"Do I Have To Pay Again?"

How many of you have gone to your doctor for a problem, had a tentative diagnosis made, and a treatment plan prescribed? Then if the treatment doesn't work, you go back again. Would you demand free treatment then? Would you demand a refund on your money for the medicine that didn't fix you?

What about a mechanical problem on your car? You take it to the garage and they replace a part they suspect is the problem. Well, the problem doesn't go away. Would you demand that they fix it for free since you already paid once?

In situations like this I bet that most people realize that not all problems can be fixed quickly, and that it's often a process that can take some time or trial and error. Why does it seem like people don't consider vets in this equation?

It's not uncommon for me to have clients that are unhappy about having to pay for a follow-up exam. We also have people that don't want to pay for a second round of medications when the first ones didn't work. It seems that they think that because we didn't diagnose and correct the disorder on the first go-round, that we should somehow be responsible for any further follow-up. I hate to tell them (and any readers who feel this way), but medicine is not always precise. I sometimes tell people that medicine is as much art as science. Some problems are easy to diagnose and fix. Others simply aren't, and take repeated visits and attempts to find just the right solution. These follow-ups cost the doctor time and money, and so that cost gets passed on. Our knowledge and time is worth money. If we didn't get paid for it, we couldn't do what we do. Failing to correct a problem on the first visit is not a sign of incompetance. It's indicative of the disease process itself, not the attending doctor. Sometimes an important part of the diagnostic process is response (or lack of response) to therapy.

So give your vets (and physicians, and mechanics) a bit of break. We really do want to help and do it as quickly as possible. When we have to see you back it doesn't mean that we didn't do our job, but that we're actually doing it!

Feeding Pregnant Dogs

I think you all know by now how much we vets talk about how important it is to feed pets the proper pet food, and not to feed people food. Believe me, we're not in the pocket of the pet food companies, and are just trying to help you take care of your pets. Here's another reason why.

Mattie was a little dachshund, about 2 years old. I saw her last week for sudden weakness, incoordination, and overall just acting strange. She had given birth to a litter of 5 about three weeks previously. As I did my exam I noticed a dazed look to her eyes and muscle trembling, even though she was alert and could walk around. My immediate thought was a low calcium level, and lab tests confirmed this. I spoke to the owner, and he said that his wife kept insisting on feeding the dogs hamburger and hot dogs, and that Mattie didn't eat much dog food. That's where the problem was, and he agreed with me.

When a person or an animal is pregnant, the baby (or babies) don't take in their own food. Every bit of the nutrition they get comes from the mother, including minerals. The babies are drawing a lot of calcium from the mom as they begin to develop and grow bones. Mom also draws a lot of calcium from herself by making milk, which the babies further reduce by nursing. If the mother isn't getting any extra calcium in her diet, she will use her own body's stores of it, potentially putting her in a dangerous situation. That's what happened with Mattie. By eating mostly "junk", she was not getting enough calcium in her diet. The pregnancy and nursing of a relative large litter further depleted her.

Calcium is important for a number of reasons in the body. Everyone thinks about it in relation to bones, but it is also essential for proper muscle contraction. Hypocalcemia can lead to poor muscle contraction and coordination, including the heart. This problem can develop rapdily, but thankfully is easilly corrected. I gave Mattie intravenous calcium supplements and she responded quickly, going home at the end of the day. I made sure to have the owner talk with his family and let them know how dangerous this was. Female dogs and cats should be on a high quality puppy/kitten food from the time they become pregnant until the babies are weaned (at around five weeks old). The extra nutrients in the juvenile food will help to support the adult mother during the pregnancy and nursing, similar to prenatal vitamins taken by human mothers.

Mattie is now doing great, and I think the family learned an important lesson. Their bill was a little over $300 last week, and this was a preventable issue if they had only fed the right kind of food. A bag of dog food doesn't seem expensive by comparison, does it?

Escaping The Modern World

Sometimes I think it's easy to forget that doctors are just people. We have interests and hobbies outside of medicine. Our lives aren't filled with diseases, injuries, diagnostics, and surgeries 24/7. We aren't constantly thinking about medicine. And sometimes our other interests are far removed from our jobs. In my case one of these departures is Renaissance Faires.

I have always had an interest in Medieval and Renaissance time periods. The ideas of knights, damsels, intrigue, and swashbuckling have always drawn me to them. When I was in college and was required to take Physical Education courses, I deliberately chose classes in this vein: archery, fencing, and canoeing. When I was in graduate school I attended my first Renaissance Festival and was hooked. That was back in the early '90s and I haven't given up since then. I took my wife to one when we were dating, and she began to embrace them as well. Over the years we have collected clothing and equipment for several outfits and have gotten our kids interested in the hobby.

For those of you who have never been to a Ren Faire, let me describe them a bit. They usually begin in the Spring and the "season" lasts into the Fall. Depending on the size of the Faire, some will last anywhere from a week or two to several months. They are held on the weekends in parks and other natural areas where permanent buildings are often erected. Once inside the Faire you can visit artisans and vendors for clothing, weapons, tapestries, candles, jewlery, and many other crafts. Official workers at the Faires walk around dressed in period clothes, and will enact various scenes to tell a larger story that goes on throughout the day. There will be a king and queen presiding over the affairs. And there is usually an arena where live jousts and swordfighting happen. The larger Faires will have stages where other performers will give shows ranging from music to comedy, daring acts of tightrope walking or juggling, and singing to belly dancing. Many attendees (such as my family) also dress in costume to the point where it can be difficult to tell who works there and who simply showed up.

The Faires are not always interested in complete historical accuracy, and are more about the idealized versions. They exist more for fun and escapism than anything. But it's so nice to be able to spend a sunny day wandering for miles in a world pulled from the 15th, 16th, or 17th century. For a day you can imagine yourself a stalwart night, a dashing musketeer, a rougish pirate, or a delicate princess. You can address people as "my lord" and not feel silly. You can say "huzzah" when you cheer and feel completely at ease. And above all you can pretend that the worries of the 21st cenury don't exist for a few hours.

For those of you who have never been, I would highly recommend it as a fun family outing. Who knows, you might actually run into me and my family one day.

X-Ray Week: Knee Problem

This dog came to me because of fluid draining from his knee. Over a few years he had undergone two surgeries for a torn anterior cruciate ligament (ACL). I could feel the suture material in the knee, and was concerned that the fluid had been caused by the surgery. Over time the suture had caused inflammation and irritation in the joint, which had begun draining through the skin. To see there was any problem with deterioration of the bone, I took some x-rays.


There are two things that stand out on these x-rays. First, the suture material had broken, likely leading to significant irritation. Second, the suture isn't placed correctly. One of the loops should be placed behind the knee, not to the side. I don't know if the suture migrated, or if the vet who did the surgery didn't do it correctly, but the suture material wasn't doing anything to help the problem and in fact was causing more problems. I recommended that the dog go to a surgical specialist to remove the suture and repeat the surgery a third time, this time properly. I never heard back, so I'm not sure if the owner ever did it.

X-Ray Week: Esophageal Disorder #2

This case is from a middle-aged dog that my associate saw. He had been vomiting frequently, so she took some radiographs of his stomach and chest. The ones from the chest were the most interesting. See if you can notice the problem here....


The vets reading this probably can see the issue. We have lots of training and experience in seeing subtle problems. For the laypeople, take a look at the parallel white lines through the chest. Here is the same image with some highlights to emphasize this.

See it now? This is a pretty big abnormality, and indicates an extremely abnormally large esophagus. Megaesophagus is most commonly diagnosed in younger dogs, and is usually the result of a persistent arch around the aorta that encircles the esophagus and crimps part of it. The esophagus is stretched so much over time that the muscle looses tone and it becomes very dialated. Other causes can lead to the same result, including metabolic disorders such as thyroid disease. Unfortunately, this is a permanent disorder where the muscle comprising the esophagus is too loose to be able to contract. This means that food can't go from the mouth to the stomach very easily, and requires life-long special feeding.

More orthopedic x-rays tomorrow.

X-Ray Week: Esophageal Disorder #1

Here's a bit of a strange case for those vets reading this blog. And some cool images for everyone else.

This dog came to us about 3 weeks ago for vomiting. Blood tests showed nothing abnormal, so my associate started her on anti-nausea medication and some easily digestible food. The dog was acting good overall, and is a 2 year-old spayed female terrier mix. The problem didn't seem to get any better, so the client brought her back. This time we did x-rays. When we start this kind of diagnostic we do what we call a "plain film", which is a basic x-ray. This is what we found.



See the problem? Yeah, neither did I. So I made the dog swallow barium liquid and took another set of radiographs immediately afterwards. Since barium is a metal, it shows up bright white on an x-ray film and will often highlight things that aren't obvious in any other way. Here's what we saw.

See the problem now? The first image is less obvious, but there is a bulge in the esophagus just before it passes through the diaphragm and into the stomach. This is due to one of several things. There could be a hiatal hernia, where part of the stomach bulges back through the diaphragm and into the chest. But a more likely possibility is that there is a narrowing of the esophagus just before the stomach. So the dog wasn't actually vomiting, it was regurgitating the food. She would swallow too much too fast, and since it couldn't pass into the stomach most of it would come right back up. She is doing well being fed small, frequent meals of soft foods. But she is also being referred to a specialist for upper GI endoscopy to visualize what the problem is and how we can fix it.

This is also a case that illustrates the importance of continued diagnostics. I had to convince the owner to do the barium views, but that's what it took for us to make the diagnosis. I had suspected a problem like this, but we needed to be able to actually see it. So when your vet recommends doing further testing, please listen to him or her!

Tomorrow...a different problem in the same area.

X-Ray Week: Broken Paw

Here's an interesting set of images that I thought many of you would find interesting. This dog is a boxer puppy, about 5 months old. He was playing with a neighbor's dogs when one of those dogs bit him hard on the foot. Normally this would cause some wounds, but not necessarily anything serious. Not so in this case. There really weren't any deep wounds, but there was some obvious damage to the foot. When he came in I could tell that the paw was at a slightly odd angle, and the x-rays confirmed it.


All four metacarpal bones are broken, and a couple of them are pretty displaced. In a human these are the bones in the hand between the wrist and fingers. Being a young puppy he has a great chance of this healing. However, the misalignment of the bones is significant enough that he probably needs surgery. Splinting this has a relatively high likelihood of improper healing, though we placed a temporary splint to stabilize it. I saw him for a recheck today and he's bouncing along on his splint like it doesn't bother him, which isn't good as he really needs to have more restricted activity.

I'll be posting some other interesting images as the week goes on.