Wolf In The Fold

It was like a scene in a science-fiction movie.  The dog had a swelling under its arm with inflammation and a small hole in the center.  Just inside the hole you could see something small moving.  Very carefully we used a pair of hemostats to gently grasp the object and start to pull it out.  We place the object on the table and see a fat larval creature wriggling around.  It was like the ceti eel in Chekov's ear in Star Trek II: The Wrath of Khan.

As odd as this sounds, it's not uncommon to vets, especially those who practice in rural areas.  These "worms" are larvae of a type of fly called cuterebra.  More commonly these are referred to as "wolf bots".  The larva comes into contact with an animal's skin and burrows underneath, or into an orifice such as the eye or the nose.  It remains there and grows, eventually molting into a fly.  While in its larval stage it can get up to over an inch long and can cause a lot of localized inflammation and infection.  They can infect just about any animal, but are most commonly found on dogs, cats, rabbits, squirrels, and other rodents.

Thankfully, once these are noticed they are usually easy to take care of.  A veterinarian is usually able to remove these from the hole, and then it's a matter of cleaning and disinfecting the wound and putting the pet on antibiotics.

Here are a couple of videos I found of cuterebra larvae in animals.  Don't watch these if you're not prepared to be a little disgusted.





Though this is usually simple to fix, don't ever try to remove them yourself.  If the larva ruptures while in the animal, there is a chance of a serious allergic reaction and even anaphylaxis.  If you see something like this on your pet, be sure and seek veterinary assistance.

Vet For A Vet

New reader Rockjdog made this comment about my recent post on my own dog's illness.

I am sure you have been told this but would'nt the best course of action be to have another vet treat the dog?

That's actually a very valid question, and it's one that we have to wrestle with periodically.  On one hand it does make sense to give the main clinical duties over to another doctor.  As I mentioned when dealing with my own pet, when you have that close emotional tie it's difficult to maintain good clinical objectivity.  The feelings that run through you as you fret and worry can make it hard to keep good judgment.  Last year I had another vet I know have her husband bring her dog to me for a second opinion.  The dog was in congestive heart failure and she was scared that she wasn't making an objective decision because of how close she was to her dog.  She wanted to hear from another vet what she really knew but couldn't bring herself to relate to her own dog.

However, as a vet we don't like to give those decisions over to another person.  We know how to work through a case, and have a hard time letting go of that when it's a personal pet.  It's a corollary to the above point...because were so emotionally invested we have a hard time letting go, as well as a hard time being objective.  We kind of feel like we'd be letting our own pet down if we didn't handle it ourselves.  In my career I've had to euthanize two of my own cats.  Even though it was the hardest thing I've had to do, in both cases I pushed the plunger and put my own cat to sleep.  Yes, that emotionally draining and hurt immensely.  But I couldn't bring myself to let a colleague be the one to do it.  It was my own pet and I felt that I had the responsibility to do the task myself.

So it's not a clear-cut decision.  For a veterinarian, letting another vet work on your own pet may be the best in some cases to allow clear clinical judgment, but it is difficult to completely let go and trust that to anyone else.  I don't think there is an easy way to handle it, but I dare say that most vets would react similarly to me.

So what about my vet readers?  How have you handled similar situations?

Doing The Right Thing?

Brandie sent in a rather lengthy letter.  For the sake of brevity, I've edited it a bit, though I appreciate the detail I got to read.

When [my lab] was about 8 years old I noticed she was having trouble keeping up and getting tired a lot. Extensive testing only revealed mild hip dysplasia.  At about 9 1/2 years old I noticed she was walking differently, more stiffly, and it would be especially noticeable after she did a large jump. So another vet visit determined that it was merely arthritis and hip dysplasia working against her. She was put on pain meds.  She seemed to continue to worsen gradually, which was expected. But then suddenly she seemed to be worsening more and more rapidly, much faster than myself or her vet anticipated based on what we thought it was at the time (arthritis and hip dysplasia). I prepared myself to have to make the decision to put her to sleep within a couple of years at the rate she was declining.  After a couple of months of rapidly getting worse, she woke up one day much, much worse than she had been, enough that I wondered if she had injured herself in the night. I took her to the vet again, who discovered that it was nerve damage causing this problem, not the arthritis and dysplasia (although those things certainly didn't help matters). She said she figured out it was nerve damage because of the way my lab was dragging her toes when she tried to walk and that she could bend my labs toes under her pads, place them on the ground, and my lab did not correct it.

She was unable to determine exactly what the cause of the nerve damage was, but strongly suspected a tumor in the spine, one that possibly may have been growing for a couple of years and could have been the real cause of her slowing down the way she did. She said that I could take her to the university hospital a couple of hours away and have a test done to find out if it is a tumor and if anything could be done, but that the test would be really expensive.   However, she told me that the test that would have to be done would be very hard on my dog, and might not even discover the cause of the nerve damage but could worsen it. Additionally even if the cause was found, the surgery and recovery involved would also be very difficult for my dog and could take months and would be no guarantee that it would help enough to have been worth it. She said that typically nerve damage does not get better, only worse if there's any change at all. So I decided not to put my dog through the testing for her own sake, since there was little chance that it would really help her without great cost to her.

I asked the vet if she thought that I should put her to sleep. The vet was very ambivalent with her answer. I know she was just being professional but it frustrated me to no end because I was afraid I could not properly judge my dog's quality of life because of bias. I feared causing her to suffer and not knowing it.
 
I got a harness for her back end and helped her walk anywhere she wanted to go, and helped her go to the bathroom for the next couple of months. She didn't mind having to do things that way. The vet told me that there was a 50/50 chance she could either feel nothing or be in excruciating pain.  After those couple of months, I noticed she seemed to just be getting tired, and not just because her front end had to do so much work to compensate for the back end. However, she was still happy and playful and outgoing as ever. I suspected she was started to hurt quite a lot judging by the change in her panting patterns, the positions she slept in, and how she reacted to events in life compared to the past. But, I could never really be sure. As soon as I would decide that she was indeed hurting and was just being really good natured about it, I would second guess myself. No one else would really give me advice about it. The vet refused to say one way or the other. So I had to make the decision completely on my own, and I decided to err on the side of comfort for my dog.

I thought long and hard about it and decided that I would rather put her to sleep too soon, than to wait until she was hurting so badly that her seemingly unbreakable happy spirit started breaking, or worse yet, wait until something happened that the only humane choice was to immediately put her down. So I got one last month with her to say goodbye, and in the week prior to the big day, all rules were thrown out the window and she got to eat and do anything she wanted. I spent that entire week making it all about her and doing everything I could to make every hour as happy as I could for her. 

Mission accomplished, she was extremely happy, bouncy (as well as she could be with her back end out of commission), playful, outgoing, etc right until the very end. You'd have never known she was having the problems she was having if you didn't know her unless she tried to stand up and walk. And therein lies the problem for me. I thought that knowing I would rather do it too soon than too late would keep me from regretting the decision, but alas, it didn't work that way. I have since wondered if I did it too soon after all. it has been 10 months and I still cry wondering if I should have waited and given her more time. I wonder if I just imagined all those signs that she was in pain, or imagined the feeling I got from her that she was ready to go if I'd let her even though she was still happy, and constantly second guess myself. I wonder how much longer I could have had with her if I had waited until her happiness began to fade before going ahead with it. What if, just what if, she would have gotten better?

All I've wanted since that day is an objective, educated voice to give me peace of mind by telling me I did the right thing, or be honest by saying I did it too soon and giving me the chance to process that so I can let it go and work on forgiving myself. Some people have told me that I did the right thing, but it doesn't help because I had several people question my decision at the time as well. But it's not like I could really ask my vet if I did the right thing and expect anything but a professional answer, either. As frustrating as it can be I totally respect that.

I am hoping since I am not a client of yours, that perhaps you will disregard the need for professional neutrality and offer your educated, experienced, and objective opinion. You would do my heart a world of good, either way. I think not knowing if I messed up is harder than knowing I did mess up.

Okay, so here goes my response, probably equally as long.

First, Brandie, let me say that based on what you shared your vet did everything correctly and appears to have given spot-on information.  Spinal tumors can be very difficult to discover and usually don't show up on regular x-rays.  Combine that with a breed that is prone to joint problems and some signs of arthritis, and anyone would likely come to the conclusion that your vet did.  Your vet was probably talking about a myelogram, where they inject dye around the spinal column and then look at the pattern of that dye on an x-ray or other imaging method.  Yes, neurological damage is hard to predict and usually doesn't get better, so in this circumstance I can certainly understand not pursuing that option.

I often get asked "should I euthanize my pet?"  This is a difficult question for any vet to answer.  Part of it is professionalism.  We don't want to force someone into a decision that they're not ready for, and ethically we shouldn't make decisions for the client.  Our job is to give the client enough knowledge to make an informed decision on their own.  Even if I'm 100% behind the euthanasia, I ethically and legally can't make that decision for any pets other than my own.  The final decision has to come from the owner, as hard as that can be for them.

Another reason why vets can't make that decision is that we only see the pet for a short period in our hospital.  Even if someone is giving great information and descriptions, we can't really tell how their quality of life is at home.  In these circumstances the owner is the only real judge, and we have to rely on their intimate knowledge of their pet.  The only person who can really determine a pet's quality of life is the family that lives with them.  A vet can guide, educate, and give opinions, but because of the emotional bond only the owner can truly determine the elusive quality of "suffering".

Now with all of that being said, there are some things that a vet can do to help the decision.  I have said in particular cases that I don't think euthanasia is necessary.  When I think it's valid, I'll give the owners all options and include euthanasia in that list, letting them know that if they choose it I would agree with them.  I can say that the odds are and whether a given disorder is likely to be painful.  Again, all of this is merely to help the client make the decision on their own.

But you came to me for some closure and assurance, Brandie, and I'll try to help.  Your vet made sound decisions and gave you solid advice.  Your dog likely had an untreatable and eventually fatal disease.  Before she died, she would have gotten progressively worse and have suffered even more.  You allowed her to pass away when she was still in good spirits and wasn't hurting.  Euthanizing her wasn't a matter of "if", but of "when".  If you had waited, you would have been postponing the inevitable and getting to the point where you would have been more heartbroken at her condition.  By making the decision when you did, you were able to do it on your and her terms, with peace and dignity.

You did the right thing.

To Catch A Thief

Yesterday I had to do something very unpleasant.  I had to fire one of my staff members.  A few weeks ago we noticed a strange transaction, with another one almost a week ago.  After some investigating we suspected that there was something wrong happening, and there was one common denominator.  Yesterday this person was confronted, admitted to stealing money for several months (much more than we had realized), and was subsequently fired.

Most people don't think about these sorts of things going on in a veterinary practice, but it happens more commonly than most may realize.  I remember when I was in college and working at a local veterinary clinic.  There was one woman who was pretty much the office manager, and very well liked and trusted.  She had everything at that place and had worked there for years.  It happened to be discovered that she was "returning" flea products, taking money out of the register for the refund, and then pocketing the cash.  The whole thing was a scam as there were no actual returns.  Nobody suspected her because of how trusted she was and how long she had worked there.

It's an unfortunate reality of business that there will be unscrupulous people who will take advantage of their employment.  They will steal and cheat and otherwise try to get things that they didn't earn or deserve.  Thankfully, most people are trustworthy and can be relied upon.  But part of being a business manager is having to watch for and handle situations like this.  Though I've suspected people of theft in the past, this was the first time I was able to directly link something and prove it.  It wasn't something I wanted to do or enjoyed doing, but it really angered me that this had been happening and I was very ready to exit this person from the practice.

Crime doesn't pay, and criminals do eventually get caught.

Doctor Death

Some days are rougher than others when you're a vet.  One of the hardest things we do is euthanize pets.  Even when we know it's the right thing to do and will end their suffering, it can still be emotionally draining.  The worst part isn't that we're ending a life, it's the reactions of the owners.  Seeing people say goodbye to their loved ones is pretty hard, and no matter how many times I see someone break down in tears it never gets easier.  Frankly, I wish we had more training in grief counseling, as it is an important part of being a vet yet something that appears to be under-appreciated by vet schools.  It can be difficult to make it through some of these cases.

And then some days are even worse than others.  Like today. Most vets would consider it bad if we had to do four euthanasias in one week.  I had four of them in one day. 

Each case was very justified.  The first was a puppy with parvo that we had treated for four days and he began to worsen.  The second was an elderly basenji who had neurological signs and I had strong suspicions of a brain tumor or other central nervous system disorder.  The third was a 15 year-old schnauzer who had stopped eating and wasn't moving around much.  The last one was a dog I had seen for quite a while and who had multiple medical problems that had worsened.  I had no problem with the decision to euthanize each of these pets, but none were easy.  The owners cried with all of them, and like I said that's the worst part.

Days like this I feel like "Doctor Death".  Euthanasia isn't a bad thing, and it allows me to ease suffering and give a quick and peaceful end to an inevitable circumstance.  But I'm very glad to be home from work and trying to decompress from such a day.

Tomorrow I hope I get to see only healthy puppies for their vaccine boosters.

Smells Like Work

When you're a vet, your nose tends to get pretty immune to most odors.  I regularly deal with diarrhea, blood, pus, rotted tissue, anal gland excretions, and many other undesirable things.  All of these can have some pretty offensive odors, and you simply get used to them.  There are very few scents that turn my stomach anymore.  However, I still can find them offensive and certainly don't like smelling like these things.

The worst part about odors is when they stick with you.  Today I had a severely constipated and impacted cat and had to give it an enema and pull firm feces from its rectum.  There was several days worth of stool backed up in its colon and all of it needed to come out.  So I ended up filling the colon with soapy water and digging the stool out with my finger.  Needless to say, this was not exactly pleasant and had a rather "distinctive" odor.  I did what I had to do and began washing up.  I was rather unhappy to find that odor clinging to me for the rest of the afternoon.

However, that's not as bad as what swine vets have to face.  When I was in vet school I did a swine rotation and had to spend some time in pig barns.  Let me tell you, that was an ordeal.  I would be in a facility for only an hour or two and then take several hot showers once I got home.  Even with repeated washes I would smell like pig waste for a couple of days.  I can't imagine having to deal with that every day, and am glad that other people can put up with it.

Even when I can't smell "work", my pets can.  One of my cats (Perceval, who passed away last year), used to rub all over my shoes after I came home, trying to cover the scent of work with his own.  And my dogs commonly spend great attention to the odors attached to my pants, especially if I managed to get feces or urine on me during the course of the day.

So tell me again what the glamorous part of veterinary medicine is?

With Clear Vision

Okay, so sometimes I'm a little late to the game.  I'm 40 years old and have just gotten my first pair of contact lenses.  I've been wearing glasses since I was 10 or 11 years old, and in the last 5-6 years my sight has worsened to the point where I have had to wear them all of the time and not just occasionally. Honestly, it's never bothered me to have my glasses.  I'm so used to wearing them that I don't notice them, and I don't mind how they look on me.

So why the change?  Well, I do a lot of costuming at sci-fi conventions and Renaissance faires, and when I'm in costume I don't want to wear my glasses because they don't fit with the theme.  However, without my glasses my vision is more blurred, making it harder for me to enjoy looking at the vendors.  For a couple of years I've considered contacts but finally made the commitment.  For the last week I've been wearing them and have found them surprisingly enjoyable.

My contacts don't give me quite the clarity of vision that my glasses do, but it's still much better than without them.  I'm finding them very comfortable, and have gotten to the point where I forget I have them.  However, I'm so used to my glasses that I find myself in the same habits.  For example, when I go to look at the microscope I still reach up to take my glasses off.  There are benefits though, such as not having to worry about glasses fogging up because of my surgical mask.

So even though I got the contacts for cons and faires, it looks like I'll be wearing them more often than not.