Tiny Surgery

Last week I had a very unusual case.  A young bearded dragon had somehow gotten its leg stuck on an artificial rock in its enclosure.  In trying to free itself, it had ended up twisting its left hind leg around several times, ending up with a complete spiral in the leg.  The tissues were obviously damaged beyond healing and the only choice was amputation.

However, this was a very tiny patient.  Its entire body was no longer than the length of my palm and it weighed only about 2 grams.  I've done surgeries on exotic pets before, but never on one this small.  I knew that he wouldn't survive without the surgery, but I also worried whether or not he would survive the surgery itself.  On such a small patient we can't take standard precautions of using monitoring equipment, intravenous catheters, tracheal intubation, and so on. It's also difficult to do surgery on reptiles because their body temperature affects their metabolism and cardiovascular system.  Under anesthesia the temperature naturally drops, which can suppress breathing and other vital functions in these animals.  A small pet like this only compounds the problem.

So knowing the risks, we did the surgery.  I amputated his leg in the middle of the femur and closed the wound with a few small sutures.  I worried for a while as it recovered, because its breathing was so shallow.  But he slowly did wake up, and after a few hours was standing well on its own.  With the first hurdle passed (surviving the surgery itself) I knew that the next step was the most crucial.  Would it begin to eat by itself?  Would it heal properly?

Yesterday I check on the little beardie's progress and found that it was eating mealworms on its own.  Success!  I was so happy and excited to hear this news, as its survival at this point was beyond my ability to manage.  The tiny little thing isn't out of the woods yet, but if things continue to go well for another week, we'll likely have a healthy but three-legged lizard that can live to grow up normally.

Waiting Too Long?

A common complaint heard in veterinary offices is the clients being bothered by how long they have to wait.  Being in a room for 30 minutes is too long.  Having to wait several hours to pick up their pet is too long.  Waiting 15 minute for the fecal exam to be read is too long.  Yet those same people are more accepting of waits for their own doctor.

All of that went through my mind as I was doing my own waiting today.  My son was running a fever yesterday and complaining of a painful neck.  This morning my wife took him to an urgent care center to be examined (it's Sunday, so no doctors' offices are open, and we wanted to avoid the Emergency Department at the hospital).  The doctor easily determined that he has strep throat, but was concerned about the fact that his neck hurt so much.  Though he didn't think it likely, the doctor thought there was a small possibility of meningitis, and wanted my son evaluated for a spinal tap.  So we ended up at the hospital anyway.

It took over an hour and a half of waiting after we checked in before anyone took him back to an exam room.  Then it was probably close to another hour before the doctor came in to look at him.  She spent about 5-10 minutes examining him, determined that he didn't have the signs of meningitis, and just had a very bad case of strep.  It was probably about another 30 minutes before the nurse finally got our discharge paperwork and we left.  The day started at 11:00 with the visit to the urgent care.  By around 3:45 we were leaving the hospital with merely a case of bad strep throat.  Almost five hours involved.  Thankfully, it wasn't serious and he's perking up and doing well now.  By tomorrow he should be pretty much back to normal.

Even with all of that waiting, I'm not upset.  I feel that we were treated politely and respectfully.  Both doctors were very nice, and I can completely understand slight differences in diagnoses between doctors.  So even though I hated having to wait, it was important for me to make sure that my son was going to be okay.  I also think that most people would understand that kind of a wait on a Sunday afternoon when everything else was closed.

But what would happen if that same situation was in my own office?  What if a client waited a couple of hours after checking in before I walked in the room?  What if their total day was five hours of waiting and it turned out to be something simple?  Yes, many clients would understand, but I would argue that more would be upset and would feel inconvenienced (just remember the story earlier this month).  For some reason, it seems that people expect quicker service from their vets than they do their physicians.  Yet we vets have many of the same situations with different types of cases and having to triage to put the more serious ones first.  Waits can happen, and are unavoidable in many circumstances.

But I can't be too upset today, because my little guy is feeling better.  By tomorrow, I'll be wishing he was back in school!

Yes, It Can Happen To Vets

Today I took my dog, Inara, to work with me for her annual vaccines.  She received a rabies vaccine, distemper-parvo, leptospirosis, bordetella, a fecal exam, and a heartworm test.  All of the things I recommend to my clients I also do for my own pets.  Inara was a trooper and handled all of it well.  I did her services first thing in the morning and then put her in a kennel while I started to work on morning appointments and surgeries.

Two hours later I was in the back getting a patient and decided to give Inara some attention.  To my great surprise I saw that her whole face was inflamed and puffy.  Yes, my own dog was having a vaccine reaction.  She had received these same vaccines as a puppy, and these were her first annual boosters.  When she was younger she didn't have any problems, so I had no reason to suspect a reaction this time.  Unfortunately, reactions are individual and unpredictable.

Thankfully, most vaccine reactions are merely uncomfortable and not life-threatening.  In 13 years of practice and having given untold thousands of doses of vaccines, I have only seen three pets have a truly anaphylactic reaction.  Inara wasn't one of these severe reactors, and was wagging her tail as I started at her swollen muzzle and eyes.  A quick exam told me that she was very stable, but had some discomfort in her face.  I couldn't blame her, as all of her subcutaneous tissues were inflamed!

I gave her some antihistamines and antiinflammatories and continued to observe her through the day.  Over the course of the day her symptoms improved and she was still her normal self (except for some itching at her face).  Tonight she is resting comfortably, had a normal dinner, and looks almost completely normal.

Now here is the point where many people would panic.  "Oh, my gosh!  My dog almost died!  She can't ever get shots again!" As I said before, most reactions are not potentially fatal, and simple precautions can help prevent many mild reactions.  Her distemper-parvo and rabies vaccines have a duration of three years, so I won't have to booster those until 2013.  However, I will most certainly give them when they are due.  I'll premedicate her with antihistamines, place an IV catheter in case any future reactions are more severe, and will keep her in my clinic for the day.  All of the same things I would do for any of my clients' pets.

I try hard to practice what I preach.  I don't recommend any preventative care that I don't do for my own pets.  And I treat my pets like I do my patients.  This is the first pet I've ever owned that has had a reaction to vaccines.  However, it's not a crisis, and I trust my ability to vaccinate her in the future.

Disolcated Hip

Last week I saw a dog for some vaccines.  The owner happened to mention that he had been limping for a few days (often seems to work that way..."Oh, by the way, doc...").  When I was looking at him I quickly noticed that he didn't want to put any weight on this left hind leg, and some manipulation isolated the problem to his hip.  I was able to put a finger of each hand on the point of the femur and noticed that my fingers were uneven.  So my first thought was that somehow he had dislocated his hip.  A quick set of radiographs confirmed my suspicion.

Looking at the images you can see that the hip is completely out of the socket and displaced slightly dorsal ("up") and cranial ("forward").  It takes a pretty good injury to move a hip this far, as the femur is normally very tightly held in the socket.  There is a short, tough ligament connecting the bones, as well as a capsule around the joint. Displacing a hip this far requires a tear of that ligament and likely a tear in the joint capsule.

Depending on the severity of the injury, it can be possible to put the hip back into place without surgery.  However, extensive damage to the connective tissues can mean that the hip will dislocate again easily.  In cases like this, surgery is the only option for a cure.  In this case it seemed like a pretty bad dislocation so I referred the dog to a specialist for a further consultation.  With proper treatment, these cases can have a very good outcome.

What Voice Mail?

Does anybody bother checking their voice mail anymore?

Here's something that's happening with increasing frequency. I call a client to let them know that their pet is ready to be picked up. I end up getting their voice mail and proceed to leave a detailed message with any findings, treatment plans, and other information. Now, I'll only do this with routine cases, not ones where I really need to get more information or discuss something at length. But I do this in cases where I just need to pass on some quick details and don't need to speak to them directly.

Then the client calls back shortly afterward...."Yes, I received a call from your office."  But they don't know what the call was about.  What?  Obviously they simply saw the number on their caller ID and never bothered checking their voice mail.

Now, I don't know about everyone else, but when I see that someone has called and left a message, I listen to that message before I call them back.  After all, there might be something in the message that would make me do something else or I would see that I didn't need to return their call.  To me, that's common sense and something everyone should do. But obviously not everyone sees it this way, and for the life of me I can't figure out why. 

So if you ever get a call from me, check the voice mail before calling me back!

Dogs & Cats, Living Together...

It's a great line from one of my all-time favorite movies...

Dr. Peter Venkman: Or you can accept the fact that this city is headed for a disaster of biblical proportions.
Mayor: What do you mean, "biblical"?
Dr. Raymond Stantz: What he means is Old Testament, Mr. Mayor, real wrath-of-God type stuff. Fire and brimstone coming down from the sky! Rivers and seas boiling!
Dr. Egon Spengler: Forty years of darkness! Earthquakes, volcanoes...
Winston Zeddmore: The dead rising from the grave!
Dr. Peter Venkman: Human sacrifice. Dogs and cats living together. Mass hysteria!





The implication is that the idea of dogs and cats living in harmony is pretty ridiculous and isn't likely to happen under normal circumstances.  However, many of us know better.  And obviously the writers of Ghostbusters never visited a home like mine.  I have three cats and two dogs, for the most part living together well.  But one of the closest bonds is between one of my cats, Ash, and my oldest dog, Guinevere.

Guinevere has always been a very sweet girl, and is friendly towards pretty much any person or other animal.  She loves getting to know new pets, and is very low-key for a Labrador retriever.  When we first brought Ash home a couple of years ago she was curious but willing to let the newcomer be.  Ash was a bit freaked out by this big yellow dog, and would hiss at her for the first few days in our home.  But he quickly became used to her, and somehow they became friends.  That bond continues to this day, when we will see them laying together and see Ash grooming his big doggie friend.  It's really heartwarming to see how closely these individuals from traditionally antagonistic species have bonded.

Unexpected Hernia

Here's the case that kept me from getting to the dog I mentioned in yesterday's blog.

A client of ours had found a little stray kitten and brought her in for the first exam and vaccines.  At first glance she seemed a little dirty, but overall a sweet little four month-old kitty.  We proceeded to collect blood for a feline leukemia and feline AIDS test, ear swab to check for mites, and a fecal sample.  As I started my exam, things seemed okay until I listen to her chest.  Very quickly I noticed something strange.

Like humans, dogs and cats have hearts that are in a position slightly to the left of the midline of the body.  This means that in a vertically-positioned chest, the heart sounds louder on the left side of the body.  When I used my stethoscope on the kitten, I found it very difficult to hear the heart at all on that side.  As I started listening to the opposite side, I suddenly heard the heart much louder than it should be.  The more I listened, the more it became clear that the left side of the chest was very muffled and the heart was pushed to the right.  There are only a few things that could cause this, especially in a young kitten.  I knew that there was something that was filling up the left side of the chest and pushing organs to the right. The most likely possibility was a herniated diaphragm with abdominal contents in the chest.

The main purpose of the diaphragm is to allow movement of the chest to facilitate breathing.  But the diaphragm also separates the chest from the abdomen, keeping organs where they should be.  A sudden trauma can put enough pressure on the body or abdomen to "pop" the diaphragm, similar to a full balloon being stepped on. Once the it has ruptured, the contents of the abdomen can spill into the chest.

Here are the kitten's radiographs.

On the top image you can trace the line of the diaphragm and see the place where the normally sharp border becomes distorted and indistinct.  If you look at the left side of the bottom image you will see compressed but otherwise normal lung tissue.  The right side of that image is very hazy and opaque.  The astute observer will notice patterns of gas from the small intestines.  So it was very quickly evident that small intestine and possibly liver and stomach were sitting in the left side of the kitten's chest.  Such an problem compromises the ability of the lungs to inflate, making it difficult to breathe.  There is also the risk of some of the abdominal contents becoming "pinched", cutting off blood supply.

Surgery can be done to correct this type of injury, but it is risky and expensive.  I've performed this surgery successfully several times, once on a kitten this small.  However, the client didn't have the money and didn't want the kitten to suffer, so they elected to have her euthanized.  Her two children were in the room as we talked about this and they began to cry.  I was trying to help her explain to them that as sad as this was, putting the kitten to sleep was the best thing for her.

And it was while I was handling this case that the shih-tzu owner I talked about yesterday came in all upset because I didn't have time to come right out and speak to her.

A Little Patience, Please

Sometimes I just don't understand the impatience of people.

Today we had a client call us saying that her dog was sick, wasn't acting well, was dehydrated, and hadn't urinated in over a day.  That sounded pretty bad, so we told her to bring her dog in.  All of our appointments were booked up and we were still finishing up morning surgeries, so we told her to drop the dog off and we would look at it and call her back. My receptionist told her that it may be a few hours before the doctor could look at the dog but we would call as soon as we knew something.

Between surgeries I peeked in on the dog, a shih-tzu around a year old.  He was wagging his tail and barking, and certainly didn't look sick.  So I finished my morning drop-offs and procedures, took lunch, and came back a little early to check him out before afternoon appointments started.  His physical exam was completely normal and he urinated several times while with us.  Overall, I couldn't find anything wrong with him.  My plan was to call the owner and discuss the case with her to see if there was something else going on.

The afternoon started with some pretty big cases.  A Yorkshire terrier was limping, and on exam I thought he might have a dislocated hip.  A stray kitten that someone brought in had abnormal sounds in her chest, and I thought she might have a herniated diaphragm.  While starting this the shih-tzu's owner called.  I had my receptionist tell her that her dog appeared perfectly normal, but I wanted to talk to her and would call her as soon as I could.  Frankly, I thought that would be that.

The little kitten did have abdominal contents in her chest (I'll try and post about this later this weekend with pictures), and the owner couldn't afford the very expensive and risky surgery necessary to fix her.  So in the middle of getting ready to euthanize this kitten (with kids crying in the exam room), the shih-tzu's owner comes in, irate that nothing had been done with her dog.  I wasn't about to stop working on a very sick kitten and had my receptionist explain to her that we had some serious cases come in, her dog was fine, but I wanted to talk to her.  The client couldn't wait the 15 minutes it would have taken me and insisted on taking her dog, leaving in a huff.

Okay, somebody please correct me if I'm wrong here.  The client's dog had been with us for not quite 3 hours when she came back in.  During that time I had examined the dog and found nothing abnormal and nothing to support her claims.  Because the dog was very healthy and stable, I moved on to more serious cases, planning on doing them first and then calling the shih-tzu's owner. Sounds reasonable, right?  Apparently, not to some people.

Taking It In The Face

I've already talked about how gross veterinary medicine can be sometimes.  But what I didn't mention is where all of the fluids and other things can end up.  Often, it's right in the face.

Last week I was flushing out a dog's anal glands and had some of the fluid splash back into my face.  A few months ago I was looking at a problem with a dog's rectum and narrowly missed being squirted in the face with explosive diarrhea.  It's pretty routine to have a dog sneeze kennel cough vaccine back on us after we've given it (it's an intranasal spray).  I've had arteries arc towards my face after being cut during surgery.  Frankly, I'm glad that I naturally wear glasses and have some built-in eye protection.  But the worst case I've ever heard of was about 11 years ago with a guy named Earl.

Earl was a veterinary assistant at the practice I started at after graduating from vet school.  He was a laid-back, easy-going guy and a lot of fun to work with.  He had incredible compassion for the animals, and was a very hard worker. 

One day we had a dog come in with a horrible skin infection and maggots crawling over it.  When moist dermatitis happens during warm, humid months, flies may lay eggs on the diseased skin.  When the eggs hatch, the maggots will emerge.  There's nothing quite like seeing a mass of squirming white worm-like creatures wriggling over a dog after you've cut off the mats.  And this dog was pretty severely affected.

Once we did the initial cleaning, Earl took the dog to the kennel to bathe it and wash both the maggots and the dirt off the pet.  He was back there for several minutes when suddenly we heard a loud, horrific scream.  We rushed back there to see what was wrong and found Earl almost wretching into the tub.  Apparently he had the water on too forcefully when he started washing the dog and when it hit the skin the spray rebounded into his face...carrying maggots with it.  To make it worse, when the maggoty spray reached him he happened to have is mouth open.  Yes, he ended up with a mouthful of little maggots.  Frankly, we could all understand his scream.

Just one more escapade in veterinary medicine!

Volunteers Needed!

Richard, a veterinary student from Ross University, sends in this email....

First off, thank you for taking the time to read my email. I've been reading your blog for a while now, and not only do I enjoy seeing the practitioner's side of some issues, it is a great example of how to communicate with the public at large. I know that you encourage questions from your readers, and you may be able to help me with a little dilemma I have. I need to build a portfolio of case studies for my pharmacology class. The idea is to put together short videos of a variety of cases, before and after medical treatments, along with some basic information about the medications they received. Then I have to provide a narration discussing the method of action, pharmacokinetics, adverse effects, etc. based on lecture material. Where I find myself in a bind is that our teaching hospital does not permit photography of any kind inside the facility. I understand where they're coming from, and it is an interesting discussion for another day, but it leaves me in a bit of a bind. Do you have any thoughts or suggestions? Would any of your clients be interested in volunteering their animals, anonymously of course, to help a student?

Richard, I'll certainly try to help here. This is an official shout-out to my readers around the world. If anybody is interested in helping out, please email me (DrChrisBern@gmail.com) and I'll pass on the information to Richard (I don't want to share personal emails in a public forum). This may be a way to get a bunch of cases together in a way that you couldn't otherwise do, and will go beyond my own clientele. If you're on VIN (Veterinary Information Network) I would recommend seeking the help of other vets there, as you'll find a wide spectrum of people.

I remember having to do projects when I was in school, though nothing so fancy. My senior project was on Helicobacter pylori, a bacteria found in the stomach and implicated as a causative agent in stomach ulcers. In some parts of the world it's a major health concern, and it's found in the stomachs of some animals (ferrets carry it, and are used in research on this organism). My presentation was one of my first forays into PowerPoint, and I was so excited that I found a small animation of Helicobacter moving. This was back in '97, so I was pretty proud of my computer skills. And I actually won an award for that presentation.

Richard, I hope this may help a little, and maybe I can send some interesting cases your way!

Bragging Rights

To me client service is extremely important.  In an economy like our current one it's difficult to drive business and succeed strictly on price.  To truly win, you have to have excellent customer service.  Though I'm far from perfect, I pride myself on creating this kind of environment in the practice I manage.  And sometimes you do win.

Today I had a client pay me one of the biggest compliments I've received.  She was friends with another one of our regular clients who apparently has had nothing but great things to say about us.  The new client had come to us specifically because of her friend's recommendation.  And the greatest part is that she drove an hour and passed numerous other vets to get to us.  The word of mouth was so good, that she went out of her way to bring her pets to us.

You simply can't buy that kind of advertising.  Good word-of-mouth is the best way to develop a business, as well as the most cost-effective.  When you have people speaking well of you, word gets around.  The same thing is true of complaints and bad word-of-mouth.  If you're doing the right thing for the pets and clients, the former will outweigh the latter.

One of the most important parts of treating clients in the right way is the team you work with.  As good as a vet might be, they can't to their job without their techs, receptionists, and other assistants. My team deserves the credit for such success at least as much as I do.  Without them, I wouldn't be able to do my job and the clients and patients wouldn't get the treatment they need and deserve.

So yeah, it's time for a mild bit of bragging.  Next challenge?  Do even better!

Not Expecting The Unexpected

Today I neutered a three year-old boxer.  He had recently been seen at my practice for testicular pain, with the suspicion of an inflammation or infection in or around the testicles.  He responded well to antibiotics and pain medication, but on the recheck exam I noticed that the firm swelling had not resolved.  Suspecting other problems, including cancer, I convinced the owner to have him neutered with the possibility of a biopsy of any suspected tissue.

Normally a routine neuter takes me around 10 minutes to do.  Since I was expecting some masses attached to the testicles I thought it might add an additional 10 or so minutes to the surgery time.  After having been in practice for almost 13 years, I should know better than to expect things to go smoothly in cases like this.  The more I was involved in the surgery, the more I realized that the abnormal tissue extended much farther than I had initially thought.  I could feel irregular, firm tissue extend along the length of the epididymis (just off the testicles) down to where the tissue attached to the scrotum.  I found myself in a surgery unlike any I've done before, and ended up doing the procedure for just over an hour.

One of the things you learn as a vet is that the unexpected can happen at any time.  The bad part is when this happens during a surgery, because suddenly it becomes difficult to do it part-way and stop the procedure.  You have to trust in your abilities and experience, knowledge of surgery and anatomy, and hope for a little good luck.  In this case I knew that I had started to remove the affected tissue and couldn't very well close up the pet with the job only partly done.  So in the end I ended up removing his scrotum to make sure I removed all of the abnormal tissue (this is sometimes done for cosmetic reasons in large, adult dogs who are neutered, as the empty scrotum tends to hang down and is unattractive).

The dog recovered normally, and we sent some of the tissue to the diagnostic lab or a pathology review.  If we're lucky we'll end up with merely a severe inflammation or a benign cancer.  Unfortunately boxers are prone to cancer, so the report may give news of a malignancy.  We'll know by next week.

Now the final lesson came when the owner picked him up.  I was explaining the surgery and findings as well as the possible outcomes.  She asked me if this could have been prevented by having him neutered when he was a puppy.  I don't like to brow-beat clients, especially ones who are trying to do the right thing.  But I had to be honest with her and tell her that if he had already been neutered this would never have happened.  Testicular disorders aren't common, but they do happen.

So make sure to have your dogs spayed and neutered.  I will help to prevent many types of health disorders later in life.

Canine Couch Potato

I have come to the conclusion that one of my dogs, Inara, is a fan of TV.  However, it must be certain programs or movies.  She is around a year old and is a yellow lab mix.  Normally she's pretty active and loves to play, though thankfully she has calmed down a bit once she reached adulthood.  Television normally doesn't interest her, and she will lay quietly on the bed or couch, chewing on one of her toys.

Until a show comes on involving dogs. 

Right now we have Homeward Bound on TV and she has been watching it intently.  Whenever the animals come on she will turn and watch it, even leaning closer to the TV.  In a few scenes she has even growled a little.  When scenes have only people, she will turn away and not seem to care.  It's been very interesting studying her and watching how her attention waxes and wanes depending on what comes on the screen.  The animals really fascinate her.  Our other dog, Guinevere, could care less and doesn't even seem to notice what the TV does.

It makes me wonder what is going through Inara's mind.  Does she recognize that these are real animals?  I have to think so, otherwise she wouldn't have the interest.  Does she wonder where they are and why she can't smell them?  Does she wonder why they don't respond to her?  How much does she really perceive and understand?  We'll probably never know.  But it's interesting that some dogs can have interests in TV like people do.

Other people have hoped to cash in on the pet TV watcher market.  You can find videos of fish, birds, and other animals that are designed to keep the interest of your cats while you are away.  I can't say how well they work, and it's probably marketed towards the owners as much as the pets.  But watching my own dog I have to say that there is probably some validity to it.

Hmmmm...Maybe I should get one of those videos for Inara.

A Real Mess

Anyone who thinks that veterinary medicine is glamorous has obviously never spent time working with a vet.  I was just talking with some friends of Facebook about this, and I don't think people realize what we have do deal with in the course of a day.  I'll often say to people that if I don't get bodily fluids on me during the course of a day, I obviously haven't been to work.  Most days I'll come into direct contact at least with feces and blood.  Urine and pus are not uncommon.  And anal gland secretions are a necessary risk; I have my finger in the rectum of multiple pets per day.

Large animal vets have it even worse.  They walk around in barns or fields with an inch or more of manure.  Much of their day is spent literally up to their shoulders in the back-end of a cow or horse. Vets who work on dairy farms may have to rectally palpate several hundred head of cattle each day.  Often such work is done in freezing cold or blistering heat.

Then there are the smells.....Expressing anal glands are bad enough.  But a nasty abscess can really clear a room.  Swine vets carry the odors around with them for days, even with showers (I certainly remember my brief forays into a swine barn and how hard it was to get the stench off me).  Parvo has a very distinct, rather nasty smell.  As a vet you have to develop a strong stomach, and you become rather immune to many harsh odors.

And despite all of this, most vets love their jobs!  Yes, we're a bit of a strange bunch.