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Tuesday, December 27, 2016

Reflecting On Great Clients

As 2016 winds down to a close I've been thinking about some of my really great clients.  I've been at my current clinic for almost 6 years, and some clients followed me over from my previous one.  This means I have a few clients whose pets I've been seeing for nearly a decade.  During that time you can really get to know people and develop a close relationship.  

Many small animal vets thrive on these relationships. It's certainly something that I enjoy, and it helps when I know not just the pets but the human family members as well.  While I can't say that I really like every single one of my clients (nobody can say that), there are many that with whom I have a special relationship.  For example I had one of my long-term clients invite me and my wife to a Christmas party at their home.  Unfortunately I couldn't attend due to other commitments, but it meant a lot to me that they thought to consider us.  Because I've moved around a lot during my career I haven't had these lengthy relationships with clients until now.

This time of year we typically have clients bring us Christmas cards and cookies, and they are always very much appreciated.  It really means a lot to me and my staff when somebody takes the time to stop by and deliver a card and food just to let us know that they appreciate us and what we do.  These kinds of clients really help make up for the difficult ones and are a large part of the reason why we as vets tolerate long hours, difficult work, and comparably low pay.  

When I was younger I said that I didn't like people, and for the most part I still don't.  People as a whole are rather difficult, and being an introvert I want to minimize interactions.  However, when I was in vet school I realized that I did like "good" clients and enjoyed helping them and their pets.  I am very nice and outgoing to all of my clients, even ones I'd rather not see, because my responsibility is to care for their pets and I believe in treating people as I want to be treated, not how they treat me.  But there are some clients that I look forward to seeing because I've known them for so long, they take good care of their pets, and they're fun to be around.  It's these clients that give me the motivation to come to work every day and make the effort in my job worthwhile.

So a big "THANKS" to all of my great clients that I've met and had over the year (and previous years).  You make my job easier and keep me smiling.

Saturday, December 24, 2016

Merry Christmas!

I hope that everyone has a very joyous Christmas season, however you may celebrate it.  Spend time with family, enjoy some gift-giving, and don't leave your pets out of the fun (though limit any treats to those specifically for pets).  But remember that the main reason we recognize this holiday is because of the birth of Jesus Christ, and what He has done for the world.
Merry Christmas, everyone!

Wednesday, December 21, 2016

Yes, We Really Do Need To See Your Pet For Prescriptions

One of my favorite websites is, and I've shared things from there before.  I came across the following post and it mirrors something that I see far too frequently.

(One of my coworkers is relatively new and often sounds unsure when repeating information or instructions. Clients tend to try to take advantage of that, and my coworker isn’t confident enough to know when to put her foot down.)
Coworker: “Can you help me with this call? [Client] wants a prescription refill for [Patient]. I checked with [Doctor] and she said we need to do an exam since we haven’t seen [Patient] in so long, but [Client] isn’t liking that answer.”
Me: “Yeah, sure.” *picking up phone, to [Client]:* “Hi there, this is [My Name]. [Coworker] said you had some questions about a prescription refill for [Patient]?”
Client: “Yes! I need a refill of [medication] for [Patient], but the other girl said that [Patient] needs to be seen first! She HAS been seen!”
Me: “According to our records, we haven’t seen [Patient] in almost 18 months.”
Client: “No, no! I took her to a vet in [State]! She HAS been seen!”
Me: “Well, ma’am, pharmacy law states that in order to write a prescription we have to have physically seen a patient within the last 12 months.”
Client: “That’s ridiculous. I can’t believe that!”
Me: “I apologize, but the law is the law.”
Client: “Well, what am I supposed to do, then?!”
Me: “I can either set up an appointment to get [Patient] seen–”
Client: “But she HAS been seen!”
Me: “—or you can contact the vet in [State] that saw [Patient] to see if they will send over a prescription.”
Client: “Can’t you call them and get the visit history?”
Me: “I could, but that doesn’t change that we need to physically see [Patient], here, in the office, for an examination, before one of our doctors would even consider writing a prescription.”
Client: “I just don’t understand why you won’t write a prescription!”
Me: “Because it is illegal. You are asking us to break the law.”
Client: “Well, you’re useless, aren’t you!?” *hangs up*

Sunday, December 18, 2016

When Good Companies Promote Bad Ideas

Recently a reader joined in a discussion from a couple of years ago, and asked a very good question.

As per your responses it makes me think of two additional things. I have read the replies from you and even others that grains are not bad for our dogs and you seem to imply that the brands you mentioned do more research and would be better but have you noticed that even Purina Pro Plan and Iams and Hills Science Diet are getting into the grain free or limited grain dog foods? I do not mean this as a gotcha question but rather it all confuses me.

This very thing is something that has been bothering me lately.  I consider Purina, Iams, Hills, and Royal Canin to be good food companies who have put a lot of money into nutritional research and the development of good quality foods.  So why are we seeing them make diets that nutritional specialists routinely say are unnecessary or misinformed?  Why are they making foods similar to those produced by companies that perpetuate false nutritional information?

I hate to say it, but it comes down to money and market share.

A few years ago somebody started saying that dogs and cats shouldn't have grains in their diets.  The idea started spreading and soon people were thinking that "grains are bad" and we need to eliminate them from pet foods.  Some manufacturers made a big deal about this idea and people on the internet started writing about it and spreading it.  Yet there has never been any legitimate scientific basis for these claims and board-certified specialists and nutritional researchers have disputed the information.  While there is strong evidence that grains are perfectly fine and readily digestible for most dogs and cats, somehow people started buying into the idea that grain-free diets were somehow better.

People mistakenly thought that they were buying good food for their dogs and certain food companies heavily marketed this aspect of their diets, disparaging other brands in the process.  Poorly informed consumers started buying these foods in larger amounts and the companies who promoted grain-free diets prospered and gained larger shares of the market.

Now the following is speculation on my part, but I think I have some very valid points and with some knowledge of the various companies and the real science behind pet foods I think I'm right on the mark.

Even though Purina, Iams, Hills, and Royal Canin are all good companies and produce good foods, they exist to make a profit.  Their boards of directors and presidents were probably looking at the expansion of grain-free foods in the market and seeing their own sales decrease.  So what do you do if you're a large company?  Do you spend time and money to try and correct the misinformation and have campaigns that talk about how ridiculous grain-free diets are?

Well, that would be the right thing to do.  But when do we see companies do this?  And if they do, how successful are they?  

So these companies did what pretty much every company does.  They make products to meet consumer demand.

The same thing has happened with gluten-free foods for humans.  For the vast majority of people there is no problem with gluten in foods.  Even many of the people who think they have a gluten sensitivity really don't.  But we now see a large number of products manufactured "gluten free", and even existing products that have never contained gluten changing their packaging to say "gluten free".

The large companies aren't saying that grain-free diets are better.  If you notice, they're still making plenty of foods that contain grains.  What they're doing is recognizing a demand and interest from pet owners, then making foods that cater to those people.  By doing so they are regaining some market share and selling more foods.

This drives me absolutely crazy because now we have even good companies who are upholding the myth that these kinds of foods are somehow better.  But the only way to fix it is for people to start sharing the correct information and bust those myths.  

As I am trying to do. 

Well informed pet owners will stop buying these foods, which will decrease demand and will result in fewer products and less misinformation.

Thursday, December 15, 2016

Holiday Safety Tips

This time of the year I worry about my patients almost more than any other time.  With all of the holidays and decorations there are some significant risks for chewing on or eat things that dogs and cats should really avoid.  Pet owners need to be especially vigilant for the next several weeks.  Here are some good tips and hints to make the holidays safe and happy for everyone.

Monday, December 12, 2016

Rubber Band Tail Docks.....How To P*** Off A Vet

I've seen a lot of bad things in my 30+ years in veterinary medicine.  Plenty of neglect, some malpractice, carelessness, stupidity, and lots of things that aren't the fault of an owner.  I've become used to handling situations like these, and even perhaps a little jaded from so many years of seeing them.  We've come a long way in pet care just in my lifetime, let alone within the last century, so it somewhat surprises me when I see people still doing things that were a bad idea 50 years ago.

Recently a client brought in their brand new puppy.  They had picked her up just a few hours before and noticed that something wasn't normal with the tail.  They were told by the breeder that they had "docked" the tail themselves.

Let me pause for a moment to describe exactly what tail docking is.  Typically this is done in certain breeds when a dog is three to five days old.  There is no medical benefit for doing so, and it's only because people have come to expect a breed to look a certain way.  If done appropriately a vet will see the puppy, do a surgical scrub to disinfect the tail, and then use a sharp scalpel blade to cut through the skin and muscle and between the bones in the tail.  This hurts very briefly and there is minimal bleeding.  Either some surgical skin glue/adhesive or a quick stich are used to close the wound, and the puppy is put back with the mother.  The procedure takes no more than a minute or two in skilled hands, and within a few minutes afterwards the puppy is acting normal. 

But there are older "country" or "redneck" ways to dock a tail.  The most common is to tie a rubber band tightly around the tail at the desired level and just leave it there.  The idea is that blood flow stops and the end of the tail past the band simply falls off.

How idiotic!

Let's evaluate this method for a bit.  First, it's often done on older puppies who have thicker tails with more tissue.  The larger tail makes it more difficult to achieve the desired results.  But even so, stop and think for a minute.  Doing this is exactly the same as if you tied a rubber band around your pinkie finger and it eventually fell off.  How long would this take?  How much would it hurt?  How much risk of infection would there be?  I don't think any sensible, rational person would ever think that amputating a finger should be done with a rubber band.

The band constricts blood flow.  Without blood supply the tissues die.  With enough time they will deteriorate and fall off.  But the nerves aren't initially damaged so it will hurt quite a bit.  It's not natural for tissues to die in that amount, and restricted blood flow is not healthy.  You are not getting closure of the skin so a combination of dead/dying tissue and open wounds results in a high risk of infection.  If the tail is particularly thick you may not even get complete destruction of all tissue, leaving some muscle and the bone while the skin falls off.

Can you see how cruel and ridiculous this is? 

Now back to the puppy.  And as I'm sure you can guess, what I described above is what happened.  She was about six or seven weeks old and when I saw her this is what the tail looked like.

That white tip on the end?  That's bone sticking out.  And the whole thing looked worse than how it appears in the picture.

Immediately upon seeing it I knew what had happened, and this was confirmed when I found this elastic band around the base where the viable skin stopped. 

I'm a very even-tempered, good-natured person, and it really takes a lot for me to get angry or lose my temper.  When I do get upset, I tend to get very quiet and stern.  One of my techs noticed this as I was describing to some of the staff what I was seeing and what had happened.  She said "Uh, oh.  Dr. Bern is quiet.  He has his mad face on."  And she was right.  I was royally ticked off at the breeder for having done this, and was working on how to remain professional yet honest when I told the new owners what was going on.  In fact, I can't remember the last time I was that pi**ed off at work, especially over a client situation.  My staff has rarely ever seen me get like that so they knew something big was going on.

The puppy had been left with us for a little while so when the owners came back I went into the room with them.  They confirmed that the breeder had told them that they had been the ones to "dock" the tail, and the clients knew something wasn't right when they saw it, which is why they brought the puppy to me.  I started to explain to them exactly what had happened and showed them the elastic band.  I was polite but very firm and blunt.  I could see the husband's face becoming like mine had been just a few minutes before, and the wife looked ready to cry.  He had suspected something like this but couldn't believe that anyone could actually do it.  I told them that I had heard many times of this being done, but this was the first time I had seen it in person. 

Then I had to drop the other shoe.  A problem like that won't heal with just antibiotics and a bandage (if a bandage will even stay on a tail like that, which it likely won't).  She is going to need to have the tip of the tail surgically amputated and the skin closed over it.  We really can't save the tail tip and if surgery isn't done soon she risks worse infection.  So not only had they spent money to purchase this dog, but they were now going to have to spend $600-800 or more to have the tail fixed.  All because some dip-wad jerk thought they could shorten a tail by cutting off the blood supply with a rubber band.

This upset them even more, but not at me.  And I could tell that they honestly felt bad about what happened and that it wasn't their fault.  The husband said that he thought she might need surgery so while my comments bothered him they didn't surprise him.

The three of us shared several moments of being furious over what the breeder did to this poor puppy.  They were in a tough situation because they had only had her for a few hours and were now faced with expensive surgery.  At the same time they couldn't bring themselves to take her back because of fear of what would happen to her then.  So they made the decision to keep her and fix the tail.  I was really impressed with their commitment and compassion for this little pup.

Part of our discussion was around the cruelty of this breeder.  And I'll be very, very blunt.  I consider this animal cruelty without any doubt.  I don't see how any reasonable, compassionate person could think otherwise.  If anyone reading this is one of the breeders who does such things, I would say the same thing to your face.  This is inexcusable, intolerable, and unnecessary.  That puppy was put through pain and developed an infection because a human wanted their tail to look a certain way and took it upon themselves do try and cause physical change in a way that would make cavemen cringe.  It's one thing if a veterinarian performs surgery in a sterile way and manages pain.  It's another thing to simply tie a rubber band and wait for the tissues to die and fall off.

We did discuss contacting the local police department animal control division to report the breeder for animal cruelty.  The clients seemed very ready to do this, and I hope that they did.  The breeder needs to never have dogs around them again, and absolutely should never be allowed to breed anymore.  There needs to be consequences for such inhumane actions.

I haven't seen the puppy for a follow-up because they have a different vet they normally see and we just happened to be close by and open on a Saturday.  But the clients said that they knew she'd be just as upset.  With proper care this puppy should end up being fine in the long run, and I think she has the kind of people who will do whatever it takes.

I'm glad that there are people like those clients.

Friday, December 9, 2016

No, I Can't Just Give An Injection

Giving oral medication to some pets is very difficult.  It can also be tricky to remember to give each dose.  So I understand why clients want me to just give their pet a shot rather than making them give medicine a couple of times per day.  But it's not as easy as many might think.
Most medicines take time to work, anywhere from a few days to several weeks.  Most medications have a "half-life" measured in hours.  This means that there are X hours before half of the drug is cleared from the body.  Then the same X hours before half of the remaining is cleared.  At some point the medication will be reduced below a therapeutic threshold where it will have any beneficial effect.
Antibiotics must stay above this threshold for at least a week and often several weeks in order to result in the death of all bacteria.  Anti-inflammatory medications have to stay above a certain concentration in order to keep inflammation in the body reduced effectively.  If the therapeutic blood levels are not maintained for an appropriate period of time therapy may fail or be less effective.
Some drugs are removed by normal body processes in a matter of a few hours.  In order to keep the levels high in the bloodstream the medication must be given several times per day.  Other drugs take longer to clear and so we can decrease the frequency of use to twice daily or even once daily.  How often we give medications is entirely dependent on the drug's half-life in the body and how well we can keep it above a minimum therapeutic concentration.  If you miss a dose then the concentration dips below this level, allowing bacteria to grow, inflammation to return, and potentially prolonging therapy.
Most injectable drugs differ only in the route of administration.  Both an oral or injectable cephalosporin antibiotic need to be given every 8-12 hours to be effective.  How we give it doesn't change what the body does to break it down and remove it, so while giving an injection at the vet clinic is easier than having to give pills at home, it isn't going to treat most problems.
With all of that being said, there are a few long-acting medications we can use.  There are two different kinds of steroids that will last for 7-14 days, and are often used as a quick fix for hot-spots, itching, or similar skin problems.  These are a nice option when you don't have a frequently recurring issue and want to help the pet quickly but don't want the client to have to give daily medications.  The down-side to these injections is that once it's in the body you can't take it out, and using them will prevent you using oral steroids for several weeks.  Oral medications allow more precise dosing changes to be done on a daily or weekly basis if needed.
There is also a long-acting antibiotic, currently used in the US under the brand name Convenia.  One injection is equivalent to two weeks of oral antibiotics.  This probably sounds miraculous and many people reading this are probably wondering why we don't use this for every infection.  That's a great question and there are legitimate answers.  First, no antibiotic is effective against every kind of infection.  There are so many different kinds of antibiotics because some work better in one part of the body or against certain bacteria than other antibiotics.  We use antibiotics based on the type and location of the infection, sometimes after performing a culture to test the effectiveness of several medications against the bacteria.  Convenia works well for skin infections, urinary infections, and abscesses, but won't work well for infections in the mouth, respiratory infections, bone infections, or most other kinds of problems.  So while it's great in certain circumstances, it's not a cure-all and will only be recommended if it's appropriate.  Also, Convenia is quite a bit more expensive than most other antibiotics, which can be a deal-breaker for some clients.  A $40 injection compared to $20 of pills probably is worthwhile to most people with a small dog or cat.  But a $100 injection compared to $40 worth of pills is a completely different situation.
I bring all of this up because I frequently get asked "Well, can't you just give him a shot?  I can't give him pills."  I really, really wish that I could!  But most injections that I give will last for 8-24 hours (depending on the drug) so the client will still have to end up giving pills later that day or by the next day.  While injections are simple, they will rarely fix the problem with one shot.

Tuesday, December 6, 2016

Fatty Liver Syndrome, Feeding Tubes, And Guilt

A few days ago I received the following email....
My sister lives in Italy and has just had to put her beloved female cat down of 12 years due to a bad case of hepatic lipidosis.  They were moving house, the cat was stressed and feeling out of sorts, and had lost weight. The problem was they have two cats and my sister in all the stress of moving wasn’t aware that she had stopped eating as the other cat was obviously eating for both.  I live in Australia and when I first heard that her cat was sick and a trip to her vet with blood tests came back normal, except for an elevated liver result, I immediately started to research this exact thing. ‘Excessive weight loss, no interest in eating, blood tests normal except for high liver result, ultrasound normal showing no mass, but slight inflammation of liver’… It told me a number of things but kept flagging lipidosis as primary or secondary outcome. In any case, I sent my sister this information and she discussed with her vet.

The vet kept the cat in for a few days and immediately rehydrated her via a drip and gave her AB’s, a shot of Vitamin K but at no point did she suggest an entero tube for feeding, instead she allowed my sister to take the cat home (understandably my sister felt that the cat would respond better with people she knows around her) and for my sister to force feed her via syringe a special supplemental food to get her back on track. Of course, my sister did that but noticed not much of an improvement in her cat. She was walking albeit wobbly, rapid, at times laboured breathing and was very emaciated. However, with the force feeding she had started to gain weight. My sister took her back after a week for a check up and they vet gave her a shot of anti-inflammatory medication and then a course of anti-inflammatory pills if she wasn’t vomiting. My sister noticed the next day the cat had really come alive (wanting to go outside for a walk, drinking water and using litter box as normal) but still no interest in eating on her own. Still, there was no mention of putting the cat on a gastro feeding tube via the stomach (which I read is less invasive to the cat and can be administered at home by the owner) which I know my sister would have happily done. In direct contraction now I read that giving an anti-inflammatory medication can make a cat with a liver issue much worse, so I have no idea why this was given when the blood test and ultrasound originally showed pointers to the liver being affected.

To cut a long story short nearly 2 weeks passed of my sister force feeding her cat, the continued laboured breathing got worse, she started vomiting a bit and wetting herself, then her ears became tinged yellow, a clear sign of jaundice related only to the lipidosis. She had to take her back to the vet when it was clear that she was suffering. Two days ago they had to put her down and my sister is blaming herself for a( not noticing her initial lack of appetite amidst all the stress of moving, and not knowing that a cat not eating for a certain period can affect the liver so seriously. What I cannot understand is the vet not immediately putting the cat on a gastro feeding tube, instead allowing her to go home to be force fed and ultimately allow the lipidosis to take a hold where it got beyond manageable. I feel she could have been saved 2 weeks ago and I’m so upset at what has happened.

I guess what I’m asking is do you think there’s a reason it wouldn’t have been offered? Perhaps a cat that is under so much stress from moving house, even with the feeding tube and recovery (and from what I’ve read 80% of cats can recover after a bout of lipidosis) perhaps if the initial stressor remains i.e moving house the cat will still refuse to eat on her own and continue to go down hill?

Maybe I’m clutching at straws, but both of us are feeling incredibly upset, guilty and frustrated that we didn’t do all we could to save Kity.

I would appreciate and be very grateful for any input/insight you have regarding a situation like this.

I definitely don't want to second-guess the vet in charge of this case, or say that they were wrong.  I wasn't there and don't have access to the medical notes, so I'm not going to assume that I know better.  That's not ethical for me to do as a veterinarian, and it would be the height of hubris for me to assume that I know better than the doctor who is directly involved with the case.  So I'm going to take this from a perspective of what I would do, as well as explain a few things about some of the points.

Let's start with the question of elevated liver enzymes.  Typically we look at two main values:  alanine transferase (ALT) and alkaline phosphatase (ALKP).  ALT is more specific to the liver as it is found exclusively in liver cells, while ALKP can be found in a few other tissues.  There are also several non-liver conditions that can cause ALKP to become elevated, including steroid use and laboratory artifact.  The is always a baseline level of these chemicals in the body, which is why we have a normal range for them.  When we see elevations in these values, especially when ALT increases, we generally assume that there is a problem with the liver.  However, these values don't give us the specific disorder, and only indicate liver damage with increased destruction of liver cells.  The cause for this damage can be from dozens of reasons, including toxins, infection, cancer, trauma, abnormal blood circulation, and many, many other things.  Elevation does not necessarily mean liver "failure", as the liver can still be functioning completely normally even while there is damage.  So when we see abnormalities in these values, we need to try and do further testing to determine the cause so we can focus treatment on the appropriate disease process.

Hepatic lipidosis, more commonly called fatty liver syndrome, is a condition that in veterinary medicine we see almost exclusively in cats.  This happens when abnormal fat metabolism results in infiltration of fat into the liver, causing abnormal liver function and possible liver failure.  Overweight or obese cats are far more likely to develop this condition than normal weight cats, and in my personal clinical experience I've never seen a normal weight cat develop fatty liver syndrome.  A key thing to keep in mind is that rarely is this a primary condition.  In almost every case lipidosis is secondary to another disorder.  That primary disease causes the cat to stop eating, and when that goes on for long enough the liver becomes infiltrated with fat.  So really it is a cessation of eating that leads to hepatic lipidosis.

Remembering this underlying cause is important for two reasons.  First, we need to find out why the cat is no longer eating.  We can possibly treat the fatty liver, but that doesn't tell us why the cat stopped eating in the first place.  The reason for the anorexia could have nothing whatsoever to do with the liver, and sometimes can be difficult to determine. Second, the primary way to treat fatty liver syndrome is to get food in the cat.  And that's not easy.

If a cat won't eat on their own, you have to force food into them.  This is rarely done intravenously because the IV feeding solutions carry a significant risk of systemic infection if not handled properly, so they are not done outside of critical care hospital situations.  That leaves having to somehow get food into the stomach.

The least complicated but often most difficult method of force-feeding is simply to use a critical care food and give it with a syringe by mouth.  Cats hate having anything forced into their mouth, and a cat that is nauseous or sick will typically resist having this done.  You also end up wasting some food as it dribbles out of the mouth, you miss with the syringe as the cat pushes away, or they push it back out with their tongue.

Another option is a nasoesophageal tube.  This is a small, soft rubber tube that is passed through the nasal passage into the esophagus.  It's relatively easy to perform and usually doesn't require any form of sedation.  The external part of the tube is taped or sutured to the top of the cat's head.  A syringe can be attached to the end of the tube and liquified food be fed through the tube directly into the esophagus.  This is a relatively short-term option and is usually used for only a few days.  A longer-term option is to perform minor surgery, making a small incision through the skin and esophagus to place a tube directly into the esophagus through the side of the neck.  While this second procedure allows longer feeding through the tube it also requires anesthesia and a higher level of skill to perform.

There is a downside and a risk to either nasoesophageal or esophageal tubes.  If the cat vomits, the end of the tube can turn back on itself, and the vet or pet owner can't always tell that this happens.  The end of the tube can advance back up towards the mouth, and when food is placed into it there is a risk that it can be forced up towards the trachea, resulting in aspiration of the food into the lungs.  This is a very bad situation and will result in a form of pneumonia.  While the risk of this happening to the tube is low, it is definitely a risk and something to watch for.

A more permanent option is a full stomach tube, often called a PEG tube.  This is performed under general anesthesia and usually with an endoscope.  A probe is placed into the stomach and pushed up against the stomach wall.  A small incision is made through the stomach and abdominal wall, enabling the placement of a small device that goes through the skin and into the stomach.  This device has a cap on the outside to allow closure between feedings.  The wound quickly seals around the PEG device, giving a long-term way to place food and liquid directly into the stomach, bypassing the esophagus and mouth.  These devices can be used long-term, and I've known cats to have them for up to a year.  Because of the equipment and expertise needed, PEG tubes are usually placed by a specialist.

As you can see, putting a tube in a cat isn't always simple, and each method carries various degrees of risk and cost.  Some vets don't do it because they don't feel comfortable with the procedure or worry about the secondary risks.  But if you're trying to treat fatty liver syndrome you absolutely HAVE to get food in the cat.  With proper feeding the fat will eventually come out of the liver and the liver has a great ability to regenerate.

Now let's get to some specifics of this particular case.

I've seen a lot of cats get stressed from a move, but I've never seen one completely stop eating.  Yes, it's possible, but not common.  Most of the time when a cat is stressed from a move it will have other behavioral changes, such as inappropriate urinating and defecating, marking behavior, hiding, and so on.  So in this case I would look for other causes of the sudden decrease in appetite, and come back to stress only if other problems have been eliminated.

The vet in this case did what I would have done as the next step after blood tests and performed an ultrasound.  It sounds like there was no evidence of a tumor, and apparently the imaging showed "inflammation".  Unfortunately this is a very non-specific term, and doesn't indicate lipidosis or any other specific disease.  I would also want to know if the inflammation was diffuse throughout the liver or if it was in focal areas.  Fatty liver tends to be more diffuse.

A yellowing, or jaundice, is specific to diseases of the liver or gall bladder, but is not specific to fatty liver syndrome.  Any advanced liver disorder can lead to this discoloration of tissues

If this had been my case, I would have likely done a trial of antibiotics, low-dose prednisolone, and a liver supplement to improve function.  At the same time I would have used an anti-nausea medicaiton and an appetite stimulant to help the cat eat better.  If it still wasn't eating I'd recommend at-home syringe feeding of a critical care diet.  A recheck would have been scheduled for one week when I would have repeated the blood tests to see if there was any improvement in the lab values, as well as looked for improvement in clinical symptoms.  Steroids can be indicated in many cases of liver disease as they do decrease inflammation.  However, I feel that oral medication should be used instead of injections because the pill or liquid can be more precisely dosed up or down and gets out fo the system faster.

If the cat wasn't improved I would next recommend a liver biopsy.  If someone has the right skills this can be done with a special needle guided by ultrasound, and doesn't always require surgery.  The biopsy should be able to tell us more specifically what is happening with the liver.  In fact, you can't accurately diagnosis lipidosis without a biopsy.

Yes, that's correct.  We can strongly suspect hepatic lipidosis based on clinical signs and the cat's weight but you can only truly diagnosis it by documenting excessive fat within the liver tissue on a biopsy.  So "inflammation" on an ultrasound may or may not indicate a fatty liver.

All of these steps and tests are to get down to the bottom of what is causing the lipidosis.  Remember that this is typically a secondary condition and we always need to find out why the cat stopped eating.  If we don't address that primary problem we'll never get the cat better.
Your sister shouldn't feel guilt.  I've moved many times and it's always stressful.  You have so many things going on that it's really hard to keep track of it all.  Also, the vast majority of cats go through a move with minimal stress, and if there is stress it rarely causes them to stop eating.  If her cat became so stressed that it wouldn't eat and that led to a fatty liver, this is an extremely rare situation that she couldn't have predicted.

Since fatty liver syndrome can only be properly diagnosed with a biopsy the vet probably had no reason to immediately suspect this as the main problem.  I probably wouldn't have.  Most vets probably would have proceeded similarly, with the potential exception of recommending a liver biopsy earlier in the process.  Again, I'm not going to completely second-guess that vet since I wasn't involved with the case.  But there are many reasons I can see for why they made those decisions.  Honestly, the best thing to do is ask that vet these questions, and see why they proceeded as they did.

Friday, December 2, 2016

A Client Apologized

A few weeks ago I had a client do something that has never happened to me in almost 20 years of practice.  She apologized for her behavior.
Vets are often faced with rude, thick-headed, or just difficult clients.  Most of us realize that this is part of working with people and most of those clients aren't intentionally causing problems.  We don't enjoy those kinds of people as it makes communication and treatment much more difficult.  But we learn how to handle it and how to continue caring for that client's pets.  Sometimes a client becomes very belligerent, unreasonable, or a general pain in the tush.  If the person is beyond the norm in their behaviors many vets will politely but firmly let that client know that they should seek veterinary care elsewhere.  While we can be used to tricky interpersonal situations, we're not psychologists and don't get paid enough to put up with anything that the worst client can throw at us.
Let's call my client Ms. A.  She is a long-term client of mine and I've cared for her pets for several years, being the preferred doctor when she comes in.  In October I saw her dog for some skin issues, and not serious ones.  I vaguely remember her being worried and asking some very pointed questions, even repeating them and saying "are you sure?"  But overall I didn't think much of it.  She can be a slightly difficult person, but well within reasonable limits and I've learned to have patience with her because she really does care about her animals. 
She came in for a follow-up visit and I was happy to see that her dog was much better and the problem had completely resolved.  As we were finishing up she asked my tech if she could speak to me alone.  That sent up some red flags!  I have never had a client do that, and I immediately started worrying and trying to figure out why she needed just me in the room.  I considered that there were problems with my staff, that she was angry at me, and a whole list of bad situations.  I was completely unprepared for what happened next.
"Dr. Bern, I need to apologize to you for my behavior last visit.  I was a real jerk."
I swear I think my jaw dropped open.  That was definitely not what I was expecting to hear!  And I started going through my memories to try and figure out what in the world she was talking about.  As I thought back to the previous visit I honestly couldn't remember her being a problem, and definitely not something that needed an apology.
I told her that and she thought I was just being nice.  I had to really firmly let her know that I couldn't remember anything bad that she had said or did, and emphasize that if I couldn't remember it then the incident must not have been a real problem.  She appreciated that but continued to explain and say how sorry she was for her attitude, as I've always done such a great job of caring for her pets and listening to her.
We talked for a bit, I assured her that there were no problems at my end, and we hugged it out.  I walked out of the room and explained it to my tech, who had also been wondering why she was asked to leave.
Over my career I've had numerous clients who really did owe me an apology.  I've been yelled at, cursed at, called names, blamed for every problem under the sun, and generally been treated by dirt.  Thankfully these bad clients are few and far between, otherwise I probably wouldn't be able to keep working in this field.  Most of my clients are wonderful and appreciative of our care.  But many of those difficult clients really did act impolitely and unreasonably, completely out of the realm of normal reactions.  Yet with all of those people I have never had a single one apologize.
Now I've had a client apologize for an attitude that I can't even remember! 
I told her how much I appreciated her and her apology, even if I couldn't recall any of the specifics and it didn't stand out in my mind.  Too many people don't take personal responsibility for their actions, and always try to blame someone else.  Ms. A absolutely sucked it up and put herself in a vulnerable position because she felt it was the right thing to do.  That amazed me and restored some of my faith in humanity.  And I'll be happy to put up with her in the future if she continues to have this attitude about herself.  A great client and one of the most positive experiences I've ever had.