Determining Lifestyle Risk

As vaccine recommendations and protocols have changed over the years, the profession has moved from recommending a set of vaccines to every pet, to more of a risk-based assessment that takes into account a pet's lifestyle and environment.  It seems to make sense that a pet who isn't at risk for a given disease shouldn't worry about being vaccinated for it.  However, I don't believe it's as clear-cut as many might think. 

Let's take my in-laws as a great example.  They have a chihuahua and recently got a yorkie-chihuahua mix puppy.  These are small dogs who are completely babied and spoiled.  Most of their existence is inside a home, though they do go outside for short periods.  If I saw them in my practice as a regular client, I'd ask about their environment and likely come to the conclusion that these are indoor-only pets with little risk for exposure to leptospirosis or bordetella (kennel cough).  Based on a risk-assessment analysis, these vaccines (both consider non-core by many or most vets) do not need to be given.  However, I know a bit more about the environment of these dogs than the average person.  There is another dog next door to them that stays outside and lives in a fenced yard where there can be nose-to-nose contact, as well as spread of urine along the border.  My in-laws have also seen coyotes in the woods behind their house and though there is a fence eliminating direct contact, there is risk of the coyotes as lepto carriers urinating into the yard and therefore contaminating the soil.  Knowing these things it seems like my in-laws' dogs should certainly be vaccinated for lepto and possibly bordetella.  Would these risks be obvious to someone who hadn't been to their house?

How much of this information do we really get in a routine exam visit?  How many questions do we really ask of the lifestyle?  And how open are we to non-standard options?  I've seen plenty of "fluffy" dogs such as yorkies, shih-tzus, and other traditionally indoor dogs who go hiking and camping with their owners.  These dogs are at higher risk for exposure to lyme and leptospirosis, yet just to look at them you might think that they rarely touch grass and only through careful questioning do you learn the truth.  Also, do owners really share or volunteer all of the information we might need?  Where I practice there is only a low risk for lyme disease, so I don't recommend it for most pets.  But what about the pet who travels with their owners to the northeast where it's frighteningly common?  Will owners even think to tell us that they go to New Hampshire three or four times per year?  Will we think to ask about traveling?  

Now don't misunderstand me.  I actually do support asking the right questions and determining preventative care based on a pet's risks.  And I don't think we should vaccinate every pet with every vaccine "just in case".  But anyone in this profession needs to be very, very careful in their assessment of these risks and ask the detailed questions.  As in the case of my in-laws it might not be so clear-cut and we shouldn't let prejudices for or against vaccines cloud our judgement and decisions that would be best for the pet.

And to pet owners I would strongly recommend having open and honest discussions with your vet about every vaccine available.  Ask your vet what vaccines they carry, which ones are available, and whether or not your pet is at risk for each one.  You might be surprised at what your pet could be exposed to that is potentially preventable.

Leptospirosis Is Still A Concern

There has been a misconception over the years that the leptospirosis vaccine is unnecessary and even dangerous.  Some persist with the opinion that the lepto vaccine has a higher risk of causing reactions, and therefore should not be given.  I've seen veterinary staff perpetuate this idea, yet when asked what the reaction rate is or any data to support it, they can't give it.  I've seen clients come in with sheets from breeders with a big "never give leptospirosis" plastered in bold letters.  Such viewpoints over the last 15-20 years has led to a decrease in vaccinating for this disease.  And I believe this is a mistake.

Leptospirosis is a bacteria that can be found in numerous kinds of wild mammals.  Infected animals shed the organism in their urine, which can contaminate soil and water.  Anyone or any animal coming into contacted with these areas can in turn become infected.  This is a serious disease, leading to often deadly kidney or liver failure.  Humans are as susceptible to lepto as animals, and an infected dog could be a risk for its owners.

Why bring this up now? An article was published a few days ago about an outbreak of leptospirosis in Detroit, Michigan.  Twenty cases were recently diagnosed and nine dogs died as a result of the infection.  This is not rare, and may be a growing concern.  Over the last few years cases of lepto have increased around the country. Personally, I believe that the increase in lepto cases coincides with the decrease in people vaccinating.  I also believe that the true rate of infection is much higher, as most vets (myself included) don't think to test for lepto when we have a case of acute liver or kidney disease.  In fact, we have historically done such a good job of vaccinating that many vets have never seen a case of leptospirosis, though this may change.

Lepto vaccines are common, easy to give, and available at just about every vet.  A few studies have compared reaction rates of the distemper-parvo vaccine with and without lepto components and found the reaction rate to be statistically identical, which means that modern lepto vaccines are NOT more reactive and are NOT an increased risk.  And with cases such as the one above, we should be recommending the vaccine MORE and not less.

Inside/Outside Dilemma

Early on in my career I learned an important lesson.  When asking about a pet's environment and lifestyle, don't ask "does he/she go outside?"  Instead ask "how much time does he/she spend outside?"  That's a subtle but important distinction, and one we have to often almost physically extract from owners.

Today is a great example.  I saw a chihuahua mix for the first time, a really sweet little girl.  The owner didn't want to get vaccines done because she never really went outside.  Now at face value, this may make some sense, as many small-breed dogs rarely touch grass.  But it's important to dig a bit deeper, as it can have implications on the best recommendations for the pet.  As we talked more I learned that the dog went outside to potty, and sometimes on walks.  Then the owner started talking about going to parks and interacting with other dogs.  Huh?  Wait, I thought he said the dog never really went outside and therefore didn't need much preventative care!  Yet the dog is really at pretty high risk since it goes to public parks and is around other dogs.

We see similar issues with cats.  I've had so many clients who say things like "Oh, my cat's completely indoors.  He just goes out on the porch and then a little into the yard when we're outside also."  Um, what part of "indoors" extends to grassy areas?  Again, there is a much higher risk of disease exposure with being outside even a little bit compared to truly never going outside.

So you pet owners, try to be a little more honest about whether or not your dog or cat really stays inside.  To veterinarians if your pet moves outside the walls of your home, it's at least partially outdoors, even if only for a short period of time.

And to vet students and new vets, be sure to ask the right questions to get the complete answer.

Peeling The Couch Potato

Sometimes it's hard to keep in shape, especially as you get older. Working 40+ hours per week I often feel like I don't get enough time with my wife and children.  I also work long days, around 9am to 7pm.  This kind of schedule makes it hard for me to find time to work out, even though I know its in the best interests of my health.  The last time I went to the gym regularly was shortly after graduating vet school, and that pretty much stopped once I got married.  In the intervening years I've ended up in the typical middle-age situation where I'm not in great shape and am carrying about 10-15 more pounds than I'd like.  Part of my problem is that I like cookies and pastries too much and have little willpower when it comes to these foods.  We eat pretty healthy overall, but I indulge in high-carb and high-calorie foods a bit too much.  I'm also rather lazy and honestly hate the amount of work it takes to get in good physical condition.

My wife recently found a "Couch to 5k" program. The idea is that over 9 weeks you gradually go from a couch potato (me) to being able to run five kilometers.  Though I really don't like running, the idea of getting into shape is a good motivator, especially if my wife and I do it together.

However, I have to admit that I have a slightly different motivation.  Regular readers of this blog should have learned early on that I'm a big geek.  A friend of mine posted a link on Facebook to a "zombie run" and the idea intrigued me.  This is a pretty unusual 5k run, as it involved an obstacle course and being chased by people dressed as zombies.  The runners have "life" flags, sort of like in flag football, and must run the 5 kilometers through a park. There are some obstacles along the way that you have to overcome.  And then of course the zombies chasing you, trying to get your flags.  The goal is to make it to the end of the course with some of your life still intact.  It's a race not just against other runners, but also a race for survival against zombies.  To a geek like me this is very intriguing.  Check it out yourself...appropriately enough it's called "Run for your lives."

We started the training this week and I was surprised that I did well on the first section.  We'll see how well I do next week when we increase the intensity.  And the nice thing about doing this is that not only will I be improving my health and spending time with my wife, but I'll be better prepared to survive the inevitable zombie apocalypse!

Ear Mites Or Not?

Alycin sent this email....

I found your blog by searching for "symptoms of ear mites but not ear mites"... But the thing is, it isn't an ear infection, either, according to two different vets I took her to.

I love my dog more than anyone, whether that's healthy or not. I am at a loss because I can tell she is miserable. The vet I took her to today gave me an ear wash (epi-otic I think?)  but assured me her ears looked fine. I don't have the money to keep taking her to different vets to get told there isn't anything wrong with her.

Are there any other possible causes of these symptoms? Thank you for any help you may be able to offer.

One of the most common things I see in practice is people thinking their dog has ear mites.  Honestly, it's not that common.  I see this probably less than once per year.  Yes, it's possible, but the huge majority of the time there is something else going on, usually an infection.  For whatever reason it seems that more people have heard of mites than infection, so that's what people jump to.

There are a few symptoms that tend to lead to people bringing their pet in for an ear problem:  debris or "goo" in the ears, itchiness (shaking the head or scratching at the ears), redness, or a bad odor.  Any or all of these can be signs of an infection or mites.  Personally I've noticed that ear mites tends to cause a darker, drier debris than ear infections, but you can't make the diagnosis based on this alone.

Every veterinary dermatologist will tell you that when you have a suspected ear problem, the very first thing you do is get a swab from the ear and look at it under the microscope.  If your vet isn't doing this, you need to have a talk with him or her.  In cases of ear mites it's normally easy to find the mites and/or their eggs.  In fact, I commonly will see several life stages and even mating mites when I have a confirmed case.  We stain the material from a swab and examine it under the microscope for yeast and bacteria.  Certain types of bacteria may be resistant to treatments, so if there are "rods" we usually want to send a sample to a diagnostic lab for culture and testing against antibiotics.

So we have a couple of possibilities in these cases.  

1.  The vet finds evidence of mites.  The ear is cleaned of debris, and medicine is prescribed.  Most commonly this involves drops in the ears, though Revolution and Advantage Multi are also effective against mites.

2.  The vet finds yeast or bacteria. The ear is cleaned of debris (yes, this is very important!  debris can inactivate some medications!) and medicine is prescribed.  Since ear infections typically are in the skin lining the ear canal, we heavily rely on topical treatments.  There are numerous types of drops or ointments on the market, and the vet's choice is normally based on the types of organisms seen as well as a liberal dose of personal experience and preference.

Then we have #3.  The pet is itchy and the ear may be red.  But ear swabs come up negative!  No mites, no yeast, no bacteria.  What do you do then?  What could the cause be?

Now, I'm not a dermatology expert, and in fact I really hate dermatology.  But practicing in the southeastern US where it's hot and humid for most of the year I've by necessity had to become good with skin and ear problems.  One of the single most common reasons for skin and ear irritation and infection is underlying allergy disorders.  I have seen several cases over the years where the dog is very itchy and the ear is reddened, but there is no debris or infection. In my personal experience these cases have always responded to treatment for allergies.  A food hypersensitivity or seasonal allergy can cause intense itching without automatically having lots of other symtoms.

Alycin, this is the direction I would recommend you pursue.  If several vets are absolutely sure there is no infection or mites, talk to them about therapy for allergies.  I have seen many vets miss this as a cause of problems like you describe, as well as chronic skin and ear infections (and I've blogged about this mistake).  Depending on the situation and severity, your dog might be helped with antihistamines, corticosteroids, or a switch to a hypoallergenic diet.  Some of the options are very inexpensive and affordable.  Talk to one of the vets you've seen about these options and possibilities.

Wild Animals On The Loose

Apparently this story has been a big news event overseas and not just here in the US.  The owner of a private zoo in Ohio released all of his animals before killing himself.  Lions, tigers, bears (oh, my!) were roaming around and authorities had to kill most of them.  This was tragic, and bothered Olivia enough to email me.

I'm particularly saddened by this situation. Everyone on the news appears to be saying that it was the best thing to do to shoot and kill all these escaped animals as opposed to tranquilizing and relocating them elsewhere. I understand how incredibly dangerous it is to have bears and lions on the loose, but is it true that tranquilizing them 'excites them and causes them to go and hide'? I wish there had been a better way. I'm especially angry seeing this mans cruel past with animals. It's worrying that people like him are allowed possess animals, especially ones of this nature.

Personally I'm not a big fan of private zoos, even though I have known some well-run ones over the years. In the US (as is likely true in most countries) you have to have special permits to have "wild" or exotic animals in captivity.  These permits mean that you have to be inspected and approved by the government, and the government does have some oversight.  There are a lot of laws that regulate such animal ownership.  Zoological organizations and state-run zoos are not exempt from potential neglect or abuse, but I do feel like they have more oversight than a small, private institution. 

Wild animals are just that...wild.  Even if raised around humans, they never loose that wild instinct that can cause them to injure, maim, or kill somebody.  I believe that they should only be kept in captivity for purposes of education and preservation, not just for personal entertainment or pleasure.   I'm not sure if that was the case in this particular situation, but I have to wonder given the man's deliberate release of the animals, knowing how dangerous they could be and knowing that they wouldn't have natural prey around and would therefore likely not survive long.

Now related to Olivia's question, tranquilization is not as quick as people may think.  When a tranq dart impacts, the needle goes under the skin and hopefully into the muscle.  An intramuscular sedative will not work immediately and can take more than 10 minutes to have full effect (sometimes as much as 20, depending on the dose and particular drug).  When dosing patients in a veterinary clinic we work based on their exact weight, and the dosage may be down to the hundredths of milliliters.  When you come across a tiger or bear, you're making a guess as to its weight based on averages for the species.  You likely won't have any way of knowing the exact weight, so the dosage of tranquilizer is a bit of an educated guess.  And this means that you may under-dose, resulting in the animal taking longer to become sedated.

The initial stages of many tranquilizers can be excitatory, and vets see this often.  Some drugs cause extreme excitement and dysphoria before the patient succumbs to the effects.  So let's say we get the dose right when shooting a tranquilizer at a lion and it's going to quickly go to sleep...in about five minutes.  What could happen to it during that time?  Also remember that much of this story happened in the dark and the animal control officers couldn't see the terrain or the animals well.  There was a risk of the animal running away and hiding, falling and becoming injured, or simply not being easily seen by the officers.  

As tragic as this was, I do support the decision to shoot to kill in cases like this.  Tranquilizing and relocating is not as easy as it seems, and there is danger involved to the animals as well as surrounding people.  And as much as I love animals, I will chose the safety of people over that of animals.  The sheriff and officials involved acted wisely to protect their people and the community.

The Tragedy Of Owner Failure

Yesterday I saw a nine year-old mixed breed dog who came in because of a swollen belly.  The owner reported that the abdomen had been growing larger and larger over the last six weeks or so.  When I examined the dog she was about as wide as she was tall (a short dog, but still....) and was breathing somewhat rapidly.  I suspected ascites (fluid in the abdomen), did a quick abdominal tap to confirm my thoughts, and was "rewarded" with a rapid 20ml of yellowish fluid.  To make a long story short, the heartworm test was positive, indicating that the dog was in end-stage heartworm disease and right-sided heart failure.  And yes, the dog had been coughing prior to the fluid ever being noticed.

The day before that one of my associates called me to tell me that a patient had pyometra, a severe and life-threatening uterine infection.  The owner couldn't afford to take her to the emergency clinic for surgery, and was going to bring her to me the next day.  I had been in the clinic a while yesterday morning with no sign of the client, so I had the other location called (I work for a practice with multiple satellite clinics, and I was working at a different one than my "home" location).  Apparently the client wasn't going to be able to come in until after 3:00, which was too late to safely do surgery and monitor the patient as it would come too close to closing time.  My associate was going to try and get her to somewhere else sooner, as I'm not working again until Tuesday, but the owner didn't seem rushed.  While she's checking her calendar, her dog might not live.

All too often I see cases that happen entirely because of owner non-compliance or otherwise their failure to properly care for their pets.  In the first case about $6 per month worth of prevention could have kept the dog from ever getting ill.  And if they had brought the dog in at an earlier stage, it wouldn't have lead to such severe illness and could have been treated easier.  In the second case, spaying the dog when she was young would have again completely prevented such a potentially deadly infection.  And when your dog might die, do you really want to spend several days checking to see when a life-saving procedure fits into your schedule?

These situations are some of the greatest frustrations of a veterinarian.  We go into this profession because we love animals and want to make and keep them healthy.  We spend incredible amounts of time, stress, and money learning how to heal and do surgery, and then work hard to improve our skills once we're out of school.  And in most cases the biggest barrier we have to successfully doing what we're trained to do is not a lack of skill or equipment, it's a lack of caring from owners.  In the first case above, the client had thought the coughing might be heartworm disease, but didn't bring the dog in until it was almost too late.  I don't know anybody who hasn't been told "spay or neuter your pet".  And then when we do still have the ability to help these pets, often our hands are tied by the owners' decision.

And the hardest part to us is when these cases should never have even come up, as they are completely preventable.

Owners, please do what your vets tell you to do.  We're honestly looking out for YOUR pet's health.

Is Euthanasia Painful?

Stefanie sent me this email...
 

I have been reading "No Compromise" by Melody Green (a non-fiction book - an account of Keith Green's life and ministry) and towards the end - in just a very brief paragraph, it is discovered that Keith and Melody's dog becomes ill and they take it to the vet who tells them she has advanced cancer and the dog can either be euthanized at the vet office or taken home and shot. The vet strongly urged Keith to take it home and shoot the dog because it was more humane. I was a little taken aback by this and wondered - since this had happened in the early 80's - just how far humane euthanasia has come? I mean, were the injections given at that time painful or ineffective? 

Some of my older readers may be able to help with this.  I started working for a vet in 1984 and remember euthanasia as a simple, painless injection.  I had dogs euthanized before that, but wasn't present.  Still, I don't remember hearing it as a painful procedure.  Readers older than me may be able to give a different perspective.

The American Veterinary Medical Association does have guidelines for humane euthanasia of all animals.  Believe it or not, a properly aimed and delivered gunshot is considered a humane method of euthanasia.  However, you have to do it the right way and have the right caliber of gun in order to provide an instantaneous kill, and because of this I really don't recommend anyone trying it.  I've seen and heard of euthanasias attempted in this way going horribly wrong and the animal suffering.

For all of my studies and practice, euthanasia on companion animals is done by an intravenous injection of pentobarbital (sold under various brand names).  In more dilute solutions, pentobarbital can actually be used as anesthesia, though not really safe anymore compared to other modern drugs.  In human medicine it has been used to treat seizure conditions and similar brain disorders. The concentrated euthanasia solutions therefore induce a sudden and deep anesthesia, followed in seconds by cessation of brain activity and then heart activity.  Because we're basically overdosing the pet on anesthesia, they literally fall asleep and don't wake up, hence the common term "putting them to sleep". 

The procedure is generally considered quick and painless, no worse than being induced for anesthesia.  In most cases the only pain involved is the quick needle poke from the injection or IV catheter (which I prefer to do, especially if an owner wants to be present).  That doesn't mean that every case goes well.  I have had pets suddenly move, pulling the catheter or needle out of the vein (another reason I tend to use IV catheters, as this is less likely to happen), requiring a second poke.  Occasionally a pet will need a higher than normal dose, which is why I typically go ahead and give a little more than the calculated amount, and also keep the bottle in my lab coat pocket in case I need to give a little more.

Very rarely does the injection go horribly wrong. My worst experience was during a routine euthanasia on a cat.  As soon as I gave the injection the cat screamed, launched itself straight up off the table a full 1-2 feet in the air, and then landed on the table dead.  It happened suddenly, and I was at a loss.  It freaked me and the owner out, and I had no explanation for the sudden reaction seconds before death. In my so-far 14 years of practice that was the worst one, and I hope the only one like it.

The huge majority of euthanasias are smooth and quick, with the pet quietly passing away within 10-20 seconds of giving the injection.  Obviously this is the way we want it, as a dignified, peaceful exit from their life.  And that's the way I've observed this procedure for a little under 30 years.  If it wasn't so painless and easy, I wouldn't feel as comfortable doing it when the end of life comes.  But with the drugs available, it's a way to end suffering, not cause more.

Economical Impact

Earlier today I was reading one of my regular journals, DVM Newsmagazine.  In the most recent issue there were several articles on the impact of the current US economy on veterinary medicine, as well as changing trends in customer/client perceptions and actions when it comes to their pets.  If you're interested, check out some of the articles above, including this link which is probably most relevant. 

The articles show a growing problem in the veterinary profession with a reduction in income that can in part be tied to the economic downturn in recent years.  However, there are other causes as well, including a push to increased duration of vaccines and a misconception on the part of pet owners that their dogs and cats don't need regular exams.  I've seen it in my own practice, especially recently, where the last 4 weeks have shown us behind the revenue compared to the same four weeks in 2010 (though we're still ahead year-to-date compared to last year).  Personally I think there are multiple factors, with the economy being a large part of that.  What is interesting is that owner spending on pets as a whole has increased, while veterinary expenditures have decreased.  So pet owners are simply not spending as much money at their vets, even while they are buying plenty of food, toys, and trinkets.

To me and many vets this trend is bothersome, and not just because it can affect our bottom line and our livelihood.  Less spending at the vet and fewer visits means that pets aren't getting the care they need, especially preventative care.  In the long run people can end up paying more by skipping visits, as we don't have as many opportunities to catch problems early. 

I haven't done a poll in a while, so I think it's time to put up a couple.  Since I have readers who are vets as well as readers who are just pet owners, I'm putting up one for each group.  We'll review them at the end of the month and see what they look like in this very non-scientific survey.

Reflections In A Cemetery

Last night my wife and I participated in a local event at the city cemetery.  For the last seven years the local history museum has organized walking tours through the cemetery with actors portraying people buried there, telling stories of a bit of the history in the area.  This was the first year that my wife and I were actors, having been given the opportunity through our involvement in the local community theater groups.

My character was Augustus Foute.  He and his three brothers fought in the Civil War, lost his arm in the Battle of Kennesaw Mountain, and afterwards he settled down in this area and became a judge at the city court.  I was standing next to his grave all night and had the opportunity to study his family as well as neighboring graves.  The grave with the oldest known date in the cemetery dates to 1844, but there are unmarked graves that likely date earlier. 

As many readers know, I'm a big history buff.  And one of the things I enjoy most about history is the daily lives of the people.  How did people live in a given time period?  What they do day-to-day?  What did they do for work and for fun?  Because of my slant on history, I've always been kind of interested in graveyards, reading the headstones and tombs and wondering about their lives.  For example, Foute married in 1875 and had two children buried there who each lived only a year.  He married his wife when she was 29, rather old for that time period.  My wife's character was from the same time period and married when she was 36, an old maid by standards of the time.  She died after a year and a half of marriage and her husband never remarried.  What were the lives of these people like?  How did they get by after the deaths of their children?  Did the husband of my wife's character love her so much that he could never bear to be with another woman again?  Foute fought in many battles during the war, and though he lost an arm he lived a long life.  What was it like to pick up and start a life, working for the legal system in a country that he fought to prevent?

Yes, you can get a bit melancholy in a cemetery, contemplating your own mortality among the graves.  What will my grave say?  Where will it be?  In 150 years will I have someone portraying me in a historical reenactment?  What will they know and remember about me?  But at the same time, I find that places like that can be very life-affirming.  Foute went on to be very successful after a brutal war and the loss of young children early in his marriage.  The grave sites around me held several generations of people, showing that life continued.  And we were remembering and honoring the lives and memories of these people who thought dead, were not forgotten.

To me one of the attractions of history is to put perspective on our current lives and times.  Hardship and trials will always exist.  It's our ties to family and love for each other that will get us through and will help us be remembered.