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Thursday, June 26, 2014

Veterinary Tuition Freeze?

It's no secret that the costs of aquiring a veterinary degree are skyrocketing.  Just look at my blog over the last year or two and you'll see many discussion on this issue.  New graduate debt is increasing annually while starting salaries are decreasing, further widening and already significant debt-to-income ratio.  It's not uncommon for newly minted vets to start a job for a salary of $65,000 while trying to pay off $200,000-300,000 in debt.
There have been many studies, articles, and debates on the subject of veterinary tuition and debt.  Everyone in the profession and many outside of it are well aware of the issues.  But the problem is that so far it's only been examination and talk.  Nobody is actually doing something to combat this issue.
At least one student is trying, though.  I came across an article today about Ashley Hall, a veterinary student at the University of Minnesotta.  She has been meeting with school administrators and state legislators to try and address the problem of burdensome tuition and debt load.  The College of Veterinary Medicine has frozen tuition for a year, but she is trying to get this extended to mirror some human medical schools.  In many human programs the student is guaranteed to be the same for all four years in the program, and they are protected against rate hikes during their studies.
While this is not an ultimate solution, it's a step in the right direction and at least an attempt to start fixing the problem.  We need to move from talk to action and actually try to start solving this issue.  It's the right thing to do for future vets and will help strengthen the profession.

Wednesday, June 25, 2014

Overdue For A Stethoscope

One of the single most important pieces of equipment for a doctor is a stethoscope.  I use it on every patient and it is the only way to properly make an initial assessment of the heart and lungs.  Most people may not realize that not all stethoscopes are created equally, and some are better than others.  You can buy a very basic one for $10-15, and you can also spend $200-250 on a high-end one.  The price reflects the quality (in general), and yes, quality makes a big difference.
When I graduated from vet school in 1997 I had only a basic one.  It wasn't the best but wasn't the worst, and got the job done through school.  But I knew that I wanted a much better one when I started practicing.  One of my classmates had bought a Littmann Cardiology II early in vet school, but she was going into swine medicine and wouldn't be needing one like that.  So she sold it to me for $50, a really great price at that time for a used high-quality stethoscope.  And that stethoscope has served me very well for the last 17 years.
For those who don't know much about these things, Littmann is pretty much the preeminent brand of stethoscopes.  They make the best ones, and are the most recommended by doctors and nurses.  At the time I got it my stethoscope was one of the best out there.  But nothing lasts forever, and recently I started having problems.  I would periodically have difficulty hearing out of the right side, and nothing that I did helped.  I cleaned the ear pieces, tried to blow through the tube to clear any obstruction, and so on.  I could still use it, but sound would inexplicably and unpredictably go in and out.
Obviously I can't practice like this.  I really need a working stethoscope and I like using the high quality ones.  I've replaced the ear buds, seals, and diaphragms in the past as part of routine care, but I started to think that this was time to look at getting a new one.  After all, this particular item had been used for nearly 20 years and had far exceeded its warranty with minimal problems.  In fact, I think the fact that it lasted this long is a testimony to the quality of Littmann stethoscopes.
So I looked around and settled on a Littmann Master Cardiology.  This is the top of the line stethoscope and is the best you can get without going to electronic ones.  It set me back $200, but if I can get even close to the same duration of use it will be well worth the investment.
Things have changed since I last purchased a stethoscope.  Now you can get differen color tubes and bells.  What excited me most was the fact that I could get different finishes on the metal!  Of course a simple steel color won't do.  I ended up ordering one with a brass finish.
Why brass?  Okay, this is where my geek side comes in.  I really like the style and aesthetics of steampunk, which leans heavily towards brass, copper, and earthy colors.  When I saw this particular finish I immediately though "Steampunk!".  Though there are no gears on it (I'm still working out how to improve that part of it and add something to give a more "steampunk-y" feel), it is really, really nice.  It  also stands out at my clinic so everyone knows which one is mine.
Today was the first day I had a chance to use it, and I'm loving it already.  It's only a minor upgrade from my previous one, but it works great and looks spiffy.  It has also spurred discussions among the staff about stethoscopes and quality.
By the way, I'm just excited and geeking out a bit about my new toy.  This is in no way and advertisement for Littmann and I received no money for making this blog.  It really just is "a vet's guide to life", showing how something seemingly unimportant to the average person can instill a bit of giddiness in the appropriate person. 
Here's to this one lasting another 20 years!

Friday, June 20, 2014

New York Makes Tattooing Pets Illegal

Two years ago I wrote a blog about tattoos, earrings, and other body modifications on pets.  I'm very much against such things, as they are medically unnecessary, carry some risks, create unnecessary pain, and are purely for the owner's satisfaction.  And it looks like the government of the state of New York is also against them.

This morning I came across an article on the NPR website announcing that New York just passed a law banning the tattooing of pets.  Politically I'm a Conservative with some Libertarian leanings (I don't even want to call myself a Republican anymore because I'm as ticked off at them as with Democrats on most issues).  This means that I don't think we need a bunch of laws telling us what to do or not to do.  I believe in minimalist government, just as much as is necessary to keep people safe, prevent abuses, protect our country and citizens, and regulate international relations.  However, I think that this law is a good one, as are laws regulating pet breeding to help prevent "puppy mills".  Earrings and tattoos, as well as any surgical/modification procedure that is done for purely cosmetic purposes is borderline animal cruelty.  And yes, I include ear crops and similar common procedures in that category (I'm sure I'm going to get some flack for that statement, but I won't back down).  

Pets have emotions, feel pain, and develop relationships with their humans.  Forcing them to undergo procedures like this isn't any different in my mind that having a three year old child to get a tattoo.  And for the record, I disagree with a child having pierced ears until they are old enough to make the decision for themselves (yes, I'm looking at the folks who have their infant's ears pierced, and yes, I'm sure I'm going to get someone yelling at me for judging them.  Deal with it.).  While I don't believe in animal rights, I'm a big supporter of animal welfare (don't know the difference between the two?  Check out this link, and this link.), so I can fully support a law improving the health and condition of pets while reducing their pain.  I don't want too many laws regulating every aspect of our lives in the US, but I'm in agreement of this one.  People who have their pets tattooed and pierced are only thinking of themselves, not their animal companions.

Good job New York!  Now let's see other state legislatures do the same thing.

Wednesday, June 18, 2014

Catch-up Blog #12--Rabbits Who Didn't Read The Textbook

My last overdue blog!  YAY!  Now I'm down to things from this month.  And this last catch-up blog is from my own home.  My wife has been surprised that I didn't post it earlier this year, but with my semi-hiatus from blogging I just never did.  Better late than never.

Last year we rescued an orphaned wild rabbit, and raised him until he could be released into a large local park where other wild rabbits lived.  After that my wife decided that she really liked rabbits.  I had never really felt much for them even though I've seen them as a doctor and worked on them many times.  We went to a state fair in the Fall and looked at the various breeds that were being shown.  After some searching and comparing she dediced that she liked mini-lops and Holland lops.  So we started doing a web search of local breeders, finally finding a few that were expecting litters.  One of them gave birth on Halloween and we laid claim to two of them, a brother and sister, whom we named Westley and Buttercup (we're big fans of The Princess Bride).

This is Westley....

And his sister, Buttercup....

Just after Christmas, when they were eight weeks old, we took them home.  All of us fell in love with them, even me.  Though I've been seeing rabbits as patients since the late '90s, I had never owned one so this was a new experience.  I did a lot of research on the medical and nutritional side, while my wife covered the husbandry.  I had build a three-story indoor rabbit house and everything seemed good.  A day or two after he was four months old I took Westley to work with me and neutered him.  I had planned on spaying Buttercup the following month.

One morning my wife was cleaning the rabbit cage and litter boxes when she noticed a large pile of fur in one of the boxes.  That was strange but she didn't think much about it.  As she started to pull it out she saw a stillborn baby.  She yelled up to me (thank goodness it was one of my days off) and I came running downstairs.  The little baby was indeed dead, and I was absolutely flabergasted by the fact that Buttercup had given birth.  But more on that in a sec. 

I took the baby and my wife started cleaning the box as we were wondering what was going on.  That's when she noticed movement, which startled her.  Buried in the fur nest were two more babies, both alive and wriggling.  Now I was really dumbfounded, and started looking for more.  We found another stillborn, so in total there were two living and two dead babies.  And since we hadn't had them outside of the home since they were eight weeks old, there wasn't any other conclusion other than Westley having impregnanted his sister.  But he had been neutered!  The gestation length for most rabbits is around 30 days, so we did some quick math and came to the conclusion that the two had mated literally a day or two before he was neutered. 

Now some of you are probably thinking "C'mon, Chris, you're a vet!  Didn't you ever think that this would happen?  Haven't you heard about the prolific breeding of rabbits?  Geez, what an idiot!  How could you be surprised?"  Believe me, I had those same thoughts about myself.  I've advised clients on this very point many times, and have always said that they should be spayed or neutered between four and six months old.  Why that age?

Because that's what the textbook says!

One of the best and most used veterinary texts on exotic mammal medicine is Ferrets, Rabbits, and Rodents: Clinical Medicine and Surgery.  Here is a direct quote from page 166 of the third edition, printed in 2012 (so it's a very recent resource).

"Small breeds develop more rapidly and are mature at 4 to 5 months of age.  Medium-sized breeds mature at 4 to 6 months, and large breeds reach maturity at 5 to 8 months of age.  Does mature earlier than bucks, which do not achieve optimal sperm production and reserves until 40 to 70 days after puberty."

So according to my medical text rabbits of this size should hit puberty around 2 to 2 1/2 months old, and the buck shouldn't have adequate sperm production until around four months old.  Even the breeder was surprised when we called and told her.  Since then I've found some websites that say that occasionally rabbits will breed younger than four months.  However, most of the resources I've looked at still say that the average house rabbit doesn't breed until after four months old, which is why I waited until that age to neuter.

Guess our bunnies were early bloomers.  And that is NOT a mistake I'll make again.

Okay, so now I've had my skills as an exotic pet veterinarian challenged and humbled.  But I can now better advise my clients who might be in similar situation.  And now that we have that little SNAFU behind us we get to the next question.  How are the babies?

Thankfully, doing just fine!  Buttercup did a great job of taking care of them and Westley really didn't care much about them.  Here are some pictures from that infamous day that we discovered them, March 25th.

Here they are just three days later!  Yes, they grow and change that quickly.

And then just a few days later, on April 1st.

They continued to grow and do well, and I by six weeks old I was able to tell that they were both female.  Thank goodness!  Yes, I checked several times over the next few weeks and confirmed my first thought.  So now we had one neutered male and three unspayed females.  No more bunny breeding in the Bern household!

Everyone has grown well and done great.  All four of them live together and are getting along together without any problems.  Here are Westley and Buttercup, along with the babies, on May 20th.

This is Tinker Bell with my son.

And Periwinkle with my daughter.

And now Tink and Peri together.  Yes, they absolutely took after their mother, though their fur is a little longer than hers (Dad's influence).

It has been an adventure!  They are well handled and very sweet, especially the babies.  And even though there are no intact males among them, I'm going to get the others spayed, starting with Buttercup.

Lesson learned!

Catch-up Blog #11--Misbehaving Rottie

Next to the last "catch-up" blog!  This one is from Rachelle...
Hello... I've just discovered your blog and enjoyed reading a page or two.
I read your post about humping, from 5/2012 I think. I have an 11 1/2 mos. old male Rottweiler; he is of excellent lineage, AKC fully registered, and not yet neutered (scheduled for June 2014, though).
He is my 5th Rottie, but the first I've not neutered by 6 mos. old. There are SO many CERTAIN opinions from SO many people about why he humps but I don't know which is right - or maybe it's a little of all. From "dominance" to "over-excitement" to "he doesn't know what proper play boundaries are" to sexual excitement. I tend to go with the over-excitement, because he's very energetic and just goes bonkers at the dog park. He just loves people, but he has gotten a short fuse lately at the dog park with dogs, going from excited greeting and butt-sniffing to humping anything that moves, including people, to losing his temper when the other dog expresses HIS displeasure at being humped. Earlier this week he even bit his own tongue or lip (I couldn't find the nick but there was plenty of blood) when a bullying dog - an Australian Shepherd with a bad attitude toward any dog - went after him. He has also gotten much more reactive to my senior dog, an 8 y.o. 25 lb. blue heeler/kelpie mix, who himself is the dominant one, and is an excitement humper - but not to the degree that Rufus is... unless it's Rufus he's humping during rough play. But that rough play turns around in about 1 second when they piss each other off. I wonder if Harley has taught him this, sometimes. Rufus also started urinating on people's legs at the dog park, and he now humps anyone that comes in my office to talk to me (I've taken him to work with me from 8 weeks old so he would get very people-social; it worked!). I had to stop taking him to work because he was just too active (unless I exercise him and he conks out for about 3 hours before he's up again). I know he's not getting enough exercise (I'm disabled) and that plays a roll, probably a big one. Incidentally (or not), before this behavior started, he HAD been attacked at the dog park by very dog-aggressive dogs who picked fights with other dogs, too.
I took him to a new groomer today, who had an 18 week old male Rottie puppy loose behind the counter. When they introduced them, Rufus' hackles went up and within about 45 seconds he lashed out. I didn't see the trigger, though. They kept them separated after that, and when I picked him up, the groomer said he loved playing fetch and tug with her, but wouldn't tolerate the puppy without losing his temper.
My vet recommended not neutering him until 18 mos. but I just can't deal with this behavior. He's been much harder to control on-leash as well... very stubborn, and I'm not always able to anticipate when he is going to yank me off balance. Will the neutering really help? or will it not make a difference if I wait til he's 18 mos.?
Rachelle, I think that this is a case to have seen by a local board-certified behavioral specialist.  Something like this shouldn't be handled over the internet.  And if your vet doesn't feel qualified in fielding a challenging behavioral case, try to find one who does (nothing against that vet, though....we get little behavioral training in vet school and many vets don't like these cases).  However, there are a few things that I'd recommend as a start.
First thing to do is to get him neutered!  The sudden increase in testosterone at puberty (around 8-9 months old for most dogs) can cause a slew of problems.  Territoriality and aggression are the biggest concerns we see, and it sounds like Rufus is starting to show some of these issues.  The "humping" may also be caused by the hormones, and with him not being neutered it becomes more difficult to separate this behavior into excitement, sexual, or dominance.  Two out of those three can be worsened by hormones so we need to eliminate the hormones to try and narrow down the possibilities.
Any behaviorist I've ever talked to or heard lecture has said that if you want to get a handle on behaviors along these lines the very first thing you do is to have him neutered right away.  With this definitely fix the problem?  Maybe or maybe not.  There isn't any guarantee as behaviors are usually more complext than purely hormonal.  But we need to decrease his testosterone levels and the only way to do that in his case is neutering.  I wouldn't wait until he is 18 months old, as the longer he acts like this the more it becomes a habit rather than hormones.  At that point it becomes more difficult to change his behavior even without the hormones, as he has established a behavioral pattern. 
Because of his breed, size, and the nature of his problems I would strongly recommend talking to a board-certified behaviorist.  This is a veterinarian who has done a residency in animal behavior and does nothing but practice in this field.  It's like the difference between a therapist, psychologist, and psychiatrist, with the behaviorist being the latter.  You can go to the website of the American College of Veterinary Behaviorists to find someone local to you.
Good luck, Rachelle!

Monday, June 16, 2014

Catch-up Blog #10--Becoming A Vet, Relationship With God

Almost caught up on my inbox full of emails!  Then I can get back to a more leisurely pace of blogging.  Here's a more recent one from Jessica.

 I'm Jessica. I'm a seventeen year old girl who lives in New York. I've been dreaming of becoming a veterinarian since I was seven years old. I would love to specialize in horses and cattle. I've been reading your blogs and they are extremely interesting. I've always wanted to email a vet and ask them about their job. I also wanted to know the criteria of being a vet. I'm excellent in biology, algebra, and chemistry. I also love animals. I have two guinea pigs, a dog, and a fish. I also have a lot of experience with different types of animals. What steps should I start taking to become a successful vet?

This is the perfect time to plug my most recent post presenting a single source for all questions about being a vet!  Check it out here.  That should answer the basic questions you have.

   I am also a Christian. I am a junior at Hawthorne Christian Academy. How has becoming a veterinarian helped you with your relationship with God?

I'm not deliberately trying to make this into a religious blog.  Honestly!  However, it is a huge part of who I am and guides most of my daily decisions, so it makes sense that it would come up in my blogs.  Since I'm open about the subject I'm not surprised that people would ask me about it.

Personally I don't think that I'm closer to God because I'm a vet or that my job has aided in that relationship.  The strength of my relationship with Him is more due to personal study and interest, as well as facing the challenges of personal life:  being a husband and father, dealing with financial struggles, having psychological issues, and so on.  But I do think about God in relation to my job.  I have prayed for and over my patients.  I ask God for help with my attitude and being a leader/manager.  As someone with a lot of scientific training and knowledge, my views of science only help deepen my belief rather than shake it.  Creation is an amazing thing and the intricacies of biology can only come from a Creator!  I also occasionally get a chance to share my faith with clients and staff, opening the doors for discussions about how awesome God and Jesus are.

Hope that helps, Jessica!

Questions From Students--A Vet's Guide To Life

Over the nearly six years I've been writing this blog I've had many questions from people interested in veterinary school and the life of a vet.  Most of these questions are from people in high school and college, and it's not uncommon for them to be asking as part of a project.  Often the questions are essentially the same so I've had to answer them in different ways.  I realized that with hundreds of blog entries it was hard for someone to find these questions, thus resulting in multiple emails over the years.  To help alleviate this as well as make it easier for students to find answers, I'm going to provide this post as a central place to provide links to previous posts.  

Okay, kids (and adults), here is a list of times I've answered questions about veterinary work and life.

All Work And No Time To Work--Can you work and be a vet student at the same time?
Free Time As A Vet?--Can a vet really have personal time?
Vet Or Tech?--The pros and cons of becoming a veterinarian versus a technician.
Hope For The Fainters--Does fainting at blood negate you from becoming a vet?
A Vet's Life, Part 1--Questions about being a vet and living the life.
A Vet's Life, Part 2--More questions about the life of a vet.
A Vet's Life, Part 3--Last in the series of multiple questions about a veterinary career.
Questions From A Prospective Vet Student, Part 1--Questions about becoming a vet.
Questions From A Prospective Vet Student, Part 2--Questions about becoming a vet, part 2.
Questions From A Prospective Vet Student, Part 3--More questions about becoming a vet.
Staying Sane In Vet School--How to maintain your sanity during the rigors of veterinary study.
Fifty Different Directions--Managing family life as a vet.
Work/Life Balance--The challenges of balancing work life and private life.
A Vet's Biggest Daily Problems--The hardest things in the daily life of a vet.
Advice On Becoming A Vet....Almost Ultimate Guide--The ins and outs of getting into vet school.
Getting A Start--How minors can get experience in the profession.

Okay, I think that about does it!  Hopefully now people can more easily find information about becoming a vet and the kind of life we live.

Catch-up Blog #9: Jesus, Corn, And A Dog

Despite the almost whimsical title of today's blog, this is actually serious.  I've been pondering how to reply for a while know, so bear with me.  And I would ask everyone reading to have compassion for this pet owner and not just launch into the stereotypical tirade about how corn is bad.  Here's the email...
Hello Chris. I read what you had to say about corn being good for dogs, not bad; then, clicked on your blogger profile and read about you. My dog has liver illness God healed through Jesus Christ, my Lord and Savior, several days ago. An African-American woman and I, a Caucasian woman, both seniors, prayed over my little 10 lb dog who weighs but 7 lb. 8 oz. as of two days ago. We believe He healed her, and that it's up to me to get weight back on her but I'm having a hell of a time achieving that. 
She's been to two vets, my regular one Feb. 4th, who took full blood panel and X-Rays; and a specialist at an emergency clinic in another town for a consult and an ultrasound. The first vet said that on a scale of one to ten, ten being the worst, her liver is at a 9. That was on Feb. 4th. Penny Lane, my dog's name, is still here, but getting weaker. She weighed 8 lb. 6 oz. then. 
It's been a real crap shoot as to what she'll eat, day to day. She'll eat, but not as much as she should eat to gain the weight back. Three nights ago, a friend of mine gave me some cheap food for small dogs put out by Pedigree that he feeds his dogs that has corn as the first ingredient. My dog ate it that evening and for the next two days so that I began to think my troubles were behind me. Then, yesterday, she wouldn't eat more than a fourth of a cup in the morning, and another fourth of a cup in the evening, a half a cup all total.
Today, I went to a pet food store and bought another brand of food, paid three times as much, to get better quality food in her as one of the employees at that store who knows of my dog's illness and who has a dog who is recovering from surgery for bladder stones, said bad things about corn; that it's empty calories the dog poops out, that's it doesn't have enough nutrition in it for my dog's illness, etc. 
I know liver disease makes a dog nauseated so she's now taking Maropitant for that as of yesterday. Before that I was giving her an appetite stimulant; then, stopped for three days as there was an emergency that threw everything off in our routine. 
Here's the thing: 
If Jesus healed my baby girl, why doesn't she want to eat? Why is she dangerously low in weight, not putting weight back on? 
When Pauline and I sat down with my dog on my loveseat couch, my dog really took to her, climbing up on Pauline's lap. Then, I put Penny between the two of us, and Pauline prayed in earnest, asking that Penny be healed, and I have enough money to pay the bills as I'm broke these days thanks to the recession that severely hurt my business. Pauline and I held hands over Penny, with Pauline's other hand on Penny's head. In the middle of the prayer, Penny suddenly got up and moved over to the far side of me away from Pauline as I had been sitting to the left of Pauline, so Penny climbed over me to MY left side. However, when the prayer was over, Penny got back up and moved back to where she had been for the prayer--between the two of us. What else could it have been but Jesus touching her? The energy so powerful, my dog has to suddenly move away from it? 
To us, this was a sign that Christ had been there.
I told Pauline that Christ has come to me before but I usually feel shivers all through my body and/or tear up or cry thanking Him for coming to me. Well, the following day after we prayed, He did come and I did feel some light shivering and light tears came as a result. 
So I believe Jesus came to us, I believe He heard our prayer, I believe He healed her. I just can't understand why she won't eat enough to put the weight back on. 
I was hoping this Pedigree kibble for small dogs that I got at KMart would be an answer to a prayer but if it's just going through her and not providing nutrients, well, you see my dilemma. From what you said, corn both has protein and 80% carbs which is good for energy. This brand name product has chicken by products in it which I don't think are good but at this point, just getting her to eat has been my goal, not matter what she will eat, I don't care. 
I am contacting you about all of this because neither vet will speak to me about Jesus healing my dog. I need to talk to somebody who knows the science and who is a believer, you know?
Once we go beyond the surface, there are a few issues to address here that may not be immediately obvious.  First of all, there is nothing said about why the liver is "bad".  There is no such disorder as "liver disease" or "liver failure", believe it or not.  These are catch-all terms for when we haven't gotten down to the root cause.  The liver can be "bad" due to cancer, toxins, congenital problems, infection, fibrosis, and many other things.  Each disorder is going to be treated very differently, so unfortunately I can't make generalizations about why the liver is not working correctly in this case.  The first thing that needs to be done is get down to the bottom of the "why".  Why isn't the liver working?  Why did this happen?  Once we understand the primary cause the vet can start to work on a treatment plan.
Second, the pet store employee is misinformed.  Ground corn is absolutely NOT "empty calories", and if you talk to any board-certified nutritional specialist you will quickly learn that there are some important nutritents found in this ingredient.  It is most certainly not included as "filler".  By-products are also not bad, as they include organ meat.  Organs such as the liver provide many important nutritents that can't be found in muscle meat.
That being said, these diets may not be appropriate for a dog with liver disease.  Hill's Science Diet, Purina, Eukanuba, and Royal Canin all make a veterinary diet line, and all of them have a food specifically designed to help with unhealthy livers.  The nutritional content is different than "regular" dog food and may be more appropriate for a dog in this situation.  But again that depends on the cause.  A liver diet may not be the best choice for a dog with a large tumor, or may not be needed for an infection.  Ask your vet as to whether or not one of these specialized foods would be beneficial.
What about other treament?  Were medications prescribed?  Did the vet want to do follow-up visits and tests?  What was the final diagnosis?  Unfortunately there isn't enough to go by in this email, and I suspect that treatment would involve more than just changing foods to get the dog to eat.
Now on to the religious issue.  This is where I take off my stethoscope and put on my minister's hat.
God doesn't always answer our prayers for healing in the way that we want.  People and pets die every minute of the day despite prayers being said over them.  That doesn't mean that prayers don't work, as I've seen some miraculous, unexpected, and downright impossible healing happen in animals and humans as the direct result of prayer.  I am personally a very big believer in the power of prayer to heal physically, emotionally, and spiritually.  But sometimes that's not God's plan.  Sometimes He allows illness to lead to death.  That doesn't mean that He is cruel or that the person wasn't praying earnestly enough.  Every living thing has a normal lifespan, some short and some long.  We have disease and illness due to the sinful nature of our world, and until the second coming of Christ it will continue to be this way. 
Sometimes God allows us to go through hardship to draw us closer to Him.  We often forget about His blessings when everything is going wonderfully (something I'm guilty of), and it takes sadness or tragedy to remind us that our true joy comes from God.  We may not always be able to see His plan, but we can trust that it's there.  Over the last year I've looked back on my life and have seen that none of my long-term plans have ever turned out how I wanted them to.  Often that would cause me great heartache or frustration.  Years later I have the perspective to see how His hand was guiding me the whole time, and how His plans were far better than my own.  A wonderful part of being a Christian is learning to have the assurance that we really do have someone watching out for us, and while that doesn't mean that we won't have troubles (the Bible even says that we're guaranteed to have them), we'll always have someone to walk with us through those times.
26 In the same way, the Spirit helps us in our weakness. We do not know what we ought to pray for, but the Spirit himself intercedes for us through wordless groans. 27 And he who searches our hearts knows the mind of the Spirit, because the Spirit intercedes for God’s people in accordance with the will of God.
28 And we know that in all things God works for the good of those who love him, who have been called according to his purpose.
Romans 8:26-28
I think the key thing here is verse 27, where we have to understand that prayers are answered according to God's will, not ours.  And that means that sometimes our will is in opposition to His. That has happened to me many, many times, and I'm stubborn and thick-headed enough for it to take several decades for me to learn my lesson.
I believe that God can heal without any medical intervention.  However, I also think that God grants doctors the skills, knowledge, and gifts to heal through traditional means.  So I would continue to talk to the vets in this case and continue to pray.  But above all trust the hand of God, and that He really does love you.

Catch-up Blog #8: Animals In The Afterlife?

Even though I don't make it a major point all of the time, I've also made no attempt to hide the fact that I'm a conservative Christian.  Because my faith is even more a part of who I truly am than my profession, it's something that comes across in my blog on occasion.  And it's what prompted this email from Annette.

A friend shared your blog posts with me because she knows I have the same frustration with rat owners who don't want to get vet care for their rats due to cost.

I happened to notice in your bio that you are a born-again Christian! I am also a Christian (convert to Traditional Roman Catholicism from Orthodox Judaism).

I was wondering what your feelings are on an afterlife for animals? I'd like to direct your attention especially to Romans 8:18-22 where St Paul seems to indicate that ALL CREATION will be restored from the corrupt state brought upon the world by the sin of Adam.

One thing that keeps me going in rat rescue work (with all the abuse and neglect I see of rats day in and day out) is the firm belief that I will see these sweet, affectionate animals again someday. When any of the elderly/terminally ill rats in our St Francis Rat Sanctuary/Hospice are in the process of passing away, I pray over them, I read Romans 8:18-22 to them, and I anoint them with blessed oil. I like to think it comforts them, and gives them some of the love that the world never gave them.

Anyway, I'd be interested to know what you think, as someone who is both a Christian and a veterinarian.

For those who don't have their Bibles handy, let me share those scriptures.

18 I consider that our present sufferings are not worth comparing with the glory that will be revealed in us. 19 For the creation waits in eager expectation for the children of God to be revealed. 20 For the creation was subjected to frustration, not by its own choice, but by the will of the one who subjected it, in hope 21 that the creation itself will be liberated from its bondage to decay and brought into the freedom and glory of the children of God.
22 We know that the whole creation has been groaning as in the pains of childbirth right up to the present time. 

Okay, now into the meat of things.  While I'm not an official theologian I do think about God and the Bible a lot and have tried to study as much as I can.  So realize that my comments are my opinion and shouldn't be taken as being the last word on the topic.

First, I think we have to think about whether or not animals have souls.  I don't think that they do, at least in the same sense that humans do.  When we read Genesis we see that humans were created in God's image, but animals weren't.  Throughout the Bible we see that murder is prohibited and is a sin, while animal sacrifice was an acceptable (and often only) way to appease God for someone's sins.  Additionally, in Genesis 1:26-28 we see God giving Man dominion and rule over animals.  So despite what many animal rights folks want to believe, a Christian can't hold to the idea that humans and animals are equal in God's eyes. It is clear that while God loves animals, humans hold a special place in His creation that animals don't.  God Himself puts humans "above" animals.  

But does that mean that animals won't be in Heaven?  Reading the Bible I'd say that they will be.  Besides the passage above in Romans, look at Isaiah 65:25--

The wolf and the lamb will feed together,
    and the lion will eat straw like the ox,
    and dust will be the serpent’s food.
They will neither harm nor destroy
    on all my holy mountain,”
says the Lord.

In Isaiah's vision it seems clear that after the time of Judgement animals will be in heaven, and they will be redeemed from the corruption that happened after the Fall when Man first sinned.  This is the same point raised by Paul in Romans 8.  And in Revelation John describes Jesus and the armies of Heaven riding on horses.

So what does all of this mean?  Will our favorite animals be in Heaven?  I think it's clear in the Bible that there will be animals in the afterlife, and they will be with us in Heaven.  They don't have souls to be saved because they did not participate in or contribute to the Fall in the Garden of Eden, and Man still has God-given authority over them.**  Therefore their position in Heaven will not be the same as ours, and I don't believe that they will be welcomed in the same way because they are never lost in the same way that humans are.  There can't be a celebration for a long-lost loved-one without that person actually being lost, hence the special place that God has for humans in Heaven.  The animals will be there, but God will still cherish us more and give us a more special place.

In the end I think it comes down to a point made by a story told to me by my father-in-law (a pastor) many years ago, and which I've seen repeated since.  I share it as written by Jack Zavada as part of an article on this topic.
"Parson," she said, tears streaming down her cheeks, "the vicar said animals have no souls. My darling little dog Fluffy has died. Does that mean I won’t see her again in heaven?"
"Madam," said the old priest, "God, in his great love and wisdom has created heaven to be a place of perfect happiness. I am sure that if you need your little dog to complete your happiness, you will find her there."
Annette, I hope this helps!  And I know how you feel about rats, as my daughter has had several and they're amazing creatures.

**I wanted to add this footnote to clarify a point that some may bring up in opposition to my comments.  There is no way that you can read the Bible and say that God did not give Man rule over animals.  However, if you look at the larger context we know that the universe, world, and animals are actually God's, created by Him without any human assistance or intervention.  So when God gives Adam rule over the animals, He is partially giving permission to utilize them, but He is also giving responsibility for caring for them.  As a Christian veterinarian I have no problem with eating meat and wearing leather, because God has given us the authority to do so.  However, we are also given the burden of being sure that we use God's world responsibly and do not abuse our position in it.  Being given "rule" or "dominion" doesn't mean that we have permission to do whatever the heck we want.  It means that we are allowed to use what God has created, but we are also held accountable for what happens to them.  Thinking about it in this way should be humbling, because basically God has given us the entire world and essentially said "Here, this is yours.  Don't mess it up."

Thursday, June 12, 2014

Vets, We Did It To Ourselves....Vaccines Vs. Office Visits

Three weeks ago I saw a client for a routine checkup and vaccines for her dog.  I had seen her for the same thing a year ago and she had liked me enough to want to come back this year.  In 2013 she only allowed me to give a rabies vaccine, but this year she allowed me to do heartworm testing, distemper-parvo, and all basic preventative care.  When everything was done her bill was around $200, which she paid without problems.  One of the vaccines had never been given previously, and based on currently accepted immunology we needed to boost that vaccine in three weeks to properly stimulate long-term immunity.  The appointment was made and she came in today.

That's when the problem happened.

As she was being checked in our receptionist went over the charges for the day.  The vaccine was $16 and the office visit was $39.  She started to flip out and absolutely refused to pay for the office visit since we had just seen her dog three weeks prior.  She started to get irate, so my office manager checked with me in the back.  I'm not willing to back down unless there is a legitimate reason, and a client not wanting to pay for something we charge to everyone is not such a reason.  So I told my manager that the client would have to pay.  She went back up front while I was working with a patient in the back, but the owner wasn't satisfied.  She insisted on speaking to me, even though the office manager told her that the decision came from me.

I finished my patient, took a deep breath, and went up front to talk to the client.  She was obviously upset, but she had calmed down enough to be able to talk to her.  She simply didn't understand the need for the office visit charge, and kept saying that it was "a racket".  I informed her that we did a full exam on every patient and therefore there was a charge for every patient, regardless of the reason.  This didn't make sense to her, as we were the ones who set up the appointment, not her.  Because we set it up, she shouldn't have to pay.  I asked her if we were not entitled to compensation for our time.  She said that when she had follow-up appointments with her kids' doctor, she didn't have to pay for that visit.  

Well, actually, she didn't have to pay a copay.  That's when I pointed out the differences.  With her insurance she paid a copay (probably around $20, though I didn't ask).  On some visits there was no copay.  So in her mind the value of the first visit was $20 and the value of the follow-up was $0, since that's what she paid for them.  But she didn't seem to realize that the doctor still got paid, just by the insurance company, not her.  Even if she didn't have to write a check for it, the doctor still charged an office visit and still received compensation.  In my experience most human physicians have an office visit around $75-100, but if someone has insurance they only pay a fraction of it.  I think that realization surprised her a little, though it didn't change her attitude.

I didn't offer to waive the office visit and she didn't want to pay.  So in the end I provided her a copy of her medical records and wished her well with another veterinarian.  And I'm not at all bothered by the loss of the client, as she wouldn't have understood most things we wanted to do.

She's not the only client that hasn't seemed to understand the need for office visit charges, especially for vaccinations, and even more especially for booster vaccinations.  Though I've rarely gotten into arguments with clients, I've had plenty who thought they only needed to pay for the vaccine itself and shouldn't have to pay for the office visit.  

And we're the ones to blame.

Yes, that's right.  The veterinary profession is at fault for this perception by clients.

I started working for vets in 1984.  The practice that I worked at had a policy that when someone came in for vaccines, an office visit wasn't charged.  This way of charging encouraged competition and helped entice people to come to the clinic and have their dog or cat vaccinated.  It was pretty common then and I still know vets in my area who do this.  "No office charge if you come for vaccines!"  And the idea works to bring in the people who are most cost-conscious.

But this idea does a great disservice to our profession and what we actually should be doing for pets.  For decades veterinarians who have avoided or undercharged for office visits have devalued the importance of a physical exam.  They have trained the clients to think that the vaccine was the most important part of the visit and the doctor's time and skill in medical observation was essentially worthless.

Vets were and still are in essence saying "Come in for vaccines and while you're here we'll do a quick exam."  What we as medical professionals should be saying is "Come in for an annual exam and if everything looks good we'll give vaccines."

Last month I saw a client with an 11 year old cat for a routine visit.  Three years prior to that another vet had told her that the cat didn't need to get any vaccines the rest of its life and didn't need to come to the clinic unless it was sick.  Essentially this was like a human physician telling a person that after their 50th birthday they never needed to be examined, have routine testing, or get any kind of preventative medical care.  Does anyone really think that a human at that age doesn't need to have regular exams?  Yet that is what a veterinarian was advocating for their patients.

The single most important part of any medical service is the physical exam, no matter which species is being discussed.  "Why do I need my dog/cat to get an exam?  I know they're healthy.  If they get sick I'll bring them in."  Really?  I have diagnosed numerous problems on "healthy" pets during a routine physical on an annual visit.  Some of the health concerns have included cataracts, bladder stones, tumors, heart murmurs, gum infections, advanced periodontal disease, arthritis, and others.  All of these were diagnosed with an exam using my own eyes, ears, and hands, and without any equipment other than a stethoscope, otoscope, and ophthalmoscope.  And I can think of specific cases for each of these disease where the client was completely unaware of the disorder, thinking their pet was completely healthy. 

When we include diagnostic testing, our ability to make early diagnoses goes up considerably.  Well over 90% of the cases of heartworm disease I diagnose are on dogs that don't show any obvious outward symptoms.  With blood tests we can detect kidney disease well before the patient starts acting sick.  And I can't guess at how many cases of liver problems I've found on annual blood tests, all while the dog is acting like nothing is wrong.

As medical knowledge advances we are seeing greater duration of immunity for vaccines.  Most immunizations are valid for three years and some argue that they are actually good for 7-10 years.  I expect this viewpoint to be upheld and embraced by the scientific community at some point before I retire.  As honest, scientifically based professionals we should welcome such news, as it means less risk for our patients.  But because veterinarians have over-emphasized the vaccines for literally a couple of generations, when we advocate longer periods between vaccinations our clients think that this means they can go longer without their pet being seen.  And I believe that the biggest reason for this trend (which is happening and has been the subject of many studies and articles) is because veterinarians have "trained" their clients to think this way.

Vets, this has to stop.  If we really, honestly want what is best for our patients and want to diagnose diseases in the earliest stages, we need to change how we talk to clients.  Right now I'm deliberately calling out vets who operate vaccine clinics without full examinations, and vets who give vaccines without an office visit.  Sure, I expect some vets will lash out at me, but that's okay.  I'm firm in my beliefs and I have a thick skin.  I also know that my views are supported by the American Veterinary Medical Association and countless medical specialists.  We need to charge appropriately for our time by charging an office visit on every single case.  Increase the office visit charge and decrease the charge on vaccines.  Changing our policies, outlooks, and pricing structures will help guide the next generation of pet owners to the right way of thinking.

Pet owners....please understand that if you are simply going to a low-cost shot clinic and the vet barely looks at your pet that you are not helping yourself out.  You are missing out on the chance for a skilled doctor to catch problems before they become severe, expensive, or life-threatening.  Understand that the emphasis on pet health needs to be on the exam, not the vaccines.  And your vet is absolutely justified in charging for their time and expertise.  If you aren't already, be willing to step up and stop supporting clinics that devalue the importance and meaning of a physical exam.

Being a pet owner is a big responsibility, and our fuzzy, furry, feathered, and scaly family members rely on us to make the best decisions about their health.  If you can't afford proper care, you may need to re-think owning that pet.  And being a doctor is just as big of a responsibility.  Veterinarians need to be a true advocate for their patient's health, which means a shift in paradigm regarding vaccines and office visits.

Wednesday, June 11, 2014

Catch-up Blog #7: Reader Understands The Difficulty

I normally try not to be one to toot my own horn, and I don't typically post emails from readers who are simply giving thanks or praise.  But in this case I thought it was worth sharing.  This is from Alhana.
I am a student aspiring to be a veterinary technician (I can't do the 8+ years it would take to be a real vet) and I stumbled across your blog today while doing research for a project on how owners should react to emergency situations, namely something getting stuck in a dog's mouth.
I ended up reading through some posts and the comments on them. I just wanted to say you are a champion. I love that you are a vet willing to speak honestly to pet owners about what it's like to be a vet and not afraid to push back when they criticize you for "not giving enough information" and "just telling them to see their own vet". Two years has put me from one of those "why can't they just tell me what to do!?" owners to "oh... that's really complicated. There's no way you could or even should diagnose that over the phone". I haven't worked in a clinic yet, but even trying to talk to my family and friends about their practices regarding their animals is like trying to pull teeth without any pain-killers on board. They think they're qualified to behavior train and treat their animals just because they've had animals their whole lives, and that re-using three month old liquid Clavamox is completely fine.
Also, it is very nice to hear that I'm not the only one who doesn't understand the misconceptions owners have about their animals or how they lack some common sense in general. Or how they don't understand that you have a million things to sift through to come to a diagnosis. Or how every case is different. Or how important it is that THEY follow a treatment plan.
Anyway, I just wanted to say thank you for being an honest and awesome vet.
Why did I share this?  Because she understands the dilemmas that I go through when dealing with clients, and especially when dealing with people on this blog.  Comments I make or responses I give are actually pretty normal in the veterinary profession.  Most clients don't realize this, but I've worked in and around small animal vet clinics for 30 years now, and believe me, my opinions and attitudes are shared by the vast majority of veterinarians.
As I've said before, part of the reason for my blog is to pull back the curtain around veterinary practice and show people the true "Wizard of Vet".  Vets are as human as the rest of you, and yes, we do talk about clients.  Sometimes it's in a very positive, praising way, and sometimes it's not.  Think about your own job and the frustrations you've had with vendors, staff, customers/clients, and so on.  Think about how you and your coworkers have talked about people that drive you crazy or that have done something wonderfully awesome.  Yes, vets do the same thing.
It's also not easy being in a profession like this because owner compliance is horribly low.  People don't follow restricted activity directions, stop medications too soon, self-medicate, and plenty of other things, usually without telling us.  Then they get upset when the treatment plan doesn't work, even though they've significantly altered it.  I've gotten used to it and can handle it better than when I first graduated, even though it still frustrates me as much as it ever did.  Being in practice for 17 years and being a blogger for nearly six years had helped me develop patience and a thick skin.
Alhana, thanks for the kind words, and thanks for "getting it".  I know that I'm not the only vet who appreciates people realizing what we go through.

Monday, June 9, 2014

Catch-Up Blog #6: Are Multiple Issues Reason To Euthanize?

Susie brings a very difficult situation:

We have a ‘giant’ dog (Akita and possibly Leonberger mix,) Coco, about 8 years old, weighing in at 103#.  Several years ago, she tore the ligament around her left rear ‘knee’ and we had her operated on.  The vet repaired the ligament and installed a plate to help support her leg to the tune of $3,000+.  Since that surgery, she has been diagnosed with Atypical Addison’s Disease.  She is on a low dose of prednisone for this. Where a higher dose might provide better results, it causes her to pee, frequently, like a race horse, which means we prefer her to stay outside.  We live in Las Vegas, so this isn’t really feasible during the upcoming summer months. It would require the purchase of a $700-$900 swamp cooler to place on the patio to help keep her cool.

She also has a very crusty nose (bridge) and the inside of ear flaps are extremely crusted.  This crusting is now beginning to develop around her eyes.  There doesn’t seem to be blistering, just very rough, crusty tissue. The vet has taken a biopsy culture and nothing fungal has developed.

Last week, her right leg failed, another torn ligament requiring another $3,000+ surgery, and would require her an overnight stay because of possible Addison shock. Because of the Addisons, the vet wants her to be seen by a dermatologist, first, to rule out that the crusting isn’t anything autoimmune related, which could cause further complications…another $300-$500.

This girl is the sweetest dog you would ever hope to have in your life and does not seem to be ‘suffering’ in any way.  She has a good appetite (possibly due to the prednisone) and, while lethargic and down at the moment, is of good disposition. She is not an active dog, again, our fault due to our schedules. We hate the thought of putting her down, but I guess we just need a professional opinion as to when is enough enough.  We have considered just having her fit with a custom leg brace, but that isn’t cheap either.  Your opinion is respectfully appreciated.

I'm not going to address all of the medical issues, as it seems like there are numerous ones.  My advice and comments are going to be more about the timing of euthanasia rather than how to "fix" her.  But I will say that prednisone alone is not adequate treatment for Addison's disease.  That drug is a glucocorticoid, and Addison's results in a deficiency of both glucocorticoids and mieralocorticoids.  While prednisone is part of the treatment, in almost every case it is not the only treatment.

In veterinary medicine we have incredible capabilities to treat disease and injury, just about on par with our human counterparts.  Our limitations are not knowledge, technology, or skills.  In these areas I would put an average vet against an average physician any day of the week and consider them equals at minimum.  In virtually every case our ability to treat is limited by finances.  There are many cases that I end up euthanizing that might have a chance of treatment, or even a guarantee of full recovery, but the owners can't afford to do so.  So in a situation where money isn't an object, I would recommend pursuing as far as you can afford.

But sometimes it's not just a matter of money.  Since our pets can't make choices for themselves, they rely on us to face the hard decisions.  How many things do we put our pets through?  How far do we push before it becomes for our sake and not for theirs?  This is something I face frequently, as clients don't always know what the limit is.

To me it really comes down to one thing.  Do the "good days" outnumber the "bad days"?  With reasonable management does the pet seem "happy", have little difficulty doing normal functions, and has a normal appetite.  It's all about the quality of life.  If a pet with multiple health issues can be kept in the "good" category more often than not, then I think it's reasonable to keep going.  But if any of the health issues makes the bad outweigh the good, it's time to let go.

My prayers are with Susie and her dog.  That's not something easy to go through.

Catch-up Blog #5: Obese Cats

Here's an email from Abigail:

I’m ashamed to admit it, but I’ll come right out and say it: I have an obese cat. He’s 7 years old and I adopted him about 8 months ago. In that time he’s gone from a hefty 16 pounds to a chunky 18.5 pounds. I don’t have any information on weight changes before I got him.  I feed him half a cup of ‘weight management’ dry food and 3 oz of wet food per day, and I don’t think I can reduce his food any further without leaving him hungry. He gets a catnip toy every morning which he goes crazy over, there’s another cat which keeps him on his toes, and I play with him daily with a laser pointer. I feel like I’m doing everything I can with his diet and exercise to get his weight down, but still nothing is working. Am I doing something wrong, or is there more that I can do? I’m starting to think it might be a medical problem. What sort of issues besides too much food and lack of exercise can cause obesity in cats?

As with all American pets, obesity is a growing problem with cats.  While many people think that their cats are just "fluffy", it's a serious health problem.  For example, obese cats are six times more likely to develop diabetes, and this is a notoriously difficult disease to regulate in this species.  At the same time, it can be difficult for some cats to lose weight because most of them have a relatively sedentary lifestyle.  There really are very few medical problems that would lead to obesity in cats, so most of the problem is too many calories and too little exercise.  

To help Abigail's cat, as well as everyone who has an overweight cat, here are some hints on how to achieve normal weight.
  • Feed a specific measured amount of food to your cat daily.  If you are having difficulty achieving adequate weight loss, talk to your vet about diets specifically designed to do so.  Over-the-counter "weight management" foods are for maintaining lower weight, not losing it.  Abigail is correct that you can only reduce the amount so far before you're withholding nutrients as well as calories.
  • DO NOT "free feed" if you have multiple cats.  This is one of the most contentious points with my clients.  Each cat needs to be fed separately and a measured amount specific to that cat's needs.  If one cat eats faster than the others and then goes to a bowl other than his/her own, the cats need to be placed in separate rooms to eat.  "But I can't do that.  It's too hard.  It takes too much time."  I call 100% bull on that.  I have three cats of my own and each is fed in a separate room.  It takes an extra minute or so to do, and once the cats are done eating they are allowed back into the rest of the house.
  • Switch to a completely canned diet.  Studies have shown that a high protein, low carbohydrate diet is better for weight maintenance (a so-called "Catkins" diet).  Canned foods meet this requirement better than dry, though it is messier, more expensive, and some cats used to dry won't eat canned.
  • Force exercise.  Laser pointers are a good option.  But get more creative.  Instead of putting a bowl of food in front of the cat, make mealtime into an active game.  Take pieces of dry kibble and with the cat watching throw pieces to an opposite side of the room.  When the cat runs and eats those pieces throw some into a different area of the room.  This forces the cat to move towards the different areas in order to eat.  You get exercise while enforcing restricted food amounts.
  • An alternate to the above....At mealtime put the cat in a closed room.  Hide small piles of food around the room so the cat has to walk around and hunt to find them.  This mimics foraging behavior like cats do in the wild.  And even when the food is gone the cat will likely keep searching (thus exercising).  Each day put the food in different locations so the cat doesn't know to always go to a specific area.
While there is no "magic" to getting a cat to lose weight, it's also not impossible.  If someone uses the above guidelines consistently, and really puts the effort into it, success is very likely.  If there are still issues even doing all of these things, bring the concern to your vet's attention.

Saturday, June 7, 2014

Catch-up Blog #4: Don't Use The Internet For Emergencies

Since I'm open about being willing to take emails and questions from readers, I will from time-to-time get someone asking about a sudden problem with their pet.  Here is an actual question (name withheld):

My houndog was chewing on a medium sized rawhide strip, she choked on it and then swallowed it ( about half of it) before I could get it out! Will it hurt her??? What do I watch for? Bloating? I'm worried!   Thanks for your time! 

I am very careful on my sidebar and disclaimer to note that my advice or comments do NOT take the place of a veterinary visit, and that any response I make can be very delayed.  Yet I still have people contacting me during a possible emergency.  I know that this is because people want free advice and don't want to have to pay for a veterinary visit.  I know that people like me are partially to blame for the "Dr. Google" phenomenon so common nowadays.  But I still don't get the lack of urgency and common sense in sending a small-time blogger like me an email.  

In the time it takes someone to do an internet search, find my blog, read a few posts, discover my email, and send me a message, they could have already been on and off the phone to their local veterinarian or veterinary emergency clinic.  And they could have spoken to a real person.  Now, that person would likely have told them that a diagnosis could not be made over the phone and the would need to bring their pet in, which would have cost money.  But you know what?  That's what I would say also.  If one of my readers were able to get me immediately and chat with me online, my response would be "Call your emergency vet."  I would say that every single time.  I've even told friends that over the phone, since I can't be there to see their pet.  

Does that mean that sometimes you're going to pay the vet and it turn out to be a minor issue?  Yes.  But there's no way to tell if it's a major or minor issue without the exam.  I know that personally from a few days ago when I had to have surgery for acute appendicitis.  I thought it was just gastroenteritis, but I ended up at the ER and in surgery within a few hours.  There is no way to know what's going on without an in-person visit.

So here's the bottom line.  If you have a simple question, it's okay to look on the internet.  But if you have a possible emergency, call someone.  Don't take the chance of waiting for a reply online that may or may not come, as a delay could result in a health risk for your pet.  It's worth paying a little money to have the best possible outcome.  And when you're contacting someone on a blog, read ALL disclaimers and don't expect to hear back right away.