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Wednesday, June 30, 2010

Yes, There Is A Real Reason

Today I saw a dog for a behavioral consultation, a particular interest of mine.  He was showing aggression towards the other dog in the house and the owner was concerned.  After a lengthy visit and asking many questions, I determined that besides changing some things in the household and doing behavioral therapy, he would likely benefit from medical therapy.

Whenever we're evaluating for a behavioral problem we want to rule out the possibility of an underlying medical disorder that is leading to the abnormal or unwanted behaviors.  So besides doing a thorough history and physical exam it's common to do routine lab tests, even if the pet otherwise appears healthy.  And when we are considering placing a pet on long-term medication we want to screen for any underlying problems that might make it dangerous to use these drugs.  For both of these reasons I recommended that we do a battery of tests on the dog. The client balked at the cost and was concerned about the necessity of the tests.  After explaining it again, she reluctantly agreed.

And it's a good thing we did, because we discovered a potentially serious liver disorder.  His liver values were significantly elevated on the blood tests (for my vet readers....ALT was 654, and normal range is 10-100; ALKP was also elevated at around 250).  First of all this meant that we couldn't start him on drug therapy because of the potential risk of of complications due to a liver problem.  Second, it meant that he would need to have even more tests, likely with a specialist, to discover what was causing the problems with the liver.  Now when the liver is abnormal, waste chemicals can build up in the blood stream and lead to neurological disorders.  Usually this includes seizures, incoordination, and lethargy, but can also include behavioral changes.  So there is a possibility that the dog's abnormal behaviors are related to a liver disorder.

Now you would think that someone might be glad that we didn't just put their pet on a drug that could end up being harmful, and that we had possibly figured out a reason for the aggression.  However, the owner seemed a little upset when she left and was pretty curt at the end of the visit.  She was probably thinking of how much more money she was going to have to spend getting his problem diagnosed, and not thinking of the potential severity of a liver disease.

This is exactly why vets want to run diagnostic tests.  To just look at the dog you would think he was very healthy, never knowing that there was a hidden problem.  If we had not run the tests and simply tried medication, we could have given him complications due to the drugs, or simply overlooked a serious problem and delayed a true diagnosis.  So when your vet makes recommendations for tests, please understand that it's for a real reason, even if it may not seem obvious to you.  We really do catch problems by practicing quality medicine.

Tuesday, June 29, 2010

Treating Your Own

I think one of the most difficult things for a vet to do is treat their own pet.  When we're treating other people's pets we can maintain a clinical detachment and concentrate on mentally piecing together the problem.  Diagnosing and treating a disease requires clear thinking and a rational mindset.  When you're emotionally involved it can be difficult to think that way.

A few days ago one of my dogs, Guinevere, started vomiting and acting lethargic.  She was still eating so I watched her for a few days.  She didn't get better but wasn't really worse.  Then yesterday my wife called me and described what may have been a seizure, so I had her bring Guinevere into the office.  I ran a test for pancreatitis and took some abdominal radiographs, but didn't find anything significant.  She was acting a lot better, so my wife took her back home.  When I got home last night she was acting very strange again.  I didn't think it was bad enough to take her to an emergency clinic (I can't easily get into my practice after hours), but I was pretty worried with how weak and lethargic she acted.  This morning I took her back to work with me, planning to run more tests.  However, all day she acted normal, took treats from my staff and didn't seem like there were any problems.  So I ended up not running further tests and brought her home.  She's still a little quite, but much better than she was yesterday.

But the point of this isn't to diagnose my dog.  This was one of my hardest cases, but because of the emotional investment. Guinevere is a sweetheart and an integral part of our family.  She's also my wife's baby and the two share a close bond.  Not only was it hard to see my own dog sick, but my wife was worried and crying which made it even worse.  There were so many emotions running around that it was hard for me to maintain that clinical detachment.  And since I couldn't make a specific diagnosis and she wasn't reacting or responding like I expected, I was worried that I wouldn't be able to make her better. 

Thankfully she seems much better so something must be working its way through her system.  And my wife is much better since Guinevere is on the road to recovery.  All of which makes me feel better.  Vets can have emotional dilemmas with their own pets, as we're only human too.

Wednesday, June 23, 2010

Not Apologetic

I have a client whose cat was recently diagnosed with diabetes.  This can be difficult to regulate in cats due to the nature of the disease in this species.  In any species a newly diagnosed diabetic patient needs frequent follow-up visits and lab tests to determine the right treatment regimen. This disease is not as simple as picking a dosage of insulin and seeing them back in six months.  Each patient reacts a little differently and you have to slowly tailor the dose so that the blood glucose is in the normal range.  Too little and you remain diabetic; too much and you can become severely hypoglycemic.  Cats are special because their glucose can jump over 100 points merely due to stress, so we have to do different tests than we would in dogs.  In our practice this is about $130 every three weeks until the pet is regulated.

This cat belongs to Ms. Howlett (remember her from a May post?) a client that unfortunately annoys me to no end.  I spoke to her yesterday about the latest results and where we go from there.  Her cat is still in the process of being regulated, so we have a ways to go and several follow-ups left.  In our discussion she constantly talked about the costs.  "Is there going to be another office visit charge?"  "Is it going to cost this much each time?"  "That insulin is $88. Can you give me a volume discount?"  She doesn't seem to understand that there are charges with these things, and is continually griping about having to do more tests and charges.

I got over charging clients a long time ago.  As someone who manages and runs a business, I know that the charges are very appropriate for the services provided.  Most of the people who complain about costs don't run a business or understand how one is managed.  They especially don't understand what it takes to run a medical practice.  I was even talking about it with my dentist this past week (had to have a filling replaced) and she has some of the same problems.  Her clients also complain about charges and costs, not realizing how much money goes into keeping a medical facility open.  There are a lot of unseen costs and a lot of overhead, and most small medical practices do good to maintain a profit and aren't making money hand-over-fist.

So I don't apologize for our charges.  It is what it is, and it's what it takes to stay open.  The charges are fair and appropriate.  Yes, I know not everyone can afford it, but to be blunt and extremely truthful, it's not my job to watch out for a client's pocketbook.  We do offer credit options to help out clients, and even have a charitable fund grown through donations that can help those who don't have any money at all.  Beyond that we have to charge for what we do and I'm not sorry about that.  Honestly, most veterinary practices under-charge for what they do, and that's been shown by numerous practice consultants.

And to head off any critics, this isn't about being money-grubbing.  It costs money to have proper medical equipment.  When I send samples to our diagnostic lab, they charge me for it, so I have to charge the client.  I have staff to pay, insurance, utilities, supplies, and so on that all cost money.  I don't gouge my clients and charge them for things unnecessarily.  But I also concentrate on what is medically best, and if it costs a few hundred dollars, well, so be it.  I once heard that a client has three options in services:  fast, cheap, or good.  They can have two out of the three, but not all three.  So if they want something cheap, it's either not going to be good or is going to be very slow.  Honestly, I concentrate on quality and timeliness and charge for that.  And seeing as how my practice has grown steadily for the past three years, despite the economy, that's not a bad way to go.

Saturday, June 19, 2010

Pain In The Neck?

Here's a question from another Laura about her dachshund....

This past Friday, I came home from grocery shopping, put the groceries away, and went to finish cleaning.  Dodger usually follows me and when he didn't I noticed.  He had been in the hallway next to the maine coon cat we have.  Then I heard him yelp.  I came out of the bedroom and the cat was still in the same position-hadn't moved but I thought maybe Rufus swatted him again.  Dodger's head was leaned down like he had done something wrong.  He waddled over to me, got in my lap, and began shaking horribly.  When I tried to turn him around in my lap to look at his face for any cat scratches, he yelped like I was killing him.  I called the vet right away and took him right up.  We had to wait just over an hour and during that time he had calmed down a lot.  (Lady dachsi in the waiting room).  The vet couldn't find anything obvious so he gave us Rimadyl-suspecting maybe he twisted a muscle.
Over the weekend he did not seem much better -I took him back in Monday, this time he yelped while the doc was examining him and he suspects something going on between the middle back and his neck.  After walking a bit, he will lay down where ever, sometimes leaning on his breast bone with hind legs up.  So doc added tramadyl and valium to his meds and also gave him a shot in the butt.  It's been a week and there is not much improvement.  If you walk near him sometimes he yelps.  Also he yelps if his mother or father bump into him slightly.  Just today I noticed that dodger has a nasty dark brown spot under one of his front paw pits...and doc said before this was yeast.  I know that can be pretty painful.  I'm wondering if the yeast spot can be so sore that it's causing him to freak out this way?  If he has a zero tolerance for pain?  I hate to see my baby so drugged up and unhappy.  I'm wondering why no x-rays yet? 
Appreciate any thoughts you might have.
I'm sorry your pup is hurting, Laura.  Starting with one of the last comments/questions, a small area of a yeast or bacterial infection wouldn't be painful, especially to this degree.  And even if it was sore, if it was on a paw it should cause localized limping, not what you're describing.
The posture you're describing (front end down and hind end up) is a classic position indicating pain, though it's more common for abdominal pain.  This should be easy to determine with careful abdominal palpation by your vet.  Rimadyl and tramadol together are great pain relievers, and I suspect the valium was for relaxation, though there are better medications to achieve strict muscle relaxing.  If all of that isn't working well, there's possibly something more serious going on.

If this was my patient, the first thing I'd want to do is carefully manipulate the neck.  I have seen pets like this where there is very noticeable neck pain, and that can help localize the problem.  There are a number of different problems that can happen in this region, including a slipped disc (which would respond better to prednisone and may need surgery).  The next step, regardless of pain identified, would be radiographs.  If there was definitive pain in the neck, I'd want the x-rays only in this area.  If it wasn't readily identifiable I would want 2-3 sets of rads, concentrating on different areas of the spine and abdomen.  In many cases of slipped discs a "plain film" radiograph won't detect it, and a special study called a myelogram is needed.  This is normally done by a specialist, and involves injecting a dye into the space around the spinal cord and looking for narrowing of the dye pattern.

From your description I can't say that your vet has done anything wrong and I would have proceeded similarly with the exception of having recommended radiographs by now.  I would definitely let your vet know it isn't better, and talk to him or her about the next step.  Good luck!

Friday, June 18, 2010

Advice On Picking A Pet

A common complaint that many vets have is that clients don't choose their pets carefully enough.  Researching a particular breed or species is something important so that a person will have a good idea of what they are getting into.  Cocker spaniels are very prone to ear infections.  Westies have a high likelihood of developing skin problems.  Huskies shed a lot in the Summer and can be very active.  Knowing these things ahead of time can prepare someone for the challenges that may lie ahead and prevent some surprises.  It can be frustrating for clients to have to deal with some of these issues, and foreknowledge may change someone's choice and give them a better pet-owning experience.

I recently read an article on getting organized for picking a pet and the things to consider.  Dog, cat, or bird?  Long hair or short hair?  Small breed or big breed?  Anyone considering getting a new pet should read this article (linked here). It's really a good article and good advice.

Unfortunately, most people pick a pet based on how it looks, especially as a puppy or kitten.  Those pets look so cute when they're small, but they only stay young for a short time.  When you choose a new pet, you need to think of what that critter is going to be like as an adult and what you might be facing.  You also need to consider extra time and costs of care, as well as increased challenges when you go out of town. 

So anyone who is looking to add to their furry family or know someone who is, please direct them here and to the above link.

Wednesday, June 16, 2010

Mysterious Limp

We haven't had an "Ask The Vet" question for a while, so here's one I just received from Laura...

I wondered if you might have some insight on what might be the problem in my little 4 yr old toy poodle.  One day, out of the blue, he started carrying his left hind leg -- almost consistently.  After a couple days he would use it to walk and trot, though it was evident that he was favoring the good leg while standing. And his posture is changed so that he holds the bad leg rather out and back from the good leg. 

Since then I have stopped walking him except to let him relieve himself.  I have allowed him to roam the house though try to keep him subdued and resting most of the time. He seems to use it a bit more since then, at least the amount of carrying is greatly reduced. He might carry the bad leg right after getting up from rest---though only rest after activity since in the morning he seems best of all, using the leg without problem. 

He never had any pain with manipulation of the leg, hip, or knee.  He can run--though I don't allow it.  He managed to do it a couple of times when I couldn't restrain him.  He stretches the leg, does the kicking out of the legs after relieving himself, can stand on his 2 back legs, can pee standing on the one bad leg, and seems to sit mostly square (though I see he leans to the good leg). 

So I have noticed that if I lift his backside up by one of his hind legs (while he is standing on his front), sort of cupping the tucked leg and lifting him from that point (so that he can , he does something different from the bad side.  I attached a picture of me lifting him up from his good side.  He will resist in the good leg and bear weight in that kneeling position.  But in the bad leg he doesn't want to bear weight. 

I have been trying out different things to locate the problem. He will bear weight in the straight position though he prefers the good leg.  But in this kneeling position he won't bear weight into that tucked knee so that I can lift his hind side off the ground.  I can feel that he won't use the muscles to resist so the knee just comes up relative to his body.  Whereas in the otherside he bears down, keeping the knee lower than his belly so that I can life his hind side.  I hope that makes sense. 

I don't know if that determines one way or another whether it COULD be the cruciate or most likely a sprain/muscular problem.  I already brought him to the vet, who determined that ít's not luxating patellas and wasn't obvious laxity in the stifle area. He didn't do a drawer test, presumeably because he just did not see it as a grave problem yet.  Also, since my dog is only 5 lbs, he is of the mind that only in the 10% worse cases of small dogs does one even operate and prefers to let them heal on their own.  So since then I decided to do the 6 weeks of restricted activity before taking him in to see an orthopedic vet. 

Have you got any suggestions or guesses as to what other problem he might be suffering?

Very puzzling question,  Laura.  My first thought in reading this is that your dog has a luxating patella, though you said the vet ruled this out.  For those reading this who don't know the medical terms, this is basically a loose kneecap.  Small dogs are very prone to this problem and it can cause intermittent to continual lameness in the hind leg without any obvious pain.  A vet can usually tell pretty quickly whether or not this is the problem, though in some cases it's difficult to manipulate the patella.  However, as severe as this sounds I would imagine that it would be pretty obvious to almost any vet.

Also for readers who don't know, a drawer test is a specific way of moving the knee to look for laxity if we suspect an anterior cruciate ligament (ACL) rupture.  This type of injury involves one of the stabilizing ligaments in the knee joint and leads to sudden lameness.  Though much more common in large, active dogs, an ACL tear can happen in any dog and I have seen smaller breeds with this kind of injury.  A positive drawer test is a strong indication that there is an ACL injury.  I'm not sure why your vet wouldn't do this test, as it doesn't usually involve sedation and is quick and easy to do with most dogs in the exam room.  Even if surgery wasn't done, you would at least know that this was the problem.  I also know orthopedic surgeons who would still do the surgery on a small dog like this.  The ruptured ligament can cause significant inflammation, which will take months to resolve without removing the damaged pieces.  There can also be tears in the meniscus (cushioning pad) of the knee, which again can cause inflammation while it remains. However, this degree of inflammation can often be felt in the knee, so your vet may have been less concerned about this particular problem.  It is true that in mild cases of ACL injury in small dogs or cats that surgery isn't necessary.  However, your dog may be in the 10% that needs it.

It doesn't sound like radiographs (x-rays) were performed, and I would recommend that as the next step.  Though I agree that it sounds more like a problem in the knee, you would also want to rule out a problem in the hip. There are certain problems that small dogs, especially poodles, are prone to, especially Legg-Calve-Perthes syndrome.  In this particular disorder, the head of the femur (upper leg bone where it connects the hip) looses blood supply and begins to deteriorate.  This problem is usually easy to detect with radiographs and requires surgery to remove the femoral head.  And while radiographs can't easily detect ligament injuries, you may be able to see changes in the knee joint that can be suggestive of an ACL injury.

Exercise restriction and pain control are certainly indicated, and may be the only treatment necessary.  However, if this was my patient I would definitely recommend the radiographs prior to waiting for that long.  If rest doesn't resolve the issue, I would certainly see a specialist and be prepared for the possibility of a CT scan or MRI to try and fully view the soft tissues in the joints.

Good luck, Laura!

Sunday, June 13, 2010

Back To Work

It's been a busy couple of weeks for me.  My family and I took our first week-long vacation in an incredibly long time, visiting my father and going to a science-fiction convention.  This past week I flew across the country to California to take part in a task force identifying challenges, problems, and solutions in some veterinary hospitals that weren't reaching their potential.  Today I got back into town and tomorrow I go back to work.

I haven't been in my hospital for two weeks, and it's making me a bit anxious.  I've never been gone this long, and though I have a great staff and great doctors, I'm not exactly sure what I'll be facing when I get back.  One of the positive things I will face is a veterinary student.  I have one that will be working with us for six weeks starting tomorrow, and one doing an externship starting in another week or two.  I very much enjoy teaching and mentoring, so that part will be fun for me.

While spending some time in another hospital this past week I realized that I much prefer doing that to being in daily practice.  Though I am a good vet, my true skills like more in the areas of teaching and communicating.  There are certainly times I would rather do anything than see patients.  My hope and desire is that if I made a good showing this past week I can get more opportunities like this, and can guide my career in a different direction.

But for the foreseeable future I am still an average vet and have a practice to manage.  Tomorrow it's back to the grind, back to patients, and back to normal.  Not a bad life, really.