a potentially lengthy process and can result in aggravated pets.  But with d-rad you get the image instantly and can make quick adjustments if needed.

Second, you can adjust the image.  Digital software allows you to manipulate the contrast, magnify an area, and otherwise alter your image.  When your exposure may not be exactly perfect, this allows you to see more in the image and can keep from having to retake views.  The adjustment and magnification can also make certain features stand out more than they might on film.

Third, sharing images is much easier.  When sending a client to a specialist for further testing or another opinion you often have to give the other doctor any radiographs you've taken.  With films you have to loan them to the client with the expectation that they will bring them back.  The films are part of the legal medical records and therefore do not belong to the client.  It's not uncommon for the films not to come back, which is a problem if there are any questions in the future as to what happened, or if the doctor just wants to compare images over time.  Copying x-ray films is difficult and not something that can be done in the practice.  But with digital radiography you can keep the original file and burn as many copies as you want to discs.

After years of asking for it, we finally got ours installed last week.  Needless to say, I'm incredibly excited!  There is a bit of a learning curve on the software, but I'm already seeing a huge benefit in our diagnostic ability.  And I finally feel like our practice is part of the 21st century!

This is an essential diagnostic tool and something that we use daily.  But I have to be honest and admit that it's also a cool new toy for a geek and doctor like myself!

Sunday, February 3, 2013

"Oh, That's Today?"

I'm very odd for a guy.  I have little to no interest in sports.  Seriously!  I can't tell you when football, baseball, basketball, or hockey season starts.  I can't tell you who is the quarterback or starting pitcher on any team, even people like Tom Brady who I have at least heard of.  I'm not against sports, I just don't understand the passion with which people follow them.  

So this means that major sporting events sneak up on me.  For example, today is Superbowl Sunday in the US.  This is the final championship game for American football and is the biggest single sporting event of the year in my country.  And I have forgotten that fact several times.  I don't go to parties, won't have the game on at any point, and will generally be trying to avoid paying attention to it.  Frankly, I feel lucky to even know who is playing.  I really don't care who wins and it won't make a difference to me one way or the other.  I'm quite "meh" on the whole thing.

I think it's all about how you grow up.  I played soccer as a child, but that was the only real sport with which I was involved.  My father helped coach my team but otherwise never watched sports.  I never really had an example of people in my life that paid attention to such things, and my son will be in the same situation.  I bonded to my father in other ways, and my son and I share activities other than sports.

I'm a geek, and therefore would rather participate in those pastimes. A friend of mine in vet school described the typical "geek sports":  Star Trek, Star Wars, role-playing games, video games, and comic books.  Now if there was a World Series involving any of those, I'd be in the front row!

To everyone who stays glued to their TV during the World Cup, Stanley Cup, Superbowl, or any similar event, good for you.  I know you're enjoying yourself.  But I will be deliberately avoiding paying attention.  I'll learn who won in the morning, not because I'm interested but because everyone else is.