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Thursday, March 31, 2011

Animal Blood Types

A couple of weeks ago Paul asked this and I'm finally getting around to it. 

I wonder if you could discuss the issue of blood groups and blood transfusions in dogs.
I understand that large breed dogs often are blood donors and that unlike us humans, at least my understanding is, that a dog can receive a blood transfusion from another dog without the blood being of the same blood group as the donor's. Am I correct? How does this work? without killing the dog. Is it only once in a dog's lifetime that a transfusion of another blood group can be done? Are the blood groupings for dogs the same as humans?
Excellent question, Paul!  I'll try to answer this question in a way that most laypeople can understand.  All of my veterinary readers please be patient if I don't get into quite the detail that I know is out there.  I'm also going to deal just with dog and cat blood types, as these are the most common pets owned and the ones I'm most familiar with.
For those who haven't quite caught on, yes, animals have blood types.  Humans have four:  A, B, AB, and O.  When doing blood transfusions we have to "type" a person's blood and find out which kind it is.  Type O is a "universal donor", meaning anyone can receive this type of blood, but those with Type O can only receive their on blood type.  AB is the opposite, being a "universal acceptor" and can take any blood type but can only donate to other ABs.  Humans naturally have antibodies against blood types other than their own, so if someone receives an incompatable blood type the body will not properly recognize it and will attack it as a "foreign" substance.  This reaction can be serious and even fatal, which is why blood typing is important.  This isn't really a concern with O blood because this type doesn't have the "triggers" on their surface that the other three have, so antibodies will not recognize or attack the cells.
Dogs have eight basic blood types, though as many as 12 may exist.  The types are numbered and are structured differently than in humans.  Dogs also are believed to not have naturally occurring antibodies against other blood types (again, different than in humans).  This means that a first-time transfusion between two untyped dogs is very unlikely to cause a suddent transfusion reaction, even if their blood types are different.  However, if the blood types are different, the recipient can then develop antibodies against the donor blood type.  The next time this blood type is given, there is a chance of a reaction to the "foreign" blood.
Cats have three basic blood types, named A, B, and AB.  AB is a rare blood type, though is found very commonly in the Abyssinian breed.  Cats do have natural antibodies against different blood types, like in humans, but the severity differs.  Type B cats have a high antibody level against Type A, and are likely to have a very serious reaction to even a single transfusion with A.  Type A cats have lower levels against Type B and so reactions to B tend to be minor (however, these donor blood cells won't last as long in the body compared to A blood).  AB blood can be safely given to cats of either other blood type.
So how is all of this relevant?  Dogs can generally receive any other dog's blood for a transfusion if it's the first time the recipient has ever had a transfusion.  After the first time it becomes important to type the blood to prevent a reaction.  This is very nice in emergency situations as the vast majority of dogs have never received donor blood so if you have to do a quick transfusion you can really pick any canine blood sample.  Cats aren't so lucky, as you need to type the blood of the donor and recipient every time or risk a potentially life-threatening reaction.
Many areas have pet blood donor programs, especially at veterinary colleges.  In US there is also a national pet blood bank that can overnight blood to any clinic.  Donors usually receive free health screening and testing to make sure they are good candidates for donating, since there is normally no compensation given for allowing your pet to be a donor.
Paul, this was a great question!  Thanks for asking it!

Tuesday, March 29, 2011

Moving Elderly, Sick Pets

Nathalia send me this email...

I have two elderly cats, one is approaching 18 and the other 16.5. My 16 year old is epileptic and receives medication 3 times a day. She has been seizure free for about 4 months, but they can start up at any time…or so has been the case since they began about six years ago. My 18 year old is healthy, although the vet tells me she is in stage 1 or 2 of chronic kidney disease.
I am moving to New Zealand in August. I have begun preparations for moving the girls, but my vet suggested that I leave them behind because she did not think they could withstand the flight from Indianapolis to Auckland (flying cargo for most of the flight), plus being quarantined for 30 days in New Zealand upon arrival. (she was worried about my 16 year old going long stretches of time without her medication)
I am really torn about what to do. I could break the trip up, at least from Indy to LAX to give the girls a few days of rest before the long cargo flight. And from what I gather, I could visit them in quarantine and they would take care of administering medications.
I do have family members who have agreed to adopt my girls, but I’m devastated by the thought and have been trying to figure out what kind of impact that would have on them, as opposed to the stressful move with me. Do you have any thoughts on this?
I would tend to agree with your vet that this might be too much for kitties.  Stress is one of the things that can induce a seizure, and you won't be able to give medications while your epileptic kitty is flying across the Pacific.  I'm also not sure how comfortable you would be putting the care of old, less-than-healthy cats in the hands of a stranger for a month.  This would be a very, very hard trip on them physically, and though they might make it through just fine, I believe that there is an equal chance of having problems.  Going to live with some of your family members would also be stressful, but I don't think that it would be quite as bad as such a long international trip.
I know that this is an extremely difficult decision, and it's hard to leave such life-long partners.  As tough as it is, this is a time to put aside your own feelings and look at what's best for your cats.  Unfortunately, there is no guarantee either way, as they could do fine traveling with you and have problems back with family.  But I do think that the odds are best for them by staying in the US.  If they were younger and healthy, I wouldn't have any qualms about them traveling so far, but that's not the case here. 
In the end it's a matter of better or worse odds and not a black-and-white issue.  If you feel that you can't be without them and that they are so bonded to you that they'd suffer away from you, then it might be worthwhile to take the risk of travel.
Good luck with your decision!

Saturday, March 26, 2011

Make It Stop!

Part of being a vet is dealing with noisy dogs.  Most of the time we get used to it and learn to tune it out.  Frankly, you have to because it's just about a daily occurrence.  Dogs bark to communicate with each other, let other know they are there, and express their "displeasure" at being confined.  Any and all of these reasons can cause a dog to bark when in the clinic.  And once one starts barking it entices others to join in.  At times it can be quite a cacophony!  I've been having to put up with barking for about 27 years now, and you'd think I'd be used to it.  Most of the time I am, but sometimes it gets to me.

Today we had a little Yorkshire terrier in for a dental cleaning.  He came with a housemate, a shih-tzu, and it quickly became evident that they were closely bonded.  We kept them together initially, but had to separate them once we started the cleanings.  The shih-tzu went first, leaving the Yorkie alone.  Once by himself the Yorkie started barking non-stop with a particularly reverberating, high-pitched yapping.  This went on and on and on and on!  Once his friend was in recovery there was a delay until his own dental, during which he continued to bark.  We couldn't keep them together since one was still waking up and it wouldn't be safe.  Finally the Yorkie's dental happened and we had some blissful quiet for a while.  However, he was quickly done and work up surprisingly fast.  As soon as he was awake he began barking again! 

This was so bad that all of the clients could hear him in the rooms.  I was talking to an elderly lady about the coccidia her dog had.  The lady had a hearing aid, which really amplified the particular frequency of the dog's barking, making it very difficult for her to hear and understand me.  I had to have her to into the lobby in order for her to be able to hear my tech's at-home instructions.

Finally both dogs were awake enough that we could put them back together, and silence again reigned.  It was such a nice switch.  Normally barking doesn't get to me that much, but to paraphrase Jayne Cobb "he was starting to damage my calm." (Bonus points to everyone who correctly understands that reference)  I seriously wanted to throttle the little thing to get it to be quiet and was glad when he finally quieted down. 

Just one of the many aspects of being a veterinarian that most people don't think about!

Thursday, March 24, 2011

Men Running From Women

Veterinary medicine has become interesting regarding gender shifts.  In 1960 the profession was 98% male.  Today it's 50.9% female.  From 1976 to 1995 the enrollment rate of men entering veterinary school decreased by more than half and the female applicants doubled.  Currently enrollment in US vet schools is 70-80% female, and 2009 was the first year that women menbers of the American Veterinary Medical Association outnumbered men.  It's no secret to anyone paying attention that this has become and will increasingly become a female-dominated profession.

The question is "why?"  Most people have explained the shift in gender demographics in relation to women's rights, changing gender perceptions, acceptance of women in medicine, lower wages discouraging men, and other similar factors.  But a recent report suggests another reason.  To quote the article from DVM Magazine...

Research suggests that men avoid college majors and graduate fields that are 24 to 54 percent female, Lincoln points out in her study. On college visits, men who see a classroom full of women may be intimidated to apply—a theory backed by statistics collected for the study.

"The explanation of reduced barriers to admission for women has merit, although it fails to explain why other professions that have also eliminated that bias have not feminized or not at the same rate," Lincoln argues. "The results of this study demonstrate only one consistent difference between male and female application patterns—men's strong negative response to women's increasing enrollment."

Feminization of the veterinary profession has been fueled more by lower rates of college graduation among men and their aversion to female students than women being attracted to the field, Lincoln says. Similar trends have been noted in fields now dominated by women, like pharmacy, she adds. The trend now may also be extending to human medicine, with female applicants to American medical schools surpassing those of men for the first time in 2003. Wage stagnation over the last two decades has been linked as a factor in that case, with men more often choosing the more lucrative fields of business or law over medicine. Men also tend to revise their career plans based on decline in occupational prestige, employment security and promotional prospects, Lincoln adds.

Very interesting conclusions!  According to the study, for every 1% increase in the female veterinary student body there will be a 1.7% decrease in male applications the following year.  So the decline in male veterinarians may be because they're scared to work in a profession dominated by women!  Personally I haven't seen that attitude among my male colleagues, but then we're the ones who actually did apply and therefore seem to be the exception to the data in this study.

Women, here's your proof that men really are the weaker and more easily intimidated sex!

Wednesday, March 23, 2011

When To Spay Or Neuter

A common debate among veterinarians, shelters, and clients is when to have a dog or cat spayed or neutered.  The consensus and opinions have changed over time, and there can be some big disagreements depending on someone's experience and education.  A recent article in the journal Veterinary Medicine discussed the current views on the pros and cons of this kind of surgery on very young pets, and I thought it would be good to bring it up here.

First of all, we need to define "pediatric" spaying and neutering.  This normally means performing the surgery between 8 and 16 weeks of age.  Older vets would balk at this because the recommendation used to be to wait until six months old or after one heat cycle.  Current thinking has pretty much disproven the need to wait this long, so now most vets are spaying and neutering between four and six months old.  Most of the very young surgeries are done through shelters and rescue agencies, wanting the pet sterilized prior to being adopted out. 

Since there are many concerns about doing pediatric surgeries, let's briefly mention some of the myths (all taken from the above article) of the risks of doing these procedures.
1.  Obesity.  A long-term study at Cornell University showed that dogs who had early spays and neuters actually had a decrease in obesity risk.
2.  Stunted growth.  Removing the hormones early actually allows the growth areas of bones to stay open longer, so pediatric spays and neuters can grow taller than their late-sterilized counterparts.
3.  Hip dysplasia.  The jury is still out on this, but studies seem to be showing no increase or only a slight increase in risk.
4.  Feline urinary obstruction.  No increase risk has been found.  In fact, the diameter if the urethra is no different in cats neutered at 7 weeks or 7 months old.
5.  Urinary incontinence.  Again, the results are mixed.  One study showed an increased risk in females spayed before 12 weeks old, one showed no increased risk, and one showed an increased risk if spayed after the first heat cycle.

So overall, there appear to be no documentable long-term risks to surgical sterilizing at 2-4 months old.  What about surgical risk?  With current anesthetics and monitoring, the risks are not significantly different than waiting until later.  This was even true when I was in vet school in the late 90s, which is where I first saw some of this data.  As long as the vet is careful and monitors adequately, the surgery can be just as safe as in a six month old pet.

So with this information, why don't more people spay and neuter early?  In part I believe it's an ingrained tradition and habit in the veterinary profession.  We're just used to doing it at a certain age, and doing it younger makes us nervous because we don't really have personal experience with it.  I also think that it has to do with the timing of vaccines.  We finish the vaccines at around four months old, and it's easier to keep them on a regular schedule if we don't throw a surgery in prior to that.  It's simply convenient timing that once we finish the puppy/kitten boosters we next schedule their surgery.  But based on available data, there aren't many good reasons to have to wait that long.

Now does this mean that we as a profession should move to spays/neuters at three months old?  No, I don't think so.  There's really nothing wrong with doing it at the 4-6 month mark as most vets seem to do.  But it does mean that we shouldn't be afraid to do it younger, and shouldn't criticize those who do.  I'll continue to recommend the surgery at around four months old, but I have done it as early as 10 weeks (for reasons other than needing them sterilized) and had no issues at all.

Food for thought!

Tuesday, March 22, 2011

Expanding Opportunities

More and more this blog seems to be affording me some unique opportunities.  I've been able to connect with people around the world and in every hemisphere, I've reconnected with a client, and I've been able to share my knowledge to a far wider audience than I ever imagined.  Though I'm far from a big-time blogger, this whole thing has grown bigger than I realistically thought would happen.

Recently I was interviewed for an online college website, talking about what it takes to become a vet.  You can find the article here.  The interviewer paraphrased a few of my statements, but the answers are mine.  These are also similar questions that I have answered in this blog on previous occasions, so long-time readers may find some similarities.  And since I've gone through these questions before, I probably won't answer them again and will instead direct inquiries to previous posts and this article.

It's interesting how our world has change and how information now spreads.  In modern times bloggers are often well known and sometimes have real influence and power (just look at elections in the last few years).  When I graduated vet school in 1997 the Internet was well established, but still hadn't reached its potential.  Things like Google, Wikipedia, and blogging wasn't yet known.  Look how far we've come over the last decade! 

There is another big opportunity that I've been given and has developed over the last 10 days.  I'm not ready to fully detail what's going to happen, but things should be settled within a few weeks and then I can share and we can Gab about it.

Monday, March 21, 2011

Taking A New Oath

When we graduate to become veterinarians, we must take an oath stating our sincerity in our chosen profession. For only the third time in history, the oath in the United States has been revised by the American Veterinary Medical Association.  The original oath was adopted in 1954, then revised in 1969, 1999, and now 2011.  Here is the oath that every US veterinarian takes:

"Being admitted to the profession of veterinary medicine, I solemnly swear to use my scientific knowledge and skills for the benefit of society through the protection of animal health and welfare, the prevention and relief of animal suffering, the conservation of animal resources, the promotion of public health, and the advancement of medical knowledge."

Some of this oath may be surprising to the lay-person.  Promotion of public health?  Yep, vets historically have been called on to inspect meat and animal food sources, as well as monitor diseases carried from animals to humans.  Scientific knowledge?  Thought it may not seem obvious at first, we are trained as medical scientists and as critical thinkers.

So what's new?  The part about preventing and relieving animal suffering.  Though the AVMA doesn't define what entails "animal suffering", it hopes to make a statement by this stance, especially with the "prevention" as a proactive view.  Truthfully, I'm not entirely sure how important the change is.  The oath isn't legally binding and doesn't necessarily constitute practice standards.  I can also see lots of arguments against food production, an always touchy subject with the AVMA, as many feel that production animals are suffering in their circumstances.  Taking a tough stand on animal suffering is good, as we need to recognize the importance of pain control and other things that can negatively impact an animal's life.  But by not defining what "suffering" means, the AVMA is being rather vague (and probably deliberately so).

I remember when I recited that oath at the hooding ceremony and how important I felt.  At that time the oath really meant something and I listened to every word.  Though I don't discount the value of such a standard oath, I have to admit that I haven't really thought about it much over the last 13 years.  Time and perhaps a touch of cynicism has made me realize that saying the words doesn't really affect my day-to-day life and practice.

So for better or for worse, newly graduating vets will be reciting the above oath.  Will this change the profession or make them better vets?  Unlikely.  But it shows how the profession changes along with society, and we have come a long way from the beginnings of primarily seeing livestock.

Saturday, March 19, 2011

Guilty As Charged?

I think we all know the situation.  We come into a room and there is a mess on the floor.  Maybe a poo or pee accident, or maybe the dog got into the garbage.  As we look over the mess the dog slinks away or holds their head down.  Maybe we ask "did you do this?" and the dog looks away.  It's pretty obvious that the dog knows what they did wrong and that they are feeling guilty about it.

Or do they?

It's pretty easy to find videos online of "guilty" dogs.  Check out a couple of these...

It seems pretty clear that these dogs recognize their bad deeds and feel some degree of guilty.  However, studies have shown that this isn't the case, and we are attributing too many human emotions to our pets.

A dog has little to no long-term association between their behaviors and either punishment or reward.  Behavioral studies have shown that a positive or negative reinforcement must happen within 20 seconds or a dog doesn't associate it with whatever action they performed.  For example, say that you let your dog out to go to the bathroom, they potty and then wander around the yard for a minute or so.  They come back to the door and you praise them for being such a good dog and going potty.  However, it's been too long for the dog to link the bathroom behavior and the praise, so they believe that they are being rewarded for coming to the door (the most recent behavior prior to the reward). Similarly, if you come home and find a mess, the dog only reacts to the mess on the floor, not to the fact that they created it.

It's a subtle but important difference.  There was a study that looked at dogs in homes.  When the dog was out of the room a person turned over a trashcan just like a dog might have done, and then the dog was let back into the room.  When the dog saw the mess, it acted "guilty".  So why did it do so?

Think about the time period for reward or punishment.  If you come home and find a mess, you are likely to get upset.  Even if you don't spank or hit the dog (which you should never do), or yell at the dog, your pet can recognize the tension and anger in your body language.  When a pack leader shows signs of anger or aggression it's a typical dog reaction to start showing submissive behavior:  lowered head and tail, keeping the body low to the ground, avoiding eye contact, and so on.  Though we interpret these behaviors as "guilt", it's really signs of submission.  The dog is making a connection between a mess on the floor and your angry behavior.  They are NOT making a connection between their behavior and your anger.  When you come home their action was far enough in the past (more than 20-30 seconds) that they don't associate it with any of your actions.  In a dog's mind it goes like this:  "Mess is on the floor.  My person gets upset when there is a mess on the floor, and I have experiences in the past that show this is consistent.  When there is a mess on the floor and my person is in the room, I know they are going to be upset.  When these conditions happen together, I need to act submissive to help defer any anger from me."

So dogs really don't feel "guilty".  This is another example of how people and pets often speak in different "languages".  The dog is trying to communicate in the only "language" that they know, and are expecting us to understand.  We, however, misinterpret the language in our own, sometimes coming to the wrong conclusions.

Thursday, March 17, 2011

Distemper Still Around

Over the last decade or so there has been a move in veterinary medicine to decrease vaccination of pets due to concerns about reactions, cancer, and other adverse events.  Much of this attitude has made its way on the internet, and many clients don't seem to think that regular vaccination is necessary.  While I agree that we need to investigate and implement longer durations for vaccines, I think that some people have a very false sense of security.  And that may include some veterinarians.

In my 13 years in practice I have seen only two dogs with confirmed canine distemper, and they were littermates.  I have practiced in many different areas of the country and have seen many different diseases, but not much in the way of distemper.  There are vets who have graduated in the last few years that have never seen a case and may never see one in their entire careers.  However, talk to older vets or ones that practice in more rural areas and they're good at looking at a dog and suspecting distemper.  The "problem" is that the canine distemper vaccine is so effective and we as a profession have done such a good job of convincing owners to use this vaccine that we have pushed the disease out of the mainstream.  But that doesn't mean it's gone.

Earlier this month an article reported that shelter in Mississippi had a problem with an outbreak of canine distemper.  They tried to control it but dogs were dying and the disease can be highly contagious.  They ended up having to euthanize over 100 dogs to get the problem under control and prevent further transmission.  Back in 2004 shelters in Chicago also saw an outbreak, and ended up having to close all shelters in the metro area for a prolonged period of time to deal with it.  You can find other examples across the country of outbreaks like these.  And most of them could have been prevented with proper vaccination.

Just because a pet stays in a home or a yard doesn't mean that they are not at risk for developing serious contagious diseases.  Stray dogs and cats can bring bacteria and viruses into an environment that a pet never leaves.  It is very important to listen to your vet and keep your pets properly vaccinated.  Not doing so could lead to a costly treatment or even losing the pet.

Wednesday, March 16, 2011

The Best Veterinary Colleges In The US

Considering that my last post was on choosing undergraduate colleges, today's entry fits very nicely.  I am a graduate of North Carolina State University, and today I received an email from our alumni organization about a newly released ranking of US veterinary colleges.  For as long as I can remember, NCSU has been ranked #5, but this time we made it up to #3 (in a tie).  Click here for the article, and the list is presented below....

1.  Cornell University
2.  University of California, Davis
3.  Colorado State University
3.  North Carolina State University
5. Ohio State University
5. University of Pennsylvania
5.  University of Wisconsin, Madison
8.  Texas A&M University
9.  Michigan State University
9.  University of Georgia
9.  University of Minnesota
12.  University of Florida
13.  Tufts University
14.  Purdue University
15.  Auburn State University
15.  Washington State University
17.  Iowa State University
17.  Virginia Tech/University of Maryland
19.  Kansas State University
19.  University of Illinois
19.  University of Missouri
22.  Louisiana State University
24.  Mississippi State University
25.  Oklahoma State University
26.  Oregon State University
Tuskegee and Western Universities

Now I'm sure that every vet in the US would argue for their school having a better place on the list, and I personally wouldn't choose a veterinary school simply based on this list.  I've seen great vets and poor vets from pretty much every school, so I think a lot of it is what you make of the education that you're offered.

Still, it's kind of fun to see my school move up in the rankings!

Sunday, March 13, 2011

Picking The Right College

A commenter posted this, which I felt was worthwhile answering.

I am a high school student aspiring to become a veterinarian. I'm in the process of looking at colleges and figuring out which undergraduate programs will give me the best chances of getting into a good vet school (which I know is very competitive). I was wondering what advice you might have about what's important to consider in the whole college-search process in order to reach my goal of ultimately getting a DVM. 

I may be a bit controversial with my comments here, but I don't feel that there is much difference in colleges when it comes to going into veterinary school as long as you can meet the minimum requirements.  Yes, some schools have higher ratings than others.  But you don't need to go to a school like Yale, Harvard, or Oxford to get into vet school.  I went to a small state school in western North Carolina and received a very good education. Someone involved in veterinary student selection might be able to contradict me, but I've never seen any strong evidence that the college on your diploma makes much of a difference in entering vet school

The main thing to look for in colleges is whether or not they have a pre-veterinary program.  If they do, then pick a college based on your location preferences and budget.  State schools will be much cheaper than private ones, and that may be a big factor in your choice.  Pre-veterinary programs are designed so that they will meet the entry requirements of most veterinary colleges.  It's not to say that you couldn't get into vet school going to a college without a specified pre-vet curriculum.  But in those cases you will have to be much more careful in your choice and find out the requirements of the vet schools you might choose.  You can request a catalog from any vet school and they will list which courses and grade average they look for in their candidates.  Then you can compare these requirements against the courses offered at a college.

The important factors tend to be your grade point average, especially in the required courses, veterinary experience and recommendations (you'll need both), extracurricular activities, and sometimes an interview (depending on the school).  If you have these covered you'll be in good shape.  If you have poor grades or are missing experience, it won't matter which college you went to.

Keep in mind that you will likely be heavily in debt when you graduate vet school, probably well over $100,000 if current trends hold true. I would recommend an undergraduate school that is less expensive or that you can get scholarships or grants so that you lessen your debt load entering vet school.  I managed to make it into vet school without any outstanding debt at all, and then racked up around $40,000 in loans in four years (and this was back in the late 1990s when costs were lower than they currently are).

Good luck in following your dream!

Friday, March 11, 2011

Finding Motivation

This might be a shocker to those outside of the veterinary field.  Sometimes vets simply don't want to go to work or don't want to see cases while they are there.  Yes, I know we're supposed to love our job and according to surveys most vets do.  But we're only human and no matter how much someone loves their job there are some days when you're just simply lacking motivation to perform.

This isn't a good situation in any job.  A factory worker needs to be able to perform up to standards or they could be injured or produced shoddy materials.  A cashier may not have many responsibilities, but they should still be careful about what they ring up and what kind of attitude they have.  When a doctor is unmotivated it's a bit trickier, because they are responsible for the lives and health of their patients.  If they simply don't feel like doing their job it can directly impact lives.

There are various reasons why someone might lack motivation in their job, and I think most reasons apply to any profession.  They may not like their job, or at least not like their location and co-workers.  They might be very tired and burned-out and therefore find it hard to motivate themselves.  Or they might simply be having a lazy day and not feel like doing much (and you know we've all had those days!).  A big problem with veterinarians is that it is easy to get burned out because we work so many hours and days and have a lot of emotional stress due to some of the cases.

So what do you do when you're a vet and you have to deal with normal clients, sick pets, surgery, and a full day's schedule, but you don't really want to?  Like in any job you persevere and simply get to it.  I find that rather than thinking about the entire day or the numerous drop-offs waiting for my attention, it's easier to just look at one case at a time, focusing on that before moving on to the next one.  You might take more frequent bathroom breaks to have a bit of quite time.  You also rely on your staff, letting them help direct your day, joke around with them, and maybe even playfully complain to and with them (I've had days when about 10 minutes after I arrive in the morning I ask the staff "Is it time to go home yet?" and then keep a running tally of how long until closing).  If you really are burned out, then you need to make time for a vacation, even if it's staying home for a few days and sleeping late.

With as much stress as we have, there is no way for a veterinarian to be 100% motivated every single day, yet we can't let the quality of our medicine falter.  So as an aid among friends and colleagues, I'd love to hear what others do to maintain motivation in their jobs on those days when they don't have it.  By sharing with each other we can help one another, and help prepare students for the times ahead of them.

Tuesday, March 8, 2011

Proper Communication

LeAnne emailed me with the following...

I am currently in the process of applying to veterinary school (I have an interview next week at UC Davis - wish me luck!) and I'm a full time technician at a four doctor canine and feline practice. My question stems from my experiences at work and from contemplating my own future as a veterinarian.

Part of my job is to restrain pets during exams. Because I'm pre-vet, I like to stick around after the exam to listen to the doctors go over their observations and recommendations. One of the doctors surprises me regularly by using a lot of veterinary words such as "palpation", "crepitus", "cranial abdomen", and other words that it seems to me lay people may or may not know (she says things like "I don't feel anything when I palpate the cranial abdomen"). On the other hand, she also seems to use a lot of veterinary slang as well; for example, she refers to taking an xray as "taking a picture" (I wonder if anyone ever thought she was actually taking a picture with a camera?). Once, she told someone with a puppy who was leaking urine that she wanted to ultrasound him in back to "see if he had a bladder"--meaning check to see if his bladder was full--so we could get a urine sample. The owner blinked her eyes and said, "is it possible that he might not have a bladder?" to which the doctor replied, "sure, especially if he just urinated." The owner okay'd the ultrasound and nothing more was said. I asked the doctor in back if she thought the client could have misinterpreted her and thought that the puppy may have no bladder at all. The doctor just laughed and said, "geez, I hope not!"

It got me wondering about client communications and the assumptions that doctors make about client comprehension. It seems a lot of people just nod and say okay even when they don't have the darnedest clue what the doc's going on about. What about things like the efficacy of tests--even ones that come back negative--or the fact that, depending on the nature of the ailment, the first medication or treatment tried may not always be the most effective? There are so many situations in which techs and doctors talk about things they know well or even bored to reiterate but are like greek to someone who has never heard them before.

I was wondering if you might comment about generally about how you address this issue both within yourself as a doctor and with the vets and techs that work under you. Also, how do you "dumb it down" without insulting those clients who CAN keep up with the big words and the jargon?

This is an excellent topic of discussion and one that's often overlooked in veterinary training.  Medical terminology is very much a foreign language (quite literally considering the Greek and Latin origins of most words), and doctors spend all of their years of training learning this language.  It becomes so ingrained in us that it can be easy to forget that others don't understand what we're talking about.  At the same time this terminology is very specific and allows us to communicate with colleagues much more specifically than when using "ordinary" language.  For example, an average person might say that there's a lump in the "upper belly".  While the person might have a good idea of where this might be, it's actually very non-specific.  A doctor might say that there is a mass in the "dorsal cranial abdomen" which means more to a medical professional.

I remember similar experiences to yours, LeAnne.  When I was going an externship while in vet school I was at a surgical referral practice in Charleston, South Carolina.  One of the doctors was trying to explain to the client about the fracture in the dog's foot.  He was using terms like "distal phalanx", "comminuted fracture", and other very specific and proper medical terms.  I remember looking at the client and seeing a very blank look on his face, indicating a complete lack of understanding.  Yet the vet never seemed to notice or possibly didn't care.  That experience really stuck with me.

One of the first lessons is that there are really three different populations of people you will be talking to as a vet.  The first is the average client who has no medical background or experience.  In these cases you need to avoid using medical terms, keeping it to common terms (x-rays rather than radiographs, ear flap rather than pinna, hip socket rather than acetabulum, and so on).  The second group is people with human medical backgrounds who understand anatomy, physiology, and medical conditions, though not necessarily veterinary-specific situations.  I generally speak to these people (nurses, MDs, paramedics) with mostly proper medical terminology, but will sometimes ask questions to make sure they're following me.  The third group is the veterinary colleagues, and you can speak to them with as much terminology as you want.

You also have to avoid professions-specific slang or lingo.  "Chem panel", "CBC", "rads", and other terms are not always understood by people, and yet aren't specifically appropriate medical terminology.  There are ways to say these things and have people realize what you are saying, such as "organ chemistry analysis", "blood cell count", and "x-rays".  Each clinic may also have certain language they use that other veterinarians may not even understand.  How many vets know what a "comp" is?  In Banfield Pet Hospitals (in the US) this is slang for a "Comprehensive Exam".

This is a learned skill and one that you have to actively develop.  In general I avoid detailed medical terms and try to use common terms.  If I absolutely have to use medical terminology or if it's just easier when describing a problem, I'll define it for the client before using it.  I only slip into specific veterinary terms when I'm talking with other veterinary professionals, and then I gladly do so because it's much more specific.  

LeAnne, does this veterinarian realize what she is doing?  Has anyone brought up to her the possibility that clients won't understand?  Since communication is a skill, it may take some training and someone to point out ways to improve.

Lastly and possibly most importantly, there is something simple that many people forget.  Ask for comprehension!  Before I leave a room, the last thing I always do is ask the client if they have any questions.  When explaining something complicated, I'll ask them if they understand what I'm talking about.  This gives people the chance to (even permission to) gain further comprehension and ask any questions they may have been afraid to at the beginning.

Great question, LeAnne.  Good luck with your application.

Friday, March 4, 2011

Wait, Where's The Microphone?!?

Today I had a brand new experience.  I was on TV for a local station talking about dental care in pets.  And it didn't go exactly as I expected.

I've never been in a TV studio before, so I didn't know what was going to happen.  I brought my dog, Inara, to use as a sort of prop to demonstrate how to brush a dog's teeth, and had arranged this ahead of time with the producer.  I arrived at the appointed time, abut 15 minutes before air time, and spent some time talking to the station receptionist.  At 5:30 they called me into the studio and I quietly entered as they were starting their broadcast.  I had never actually met anyone from the station in person, so I wasn't completely sure who I was supposed to talk to.  I discovered that the person I was told to contact was one of the anchors, and she was on air as I came in.  During the breaks while they went to video and during the commercials we were able to briefly talk.  I was a little surprised when she asked me what I wanted her to ask me about, as I thought she would have done some prep work ahead of time.  And she was asking me this as they gave us the 1-minute warning before we went live!

We were sitting at an interview desk, and Inara is a 60 pound lab mix.  When she was on the floor she couldn't be seen, so they asked if she could sit on my lap.  I picked her up and she's a good enough dog that she sat there quietly even though I could tell she was a bit nervous.  I discovered that the anchor was nervous also, as she looked rather uncertain about Inara being that high and close and even asked me if she was going to jump across the desk at her.  I was quick to assure her that Inara was very sweet and most certainly wouldn't do that.

So they gave the signal and we started to talk.  I began to go into the statistics of dental disease in pets and the link between dental problems and other health concerns.  A little less than a minute into my talk the anchor said that they couldn't hear me and that my microphone must have fallen off.  Keep in mind that we were on live TV!  So right there I had to let Inara off my lap, quickly look on the floor to find the mike, and then put it back on my lapel.  All of that used up about a minute and a half of the four minute segment!  I quickly moved past that and continued my discussion of dental disease and care, using a model of a dog's mouth that I had brought.

In no time at all the interview was over and we finished up.  The anchor returned to her main desk, they thanked me, and I left.  Once I walked out I immediately began to think of all of the things I didn't say and should have said.  I covered the basics, but also unintentionally left out such important things as "be sure to see your vet for dental cleanings", "tooth brushing won't remove established tartar," and so on.  I guess hindsight is always 20-20, and whenever I've done presentations I've always had a longer period of time.  This being my first time on TV I wasn't used to the quick pace and limited time.  So now I'm kicking myself a little bit because of the things I left out.

Overall it was a good experience, and I'd like to think I handled myself well for my first TV interview and appearance.  The anchor even said that I handled the microphone issue very calmly and did well.  Hopefully I did well enough that I may get other opportunities, as I did enjoy it and really like doing public speaking.  And the next time I'll do better as I have a much clearer idea of how the process works.

Thursday, March 3, 2011

Peri-Operative Care

Amanda emailed me with this...

 My name is Amanda M**** and I am a student working on my Associate's Degree in Veterinary Technology.  I have an assignment to prepare a presentation on the preop, peri-op, and postop procedures for a surgery.  I have chosen Enucleation for my topic, but I'm having a hard time finding information specific to preop, peri-op, and postop procedures.  I read your post "Bye Bye Eye" from August 4, 2010, and it was helpful--especially the pictures (which are also hard to find).  I read that you welcomed questions, so I thought I'd send you a line.  If you have time, could you please tell me what is needed to take care of the animal surrounding the surgical procedure?  I thought you would be a perfect source of information, and I would appreciate, greatly, any information you'd be able to share with me!

That's a great question, Amanda, and one that ties in with the recent discussion and comments about the importance of technicians in anesthesia monitoring.  We veterinarians couldn't do our job without our support staff, so I'm happy to help illuminate exactly what they do in cases like this.

The veterinary technician or assistant helps perform the pre-anesthetic exam.  Often they are the ones collecting the blood and should be the ones performing the diagnostic tests. They check the anesthesia equipment for proper functioning (checking oxygen levels, performing leak tests on the machine, etc.), gather the surgical instruments and suture, prepare the monitoring sheets, and otherwise make sure everything is ready for the doctor.  Once it is time for surgery they may place IV catheters and set up fluid lines. 

Depending on state laws and legal certifications (when necessary) technicians may induce and intubate the patient.  They hook up the monitoring equipment and begin preparing the patient and sterilizing the surgical site.  During the procedure itself their primary responsibility is to keep track of the vital signs by monitoring and recording the data. They should also be examining the pet themselves (listening to the chest, feeling the pulse, checking gum color, etc.) and not just relying on the equipment.  If the doctor needs more suture, new instruments, or anything else, it is their responsibility to get it since the doctor is scrubbed and sterile.

The tech normally monitors the pet during the initial recovery and extubates them once they are swallowing.  Vital signs are taken again and the pet placed on a warming pad if necessary.  As the pet recovers the assistant is responsible for continuing to monitor, usually administering any post-op analgesics or other medications.  Depending on the nature of the surgery (routine versus uncommon) the tech will often discharge the patient, going over medications and at-home instructions.

Now these are the general instructions for just about any surgery.  An enucleation really isn't that much different.  Surgical shaving, scrubbing, and prep is different just because of the different location (such as versus a spay).  The doctor is doing a much different surgery than an neuter or splenectomy, but that's all the responsibility of the vet and not the tech.  Post-op instructions for most surgeries are going to be pretty similar, so there won't be that much difference from other surgeries.

Amanda, I hope this answers your questions!

Wednesday, March 2, 2011

The Privilege Of Pets

My latest poll was a little surprising for a couple of reasons. First, there were 152 responses, which is almost double the last poll and far higher than any previous.  Second, the opinions were very strongly one-sided.  How did people view pet ownership?

A right--5%
A privilege--93%
Not sure--1%

I strongly believe that nobody has a RIGHT to own a pet.  You also don't have a right to drive a car, a right to buy a TV at a certain price, and so on. defines "right" (in this context) as follows:
a just claim or title, whether legal, prescriptive, or moral
a moral, ethical, or legal principle considered as an underlying cause of truth, justice, morality, or ethics.
I don't think that owning a pet would fall under any of these definitions, or other similar ones.

If pet ownership was a right, then you would be entitled to have one regardless of your ability to care for it.  You would also be entitled to have a pet even if you couldn't afford to purchase would have to be given to your or provided to you.  As a right you could do whatever you wanted to that animal without remorse, or even ignore it, and nobody could object.

Having a pet is a privilege, and one that can be taken from you if you abuse it.  Legally this is certainly the case, just as a driver's license can be taken away for repeated abuse of traffic laws.  Morally it is also a privilege, as having an animal share your life is an honor and a blessing.  A privilege is cherished and not taken for granted.  Viewing a pet as a privilege gives them a status beyond mere property.

So since I can obviously relate more to the 142 people who view it as a privilege, I'd love to hear from the 8 who feel it is a right and why they believe that.

And the new poll is now up!

Tuesday, March 1, 2011

The Essentials

Back in December I talked about changes in anesthesia protocols, emphasizing how new research and technology allows us to evolve and adapt to make procedures safer.  Yesterday I discussed one monitoring parameter, and unexpectedly started a bit of a debate on the usefulness of electrocardiograms (ECGs).  Since I believe that open and honest debate is how we learn from each other, I thought that I'd clarify the things that I feel are essential to safe anesthetic events.  Personally I don't think that general anesthesia should be performed without the following things, and I know that my views mirror those of anesthesia specialists.

Pre-Anesthesia Blood Tests
Just because a pet looks healthy on the outside doesn't mean that everything is normal.  Low-grade anemia can be a sign of other problems and won't be obvious on a physical exam.  Early liver and kidney disorders also can't be detected on an exam, but could be found with simple blood tests.  If these tests aren't performed, there are many problems that can be missed and could lead to problems with the safety of anesthesia.

IV Catheter
As much as we don't want them to, things can wrong during anesthesia.  If this happens, the quickest way to put corrective drugs into the system is through the veins.  When a pet is "crashing", seconds matter and you don't want to have to struggle to put in a catheter.  If one is already in place you can have a better chance of saving a pet if anything adverse ever happens.

Intravenous fluids during surgery aren't about correcting dehydration.  They are about maintaining blood pressure and circulation.  When you anesthetize a pet it affects their cardiovascular system which can cause blood pressure to lower and can affect perfusion (how much blood ends up into tissues).  When you have fluids entering the veins you can help keep pressure and circulation at appropriate levels.

Despite the debate after yesterday's entry, I feel that this is an important and essential part of monitoring.  There are patterns on the ECG that can indicate problems with the function of the heart that you can't detect any other way.  Simply put I feel that no anesthesia should be performed without this.

Pulse Oximeter
This piece of equipment measures the oxygen content of the blood.  Obviously this is very important because even if you have adequate fluid volume and blood cells, if they aren't carrying oxygen through the body you could have a critical state. Low blood oxygen can lead to permanent tissue damage, including the brain. Honestly, though, this is the piece of equipment I would be willing to live without.  I have had problems with pulse oximeters not reading properly even if the patient was otherwise normal.  At the same time, if there is a documented decrease in blood oxygen, you need to intervene right away.

Blood Pressure
There are several ways to measure this and I'm not going to debate one method versus another.  If blood pressure drops too much it can affect how much blood reaches tissues as well as how well the heart pumps.  Conversely a case of hypertension can lead to a different set of problems, or even indicate an abnormality with the kidneys.

Trained Staff
Monitoring equipment is great and can tell us things that our eyes, ears, and hands can't detect.  But they can't replace a skilled technician watching the patient.  No computer or electronic device can have better judgment than someone standing there keeping track of the patient's vitals.  I have my staff record information from the above monitors every five minutes.  But I also train them that this doesn't take the place of listening to the heart with a stethoscope, feeling the pulse with their fingers, and looking at the color of the gums.  Equipment can fail, malfunction, or misread, so as important as the are, the SINGLE MOST important part of anesthesia monitoring is an actual person watching the patient.

My colleagues who read this entry will surely have their own strong opinions.  I also deliberately have avoided getting too deep into the science of anesthesia monitoring since I don't want to write a textbook on the subject and I have many readers who aren't medical professionals.  I want to present this subject in a way that everyone can understand the discussion.

The important take-home message is that anesthesia is a very serious procedure with lots of potential for things going wrong and leading to death.  The best way to avoid problems is to be watching the patient's vital signs in several different ways so that if an abnormality is noted something can be done quickly to correct the problem.