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Thursday, January 29, 2015

New York May Ban Declaws

My opinion on declawing cats has changed a lot over my career.  When I was growing up I had no problems with the procedure and even had my first cat declawed.  When I started blogging in 2008 one of my earliest posts was about how I supported the decision to declaw (read that here).  However, by 2011 I had made the decision to not do any more declaws and haven't done any since (I blogged about it here).  I'm not a fan of the government legislating our behaviors, and typically believe in a more limited form of government.  However, I do think that we do need laws to correct unethical behavior that people won't stop on their own.  That's why we have animal cruelty laws.  Despite my conservative, limited government political views, I'm actually in support of declaw bans.
I recently read an article about a New York Assemblywoman, Linda Rosenthal, who will be introducing a bill to ban declaws throughout the state other than for medically necessary reasons such as tumors.  Personally I think this is a step in the right direction as this is a surgery we have done for too long and about which many vets have become complacent.  I think that many vets are hesitant to go against clients and don't think about it as the kind of procedure it really amputation.

The AVMA changed its policy last year to classify feline declaws as an amputation, which was a bit of good news to those of us who are against the procedure.  A feline specialist, Dr. Margie Scherk, recently weighed in on this as part of an article on the issue by  I found her comments particularly interesting.

I know that some of my colleagues will give me heck for my viewpoint, but I'm in support of banning this procedure.  We need to change the mindset of both cat owners and veterinarians, and unfortunately the profession has been declawing cats for so long that this may only be accomplished through legislation.

Monday, January 26, 2015

Gooey Guinea Pig Abscess

Guinea pigs are generally sweet, low maintenance pets.  They don't need vaccines and their nutritional requirements are pretty simple to meet.  When they do get sick it tends to be from a rather small list of common ailments (and a large list of uncommon ones).  One of the more frequent problems I see in small rodents is abscesses.

**WARNING**  Some graphic images to follow.  You've been warned. 

This patient was an otherwise healthy female guinea pig who developed a swelling on the right side of her lower jaw.  It didn't take long to confirm this as an abscess, and we scheduled to have it drained.  In almost every case this requires some degree of surgery to fix and antibiotics alone won't resolve the issue.  The material within the abscess is thick and doesn't drain easily.  Sometimes it's as thick as toothpaste, or nearly so.  So we have to sedate them, open it up, and thoroughly flush and evacuate the pocket.

Here are some pictures after she was sedated and I was preparing her for the procedure.  You can see how large this was on her jaw.

And here's what it looked like when I opened the abscess and started squeezing out the material.  It had a consistency not unlike runny cottage cheese.

I expressed the pus and flushed the pocket with a disinfectant liquid until there was nothing coming out.  Here's what she looked like when I was finished.  By comparing to the pictures above you can see that the size is significantly diminished.  I left the incision open to allow further draining and sent her home with oral antibiotics. 

About 30-50% of the time we have to repeat the procedure or decide to surgically remove the tissue forming the pocket, as it can reoccur.  In her case the location on the jaw prevents us from being able to completely remove it without having significant issues closing the site.

She recovered well and went home.  Now we just have to keep our fingers crossed that it doesn't come back.

Friday, January 23, 2015

More Tartar Than Teeth

Pretty much every day we do dental cleanings on dogs and cats.  Sometimes it's very mild with hardly any appreciable tartar or calculus.  Other times we end up with severe periodontal disease numerous loose teeth, sometimes resulting in half or more of the teeth falling out or having to be pulled.  Many of these cases are pretty disgusting, but we're used to them.  But some of them impress even us rather jaded veterinarians.

One such case came in recently.  The dog was a pug that we've been seeing for many years, and was literally a few days away from his 17th birthday.  No, that's not a typo!  A pug that had actually lived 17 years, and though he had some age-related health problems was still going fairly strong!  It's rare to see any dog make it to 17, especially pugs.

It was no surprise that this guy had pretty bad teeth.  Due to his age the owner hadn't scheduled a dental cleaning in many years, resulting in some pretty severe dental disease.  He was missing numerous teeth due to being pulled or having fallen out due to gum and tooth infection.  The remaining teeth were obscured by the very impressive amounts of dental calculus present.  Here are some photos, though they don't really do justice to the extend of the problem.

On several teeth I literally could not see the tooth under the layer of calculus and tartar.  A few teeth had at least 1/4" (about 0.6cm) of thick calculus covering them!  I would not be surprised if a few of the teeth remained in place only because the tartar and calculus acted as a sort of cement, holding them together when they otherwise would have fallen out.

I felt really bad for the little guy, as I'm sure his mouth was very uncomfortable.  Part of me can't completely blame the owner for not risking anesthesia, even though I'm a big believer in "age is not a disease" and have done cleanings safely on dogs and cats older than him.  And there isn't a darn thing that will fix that much dental disease other than a thorough cleaning and likely extractions.

I think that the big lesson here is the need for preventative dental care.  We need to be doing at least annual cleanings on dogs starting at a young age to keep this severe of a problem from happening.  It is also important to do regular at-home dental care with appropriate brushing and/or chew treats.

As disgusting as mouths like this are, I'm certainly glad that I'm not a human dentist, having to see such problems in people!

Tuesday, January 20, 2015

"It'll Only Take A Sec!"

Let me describe a recent Saturday.  Normally we're open from 9am until 7pm, and the day was completely booked.  Every single appointment was filled, we had a full compliment of surgeries and dental cleanings, and including drop-off patients we had booked around 20-something pets for each of the two doctors working (myself and an associate).  One of our most experienced techs called in sick (something I've never seen her do so I knew it was serious) and we couldn't get ahold of anyone else to cover for her.  So we were extremely busy as well as very short-handed, missing a fourth of our normal support staff.  I was monitoring for several of the dental cleanings, running lab tests, reading fecal tests, all things normally done by a tech.  I was also seeing rooms without an assistant because everyone was busy with other patients.  
We were running a little behind and felt the rather hectic pace of the day, but were managing to get through.  It wass taking us a little longer than normal to get to some patients because of the short staff, but clients were being understanding.  We've had busy days like this in the past, and by pulling together and sharing the workload we make it through.
Then around 3:30 a client came in wanting to be seen.  He didn't have an appointment and wanted some bumps and scabs on his dog's back looked at. This was a regular client whom we have seen for years, so we did plan on seeing him.  But at that time we still had a dental cleaning we hadn't finished, were still down a tech, had absolutely no appointments available, still had drop-off pets that hadn't been seen....needless to say we were swamped.  My associate and I had not even had time to stop and eat something for lunch!!!  So I had the receptionist tell him that we couldn't see him in a room, but we'd be happy to have him drop off and we'd get to the dog later that afternoon.  That sounds reasonable, right?  We're still working him in and not putting the pet off until later in the week, right?

He threw a fit. 

"I just need the doctor to take a quick look." 
"Sorry, sir, the doctors are both busy, and we don't have any appointments available."
"Can't a nurse look at him and tell me what it is?  It'll only take a sec!"

He refused to drop his pet off and insisted on being seen by someone right away.  We explained that we simply didn't have the time or ability to drop everything at that moment, which wasn't sufficient for him.  He was genuinely angry and causing a fuss, and planned on making a formal complaint to the practice owner.

I just don't understand people like that.  The dog had what sounded like a minor skin problem and not an emergency (we had already accepted one emergency for the day and had seen it right away).  What doctor's office can you walk into without an appointment and expect the staff to put you ahead of everyone else who did schedule appropriately?  How does anyone consider such behavior reasonable?  And we weren't even making him wait a few days.  Even if I walk into an Urgent Care physican's office or an Emergency Room, I'm planning on having to wait for a long time, longer if more serious cases come in that trump my own illness.  Those types of doctors don't take appointments, so it's a first-come-first-served basis, other than serious cases that a triage bumps to the top of the list.  I don't know any human doctors that will put a walk-in ahead of the long list of appointments that people may have scheduled weeks in advance.  How is that fair to the people who took the time to schedule their visit?  Most people are very understanding for emergencies, but not for a few skin bumps.

"It'll only take a sec...." 

I hear that on a regular basis, and I don't think clients think through the process.  Nothing "only takes a sec".  While my techs are experienced and smart, they're not doctors.  They can't legally diagnose anything, and may not catch everything a doctor would.  A skin problem may not be isolated to one area and may be an indication of a larger issue, a situation I see every week.  Evaluating the patient properly means checking them in and taking the time to do a full, thorough exam by the doctor.  Depending on the condition we may want to run diagnostic tests, and then we'll have to work up a treatment plan.  All of that can take 20-30 minutes on the short end, and possibly longer.  It defintiely doesn't take "a sec".  A "quick look" is poor quality medicine and could easily overlook the real cause of the problem.

The client eventually left, still fuming, still refusing to drop off and still insisting on being seen.  But he did make an appointment for the following day to have a proper exam.  And then his wife called the day of the appointment and rescheduled for the following day.  Guess it must not have been so serious after all.  Definitely not worth having a fit.

To all pet owners reading this....if you walk into a vet's office without an appointment and want your pet seen, please be very understanding about their schedule and appointments, and realize that if you get put to the front of the line then someone else is getting pushed back.  If you had an appointment scheduled would YOU want to have to wait for a walk-in to be seen ahead of you?  We're not typically going to do that unless it's a true emergency.  Is your pet's case a "drop everything" kind of problem?  If not, don't expect us to do so.

And as I've said before, if you're going into the veterinary field because you don't like dealing with people, you are in for a very rude awakening.

Sunday, January 18, 2015

Nutrition Week #4: Feeding The Right Amounts

Over the last week I've been talking about various myths and misconceptions people have surrounding pet foods.  All of that is important, but there is also something that is just as important as the kind of ingredients....the amount of food given. 
Almost daily I'll have a client ask "how much food should I give?"  The answer is "it depends".  Just like there is no single food that is "best" for every dog or cat, there is no single amount that is appropriate across all situations.  There are a lot of factors that go into determining the right amount, such as age, activity level, health status, metabolic disorders, caloric density of the food, and so on.  Nutritional specialists and some general practice veterinarians will calculate the daily caloric requirement for the pet and then calculate how many calories the food has.  Honestly, that's too much math for me personally, so I try to make it simpler for myself and my clients. 
A good starting point is the chart on the side of the bag of food.  On just about every food you'll see a chart where you can look at the pet's weight and see about how many cups per day to feed.  However, there are several things to keep in mind about that information.  First, it's an average.  Each dog has a slightly different metabolism, so the recorded amount may be too much for dogs with a slower metabolism.  Second, they are generally made in the research facilities with animals that are not spayed or neutered.  Having a dog or cat "fixed" lowers their metabolic rate by about 30%, which has given rise to the myth that spaying or neutering "makes pets fat".  No, it doesn't, but it does slow metabolism so you have to be more careful with feeding habits.  Third, the charts are made based on dogs of average activity.  If your dog is extremely active or leads a sedentary life, they may need a higher or lower amount of food. 
But even given those factors, the chart is a good place to start.  If your pet maintains their weight, great!  Keep it up.  If your pet gains weight, you'll want to reduce the amount fed, possibly lower than the chart.  I feed my own dogs about a cup less than the low end of the feeding chart, in large part because they spend most of their time inside the house on the bed or couch, and really aren't burning calories.  I'm able to keep them at a lean, muscled body condition in this way.  If my dogs were much more active I'd have to feed them more than I do now, and possibly more than the recommended amount.
So step number one in proper feeding is to measure the food.  DO NOT just dump some in a bowl!  Get an inexpensive measuring cup or scoop, and put a specific amount in the bowl.  You'll want to know exactly how much your pet is getting, down to the fraction of a cup.  This is important for a couple of reasons.  If you're not feeding the right amount, you'll know exactly how much you need to increase or decrease.  You'll also be able to more easily monitor when your pet may not be eating quite as much, possibly alerting you to the early stages of an illness.
Now I know that there are some people out there who just leave food out for their dog or cat.  I don't have an issue with doing so IF (1) that is the only pet in the household, (2) you are still measuring out the food each day, and (3) your pet is maintaining a healthy weight.  So if your dog eats 3 cups of food per day and you put that amount in the bowl in the morning for your dog to graze during the day, that's fine by me.  We just don't want to exceed the recommended amount by filling the bowl as soon as it's emptied.
"But Dr. Bern, he seems so hungry when he's finished.  That means he needs more!"  No, that may not mean that he needs another scoop of food.  Many animals, like many people, simply enjoy the taste of their food.  How many times have each and every one of us continued to eat even when we're full, simply because it tasted so good?  Many people in Western societies are overweight or obese because they don't understand the concept of portion control and continue to eat poor quality foods because it tastes so good.  And I'll be the first to admit that I have that problem!  I often have to make a decision to turn down desert that I want because I know that I'm not really hungry by that point.  Most dogs and cats are the same way, but they have no self control.
Step number two of proper feeding is important in households with multiple pets.  You must separate pets when feeding them!  If you have three dogs and all of them are eating from the same bowl, how can you know how much each is getting?  You simply can't know.  If you have several cats and keep the food bowl full at all times, how much is each cat eating?  Are you surprised that at least one of them is overweight?  "But Dr. Bern, I put the bowls down in different places but as soon as Fluffy finsihes her food she goes over and pushes Butch out of the way."  I'm not surprised by these situations and it's normal for dogs and cats.  The solution?  Put each pet behind closed doors!
Let me give you an example from my own house.  We have three cats and two dogs.  One of the dogs and two of the cats are very motivated by food and will finish theirs quickly before seeking out other food.  In the past I would try to feed them in separate bowls but the same room.  Inevitably we'd have to shoo someone away from a bowl that wasn't theirs.  One of our cats is very docile and easily bullied by the others, and we started seeing him lose weight because he ate slower and would be pushed way from the bowl by a housemate.  When it's feeding time at our house we put one dog in the family room, on in their kennel in the laundry room, one cat in the upstairs bathroom, one cat in my son's bedroom, and one cat in the laundry room.  All doors are closed so nobody has access to anything but their own food.  Once everyone has finished eating we open the doors and let them mingle again.  That may seem like a lot of work, but the pets are trained to this method and will run to their respective places in anticipation of the meal.  Our kids feed the pets and it takes a total of less than five minutes to do all five pets in separate locations.  And all five of these pets are at a healthy, lean body weight. 
Ask yourself this....are you willing to invest five minutes per day to help keep your pet healthy?  Then you must separate pets to properly feed them.
Step number three....restrict the treats!  Most people don't realize how quickly treats and snacks add up the calories.  This is especially likely to happen in a household with multiple people.  "Oh, I only give a couple of treats per day."  Really?  Are you sure about that?  Take a week and write down how many treats you're actually giving.  Then write down how many each family member is also giving.  You may truthfully be only giving 2-3 treats per day.  But if your spouse and two children are also "only" giving 2-3 treats per day, then suddenly your pet is getting 8-12 treats!  Those calories accumulate quickly in cats and small dogs.
I'm not saying to never give treats.  Your pets like them, we like giving them, and it helps us bond with our pets.  But do so in a smart way.  Here are a couple of simple things you can do to help manage treats.
Start out by getting a small resealable kitchen container (Tupperware or other brands).  At the beginning of the day put a set amount of treats in that container (probably no more than 3-4, depending on the size of the treat and the size of the pet).  Whenever anyone in the family wants to give the dog or cat a treat, it must come out of that container.  When it's empty, no more treats can be given!  You're done for the day!  This method allows you to mange the snack output in the whole family without having to interrogate or hassle each member.
If you're still struggling with weight issues, use a portion of the food rather than separate treats.  If your dog should get 1 cup daily, measure that out in the morning and put some of the kibble in a container.  Those are the treats for the day!  By adding this modification you're able to give treats throughout the day and yet still not go over the daily calorie limit.
Step number four....exercise!  Like their human owners, animals need exercise to maintain proper weight and muscle tone.  Most dogs and cats lead a pretty simple, sedentary life, such as my own.  The more exercise in which you and your pets engage, the more calories you can get away with eating.  Olympic swimmer Michael Phelps eats around 6,000-8,000 calories per day when training, far greater than the 2,500 or so that an average person should consume.  How can he get away with that?  By having an exercise regimen that burns about 1,000 calories per hour!  Some pets can be maintained at a proper weight simply with proper nutrition and portion control.  Others need to be exercised more every day.
Other than in cases of metabolic disorders, pet obesity is a completely preventable and treatable condition.  Humans have pretty much 100% control of their pets' food, so if a pet becomes overweight, the blame can be laid at the feet of their owner.  Now, that may sound harsh and I'm not trying to beat anyone up.  In fact, I think that philosophy is encouraging, because it also means that owners have 100% control over the improvement in their pets' weight! 
Because this is a complicated issue, if anyone has pets with weight problems I strongly encourage you to talk at length to your own vet.

Friday, January 16, 2015

Nutrition Week, #3: By-Products, Limited Ingredients, Lamb

Our last bit on nutrition topics for now......
Myth #7:  By-products are bad ingredients and  must be avoided
Some food companies will try to convince you that by-products are nothing but junk, undesireable leftovers that have no nutritional value and may include things such as hooves and horns.  This is blatantly false.  By-products are cleaned and processed organ meat that by law and definition must specifically exclude hair, horns, hooves, skin, feathers, and gastrointestinal contents.  Ingredients defined as by-products can include lungs, spleen, kidneys, liver, blood, stomach, intestines, and other organs.  While we may not typically eat these parts of animals, these other organs contain important nutrients, some of which are not found in muscle tissue.  By-products are included in pet foods because they are lower cost sources of good nutrients, not as "filler".
Myth #8:  Over-the-counter "restricted ingredient" diets are sufficient for food allergies
Food allergies are triggered by exposure to a protein and/or carbohydrate source to which a pet has a sensitivity.  The treatment in these cases is to eliminate exposure of these ingredients in a pet's diet.  Typical commercial diets may not include these components on a label or in the recipe, but that doesn't mean that the allergens are not present.  Several studies have shown trace ingredients in pet foods that were not listed on the label.  This is not a problem for an average dog or cat, but for one with confirmed food allergies it could be enough to trigger a reaction. Just because "chicken" isn't listed on the label doesn't mean that there can't be trace amounts in the diet.  This finding is why veterinary dermatologists always recommend more strictly controlled "prescription" diets when diagnosing and treating food sensitivities.
Myth #9:  Lamb and rice diets are better for a pet's skin
This myth derives from a misconception about food ingredients and allergies.  When a pet has a reaction to food you will typically see symptoms related to the skin: hair loss, itching, skin infections, etc.  The way to resolve the problem is to feed a diet that eliminates the allergens and replaces them with ingredients to which the pet has never been exposed.  Many years ago we would use diets that had lamb as the protein source and rice for carbohydrates, as dogs and cats rarely ate these ingredients.  Because the allergens were eliminated the pet's skin would improve, but this only happened because the pet was allergic to other foods and not due to inherent qualities of the ingredients.  Currently lamb and rice are common in pet foods and are no longer considered good "hypoallergenic" diets because many pets have been exposed to them.  These components are no better or worse for an average pet than any other protein or carbohydrate, and for most pets won't give any benefit compared to other ingredients.

Wednesday, January 14, 2015

Nutrition Week, #2: Raw Foods, Bones, Meat

Continuing our discussion on pet nutrition....
Myth #4:  Raw food diets are better than commercially prepared diets
Raw foods carry a significant risk for bacterial contamination.  Studies have sown that 20%-35% of raw poultry and 80% of raw food diets for dogs tested positive for Salmonella, while 30% of stool samples from dogs fed these diets were positive for Salmonella.  While a healthy dog may be able to cope with some dietary bacteria, others cannot.  There is also a significant human health risk of exposure to dangerous bacteria.  Numerous parasites can be found in raw food, presenting a risk to the health of the pet and their human families.  Raw diets have been consistently shown to contain imbalances in the Calcium:Phosphorous ratio, excessive Vitamin A and D, and other mineral imbalances.  There have been no controlled, scientific studies that have shown raw diets to be better for the health of pets than commercially prepared foods.  As with grain-free diets, any perceived benefits are likely due to a higher fat content and lower fiber content rather than the issue of raw versus processed foods.
(also see previous discussions here and here)
Myth #5:  Bones are good for dogs and cats
Studies of wild dogs and cats have shown no differences in the rate of dental disease compared to pets, even though wild carnivores chew on bones frequently.  Bones are very hard and are a frequent cause of fractured teeth, which can be very painful and require dental extractions.  Small or splintered bones cause a risk of obstructing or puncturing the esophagus, stomach, or intestines.
Myth #6:  Meat should be the first ingredient
The ingredients are listed on pet food bags by pre-cooked weight.  So the first ingredient weighs more than the second before they are processed, and so on.  Meats contain a high level of water, which is removed during cooking and processing.  Water is heavy, so the pre-cooked weight is not a good indication of the percentage of nutritents that actually come from that food.  "Chicken meal" as the third ingredient, may actually contain more protein than "Chicken" as the first ingredient because the meal has been ground and dehydrated, removing the water.  So ingredients on the list are placed lower merely because they weigh less, not because they carry fewer nutritents or contribute less to the diet.  If "chicken", "poultry meal", and "corn gluten meal" are all included on an ingredient list, there is no way to tell from the packaging which ingredient actually contributes more protein than another, since the ingredients are listed by weight and not by nutrient density.  A perception of the seeming benefit of "meat" may be the fact that this ingredient contains more fat that "meal", which as discussed above can result in a glossier coat but doesn't mean the nutrition is better.
(also see previous discussion here)

Sunday, January 11, 2015

Nutrition Week, #1: Corn, Wild Diets, Grain-Free

Pet nutrition is a bit of an interest for me, and while I'm not an expert by any stretch of the imagination, I've looked into a lot of the common issues and have spoken with many board-certified experts.  Much of what I've learned goes contrary to what you will see in some corners of the Internet or by talking to some food reps, but it is still accurate and true.  Over the years of blogging I've discussed some of these issues, but thought it might be fun and helpful to dedicating a week's worth of posts to clearing up some misconceptions.  Let's begin!
Myth #1:  Corn is a bad ingredient, has no nutritional value, and causes allergies
Ground corn and corn gluten meal are important nutrients, providing good energy and an excellent source of secondary protein.  In pet foods it is over 95% digestible and is not a "filler".  It is one of the lowest sources of food allergies, causing a problem in only around 1% of patients with a confirmed food allergy.  Corn gluten is also an important source of fatty acids such as linoleic acid, antioxidants, and several vitamins (B complex, E, and A).
(also see other discussions on this topic here and here)
 Myth #2:  Dogs need to be fed a diet that resembles their wild ancestors
Dogs are NOT wolves and their digestive tract has significant differences.  Over 10,000-15,000 years of domestication their diets have involved greater consumption of grains and their genetic makeup has changed to accommodate this change.  Modern dogs are different from wolves in several key genes that involve starch digestion and gulcose uptake.  There is no benefit found to feeding a dog the same diet that would be fed to a wolf.
(also see another post on this topic)
 Myth #3:  Dogs should be fed a grain-free diet
This myth is currently popular and is not based on any scientific evidence.  As with the above myth, dogs have gentically changed to be able to handle grains and other carbohydrates.  Unless an individual pet has a sensitivity or allergy to a specific type of carbohydrate, there is no proven health benefit of grain-free diets.  Any perceived benefits may be due to a higher fat content in grain-free diets, which can help improve coat quality, and a lower fiber content, which can reduce stool volume.  But these factors are independent of the grains themselves and can be achieved even with diets containing grains. 
(also see another post on this topic)

Thursday, January 8, 2015

Veterinary Burnout, PTSD, And Life Balance

Recently I received a very interesting email from Tim.
I ran across your blog when I did a research for my own blog post on veterinarians and depression/PTSD. I had a recent conversation with a woman who used to be a vet tech and had to give it up because of too much exposure to sick and suffering animals.
I started thinking about the veterinary industry and how it may be a segment of the population that may suffer from PTSD due to occupational exposure. PTSD is an important topic to me because this past year I have been treated for the same due to my 20+ year career as a firefighter/medic. Do you know of any studies or resources that discuss PTSD and veterinarians?
The blog I write is called Self Care and Fitness Education where I discussed my own experiences as well as holistic means to return to a more balanced life. I want to raise social awareness about your profession and PTSD, as well as give my readers food for thought.
I'm not a psychologist and will have to defer to official definitions of Post-Traumatic Stress Disorder (PTSD).  I'll also admit that I'd never really given much thought to experiences in my profession as leading to PTSD.  When I think of that disorder I think of military, police, and other first-responders who frequently end up in sudden and violent situations.  I've never applied it to veterinary medicine.
Depression and emotional burnout is most certainly an issue in this job.  I've faced it myself many times.  Emotional fatigue hits us from time to time since daily we deal with often emotionally charged situations.  One of my most popular recent blog posts was on the emotional toll of the job, and I have been very surprised at that particular post being read 4-5 times as much as my average ones.  It's obvious that this topic resonates with people.
Personally I wouldn't think of this job as creating PTSD, but someone more familiar with the disorder may define it more broadly than myself.  Is there emotional and psychological trauma in veterinary medicine?  Absolutely.  Virtually every day I am faced with pets that need to be muzzled or sedated due to aggression.  Recently my hospital manager was bit severely by one of our patients and had to have her hand bandaged and put in a brace.  People outside of the profession can develop fear of animals due to the experiences of being attacked, which probably falls within a spectrum of PTSD.  I personally think that most of us in the field learn how to handle that since we face it so frequently, just like not every soldier or police officer is going to have true PTSD.  But is it possible?  Sure, especially if the attack is severe.  I know that the times I've been badly injured I'm more nervous than normal around aggressive pets.  If I was mauled, I'd probably be downright terrified by the idea of another vicious dog.
Burnout and depression is much easier for me to understand, having faced both issues over my career.  Think about our situation.  We make a fraction of what our human colleagues do, and have at least as much training and work the same weekly hours, if not longer.  It's tough for many vets to make ends meet, especially newer graduates.  We have the highest debt-to-income ratio of any medical profession.  Every day we have to almost bargain with clients to let them allow us to treat their pets.  Daily we face situations where we know what to do to diagnose and treat problems, but the owner can't or won't pay for the necessary tests and medications.  We are often physically attacked by our patients, and sometimes yelled at by their owners for things that are beyond our control or because we didn't fix the problem the first time (and those people never seem to understand that they keep denying our treatment plan).  We are in this job because we love animals, especially pets, and often become emotionally attached to our patients and clients.  This attachment helps us do our job, but it can make it especially hard on us when despite our best efforts we can't figure out a problem and lose the pet.  We are physically stressed, often working long days, sometimes coming in after hours, rarely getting full lunch breaks, and are having to get up and down off the floor after restraining and sometimes "wrestling" with pets (my large animal colleagues have even greater physical challenges).
To summarize....long hours, comparatively low pay, daily risk of physical injury, emotional roller-coasters, not being able to freely do what we were trained for....
Yes, depression and burnout are a concern.
It's also difficult to balance our work and home life.  I can't tell you how many times I've driven my wife crazy because I fret over a case for days, especially if it went poorly.  My worry over the clinic's revenues sometimes dominate my thoughts on my days off, affecting my interactions with my family.  I don't do emergency work anymore, but when I did my planned evening could be ruined by a sudden after-hours call.  It can also be hard for me to participate in plays and other outside activities because I can't say that I'll leave exactly at closing time every day.  Balancing personal and professional lives is a huge concern among veterinarians, and one that we're likely doing a poor job handling.
Tim, I'm not aware of any specific studies on these issues in veterinary medicine.  I may have seen an article or two on depression and burnout, but I can't remember where or when so I can't give you a specific reference.  In writing this I'm hoping that some of my readers will know of specific studies and can direct you to them by writting in the comments.  If there haven't been many studies, there certainly should be, as my personal experience is that these are common issues.  But more important than simply knowing the extent, we need to have good solutions on how to handle the problems.
And I have no magic answers on how to do so.

Monday, January 5, 2015

Low Risk Doesn't Mean No Risk

Jessica emailed me this recently and I thought it was a good way to open up to a larger topic of discussion.
I came across your blog posts on tail amputation while doing some research. My 3 year old bulldog had her tail amputated yesterday after a year and a half of trying to manage her chronic infections and skin irritation conservatively. I got more than 1 opinion and I really thought we were doing the right thing. It was obvious that her tail was sore more often than not and she hated having it cleaned. I was told of the risk of incontinence postoperatively but was unable to find anyone who actually experienced this. Our surgeon assured the risk was very, very low.
Well now 2 days after surgery, we are at home and our poor girl has been unable to control her bowels. At first I hoped it was just diarrhea from anesthesia & antibiotics, but twice now she has passed 2 small formed stools while sleeping. Otherwise it has just been constant small dribbles.
She has gotten in the poo position twice outside but only a very tiny bit came out.
I did speak with our surgeon who said he was confident that there was no damage to surrounding nerves or muscles but that it was a known risk of this procedure. He said that her whole backside is sore and irritated. She also had an anal purse string suture to prevent her from having a bowel movement during surgery which could be causing additional pain for her. He said to keep her on a bland diet and wait it out.
Have you ever seen this before in your practice? Is there a chance it could be temporary?
Let begin by addressing the specific condition.  I've performed several tail amputations in bulldogs as well as other breeds.  The closer you are to the rectum during the surgery, the higher the likelihood of damaging important nerves or muscles.  Tail amputations in bulldogs are normally done because of deep folds that lead to significant irritation and infection, and with their short tails you're very close to the rectal area.  Even though the risk is low, damage can happen despite the best surgical skills, and there is no way that even the most experienced surgeon can 100% predict every outcome. 
There is also the consideration of temporary post-operative trauma.  Sometimes damage is transient due to localized inflammation of the nerves or muscles.  You can have short-term problems that will resolve with a bit of time and rest.  If this dog had significant irritation there could be a situation where the tissues will heal and return to normal.
How do you determine which outcome will happen?  Time.  Really, that's it.  Temporary "damage" due to surgery should resolve within 1-2 weeks, if not sooner.  If it goes on longer than this there may be permanent damage.  Once initial healing has taken place (usually 10-14 days) your vet can check some of the reflexes and nerve responses around the anal area to see if there is a concern.  You can also consider taking her to another vet for a second opinion, though I would give the doctor who performed the surgery the first opportunity to assess her since he is most familiar with the case.
This topic brings up a bigger issue that I also want to touch on.  "Low risk" never means "NO risk".  No matter what the procedure or treatment is, there is always some degree of risk involved.  I've done several thousand spays and neuters so far during my career.  Once I had a puppy die due to problems with the anesthesia equipment, and once I had sutures slip internally during the night after surgery, requiring a trip to the ER and emergency surgery.  But those are the only serious complications I've had in thousands of cases, which are pretty darn good statistics.  Most vets consider routine spays, neuters, and dental cleanings to carry very little risk, especially with proper monitoring, pre-anesthestic blood tests, and modern anesthetics.  Even so, there is always the risk that a pet will have an unexpected reaction to a medication or something else will go wrong.  There will NEVER be a way to reduce the risk to 0%, just due to the nature of how surgery and anesthesia affect the body.
Sometimes complications happen that are beyond a doctor's control.  A pet has an unexpected allergic reaction to a drug.  Suture material fails.  The pet's body reacts severely to the sutures.  The anesthesia equipment malfunctions.  There are hidden health problems with the pet that we don't notice on our initial work-up.  I could go on and on but you get the point.  There are situations that even the best doctor and best preparation can't prevent.
Sometimes complications happen because of the fault of the doctor or technician.  Maybe a suture wasn't tied properly.  The tech may not have been monitoring properly to catch the arrhythmia.  A drug may have been overdosed.  The surgeon may have cut a little too far in one direction.  Yes, these are things that shouldn't have happened.  I hate to break it to you, but doctors and technicians are human, and we can make mistakes.  I've said it before and will say it until my dying day.  If a doctor tells you they've never made a mistake or missed a diagnosis, they are lying to you.  It is simply impossible for any human to be 100% perfect at our job 100% of the time.  If anyone challenges this idea, I will ask you to do some serious reflection on your own life and career and honestly tell me that you've never made a mistake that somehow could have been prevented. 
Let me also be clear in saying that "we're only human" doesn't excuse mistakes.  If a serious mistake happens, that professional is certainly held liable, as is proper.  We're going to make mistakes, but they should be rare and we should face the consequences and try to make ammends.  There is a difference between a rare mistake and repeated mistakes of the same kind.  The former will happen and the latter needs to be investiaged and handled differently.
Now that I've said all of this I need to go back and reassure everyone, as I know that there are people reading who have been freaked out and won't have surgery done on their pet, even routine procedures.  Don't let my comments scare you.  Every day of our lives we take risks, and usually don't even realize it.  The National Safety Council produced a nice little graphic that gives the odds of dying from various causes.  Here are a few choice bits of that data.
Motor vehicle incident:  1 in 112
Falling:  1 in 152
Assault by firearm:  1 in 356
Car occupant:  1 in 492
Exposure to fire, flames, or smoke:  1 in 1,418
Choking from inhalation and ingestion of food:  1 in 3,649
Air and space transport incidents:  1 in 8,357
I've seen data that shows that surgical risks are about 1 in 10,000 if proper pre-anesthestic work-up, monitoring, and drugs are used.  This means that your dog or cat is far more likely to die as a passenger in a car accident on the way to the vet than they are while undergoing a routine anesthetic procedure!
Worry sometimes is misplaced.  The average American is 3 times more likely to be killed in a car accident than by being shot with a gun, yet we casually get in our cars and drive every day without worrying much.  We hear so much about plane crashes around the world, yet we're about twice as likely to die by choking on our dinner than in such a situation.  Pet owners routinely fear anesthesia for their pets, yet the risk is low.
So what does all of this mean????
First, there is minimal risk of your pet undergoing an average anesthetic procedure and the huge majority of the time it is safe and uneventful.  The risks of complications with surgery are highly dependent on the kind of surgery, with some carrying far greater risk than others.  Whenever a pet (or person!) is undergoing surgery the doctor should make you aware of the potential risks and how likely they may be.  If they don't come out and tell you, be sure to ask!  But also be aware that if the complications you were warned about do happen, sometimes everything can be done right and the outcome is still not what you wanted.
Remember....low risk doesn't mean no risk, but low risk does mean complications are rare.

Friday, January 2, 2015

NDV To Treat Canine Distemper......Hogwash Or True?

One of my readers passed on this link and question....
Does your office employ the treatment discussed in this link?
I'd like to know if you've heard of this and if so, what is your take on it and why aren't more vet offices using this treatment?
My first thought when reading the website was "well, this is new..."  As I continued to read I was scratching my head in confusion, especially with some of the statements.  Several red flags were raised in my mind and I was at the point of writing it all off as "snake oil".  But I wanted to give a more informed opinion and really break things down, hence this blog post.  I'll warn readers that I may get technical with some of the discussion, so if you're not into virology you may want to skip this one.
Let's start with a quote from the website:
We have received reports from 21 vets who have used NDV to treat distemper dogs. Of those, 12 vets used NDV-induced serum in the early stages of the disease, and in 86 percent of those cases, the distemper dog survived. Dog caregivers — owners, fosters and rescuers — tell us that 63.39 percent of distemper dogs were saved by one of the treatments developed by Dr. Sears using NDV — Newcastle Disease Vaccine.
Okay, that sounds pretty promising!  So what's the issue? Why isn't this being used more?
Let's begin by talking about what these viruses are.  Canine distemper (CDV) is a RNA virus that affects a wide variety of mammalian carnivores, including canids (dogs, foxes, wolves, etc.), raccoons, skunks, and even seals.  It is highly contagious and spreads through aerosol droplets or contact with infected bodily fluids.  Puppies less than six months old are the most common pets affected.  The diseases typically starts out with fever, respiratory signs, and diarrhea.  With prolonged infection it can invade the nervous system, causing inflammation of the brain and spinal cord.  The early symptoms may be subtle and only appear as diarrhea and a runny nose, though the disease progresses quickly over a week or two.  About 50% or more of dogs will die from this disease once symptoms develop, and even if they recover some of them may have long-term neurological problems.  Diagnosis can be difficult, and typically is based on isolating the virus in cells collected from the conjunctiva around the eye.

Newcastle disease is also a RNA virus, but it affects wild and domesticated birds.  The symptoms are similar to what we would see in dogs:  upper respiratory signs, conjunctivitis, diarrhea, neurological signs, and problems with eggs.  The virus can be isolated from swabs of the trachea and cloaca of affected birds.  There really isn't a treatment in birds, and the main concern is the disease spreading among flocks and causing massive bird death.  It can pass to humans, but isn't considered severe in our species, only typically causing short-term conjunctivitis and flu-like symptoms.  Interestingly, Newcastle disease virus (NDV) has been studied as a potential treatment in certain kinds of human cancer.  Apparently a modified version of it can target and kill cancer cells, though there is variability of the result between strains of NDV and types of cancer.

Both viruses are in the family Paramyxoviridae, with NDV in the genus Avulavirus and distemper in the genus Morbillivirus.  As a point of reference, human measels is also in the genus Morbillivirus, while mumps and human parainfluenza are in the genus Rubulavirus.  For those who don't know a lot about taxonomy, "family" can include a fairly broad variety of organisms, though there are considerable similarities.  For example, the family Canidae includes domesticated dogs, wolves, jackals, foxes, and bush dogs.  The family Hominidae includes humans, chimpanzees, bonobos, gorillas, and orangutans.  As you can see by the examples, members of a family have a lot of close similarities, but also some pretty big differences.  Nobody is going to confuse the skull of gorilla with that of a human, or look at a fox and think it's a wolf.

Okay, now let's get into the specifics of this supposed treatment for canine distemper.  Here's quotes from the website again:

The basic principle of the treatment is to use the NDV as an inducer to prompt a reaction in the dog’s immune system that can create a material to kill the distemper virus.....Today, the NDV treatments include the NDV-induced serum, the NDV as an IV injection to the body and the NDV spinal tap, which is for dogs in the neurologic stage of distemper.

Okay, so vets who are doing this are giving NDV vaccine to dogs, something that is not approved and not tested, as well as being a vaccine for a disease that only affects birds.  They they collect serum from that vaccinated dog, inject it into a dog with distemper, and somehow the NDV vaccine will "create a material to kill the distemper virus".  Someone might think that because NDV is a paramyxovirus like CDV that there would be some benefit of giving it.  But if that was the case, why wouldn't giving serum from a dog vaccinated for CDV help even more, since it's the same disease?  Or a measels vaccine, since that's in the same genus as CDV?  Stop and think about that for a minute...would we use serum from someone vaccinated against mumps as a treatment for measels?  Because that's basically what these vets are doing (go back to the taxonomy above).

"Yeah, but Dr. Bern, you already said that NDV has been studied because it kills cancer cells.  See, it's got something in it that helps cure diseases!"  Okay, granted, NDV may attack certain cancer cells.  But cancer cells are quite different from a virus, and these vets are claiming that NDV destroys the virus.  Even if it attacked the cells containing the virus, those cells are still very, very different from cancer cells.  You can't assume that something that destroys cancer would also destroy viruses.

The website presents data from a study they did.  Let's look at some of the comments about that "study" (yes, the quotation marks are intentional). 
The data for the report comes from two sources:
  1. Veterinarians using NDV
  2. Dog owners, caregivers or rescue groups.
Every case reported to us has been included in our statistics. We are not selective in compiling our information.
 Okay, there's problem #1.  This is in NO WAY a scientific study, based on these statements alone.  In any true medical study it's common for cases to be omitted for a number of reasons:  different diagnosis than expected, incomplete records, improper documentation, and so on.  So this was one of the big red flags to me.

For this survey, the diagnosis of distemper relied on the judgment of each vet. Very often, the dog owners did not want to pay the additional expense of a lab test. So, the vets would make the diagnosis based on their experience, the apparent symptoms and in the context of whether they were in the midst of a distemper outbreak.

And there's problem #2.  Remember that in the early stages there is diarrhea and signs of a sinus infection.  These symptoms may not be severe.  The only way to truly diagnose the disease is by doing swabs of the conjunctiva or the inside of the urinary bladder (rarely performed for obvious reasons).  So there may have been puppies that had diarrhea and runny nose, the vet suspected CDV, treated with the NDV treatment, and the puppy got better.  But it's very possible that many of these cases of unconfirmed distemper actually were not distemper.  A simple case of corona virus can cause diarrhea and be self-limiting.  There are several mild viral and bacterial infections that lead to sinus problems, but again may be self-limiting, with the pet resolving without treatment.  If these cases "responded" to NDV treatment, but were never confirmed to actually be CDV, how do we know that they are not animals who would have gotten better without any treatment because they didn't actually have distemper?  It's very possible that many of the dogs in the study who "responded" never actually had CDV in the first place.

There's also an issue with the variety of treatment protocols.  Some vets are using NDV serum intravenously, some are giving it into the spinal colum via a spinal tap, and some are giving the NDV vaccine directly IV.  Each of those methods is going to affect the body very differently, stimulating different responses.  This lack of consistency makes any conclusion difficult, as a scientific study would be limited to a single method.  In discussing the reports the website says that several vets gave NDV serum but never got follow-ups with the pets.  Are those cases still included in the data?  That's a prime example of the type of information that you delete from a study, yet they state that they didn't delete anything.

Here's a quote from the conclusions section of the website:

As to why these treatments work, our theory is that the NDV causes a reaction within a dog’s immune system that produces a previously unknown material or group of interacting materials, that is able to neutralize the invading virus. However, finding the answer would require extensive scientific research.

If that statement doesn't raise some serious red flags, you may want to go back to science classes.  We certainly don't know everything about the immune system, but postulating a "previously unknown material" that somehow neutralizes the virus is a rather bold statement.  Scientists have a pretty good idea of how viruses affect the body, the defenses the body has against them, and what "materials" are present.  I find it rather suspicious to propose a completely new and previously undiscovered immune system response with a vaccine and diseases that have been studied extensively.  It might be different if it was a completely new drug, but it isn't. 

Essentially vets using this protocol are saying "Well, it does something in the immune system and somehow that counteracts the virus, but we don't know how, where, or why."  Does it affect the cell membrane?  Does it affect antibodies?  Are there special proteins generated?  Does it strengthen the cell nuclear membrane?  I would be very, VERY hesitant to use any form of treatment where the method of action isn't even theoretically outlined.  The people developing this treatment are certainly not acting as responsible scientists, and are certainly not using proper scientific method.  Where is the control or placebo group?  Have they done double-blind studies to prevent bias on the part of the participants?

All of the above is my opinion and analysis.  I'm certainly not a specialist or a virologist, just someone who can look at the data analytically and without bias.  Feel free to ignore my opinion.  But here are some thoughts on this treatment by specialists in the field, as posted on the Veterinary Information Network (VIN).

From Dr. Melissa Kennedy, DVM, PhD, Diplomate American College of Veterinary Internal Medicine.  She is a clinical virologist at the University of Tennessee College of Veterinary Medicine, so with a double-doctorate and a speciality in internal medicine, she spends her career studying and teaching about viral diseases.....

"No cure yet.  There are a number of urban myths out there, like the Newcastle Disease serum."

Dr. Alice Wolf, DVM, Diplomate of the American College of Veterinary Internal Medicine and Diplomate of the Amercan Board of Veterinary practitioners is even more blunt and vocal.

"He doesn't have to 'prove' that it works.  It's not a USDA or FDA product.  He can say anything he wants.  His argument would be for us to prove that it doesn't work."

"If it sounds too good to be true, it probably is."

When asked how he gets away with it she replied "A la P.T. Barnum... There's a sucker born every minute?"

So let's summarize.....We have vets using a treatment for one virus, stimulated by a vaccination for a completely separate virus, and neither virus affects the other species (birds and canines).  There are more closely related viruses that could be used (measels), yet aren't.  The treatment "works", but the people using it don't have an inkling about even how it possibly could, other than some vague and mysterious "unknown material".  The "study" performed has numerous holes in it that significantly calls into question any so-called results, and would be soundly refuted by any scientific publication.  Reputable experts in the field, including at least one virology specialist, have clearly stated that this is a "myth" and should not be considered a valid treatment.

I know that people really want there to be a cure for canine distemper.  So do I.  But based on what I can see from this information, the NDV treatment is not a valid one.