tag:blogger.com,1999:blog-43045742445944678932024-03-17T01:50:15.560-04:00A Vet's Guide To LifePulling back the curtain on veterinary life since 2008.Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comBlogger1149125tag:blogger.com,1999:blog-4304574244594467893.post-24833725399355153652017-01-26T20:06:00.000-05:002017-01-26T20:06:03.982-05:00Realistic Dog Model To Replace Cadavers<div style="text-align: justify;">
I came across <a href="http://veterinarynews.dvm360.com/realistic-dog-model-created-effort-replace-canine-cadavers-veterinary-surgical-teaching">this article last year</a>, but never got around to writing about it. It's pretty cool!</div>
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A company, SynDaver, has created realistic dog models for veterinary schools. The intent is to replace cadavers used in veterinary studies, as well as live animal surgeries. Here is a quote from the article:</div>
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<i>The synthetic cadaver is made of water, fiber and salt. Each cadaver is anatomically correct and features lifelike fat, fascia planes, bones, muscles, ligaments, joints and all body systems.</i></div>
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<i>The skinless dog not only mimics the feeling of living tissue but breathes, has a heartbeat and can be programmed to simulate various diseases and medical complications. The skin even bleeds when surgical cuts are made, since the cadaver has a circulatory system.</i></div>
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I would be very curious to try one of these out myself! I love the idea, and agree with the concept of trying to reduce procedures done on living animals. However, a surgery on a model, no matter how sophisticated, can't duplicate the feel and circumstances of a living animal. Is it close enough to be comparable for training purposes? I don't know, and I'm hopeful that it would be. </div>
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Similar models are used in human medicine, so this may be something that would be very useful for veterinary students. If nothing else it's a great step in the right direction, and shows how far technology has come, as well as where it can help us in the future.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-74971407872368322062017-01-23T19:58:00.002-05:002017-01-24T19:42:43.222-05:00The Growth Of Corporate Veterinary Medicine<div style="text-align: justify;">
A few weeks ago a small bombshell hit the veterinary community. Mars, Inc. announced that they were buying Veterinary Centers of America (VCA) and their subsidiaries. And this has fueled strong discussions and great concern in the profession in the US.<br />
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To anyone not in the veterinary field the significance of this will likely be lost so let me give some details and perspective. Mars is the largest privately owned company in the world and spans every continent. The company was started by the Mars family and is still run by that family, now in the fourth and fifth generations after the founders. Most people know them for their candy products, such as M&Ms, Snickers, and other classics. But over time they have bought up many other companies, gaining access to their product lines. To get an idea of the incredible number of human and animal products they make, head over to the<a href="https://en.wikipedia.org/wiki/Mars,_Incorporated"> Wikipedia entry on them</a>.<br />
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Several years ago Mars bought all controlling interest in Banfield Pet Hospitals. This is a national veterinary chain, primarily based in PetSmart stores, currently with over 900 locations across the US. Last year Mars bought BluePearl, a chain of specialty and referral clinics with over 50 locations, and Pet Partners, a smaller corporation with over 50 vet clinics. This month they announced the purchase of VCA, which gives them nearly 800 clinics around the country. VCA also owns Antech Diagnostics, which is the largest veterinary diagnostic lab in the US, serving a majority of veterinarians across the country. By the end of this year the Mars company will own nearly 2000 veterinary clinics as well as a huge diagnostic laboratory. This is unheard of and unparalleled in the history of veterinary medicine.<br />
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Historically a veterinary clinic has been owned by one doctor or a small group of partners. Over the last 20-30 years we have seen a rise of large corporations such as Banfield and VCA, as well as smaller regional or local corporations that may have anywhere from a dozen or two to a hundred or more. While the two biggest companies gain most of the publicity and concern, there are many other smaller corporations out there (such as Pet Partners, now owned by Mars). But even with these companies the vast majority of veterinary practices are owned as a single location and not a conglomeration. Though Mars will own a large number of clinics, larger than any other company in history, they will control only about 6% of the practices in the US. <br />
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In my experience veterinarians as a whole are very strong-willed, independent people. When I was going through school we knew that the majority of the people graduating would go on to be owners or partners of a small animal clinic. This is still the case, but the patterns are changing. Historically it was almost an expectation that after practicing for a while a vet would buy into that clinic or open their own. But the younger generations of vets are less interested in being business owners, and are more interested in flexible schedules and quality of life outside of work. The younger vets simply don't want to have to work the 60+ hours per week that generations past saw as normal. I can't blame them. This shift is in part due to generational differences, but are also because the profession is skewing highly female and many of these doctors want the freedom to raise families without having to worry about running a business. While there are certainly still many vets who want to have a clinic of their own, and can run them successfully even with kids and a spouse, we are seeing fewer vets who want to go this route.<br />
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To these younger vets a corporation can seem very appealing. They can get a good salary, have a degree of flexibility with their work schedules, and simply never have to worry about taking out loans (on top of the ones from school) to start a clinic. They get to simply be a vet for their life, which is all that many of them want. A corporation, especially the larger ones, gives them the structure and freedom to have this lifestyle.<br />
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I've been following discussions on the Veterinary Information Network (VIN) and other sites. While there are some people who shrug and don't care about the growing Mars hold on our profession, there are others who are significantly worried about it. Here are some comments I've seen online.<br />
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<em>"My big concern with the acquisition is this: Who owns our profession now? I would argue that as of the drying of the ink on the Mars VCA deal veterinarians no longer have a profession. Now Mars Co which is in essence just a very wealthy family (who so far as I know are not veterinarians) are going to be substantiatively guiding our profession. We are now going to take our professional direction from the kings of candy. We have entered the new future of veterinary medicine not as a profession but rather as a trade in which each veterinarian is now a production unit."</em> <br />
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<em>"Essentially, if there is one player who owns a significant portion of the market, they will be able to dictate the conditions of how you practice, what your treatment recommendations would be, what products you use, and who you refer to." <br /><br />"There will be little room for dissent once the vertical integration is established. How are you going to say no when the other 75% of practices in your town are effectively owned by the same entity? There has always been the ability to move to another practice if you did not agree with management or philosophy of your current place of employment. This luxury may not be as available in the future."</em> <br />
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<em>"I would like to see my clients have choices. I would like to have choices about where I am able to refer clients for advanced care. Unfortunately the only emergency facilities around me for hundreds.....yes hundreds of miles are VCA or are in the process of becoming VCA."</em><br />
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<em>"I don't like feeling like I'm speaking for everyone, but in my case it doesn't matter that Mars/Banfield bought VCA - it could be VCA buying Banfield and Blue Pearl. It could be Apple, or Google, or GM, or Lockheed Martin buying VCA and Banfield. My problem is not with who is doing the buying, but the buying and consolidation under one (albeit big) roof is happening - and veterinarians aren't going to be driving the company."</em> <em> <br /><br />"While it may be true that Mars will control less than 10 %of the veterinary hospitals in the nation what I see on a local scale is unmitigated Monopoly." <br /><br />"While I cannot discuss my prices with my local practice owners, the VCA's and Banfields are more than able and in my experience willing to price fix a geographic area. Combine that with limited exit strategies to sell my practice, the increased cost of drugs, health insurance etc on a unit basis due to economies of scale ......I can tell you I am concerned.....very concerned. I can tell you that when individuals ask me if I would make the same decision to pursue veterinary medicine as a career today as I did twenty some years ago....as a tech and then as a doctor. The answer is no...emphatically no."</em> <br />
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<em>"I find the corporate takeover (though limited at this time) of our profession a tragic occurrence for future Veterinarians. As corporations control more of the profession we will become more of a cog in the machine and easily replaceable. I always looked at practice ownership as the means to improve my financial position in life as owners do make more money than employees. If this trend continues that will no longer be an option for future veterinarians to better their position and, at least to me, it seems to severely limit their financial future. Is Veterinary medicine doomed to become the "second" family income and no longer an option as the primary family income?"</em> <br />
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But not everyone is so "doom and gloom".<br />
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<em>"In the 10+ years I've been on VIN I've been reading threads about the certain and imminent doom of the profession at the hands of Banfield and VCA. Here we are 10 years later and they still have only 6.5% of the market COMBINED. I think we have the best of both worlds as a profession. The profession has a enough economic upside to be seen as a desirable asset to large companies, yet the vast majority of it is privately owned." <br /><br />"Mars is not the boogey man, they are a large company interested in profit that pursues other successful companies within their areas of interest and expertise. Personally I think smaller private equity firms are going to have a bigger impact on our profession's ownership over the next 20 years than one corporate player. No one talks about those deals though because they are invisible. (the clinic's name doesn't change)." <br /><br />"I think we're all going to be just fine, and I say this a practice owner surrounded by corporate practices. They were private clinics before (with the exception of a Petsmart Banfield) and now that they are corporately owned that just provides an extra differentiator ("locally-owned practice") for me that wasn't there before. In any case it's counter productive to think that veterinary practice owners-- uniquely among American small business owners--ought not to have to contend with corporate competition."</em> <br />
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<em>"A few years ago at a dinner party at a friends house, another guest was some big, mucky muck who ran in house seminars for Mars. It was his only job; setting up and conducting management seminars all over the country for Mars. He had a second home in Italy, so I gathered it paid well. We sat next to each other over dinner. He was fascinating and I gained a great deal of respect for how Mars operated. This might have been before Mars bought Banfield....I want to say Mars was always a financier of Banfield....but this would have been around 2002-3. Anyway, I've always been impressed with whatever mars has done. They look like they know what they're doing."</em><br />
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<em>"It's easy to blame Banfield because it's corporate and ubiquitous, but as said above, you will find plenty of questionable things happening at private practices as well - but it seems like if a doctor in private practice does questionable things, it gets blamed on the doctor. If a doctor does something questionable at Banfield, then Banfield gets blamed - not the doctor."</em> <br />
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As you can see there are some pretty passionate views on these events. Many people are genuinely worried for themselves and the profession as a whole, and some see this as the worst thing to have ever happened. Others simply aren't worried.<br />
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So what's my take on this?<br />
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First, I certainly don't subscribe to the opinion that all hope is lost and the profession is ending. I think that there are pros and cons to corporations owning veterinary practices. These companies often have better negotiating and purchasing power which allows them to manage costs more easily and give higher salaries and better benefits than a privately owned practice. There is more lateral and upward mobility for the veterinarians. They provide some consistency and guidelines for practicing vets. But they can be limiting in flexibility for an individual doctor. Sometimes the leaders can be unfeeling because they don't have a good understanding of day-to-day challenges. Change is often slow and difficult, unlike a private practice owner who can suddenly decide to buy a new chemistry analyzer.<br />
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I firmly believe that no veterinary practice is going to be perfect for everyone. I've seen privately owned clinics that are far stricter on dress codes, behavior, and medical choices than either VCA or Banfield. I know that vets who want their own practice or more independence will not be happy with a corporate environment. Doctors who only want to practice and never want to be owners or partners will be happy to turn over all business responsibilities and worries to someone else. A place that is a perfect fit for one person may be only manageable for another and be complete misery for someone else.<br />
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Our profession is changing, and doing so pretty rapidly. The demographics of who attends veterinary school has altered dramatically in the last 30 years. Within the last 60 years we have moved more and more from a rural to a suburban and urban outlook, with an increasingly smaller percentage of new graduates choosing to go into large animal medicine. The growth of the internet has seen a noticeable shift towards clients purchasing medications and preventative products online rather than buying them from the local vet. I would say that the internet has been a bigger problem for all kinds of businesses than any large corporation has.<br />
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In the US corporately owned veterinary practices aren't going away. But I don't see them becoming so large and all-encompassing that they wipe out the traditional privately owned practices. Just as there is room for chain restaurants and "mom and pop" ones, there is room for private and corporate veterinary practices. In fact, I think having both available gives veterinarians more choices about where they want to work.</div>
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Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-44471302758618132562017-01-20T17:58:00.000-05:002017-01-20T17:58:02.401-05:00The High Cost Of Becoming A Vet<div style="text-align: justify;">
I haven't written about veterinary education costs in quite a while, and unfortunately there has been no improvement in the situation. It is still extremely expensive to become a vet and salaries still remain very low, resulting in some significant challenges and hardships as young, new vets struggle to try and repay their loans while maintaining a moderate lifestyle.</div>
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Dr. Julie Funk, an Associate Dean and Professor at Michigan State University, <a href="https://theconversation.com/the-high-cost-of-pursuing-a-dream-to-be-a-veterinarian-67513">recently wrote an article about this issue</a>. Here are some choice quotes. </div>
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<strong>"</strong><a href="http://avmajournals.avma.org.proxy1.cl.msu.edu/doi/full/10.2460/javma.243.8.1122"><em><strong>A 2013 national survey</strong></em></a><em><strong> of DVM graduates found the average debt for students was as high as US$162,113. This is similar to the </strong></em><a href="https://members.aamc.org/eweb/DynamicPage.aspx?Action=Add&ObjectKeyFrom=1A83491A-9853-4C87-86A4-F7D95601C2E2&WebCode=ProdDetailAdd&DoNotSave=yes&ParentObject=CentralizedOrderEntry&ParentDataObject=Invoice%20Detail&ivd_formkey=69202792-63d7-4ba2-bf4e-a0da41270555&ivd_prc_prd_key=D9B3A33A-B3B5-4F02-9A95-E19B7CECF07A"><em><strong>average educational debt</strong></em></a><em><strong> of $180,723 accrued by physicians in 2015. However, physicians have much higher lifetime earnings than veterinarians, making it easier for them to manage their debt.</strong></em></div>
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<em><strong>It is true at the beginning of their careers, salaries for veterinarians and physicians are quite comparable: Veterinarians get, on average, a </strong></em><a href="https://members.aamc.org/eweb/DynamicPage.aspx?Action=Add&ObjectKeyFrom=1A83491A-9853-4C87-86A4-F7D95601C2E2&WebCode=ProdDetailAdd&DoNotSave=yes&ParentObject=CentralizedOrderEntry&ParentDataObject=Invoice%20Detail&ivd_formkey=69202792-63d7-4ba2-bf4e-a0da41270555&ivd_prc_prd_key=D9B3A33A-B3B5-4F02-9A95-E19B7CECF07A"><em><strong>full-time starting salary</strong></em></a><em><strong> of $67,136 annually. Physicians, who pursue residencies for advanced specialty training under supervision, soon after graduation, earn an average first-year salary of $52,200. </strong></em></div>
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<em><strong>However, this changes over the years. The lifelong earning potential of physicians improves significantly </strong></em><a href="http://avmajournals.avma.org.proxy1.cl.msu.edu/doi/full/10.2460/javma.246.4.422"><em><strong>in comparison with veterinarians</strong></em></a><em><strong>. Over a period of time, the </strong></em><a href="http://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm"><em><strong>overall median salary</strong></em></a><em><strong> of a physician gets to $187,200, </strong></em><a href="http://www.bls.gov/ooh/healthcare/veterinarians.htm"><em><strong>whereas that of a</strong></em></a><em><strong> veterinarian remains at about $88,490.</strong></em></div>
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<em><strong>The situation is worse for women. Female veterinarians, on average, </strong></em><a href="http://avmajournals.avma.org.proxy1.cl.msu.edu/doi/full/10.2460/javma.246.4.422"><em><strong>will not even break even</strong></em></a><em><strong> on their educational investment until they are well past the age of 65 (or older)."</strong></em></div>
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That last statement is particularly troubling since in the US 75-80% of veterinary classes are female. How bad is it that they aren't likely to even break even on their education costs until they retire around 40 years later???</div>
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The future for veterinary students is not promising, as Dr. Funk points out later in the article.</div>
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<em><strong>"As a result of the growth in the colleges of veterinary medicine, more seats are available. (What is </strong></em><a href="http://aavmc.org/data/files/reports/annual%20report%202015%20aavmc_final_r.pdf"><em><strong>decreasing</strong></em></a><em><strong>, however, is the applicant-to-seat ratio.) Two new colleges are seeking accreditation, while the existing ones are boosting class size. This expansion is happening in the face of the </strong></em><a href="http://avmajournals.avma.org.proxy1.cl.msu.edu/doi/full/10.2460/javma.242.11.1507"><em><strong>2013 Veterinary Workforce Study</strong></em></a><em><strong> that estimates that there is an excess of veterinary labor nationally.</strong></em></div>
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<em><strong>High tuition, low wages, an oversupply of veterinarians and more seats to study veterinary medicine are strong signals of a veterinary education market bubble."</strong></em></div>
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What these facts indicate is that's there are more people entering the field, yet on a national average there are more vets than are needed. Colleges are increasing the number of students they accept and new schools are being built, yet there is no need to expand the number of newly graduated veterinarians. In the end this may very well result in a glut of veterinarians, which could cause lower wages as employers can pick new hires who are willing to work for less and those new hires will accept it because there are fewer job opportunities.</div>
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For most of us veterinary medicine isn't just a job, it's a calling. I started wanting to be a vet when I was nine years old, and that's typical of most of us in the profession. When your heart desires something so strongly it becomes hard to resist and look at the reality of the situation. </div>
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The veterinary colleges and national organizations have had numerous discussions, debates, panels, and reports over the last 10 years or so, but so far all I've seen is more of the same information and confirmation of previous information. For many years we keep seeing the outcome of these various studies as "Yep, debt is worse, salaries are no better, the problem is literally a crisis, and it's not getting better in the near future." Well, we know that by now. What we're lacking in the profession is a consensus of how to solve this crisis. Maybe we should be shrinking class size rather than expanding them. Maybe we should be closing schools rather than opening new ones. Perhaps if there were fewer vets entering the workforce we would see salaries rise as competition increased. </div>
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Some have suggested looking at a model where an undergraduate and graduate degree are obtained at the same time. Currently virtually everyone first spends an average of four years obtaining a Bachelor's degree, then another four years for their veterinary doctorate. Much of that undergraduate education is spent on classes intended to make someone well rounded but that doesn't have anything to do with the career. I took two semesters of calculus in college, but I couldn't tell you what I learned or how it might be useful. I can guarantee that in 20 years as a vet I've never had any cause to use the information in those classes. As much as I enjoyed my literature and history courses they really have never applied to my career. If the first 2-3 years of college were strictly pre-veterinary courses and then the last 3-4 years were on veterinary education itself you could reduce the time to become a vet by about two years. That means two years of tuition and other expenses that you don't have to pay, and don't go into debt over! Make the education year-round without summers off and some have speculated that you could become a vet in as little as five years! There are pros and cons to this proposal, but it's one being considered. Unfortunately I don't think it would be accepted by the majority of veterinary colleges or the veterinary licensing entities, so something like this in the US is probably a long way off.</div>
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I know that it's very depressing and disheartening, but I honestly can't recommend this as a good time to go into veterinary medicine. Student debt load is quickly increasing while at the same time starting salaries are stagnant or even decreasing. These horrible facts are not likely to change in the next few years. I know that young people with a passion to be a vet will read these words and potentially despair. Yes, the future is a little bleak if you haven't actually become a vet yet. If someone still chooses to follow that dream I would strongly encourage them to be VERY good at budgeting, realize the huge amount of debt they will have coming out, and even consult a professional financial planner.</div>
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I'm just glad I graduated 20 years ago when it wasn't nearly as bad as it is now.</div>
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Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-1146662423752152502017-01-18T21:11:00.001-05:002017-01-18T21:13:44.161-05:00Poisonous Plants To Keep Away From PetsRecently ProFlowers.com contacted me about an<a href="http://www.proflowers.com/blog/poisonous-plants"> infographic they have on their website</a> which lists nearly 200 poisonous plants, how toxic they are, which parts or toxic, and which species to keep away from them. Honestly, this is one of the best summaries I've ever seen, so I'm sharing it here. Please pass this around to your friends and other pet owners. If you're having a hard time viewing it, click on the original link above.<br />
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Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-53489347753491333942017-01-14T18:36:00.000-05:002017-01-14T18:36:02.277-05:00What To Do With FIV Positive Cats<div style="text-align: justify;">
A few weeks ago I received the following email:</div>
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<strong>We just had a stray cat euthanized because he had FIV and the vet recommend this because we couldn't bring him in with out cats and we couldn't keep him outside to spread the disease and he would have been hard to adopt out because of the FIV and he was a fighter. He was sweet to us but had been in fights with area cats. I am feeling extreme guilt over this. Did we do the right thing? It seems like we did what was best for us and maybe not the cat. I am devastated and am feeling like a horrible person.</strong></div>
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I've had this exact same situation come up a few times in the past. It's never easy to handle, and always a tough decision.</div>
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Feline immunodeficiency virus (FIV) is very similar to HIV in humans. In fact, some veterinary researchers on the disease have collaborated with HIV researchers and vice-versa. The virus can lay dormant in a body for years and become active at any time. Once it activates and affects the body it proceeds very similar to AIDS in humans, suppressing the immune system, lowering white blood cell counts, and making the patient much more susceptible to infections. When the virus starts along this path there really isn't anything we can do. We don't have a wide range of antiviral drugs in animals like there are in humans, so essentially a diagnosis of FIV is a ticking time bomb and an eventual death sentence.</div>
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Once a diagnosis of FIV is made, the cat may live a few more weeks or several more years. There is no way to predict what their lifespan will be. But we know that they won't live as long as an uninfected cat and will be more prone to health problems. At some point in the cat's life the virus will lead to its death. Unfortunately there is currently no treatment or cure for FIV, so once a cat has it they are infected for life and are at risk of spreading it to other cats.</div>
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So what do you do when a cat is diagnosed?</div>
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I 100% feel that these cats need to be isolated indoors. If you allow them to continue to roam outside they are most likely spreading the virus to other cats and therefore giving more animals a death sentence. When they are "fighters" as in the email above this is much more likely, and every time it fights with another cat it is probably passing along FIV. If a cat can be kept indoors they can still live a good life until they become seriously ill, and I've known many FIV positive cats who have lived more than five years indoors before succumbing to the disease. So I don't think that a cat with FIV but no symptoms automatically needs to be euthanized.</div>
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Some people can't keep the cat inside for various reasons. Maybe they have other cats, and there is certainly a risk of passing FIV to the ones that person already has. Some outdoor cats won't tolerate being kept inside and will be destructive with scratching and spraying. So there are certainly situations where that cat can't be kept in the home.</div>
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What do we do then? We can't keep the cat inside, but we can't let it outside to be a vector of infection.</div>
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As harsh as it may sound, the best option is often humane euthanasia.</div>
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Stop and think about it. Is keeping that cat alive worth having a dozen more cats develop FIV? While it sounds pretty cold and unfeeling I do believe in this situation we have to look at the greater good and the potential for the most harm. It is a bit of an ethical dilemma, but I personally think that gently ending the infected cat's life to prevent infection in 20 other cats is justifiable. It's not easy, but it's the best option in a bad situation.</div>
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With a stray cat kept outside a person also not know when that animal becomes sick. A cat with active FIV may slowly die a miserable death somewhere in the woods or under a porch. Do we leave them outside to have this eventually happen, or do we give them a quick, peaceful death before they suffer?</div>
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I have euthanized a few FIV positive cats in the exact situation described in the email. I haven't enjoyed it but I also haven't felt guilty about it afterwards. I don't think any pet owner should feel bad about making this choice, even if it's not ideal. In the words of Spock in <em>Star Trek: The Wrath of Khan</em>, "The needs of the many outweigh the needs of the few, or the one."</div>
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Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-16349818148606532982017-01-11T18:32:00.004-05:002017-01-11T18:32:57.505-05:00Predator Birds And Small Dogs<div style="text-align: justify;">
Here's a question that in over eight years of blogging I haven't been asked!</div>
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<strong>We saw a bald eagle fly over our house the other day. We've also seen hawks and owls. My concern is our 13 lb dog's safety. I was wondering if she wore a piece of clothing outside if that would somehow make her look less like an animal they would want to pick up. I was just looking online and found this page that mentions different products that are on the market. Do you know if any of these products are helpful? At the end of the article it said eagles can only pick up 4-5 lbs but other places I read much larger. Would love to know your thoughts.</strong></div>
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<a data-saferedirecturl="https://www.google.com/url?hl=en&q=https://www.adn.com/voices/article/alaskan-invents-flashy-coats-safeguard-tiny-dogs-predators/2016/05/16/&source=gmail&ust=1484259777039000&usg=AFQjCNH2ttsz6rgm_XCQUPmDJOxZeRLSKQ" href="https://www.adn.com/voices/article/alaskan-invents-flashy-coats-safeguard-tiny-dogs-predators/2016/05/16/" target="_blank"><strong><span style="color: #1155cc;">https://www.adn.com/voices/<wbr></wbr></span>article/alaskan-invents-<wbr></wbr>flashy-coats-safeguard-tiny-<wbr></wbr>dogs-predators/2016/05/16/</strong></a></div>
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When you think of a large raptor such as a hawk or eagle, you wouldn't think of them as a potential concern for your pets. After all, that's just Hollywood, right? You might think of it happening in a movie such as <em>The Proposal</em> (Ryan Reynolds & Sandra Bullock) but not in real life. Isn't it a myth?</div>
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I'm sorry to say that it's not. While rare, birds of prey will occasionally try and take off with a small dog. I've had at least one client who lost a small dog to a hawk. So this is one that is definitely not a myth.</div>
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Bald eagles prefer fish over small mammals, but other kinds of eagles may have more variety in their diet so it depends on what is native to your area. Hawks and owls do prefer small mammals, but will eat just about anything they can get their claws on. Since some of the larger raptors feed on rabbits, which can weigh 4-6 pounds or more, a dog about that size certainly isn't safe. I don't have information on exactly how much weight a large predatory bird can carry, so I'm not going to try and hazard a guess. Keep in mind that they don't always carry their prey away, and sometimes will kill and eat it on the same place.</div>
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What can a pet owner do? The link above is pretty interesting, and I think those products have some potential. It's the first time I've ever heard of them so I can't say whether or not they are effective, and I've never known anyone to try them. But if I had a small dog in this situation it sounds like it probably wouldn't hurt to give it a try. I would be slightly skeptical that a reflective surface would always work, as I would imagine it being less effective on a very cloudy day. But the dog probably wouldn't look like prey with this on, so that's a good thing. If we're merely going by whether or not it looks like prey to a raptor, you might achieve a similar effect with a colorful shirt or jacket designed for dogs.</div>
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I do recommend being aware of the types of high level predators you might have in your area, and for birds I would be cautious with any dog or cat under 15 pounds. Ones under 10 pounds are more at risk. If you know you have hawks, eagles, and owls in the area I wouldn't let your dog go outside unsupervised, and if you are in a very rural area you may consider only ever taking your dog out on a leash. A raptor isn't likely to try and kill or capture a dog when a human is a few feet away, and if for some reason it did happen you'd have your dog on the leash, preventing the bird from flying away with him or her.</div>
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Those of you who have small dogs living in the same area as raptors, I wouldn't panic. These predators tend to prefer hunting without humans nearby, so most dogs will be safe. The risk exists, but even then the incidents of this happening are very rare. I still recommend taking some precautions because you don't want to lose your dog to a situation like this.</div>
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Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-27295277776085109372017-01-03T17:27:00.000-05:002017-01-11T18:55:03.605-05:00Case Management--Anxiety, Fear, Then Relief<div style="text-align: justify;">
As I've mentioned before, most vets (and medical professionals in general) really do worry about their patients. I know that I do. It's not uncommon for me to fret over a case for days, especially if it's complicated or doesn't go well. Most of the time it's not my fault if things go bad, but I will worry anyway because I'm my own worst critic.</div>
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One of the surgeries that I occasionally do is to correct "cherry eye". For those not familiar with the disorder, it is common in certain breeds (English bulldogs, Shar-peis, Shih-tzus, and cocker spaniels are the most prone) and results when the tear gland under the third eyelid becomes inflamed and prolapses. This causes a very obvious red, fleshy bump on the inside corner of the eye. If untreated there is a risk of chronic inflammation and damage to the gland, which is responsible for the majority of tear production in the eye. We don't want to remove the gland because we would decrease the tear film and cause dry eye problems. The only real fix is surgery.</div>
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The most common method, and the one that I do, involves making an incision on either side of the gland, forming a pocket under the tissues, placing the gland within this pocket, and then closing the edges over the gland with sutures. Because the eye is so sensitive we use very small suture material, typically about the thickness of a human hair or smaller. While the surgery is typically successful there is about a 20-30% "failure" or recurrence rate even with the best surgeon. The gland can re-prolapse because the suture breaks, the technique was poor, the tissues fail to heal, or the inflammation is too persistent. Most of these reasons have nothing to do with the doctor, which is why the failure rate is so high compared to other surgeries.</div>
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I've been performing this procedure for all of my nearly 20 years in practice and have become pretty proficient with it. Though I haven't specifically tracked the numbers I would say that my recurrence rate is around 20-25%, right within expectations. Even so, I really hate it when one of my patients has a relapse and I worry about whether or not my technique was correct or if somehow I had failed as a surgeon which led to the failure of the surgery.</div>
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A couple of months ago I had that happen. About three days after the surgery the client called to say that it had prolapsed again. I had her bring the dog in and it looked like the suture had broken. We would have to repeat the surgery, and I said that I'd give her a $100 discount on the second procedure due to the inconvenience. Even though it didn't look like it was my fault, I worried about it, and started to doubt myself. I promised that the next time I did this type of surgery I would be even more careful with my steps and method.</div>
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That opportunity came in late November, with a shar-pei puppy who had both glands prolapse. When I did the surgery I was extra-careful about my incisions, suture placement, knots, and generally everything that I could potentially control. The surgery went well and the patient looked great post-operatively. I was very hopeful that this one would be successful but I remembered my last case.</div>
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About 10 days after the surgery I came in to work and there was a note for me that the client had called and I should check the medical records. My heart dropped into my stomach and my first thought was "crap, one or both of the eyes failed and relapsed". I first saw the note around 8:15 am. I didn't actually look at the record until around 5:00 in the afternoon. I had time to do so, but was worrying about it the whole day. I just knew that the client was calling to say that it had happened again and perhaps be angry that it had done so. I always tell my clients two or three times what the rate of failure is, but that doesn't always stop people from being upset when it happens. I dreaded what I would see in the notes.</div>
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As the day went on I started thinking and worrying even more, to the point of being a bit sick to my stomach. I doubted my abilities, and even started thinking that maybe I should stop doing this particular surgery if I was going to have a high recurrence rate. Maybe I should be referring them out if I wasn't going to get it right the first time. Maybe I should never have attempted it in the first place.</div>
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So I finally steeled myself, gritted my teeth, and pulled out the medical records to read the notes from the previous day, preparing myself for the worst.</div>
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The client had called to ask if they could take the Elizabethan collar (e-collar or cone collar) off.</div>
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<em>That was it!</em> The client wasn't reporting any problems, only asking if it was okay to stop using the e-collar!</div>
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I breathed a deep sigh of relief and called the client. The dog was doing great and the eyes were perfectly fine. There was no sign of any problems or any recurrence and his puppy was acting like nothing had happened to her. We talked about taking the e-collar off and watching her for any other problems.</div>
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I had worried for nothing. I spent almost nine hours being anxious for no reason whatsoever. I had doubted my abilities when my personal success rate in these cases is right in line with the profession.</div>
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That's not uncommon for me and many of my colleagues. Most of us care deeply to the point of doubting ourselves if something doesn't go exactly right. It's easy to forget all of the "good" cases when we are presented with a "bad" one. Many of us worry ourselves sick for things that are beyond our control. Because of this veterinarians have a high rate of clinical anxiety and depression. It's not easy having someone's beloved pet depend on you for their life and health.</div>
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Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-63436221907919501022017-01-01T00:01:00.000-05:002017-01-01T00:01:06.465-05:00Welcome to 2017! Let's Hope It's better Than 2016....<div style="text-align: justify;">
It is now officially 2017. Happy New Year!<br />
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As I look back and reflect on 2016, I can say that it has been successful and good for me and my family. However, that hasn't been the case for the USA or the world. <br />
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An incredible number of celebrities and musicians passed away last year, some of them particularly tragic whether due to their young age or because they were so beloved. We had the most divisive, contentious, and horrible presidential election that I can ever remember, and most people are unhappy with the final result (and would have been even if Clinton had won). Many of my clients lost old, cherished pets over year, including ones I've been seeing for many years. For many people 2016 was pretty tough, and anyone on Facebook has surely seen the complaints and memes going around.<br />
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But 2017 is a new year. Even though January 1st really isn't that different from December 31st and the days go on as normal, psychologically we look at the date as a turning of the page and a new beginning.<br />
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Let's hope that 2017 is better than 2016 was! And if you had a great year, I hope that the new one is even better!</div>
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<br />Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-16953684700850209922016-12-27T13:24:00.000-05:002016-12-27T13:24:04.374-05:00Reflecting On Great Clients<div style="text-align: justify;">
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. </div>
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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.</div>
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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. </div>
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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.</div>
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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.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-90673720858663726392016-12-24T01:00:00.000-05:002016-12-24T01:00:27.173-05:00Merry Christmas!<div style="text-align: justify;">
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.</div>
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Merry Christmas, everyone!<br />
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Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-32186753282174838842016-12-21T20:59:00.000-05:002016-12-21T20:59:01.619-05:00Yes, We Really Do Need To See Your Pet For PrescriptionsOne of my favorite websites is <a href="http://notalwaysright.com/">NotAlwaysRight.com</a>, and I've shared things from there before. I came across the following post and it mirrors something that I see far too frequently. <br />
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(<em>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.)</em></div>
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<strong>Coworker:</strong> “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.”</div>
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<strong>Me:</strong> “Yeah, sure.” <em>*picking up phone, to [Client]:*</em> “Hi there, this is [My Name]. [Coworker] said you had some questions about a prescription refill for [Patient]?”</div>
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<strong>Client:</strong> “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!”</div>
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<strong>Me:</strong> “According to our records, we haven’t seen [Patient] in almost 18 months.”</div>
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<strong>Client:</strong> “No, no! I took her to a vet in [State]! She HAS been seen!”</div>
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<strong>Me:</strong> “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.”</div>
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<strong>Client:</strong> “That’s ridiculous. I can’t believe that!”</div>
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<strong>Me:</strong> “I apologize, but the law is the law.”</div>
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<strong>Client:</strong> “Well, what am I supposed to do, then?!”</div>
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<strong>Me:</strong> “I can either set up an appointment to get [Patient] seen–”</div>
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<strong>Client:</strong> “But she HAS been seen!”</div>
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<strong>Me:</strong> “—or you can contact the vet in [State] that saw [Patient] to see if they will send over a prescription.”</div>
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<strong>Client:</strong> “Can’t you call them and get the visit history?”</div>
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<strong>Me:</strong> “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.”</div>
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<strong>Client:</strong> “I just don’t understand why you won’t write a prescription!”</div>
<div style="background-color: white; font-family: "Open Sans", sans-serif; font-size: 14.4px; margin-bottom: 10px;">
<strong>Me:</strong> “Because it is illegal. You are asking us to break the law.”</div>
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<strong>Client:</strong> “Well, you’re useless, aren’t you!?” <em>*hangs up*</em></div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-30862636795615783572016-12-18T16:30:00.000-05:002016-12-18T16:30:06.497-05:00When Good Companies Promote Bad Ideas<div style="text-align: justify;">
Recently a reader joined in <a href="http://avetsguidetolife.blogspot.com/2014/07/cheap-food-vs-expensive.html">a discussion from a couple of years ago</a>, and asked a very good question.</div>
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<span style="background-color: white; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;"><b>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.</b></span><br />
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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?</div>
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I hate to say it, but it comes down to money and market share.</div>
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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.</div>
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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.</div>
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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.</div>
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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?</div>
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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? </div>
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So these companies did what pretty much every company does. They make products to meet consumer demand.</div>
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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".</div>
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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.</div>
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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. </div>
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As I am trying to do. <br />
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Well informed pet owners will stop buying these foods, which will decrease demand and will result in fewer products and less misinformation.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-45541632328053308322016-12-15T17:28:00.000-05:002016-12-15T22:19:59.686-05:00Holiday Safety Tips<div style="text-align: justify;">
<a href="https://www.blogger.com/%E2%80%99http://www.orvis.com/news/wp-content/uploads/2016/12/Orvis-Pet-Safety-For-The-Holidays.png%E2%80%99" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/%E2%80%99http://www.orvis.com/news/wp-content/uploads/2016/12/Orvis-Pet-Safety-For-The-Holidays.png%E2%80%99" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a>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.<br />
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<a href="https://www.blogger.com/%E2%80%99http://www.orvis.com/news/wp-content/uploads/2016/12/Orvis-Pet-Safety-For-The-Holidays.png%E2%80%99" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhl4Z1IK-kvRW1HpegK-mRhG9bmPQthJi0th20jFJ3RwrwCQJyvVQfmaVKtAxB_LqzmIA4sKwLZtt9hpVm0EXwWAgEqItyU5XAwb9pyes7WltcPhupzCDj7KKqdUHdusInpRPzdJ053KA/s1600/Orvis-Pet-Safety-For-The-Holidays.png" imageanchor="1"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhl4Z1IK-kvRW1HpegK-mRhG9bmPQthJi0th20jFJ3RwrwCQJyvVQfmaVKtAxB_LqzmIA4sKwLZtt9hpVm0EXwWAgEqItyU5XAwb9pyes7WltcPhupzCDj7KKqdUHdusInpRPzdJ053KA/s1600/Orvis-Pet-Safety-For-The-Holidays.png" /></a></div>
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Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-47976301821545970322016-12-12T18:51:00.000-05:002016-12-14T21:33:09.747-05:00Rubber Band Tail Docks.....How To P*** Off A Vet<div style="text-align: justify;">
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.<br />
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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.<br />
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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. <br />
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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.<br />
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How idiotic!<br />
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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.<br />
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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.<br />
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Can you see how cruel and ridiculous this is? <br />
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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.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqE4sh1voEVb9cQpgsMwGWSV0yBABlHQh7uIZZTcoSy4KHdNA-8mPHFcfoaHJwHjeRv3jmQwWWbH8o5lZXqQwz7Oz5XW1DioOFkH2zvYnfPX9ssTvJU7o8aViEPK2nnjUj-pjkUrGybg/s1600/IMG_20161203_171219956_HDR.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqE4sh1voEVb9cQpgsMwGWSV0yBABlHQh7uIZZTcoSy4KHdNA-8mPHFcfoaHJwHjeRv3jmQwWWbH8o5lZXqQwz7Oz5XW1DioOFkH2zvYnfPX9ssTvJU7o8aViEPK2nnjUj-pjkUrGybg/s400/IMG_20161203_171219956_HDR.jpg" width="225" /></a></div>
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That white tip on the end? That's bone sticking out. And the whole thing looked worse than how it appears in the picture.<br />
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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. <br />
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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.<br />
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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. <br />
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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.<br />
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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.<br />
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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.</div>
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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.<br />
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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.</div>
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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.<br />
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I'm glad that there are people like those clients.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-89724741059695097002016-12-09T12:23:00.000-05:002016-12-10T18:46:07.901-05:00No, I Can't Just Give An Injection<div style="text-align: justify;">
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.</div>
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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.<br />
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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.</div>
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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.</div>
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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.</div>
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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.</div>
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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.</div>
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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.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-25342096056031957302016-12-06T11:06:00.001-05:002016-12-06T11:06:35.637-05:00Fatty Liver Syndrome, Feeding Tubes, And Guilt<div style="text-align: justify;">
A few days ago I received the following email....</div>
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<strong>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.<br /><br /> 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.<br /><br /> 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.<br /><br /> 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?<br /><br /> 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.<br /><br /> I would appreciate and be very grateful for any input/insight you have regarding a situation like this.</strong><br />
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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.<br />
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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.<br />
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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.<br />
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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.<br />
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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.<br />
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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.<br />
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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. <br />
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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.<br />
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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.<br />
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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. <br />
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Now let's get to some specifics of this particular case.<br />
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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.<br />
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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.<br />
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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<br />
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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.<br />
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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.<br />
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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. <br />
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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.</div>
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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.<br />
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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.</div>
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Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-78984294243862483252016-12-02T13:06:00.000-05:002016-12-02T13:06:03.254-05:00A Client Apologized<div style="text-align: justify;">
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.</div>
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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.</div>
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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. </div>
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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.</div>
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"Dr. Bern, I need to apologize to you for my behavior last visit. I was a real jerk."</div>
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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. </div>
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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.</div>
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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. </div>
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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.</div>
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Now I've had a client apologize for an attitude that I can't even remember! </div>
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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.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-77640774577931546512016-11-29T17:59:00.000-05:002016-11-29T17:59:00.161-05:00Are "Prescription" Diets Really By Prescription?<div style="text-align: justify;">
As a follow-up to the last two posts I've made on "prescription" foods, I wanted to add this topic. It's actually something that is currently being debated by the profession for various reasons and there is misinformation out there. In fact, astute readers may have noticed that I've frequently put the word <em>prescription</em> in quotation marks over the last week of posts. My discussion is going to focus on the US, even though I have an international readership, because I know US laws and not ones in other countries.</div>
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To begin, "by prescription" really does have a definition. Each state has their own laws so there are essentially around 50 different variations on the theme, but there are a lot of similarities. The basic idea is that there are certain medications that have been established by the Food and Drug Administration (FDA) as requiring a prescription from a licensed doctor. Without that prescription you cannot purchase the medication or product. States typically require a prescription to be written by a licensed doctor that has a valid client-patient-doctor relationship with that person or pet. The specifics may vary, but essentially the doctor must have personally seen the patient within at least the last 6-12 months and be familiar with their medical conditions and history. Over time some prescription-only medications can be approved for over-the-counter use, such as many antihistamines and stomach acid reducers. Whether or not a drug is by prescription is determined by the FDA, and what is required to issue a prescription is determined by the state.</div>
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What about "prescription" foods as produced by Hill's, Royal Canin, Eukanuba, and Purina? Here's a shocker for you....they technically do not fall under prescription laws. </div>
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Yes, that's right. These "prescription diets" do not legally require a prescription. They fall into a gray area of foods and supplements that the FDA does not regulate. It's similar to taking Echinacea for colds or St. Johns wort for depression. The manufacturers do not specifically claim that these products treat any specific condition, and they often even say so on the label. By not making a claim of treatment they can bypass the FDA regulations and do not have to prove their efficacy. Any claims come by word-of-mouth between people or through books and internet sites, but not directly from the product label.</div>
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So-called prescription foods in veterinary medicine occupy the same category as vitamins and supplements for humans. They do not go through any FDA trials or tests, and therefore do not fall under that agency's jurisdiction. Since it's the FDA that determines whether something is dispensed by prescription, these foods technically don't need one because the FDA hasn't ruled on it. And because they don't legally require a prescription, a valid client-patient-doctor isn't necessary.</div>
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So why do vets require a visit? Why do vets talk about these foods as "by prescription".</div>
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Some of these diets are fine no matter the health status of the pet that eats it. Others, however, could cause problems. For example, diets for kidney failure have significantly low protein levels. This is necessary to help progression of kidney disease, but it's low enough that we wouldn't want a health pet eating it. We don't want a client picking up a food for urinary issues because their dog is peeing a lot, when in reality that dog has diabetes and should be on a much different diet. Clients also aren't sure exactly which food they need or even have purchased in the past, so we don't want them to be able to just pick up any food and make their own judgment.</div>
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Using the wrong therapeutic diets can indeed lead to health consequences because of how highly specialized they are. By requiring authorization from a vet both the doctor and the food manufacturer take steps to ensure that the correct food is being given to the right patient and we're not doing any harm to pets. If someone wants to buy a therapeutic diet from my clinic we don't require that we have seen them, but we do require a written or oral confirmation from their vet as to which food is being used.</div>
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Recently the FDA has been paying more attention to these foods, since they actually are recommended and used for the treatment of diseases. Anything with that definition must be regulated by the government, and foods currently aren't. This is leading to discussions as to whether or not the FDA may actually start doing tests and requiring that foods follow the same laws and rules as antibiotics, antidepressants, and other medications. If so, expect the cost of food to go up because compliance on these issues is very expensive for the manufacturer.</div>
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This increased government scrutiny has already resulted in some changes by the food companies. For example, Royal Canin makes a diet for food allergies that breaks down the proteins into single amino acids, putting their size below the threshold that would trigger an allergy. It used to be named Hypoallergenic, but that name implies a specific claim about the function of the food in relation to a disease. Because that treatment claim would classify it as a medication and the Royal Canin wanted to avoid trouble with the FDA, they changed the name to Ultamino. Same product and no change in the ingredients, but an important change to comply with prescription laws and regulations. Several other foods have had name changes for similar reasons.</div>
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When your vet talks about a "prescription" food, realize that they are using the word loosely and probably incorrectly. Heck, I've been doing it for 30 years, so I still fall into that habit even though I know better. If you walk into a store or vet clinic and they don't know you, understand that they may not sell you the food, but not because of the law. In fact, if they say that it is illegal for them to sell it to you they are absolutely wrong since it doesn't fall under prescription drug laws. But there are darn good reasons for them not to sell it to you if they don't know the specifics of your pet's case.</div>
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Hopefully this makes sense, as it's a somewhat complex issue.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-85963953113914337422016-11-26T12:52:00.000-05:002016-11-26T12:52:00.952-05:00Are There Differences Between "Prescription" And Over-The-Counter Foods? (Part 2)<div style="text-align: justify;">
My post earlier in the week was specific for one situation but opens a wider discussion. Are there really differences between OTC foods and "prescription" foods?</div>
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The short answer is "Yes, absolutely!"</div>
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When I prescribe a specific food for a patient it is common for clients to say "Wow, that's expensive. Isn't there anything over the counter that can do the same thing?" And I certainly understand their concern. Being worried about money and affording food is legitimate, as few of us are wealthy. We do have to watch the cost of feeding our pets, and some of these therapeutic diets are two to three times as much as a "regular" bag of dog food. So I don't take offense when a client brings up to me their financial concerns.</div>
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It's hard to make a blanket statement about how all prescription diets are different, and it would take more than a simple blog post to go into the "why" behind each and every one on the market. But I can take a few examples as illustrations.</div>
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Foods for kidney disease are specially designed to lower the protein and improve the protein:phosphorous ratio. There are no OTC diets with the right ratio and a low enough protein.</div>
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Dogs with recurrent pancreatitis need to be on an extremely low fat diet to help lower the risk of future episodes. OTC diets aren't low enough in fat. In fact, the labels only give maximum and minimum percentages for things like fat, so you can't even tell the exact amount in a food without contacting the manufacturer.</div>
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Dogs and cats who have had bladder or kidney stones need to be on a urinary diet that will properly regulate the pH of the urine, lower certain minerals, and promote drinking to ensure dilute urine production. There are no OTC foods that will do all of these things.</div>
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Animals with severe food allergies need to be on extremely restricted diets which avoid certain ingredients. Currently most OTC foods don't have significant enough restriction and could cause trace ingredients. Severely allergic animals may need to be on a food that not only limits ingredients but also breaks down the proteins into smaller chains (hydrolyzed) or single amino acids in order to prevent a reaction. There are no OTC foods that process the proteins in those ways.</div>
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Like diabetic humans, dogs and cats with diabetes need dietary regulation, especially with a high protein to carbohydrate ratio. OTC diets don't achieve the same ratio and are worse at regulating blood glucose levels.</div>
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As you can see from just a few examples there really are significant differences between these prescription diets and what people typically feed their pets. When comparing virtually every therapeutic food there simply are no cheaper foods that achieve the same results. So that cat with kidney failure, the schnauzer with pancreatitis, or the bulldog with food allergies really do need to be eating a food that a client can't get other than through a vet. There are decades of research to show the importance of these foods compared to "normal" pet foods. </div>
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The ancient Greek, Hippocrates, is famously quoted as saying "Let food be thy medicine and medicine be thy food." He was referring to using the right kinds of foods as a central part of treating diseases, and no modern doctor would disagree. The same principle applies with pet foods. I have successfully treated many disorders by placing the pet on very specific diets and did not have to give medicine to some of them. Think about that for a moment...what do you think would be better? To give the dog pills twice daily every day for its life, or to feed it a specialized food for the rest of its life? Which is healthier? Which will have fewer side effects? Which will be easier for you and the dog?</div>
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Yes, prescription diets are much more expensive than other foods. But pet owners have to stop thinking about them as merely food. They are an essential part of medical treatment and are usually not recommended lightly. Sometimes it comes down to spending $90 per month for a bag of food, or $40 for food plus $60 for medications. Suddenly that expensive food doesn't seem so unreasonable, right?</div>
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If your vet recommends an expensive prescription food, it is usually for a very good reason and I recommend following their advice. It is fine to ask if there are other options, but the likelihood is that there are no other comparable OTC foods and you could be delaying or preventing adequate treatment by using a cheaper diet.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-28477271069161118672016-11-24T01:00:00.000-05:002016-11-24T01:00:19.421-05:00Happy ThanksgivingToday here in the US we celebrate Thanksgiving Day, which is supposed to be a time to reflect and give thanks for what we have. In reality it ends up being an opportunity to spend time with family and eat lots of food! And as it does every few years today coincides with my daughter's birthday (she is 14 today).<br />
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I hope that everyone does pause to count their blessings and give thanks for what they have. I hope all of my readers have an enjoyable day and truly can give thanks for many things.<br />
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P.S.: Indulge in food for yourself, but please don't share Thanksgiving goodies with your pet or you may end up at the vet soon.Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-42657612617273655372016-11-21T12:15:00.000-05:002016-11-21T12:15:00.759-05:00Are There Differences Between "Prescription" And Over-The-Counter Foods? (Part 1)<div style="text-align: justify;">
Recently I received a great question from a reader:</div>
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<strong>One of our cats was recently put on a novel-protein diet for IBD, in addition to prednisolone. He's been responding well to the steroids, and we just put him on the new diet today.</strong></div>
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<strong>The diet prescribed was Royal Canin PV, which is Venison and Pea, and goes for the lovely sum of $67/8lb bag.</strong></div>
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<strong>I see that Natural Balance also has a Limited Ingredient Diet Venison and Pea dry formula, and the ingredient list is awful similar. Is there any significant difference between the two, other than the Natural Balance being $40 cheaper?</strong></div>
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Many food companies have realized that the "prescription" veterinary diets are a huge revenue opportunity. Therefore some of them are trying to develop OTC foods that are supposedly comparable to the veterinary ones as a way to capture a share of that market. While I understand this from a business perspective and don't fault them for wanting to increase their corporate revenues, it does cause confusion among pet owners and difficulty for vets. But the OTC foods are not always comparable to the veterinary ones. </div>
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Royal Canin, Hills, Purina, and Eukanuba all make veterinary-specific diets for use in treating various medical conditions. Inflammatory bowel disease (IBD) is a common one that needs a change in food, as it is often related to a sensitivity to ingredients (typically proteins, but secondarily carbohydrates). Because these ingredients are not brand-specific we look at changing to "novel" foods, which means foods containing ingredients to which the pet has not previously been exposed. In the above case the protein comes from venison and the carbohydrates from peas. For a truly novel food you want to avoid other major ingredients, especially the protein. In order for a diet to qualify as "limited ingredient" you want single sources of proteins and also ideally carbohydrates.</div>
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I compared the ingredients of both the Royal Canin PV and the Natural Balance LID Venison and Pea. Both of them pass the "limited ingredient" test, as both rely only on venison for protein and pea as the major carbohydrate. But there are some slight differences in minor ingredients, though none that I can see will make a huge difference in the nutrition of the diet. One thing that Royal Canin has is some added fish oil. The omega fatty acids in fish oils are a natural anti-inflammatory so they can be a great additive to cases like this.</div>
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On the surface it looks like these two foods are nearly identical. However, there is another consideration that is not obvious, and there is no way tell from the packaging.....quality control.<br />
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With veterinary-specific diets the manufacturers spend a lot of time and money to ensure that other trace ingredients don't get into the mixture. OTC diets may not have those same quality controls. Ingredients must be listed by pre-cooked weight, but when you get to trace ingredients you may not have them listed because they are below a certain threshold. What this means is that if there are minute amount of ingredients not listed on the label, that is allowable. The more expensive diets are very careful to keep these trace ingredients out of the diet, while OTC diets typically don't care about them and may include them.</div>
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Why is this an important distinction? Think about someone with a severe peanut allergy. These people can't eat anything that has even touched nuts, whether or not it is an ingredient. A food prepared on a counter that had previously had nuts on it could trigger an allergy. Some people are so sensitive that even the nut dust being in the air is enough to cause a reaction. While not common, some pets are similarly sensitive to even trace ingredients that wouldn't be on the label.<br />
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When these questions come up with my own clients I typically recommend feeding only the veterinary diet until the pet is stable for several months. Once we have achieved effective control we may discuss trying a comparable OTC diet and watching for a reaction. If there is no reaction we can use the less expensive diet. If there is a return of symptoms we have to go back to the veterinary one. </div>
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Remember that when using these very specialized foods you are not just providing nutrition. These are being used as medical therapy. You need to look at these foods in the same way that you would consider pills, capsules, and other medications.</div>
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Before making any food switches be sure to consult with your veterinarian <em>first</em>. If you make the switch and the dog or cat isn't any better, the vet may assume that the prescription diet is failing when it's really the OTC one. Since the diet recommendation is a vital part of the treatment, you need to keep your vet in the loop on any decisions.</div>
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This is a great topic and brings up some other issues that I'll discuss in some upcoming blogs.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-91123089598548262892016-11-18T18:24:00.000-05:002016-11-18T18:24:03.765-05:00Joyful Parts Of Being A Vet.....An Update On The "No-Eye" Dog<div style="text-align: justify;">
My last post was rather sad and depressing, so let's talk about some happy things!<br />
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Back in 2013 I wrote about a Siberian husky named Diesel. Due to worsening glaucoma I surgically removed both of his eyes, and it turned out well. You can read about that experience <a href="http://avetsguidetolife.blogspot.com/2013/06/removing-both-eyes.html">here</a>. He has continued to be a regular patient and has been doing exceptionally well since then.<br />
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A couple of weeks ago I saw him for a routine wellness exam and checkup, and was talking to one of our new staff members about his case. It really made me think about some of the positive things about being a vet, and I thought that would be great to include in a blog.<br />
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One of the things I love most about being a vet is the bond that will often develop between me as a doctor and the clients and patients. There is something magical about being able to continue to see patients year after year and continue to get to know them. Diesel is a great example of this! His surgery in 2013 is very memorable because it was the first time I removed both eyes at the same time. I've used him as an example many, many times since then when discussing similar issues with other clients. I love when he comes in because he is still such a friendly, happy dog, and being completely blind hasn't affected his quality of life at all. In fact, the quality is much better than when he was dealing with glaucoma. It is a true joy for me to see him a few times a year since that surgery, and to see how well he has been doing. In fact, the clients recently moved to a new home and were worried about how he would adjust to the new environment. We were concerned that he might become anxious because he didn't know the layout of the home and furniture. But it didn't affect him in the least! He didn't seem to care about the new place and hasn't had any problems making adjustments. Over the last three years he's learned how to move around a place he doesn't know without hurting himself.<br />
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Here is a photo of Diesel from his most recent visit. </div>
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Besides just being able to continue to follow up on him I also have the bond with his owners. They are great people who love their dogs, and always try to do the best for them. Since he did so well they have never regretted the decision to have the surgery done, and we always enjoy talking to each other when they come in. I love clients like that!</div>
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I also recently saw another long-term client for a semi-annual checkup on her puppy. As we were talking she happened to mention that her oldest child was now eight years old and I had seen her when she was pregnant with him. I didn't realize it had been that long! During those eight years I helped her with one epileptic dog, another who developed cancer, and the unfortunate euthanasia of both of them (at different times). When she got a new puppy I was happy to see her family able to move on and welcome a new love in their home. There is something so rewarding about knowing that family for so long, and having go through so many things with their pets.<br />
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The human-animal bond is something incredibly special. As a life-long pet owner I couldn't imagine my life without my pets. As a vet I love seeing that bond in my clients, and love getting to know them over many years. When things like what I described in my last post happen, it's cases like Diesel that remind us of why we went into this profession. It's great clients like his owners and many others I have that make the job worthwhile, and give us those emotional boosts that allow us to make it through the hard cases.<br />
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Veterinary medicine is hard and often emotional. We deal with real tragedies and life-or-death situations. But thankfully it's not always like that, and we can look at all of the patients we've helped and the clients we've gotten to know. Those bright spots are what get us through the darkness, and why so many people want to become a vet.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-29035122909691230362016-11-15T20:44:00.001-05:002016-11-15T20:44:52.926-05:00Death, Death, And More Death<div style="text-align: justify;">
I think that some people look at veterinarians and imagine us playing with cute puppies and kittens every day. They think about all of the "warm, fuzzy" feelings of making animals better and saving lives. Some of those people would likely be surprised with what actually happens sometimes.</div>
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Last week was pretty tough for me. In the middle of the week I had several dogs scheduled who were old or sick. To make a long story short I ended up having to euthanize three dogs in a row. Yes, that's right, three back-to-back. At one point I had some of my staff placing an IV catheter in one dog while I euthanized the one before it, then went straight into the next room to euthanize that one. </div>
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Each of these situations were very justifiable as the dogs were suffering. The decision to euthanize was the right one in each case, though it was emotionally hard for the owner. And each one went to sleep very peacefully and quickly, making it easy for me and the owner. I hated doing so many so close together, but there really wasn't a good reason to wait on any of them.</div>
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The next day my first appointment of the morning was another euthanasia. Then a few hours later I had yet another one. Once again these were all pets that were suffering and needed to be gently eased into a painless death. But I hated being the one to do so many in such a short period of time.</div>
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Losing a pet is always hardest on the pet owner. They are making an emotionally difficult decision, no matter how justified it may be. No matter how close a vet may be to the client and patient, their sadness is nothing compared to the sorrow of the owner who is going to be mourning their pet. But that doesn't mean that it's easy for the vet.</div>
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Most of the five pets I euthanized over those two days I didn't know well, and some of them I hadn't seen before. But it's emotionally draining to end an animal's life. It can also be draining to handle the human grief that is inevitable in these situations. Whenever you try to comfort someone who is grieving it takes some of your own emotions and energy. Both of these factors make every euthanasia somewhat difficult for the vet, and can affect our feelings for a while. <br /><br />Now do that three times in the span of an hour without even a few minutes break between them.<br /><br />Then do it again the next day.<br /><br />I was exhausted after the third euthanasia on the first day. I really did feel physically tired from the emotions and sadness that happened in such a short period of time. By the time I came in the next morning I had regained my normal energy, but that quickly left me when I saw my first appointment. Because of the events of the previous afternoon I was drained more quickly than I would have been otherwise. When it happened once again the same day I was bordering on becoming truly depressed.</div>
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Thankfully this many terminal patients is rare, and it's been many years since I had to perform more than two euthanasias in one day. And my days since these two have been pretty routine, which is good because I wouldn't have had to try to handle similar set of days. <br /><br />Being a veterinarian isn't all cute animals and fuzzy snuggles. It has many ups and downs and a vet will often see tragedy. It takes great emotional strength to succeed in this profession.</div>
Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-35141783858645166352016-11-03T17:07:00.000-04:002016-11-03T17:07:00.180-04:00Not Cut Out For Vet School?<div style="text-align: justify;">
Last month I received this email from Athena....</div>
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<strong>I am currently a junior pre vet student at a state university. I will be applying to vet schools over the summer. I love animals, work in a clinic, and feel a huge sense of satisfaction helping animals and their owners. However, I hate school. I hate sitting and studying, lack of sleep, stressing, and feeling like I can't enjoy normal human pleasures. Undergrad has generally been hell for me and I barely pass with Cs in my core science classes such as organic, physics, biochem, etc, but I love classes such as repro, nutrition, parisitology etc. I am a very active person and hate being stuck inside, hence the hate for studying. I love to learn but in a more hands on approach.<br /><br /> My concern is this: I know vet school is hard. Typically 24+ credit hours, long days and nights, no sleep, no outside life. 3 cumulative exams a week, barely any time to study. Are those 4 years of what sounds like hell worth it? Would someone like me cut it? My thoughts were if I get accepted at least try to make it through the first year and decide from there. I absolutely must work with animals for my profession, but the closer I get to applying, the more stressful and horrifying it sounds. I would greatly appreciate any insight. Thank you!</strong></div>
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Over the years I've actually written quite a bit on this topic, especially my own memories and struggles. Before entering veterinary school I had acquired a BS in Biology and a MS in Ethology. Yet none of that, even a Master's degree, properly prepared me for the rigors and challenges of a vet college curriculum. My four years in this training was without a doubt the hardest thing I've ever done, and that still stands with almost 20 years of hindsight. I struggled to maintain a B average, something that had always come easy to me. The sheer amount of studying I had to do and knowledge I had to absorb was overwhelming, and I found little time to do anything other than focus on my studies. I certainly couldn't work a full-time job, instead working weekends and evenings when I could. I had little to no social life, and spent most of my time at the school, even after classes were over.</div>
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If someone can't handle that intense of a study schedule they probably aren't going to do well during vet school. And if someone finds themselves overwhelmed by this as an undergraduate, especially not being able to enjoy "normal human pleasures", then being a vet is probably not for them because vet school is far worse than any undergraduate program.</div>
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It is also very competitive to get into most schools, with a cumulative GPA (grade point average) of 3.2 typically being the lowest realistic score for entry. Considering that most vet school applicants have GPAs of 3.5 or higher, a C average is simply not going to get a person seriously considered. All of those core science classes are important to the admissions department, and if you average Cs in them they will probably move on to the next candidate.</div>
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To be perfectly blunt and honest, Athena, I don't think that vet school would be a good fit for you. I think that you would hate it and would struggle to make passing grades. If you're having a problem with a typical undergraduate course load you will drown under a vet school curriculum. </div>
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This doesn't mean that you're stupid, or that you can't work with animals. My daughter is one of the most intelligent, quick-witted, creative people I've ever known and constantly surprises me. However, she has dyslexia and doesn't do well in typical scholarly activities. She considered being a vet when she was younger, but the math and reading will be too much for her, so she passed on that as a future profession. Instead she is going into performing arts, and I think she'll be very successful. She is brilliant in her own way, just not in typical book-learning.</div>
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There are many other ways to work in the veterinary profession without being a vet. A veterinary technician program is not as rigorous, is not as long, and costs less. You still get a lot of training and it will set you up for success in the field, but it will be easier than vet school. Still not "easy", though! There is a lot of math and studying, just not quite as intensive as the training to be a vet.</div>
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I hope that helps with your decision!</div>
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Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.comtag:blogger.com,1999:blog-4304574244594467893.post-23769571515424882432016-10-31T00:04:00.000-04:002016-10-31T00:04:06.769-04:00Happy Halloween!This is the first Halloween in several years that we've actually been home. In the last few years we've been on a Disney cruise ship over the holiday, which is an incredible amount of fun. But this year we don't have any travel plans, so we were able to decorate a bit more and will be passing out candy to any trick-or-treaters that come by.<br />
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I hope all of my readers have a safe, enjoyable, and spooky Halloween!<br />
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<br />Chris Bern, DVMhttp://www.blogger.com/profile/01707072350884127181noreply@blogger.com