Vaccine Duration In Cats

Here's a question from Madeline....

My two cats come in annually to the vet for an exam and booster shots. In 2011, when it was time to have their annual, one of my cats got some sort of stomach bug and the vets advised that they do their annual routine later as she required daily anti-biotic shots and some other injection later on (she hadn't eaten or drank water for two days at that point). Just when we were about to get their annual done, the other cat somehow injured his back and they had decided not to give him his shots. So in 2011, they missed their annual shots. I'm wondering do they need to have their shots done twice in 2012 or is taking them to their 2012 annual sufficient enough?

I already know that this one is going to open a rather large can of worms since vaccines are such a hot-button topic and there isn't a great consensus of opinion in the veterinary profession.

First of all, it's common not to vaccinate sick pets.  Honestly I think it's more anecdote and speculation than hard evidence, but few vets will give vaccines during an illness.  The rationale is usually centered around avoiding stressing an immune system that is already working on a problem, as well as avoiding any side-effects from immunizations that may mask effects of the illness.  Even without hard evidence, I think the reasons are valid enough that I agree with this practice.

Madeline's question isn't as simple as it may seem.  There is great debate in veterinary medicine about the duration of immunity from vaccines, especially in cats.  This discussion is not new, having been going on for about 15 years now.  There is evidence that many vaccines provide immunity for at least three years, and some argue that it may be seven years or more.  However, there have been few challenge studies performed (where you try to induce the disease in a vaccinated pet) beyond one year.  Because of a lack of hard data, the USDA has listed most vaccines as providing immunity for only a year.  Some companies have some data that shows their vaccines can last for three years, though this can't go on the labels because they don't have government approval to say so.  Why not?  Such studies cost lots of money to perform, and the benefit of being able to change the duration on the label doesn't outweigh these costs.

Some veterinarians and immunologists are adamant that our current vaccines give immunity for 7-10 years.  However, there has been very little actual data provided, and most of the argument is based on rationalization related to how the immune system is supposed to work, as well as antibody titers.  For every specialist and immunologist that says the durations are close to a decade, there is one who says we don't have enough evidence to make such statements.  Even the specialists in the field are divided.  And titers really don't mean as much as many people think (see my discussion last year on that topic).

And to further complicate the issue, we have to look at each antigen individually, and can't make blanket statements about all vaccines.  For example, we do have good data that some vaccines for canine distemper and parvo are valid for three years.  But the leptospirosis vaccine is known to only last for one year.  Besides the antigen, the duration may vary based on the manufacturer.  And then if you throw in legal requirements for rabies we have a whole 'nother issue.

So where does this put Madeline's cats?  Honestly, a bit up in the air.  Because of these often heated debates among vets, not every veterinarian is going to do the same thing or view boosters equally.  What I say and do may be different from Madeline's vet.  Again, there is no general consensus on this topic that every vet agrees with.

Now that I've set up the background, let me give my personal opinion.  Remember, this is what I believe based on the data I've seen, articles I've read, discussions with immunologists, and conversations with the vaccine manufacturers.  I am general practitioner and not an expert, and fully realize that plenty of people may disagree with me.  But this is how I handle things in my own practice.

I do believe that many vaccines give immunity for longer than a year.  I routinely use three-year durations for rabies, canine distemper, and parvo.  With cats and the feline distemper vaccine ("FVRCP") it's a bit different because I don't think there is as much overwhelming evidence.  For cats that are high-risk and spend much of their time outside, I feel that it is important to provide the highest levels of protection and will give a duration of one year.  For completely indoor cats I will recognize the duration for three years.  I have been given support on this view by Pfizer, the brand of vaccines we carry.  

But how to booster in Madeline's case?  One thing she didn't say was when in 2011 the vaccines were due.  Was it in January and we're a year overdue?  Was it in November and we're only a few months out?  The answer does matter.  Realizing that immunity doesn't magically end on the 366th day after vaccinating, I do give a grace period.  For annual/triannual vaccines I will allow up to six months overdue and still be valid for a standard duration.  If it's supposed to be a three week booster, I'll allow up to eight weeks.  If it is beyond these periods I'll require an additional booster three weeks later to make sure that we re-stimulate immunity.  These protocols are based on discussions with specialists and vaccine companies, and are what we use.  I don't expect every vet to do the same thing.

Madeline, the best thing you can do is to talk to your vet and ask what they want you to do.  There is not one single answer to this situation and I can't say what you should or should not do in your specific case.

One Of Those Days

Weird Al Yankovic reference again....and here's a link to the song.  Today I really felt like that.

The morning was busy, but I managed to get to surgeries mostly on time.  My first one was a spay and it didn't exactly go like expected.  As I ligated one of the ovarian pedicles (the part that attaches the ovary to the body wall and is filled with blood vessel) I put the needle through a vessel, causing a good amount of bleeding.  I clamped and tied this off, then continued along.  Then as I was doing more suturing the end kept slipping out of the needle holders before I could tie the knot; nothing serious, but frustrating.  Just before closing the abdomen I always check for excessive bleeding and found some pooling blood.  This meant that I had to extend my incision to look for the bleeder, which took some time (believe me, once you get to this point in the spay the vessels are deep in the abdomen and hard to find).  After a large amount of searching I was able to see my ligatures, but couldn't find the bleeding.  A few more minutes went by and eventually the bleeding stopped, not an uncommon occurrence.  I tied off a suspicious area just to be safe, but my suture broke as I was doing so.  Again, this is something that happens, but it was just adding to the whole frustration of the procedure.  The dog was never in any danger as none of the blood loss was excessive, and any vet will tell you that each and every problem I ran into has also happened to them.  Heck, a couple of times per week I pull a little too hard when tying a knot and have the suture break, forcing me to re-tie it.  The problem was that all of these little things happened in the same surgery!  Any one of them I would have been okay with, but the cascade of events caused the surgery to take twice as long and made me quite frustrated with myself.  Thankfully the patient recovered normally and is doing great.

But it didn't end there.

As I was walking in to start the next surgery I ran into the surgery stand where we had the blood pressure monitor placed, almost knocking it over.  Really? Thankfully that spay was routine.  But the next procedure was a cat neuter, and the pet just didn't want to go under anesthesia, being particularly resistant and taking longer than I wanted.  And it didn't end there.  We collected blood from a cat for routine organ screening and I dropped the CBC tube.  Thankfully it didn't break, as it was a difficult collection.  The rest of the day continued along these lines, with little things happening like me running into things, dropping things, and getting "fuzzy brain syndrome" multiple times.  As I said before, nothing was big, serious, or put any patients in danger.  But the sheer number of things made me want to go home hit "reboot" on the day.  

Unfortunately that didn't happen, as we had an absolutely crazy busy day.  I literally had about 5-10 minutes at one point to eat my lunch before getting to my next patient (which is one of the reasons I almost always bring my own lunch) and otherwise was running non-stop from 9am until 7:30pm (we normally close at 7:00).  And today my popularity was part of my downfall.  It seemed like most of the clients wanted to see me and not my associate, so I saw around 2/3 of the patients, rather than the normal half.  The last two hours were especially bad, as every client wanted to see me.  My associate is a great doctor and has many loyal clients, but today it seemed skewed towards me.  Normally I'm grateful that clients like me, but this time it was a bit ridiculous.  My associate was available and I was trying to get caught up (or even just breathe), but no such luck. It was all on me.

Needless to say I was very glad to leave work and come home.  And after ten hours of back-to-back patients I am mentally, physically, and emotionally drained.  If there is any consolation to it all, we had a very good day business-wise.  But I'm not eager to do it on such as scale again.  I'm certainly going to enjoy the next two days off.

Coming In To Ignore Us

You vets out there will be very familiar with this scenario.  A client calls up and makes an appointment because their pet is sick.  They show up at the right time and we do our exam.  A problem is noted (maybe serious, maybe simple) and we begin to talk about what we need to do to diagnose and/or treat the issue.  A treatment plan is worked up and then presented to the client.  For whatever reason the client declines everything on the plan and leaves without doing anything at all.

For the non-vets reading this, you'd be surprised how often this happens.  The client spends their time and money on the office visit, we spend our time trying to make the best recommendation for the pet, and then the client doesn't follow anything we want to do.  It's a source of great frustration for most veterinarians.

Now I completely understand that some clients simply don't have the funds to do hundreds of dollars of services every time, and am sympathetic to this plight.  Those aren't the clients I'm talking about.  Those clients will usually say that they can't afford something, and then we do the best we can to work within their budget and find a solution that is affordable yet still medically appropriate.  Just yesterday I had one of each situation.

The first was a client who brought in a cat with a wound on its tail.  When I saw him the wound was relatively minor, but did need antibiotics.  During the exam I also noted a lot of debris in the ears, and strongly suspected ear mites.  Additionally, the cat went outside, had never been vaccinated (at eight months old), and wasn't neutered.  I worked up an estimate for antibiotics, an ear swab, ear mite medications, vaccines, and a feline leukemia test.  The client said no to everything and took the cat home.

The other case was a localized dermatitis.  The client was honest that he really didn't have much money.  I looked at the dog, suspected that we were dealing with a local contact allergy, and prescribed some topical medication.  Normally I would have wanted to do more, but we were at least doing some treatment, the client's budget wasn't broken, and he was aware of what might need to be done in the future.

Here are some hints for anyone taking their pet to the vet, especially if you have financial issues.

First of all, expect the visit to cost more than the office visit.  Vets will have an office visit charge that covers the cost of the time, exam, and expertese.  Anything else will be extra.  And believe me, most of the time when you have a health concern with your pet we will want to do diagnostic tests and some form of treatment.  This is about good medicine, not the money; but it costs money to do good medicine.  Most of us routinely forget our crystal balls and magic wands at home, so we need to do more to figure things out.   Don't expect us to be able to determine what is wrong and treat your pet only from an exam.  Plan for extra costs.

Second, if you have money limitations, be honest with us.  Talk to us.  Most vets will do the best they can to work with you on prioritizing treatments.  For example, in the above case of the cat, I would have wanted to concentrate on the wound first, then get the cat back in a week or two to update vaccines, and lastly work on the ear mites.  Yes, it's better for the cat to do it all at once, but we know this can't always happen.  Most vets will tell you that we do need to do everything on the estimate, but we REALLY need to do x, y, and z items before the rest.  We can consider splitting some things up over several weeks, coinciding with someone's paycheck.  But also realize that sometimes we really, really need to do what we recommend.

And of course all of this goes back to something I've talked about before, but haven't brought up recently.  Have an emergency fund for your pets!  Set aside several hundred dollars (or Euros, Pounds, Pesos, etc.) in an account that you use only for animal care.  Such a savings account will enable you to do at least some things for your pet when money is tight.

Veterinary Medicine Meets Reality TV

Are you tired of reality TV shows?  Me too.  But apparently most people aren't because more and more crop up.  I think there is voyeuristic part of us that likes peeking into people's lives.  And the TV producers like it because the shows cost much less than scripted ones with paid actors, sets, and special effects.  The veterinary profession is not immune to these shows, and apparently there are more coming.

I remeber Emergency Vets on Animal Planet being one of the first, if not the very first.  I've also seen commercials for a show following veterinary students in the UK.  Honestly, I've never watched either one because by the time I get home I want to forget all about veterinary medicine rather than watching shows about it.

One of the most recent is The Incredible Dr. Pol on National Geographic Wild.  The show follows an older large animal vet as he sees patients.  Again, I haven't watched the show myself, but it's creating a good amount of controversy and backlash in the veterinary profession.  Complaints have been lodged by other practicing vets that Dr. Pol's medicine is very old-fasioned and sub-standard, creating a misperception in the public's eyes of how animals should be treated.  DVM Newsmagazine recently had an article on this controversy.  For example, here's a quote related to the type of medicine he practices. 

Brothers goes on to cite Pol splinting a calf's leg using wood slivers from a bushel basket and stitching a dog's tail that had been cut off by a screen door with little anesthesia and the owner holding it down.

I can't comment too much, as I haven't seen the show myself, but the complaints I've heard seem legitimate.  From the articles I've read, I'd be in big trouble practicing like he does.

National Geographic responds with comments like this....

It is an undisputed fact that Dr. Pol has helped thousands of animals throughout his 40-year career as a veterinarian. His very successful clinic has been in business for 30 years, where residents of Michigan count on him to help their sick pets and farm animals.

I hate to say it, but number of pets treated and length of time practicing does not automatically mean that the quality of that medicine and surgery is appropriate.  I've seen plenty of older, long-term vets who practice substandard medicine that borders (or crosses the line) on malpratice.  But I don't want to spend this blog picking on Dr. Pol.

Another foray into this topic is a new YouTube channel, Veterinarians on Call, which has webisodes following several livestock veterinarians from across the US (and according to the channel they are going to expand this to small animal vets).  I find this a little more interesting, as it seems that the type of practice is closer to the reality of most vets in that part of the profession.  I do like that people are getting to see more of what the daily life of a vet is like, which was one of the points of starting this blog in 2008.  Oh, and as an extra bonus, the boy who played Charlie in the Gene Wilder version of Willy Wonka and the Chocolate Factory, Peter Ostrum, is a currently practicing large animal vet and is one of the doctors featured on this channel.

Even though I don't have cameras around me, a blog like this (and other veterinary blogs) shows those things that go on "behind the curtain" of a vet practice.  As I've seen over the years, this reality can surprise many people, and it's not always in a pleasant way.  Recently it has come to the forefront of my mind as I think about the things I've written over the last three and a half years.  I'm being introduced to some opportunities that may get me some national media exposure (no, not my own reality series...I certainly DON'T want that!), though we'll see how that works out (remember my GabCast TV experience?  No?  Search the blog archives).  However, as I contemplate being on morning network TV shows I wonder about how some comments in this blog will be perceived.  Because if I end up on the Today Show you darn well know people are going to Google my name and find this blog.**  I don't regret things I've said and I stand by all of my comments, good and bad.  But in this era of instant internet searches what you put out there is easy to find.  For better or for worse, Dr. Pol and the doctors of Veterinarians on Call are now in the public eye and are having their lives and practices scrutinized.  Will they regret what they say and do when brought to a national stage?  If I end up becoming more well known, will vets and pet owners be kind or cruel to this blog?  We'll just have to see.

And yes, I'll talk more about these opportunities if they pan out.

**If you do a Google search for "Chris Bern" the top search result is for the president of the Iowa Teacher's Union, not for me.  But I'm not far down the list, and I'm noticing that I'm getting higher in ranking compared to last year.  Yes, periodically I search for my own name.  Has the man in Iowa ever come across me and wondered?

Shakespeare Meets Pirates

My latest foray into community theater is a production of Romeo and Juliet.  My wife is the costume designer and is making most of the costumes herself.  The production is traditional Shakespeare, but we're using Pirates of the Caribbean as a setting inspiration.  The Capulets are based around the British of the 18th century and the Capulets are being dressed like pirate lords.  The sewing has been consuming my wife lately, but thankfully the production is in four weeks, so there is light at the end of the tunnel.

Last night we had some of the cast in partial costumes to take some promotional photos.  I took the opportunity to bring my camera and take some personal pictures.  Which I'm sharing here!  

 My beautiful wife as Lady Capulet.

 Lord and Lady Capulet.

 Me as Paris.  She's still working on the costumes and the pants aren't ready, so I'm wearing jeans here.  

Me and my wife again.

And my wife made all of the costumes! I'll share more official photos if we get some closer to the show date.

"You're Going To Let My Dog Die?"

Today my associate saw a dog who was in pretty bad shape:  painful in the abdomen, lethargic, not able to urinate or defecate, and generally not doing well.  She found a firm mass in the abdomen and the dog had apparently eaten part of a steak bone. However, the mass was larger than the size of the bone, so she knew something else was going on.  Being a great doctor, she obviously developed a treatment plan that started with radiographs and went from there.  

As commonly happens the client said that they couldn't afford to do anything, and in fact had come to us because they couldn't afford the $100 to walk in the door at the emergency clinic.  We gave them the information for Care Credit, and they were declined.  She didn't really have many options at this point and told the client this.  The client's response?

"So, you're just going to let my dog die?"  followed by "What vet doesn't take payment plans?"

Really?  

And this isn't the first time I've run across this attitude and comment.  Plenty of clients think that it is our obligation to treat pets and do surgery, even if the client doesn't have any way to pay.  After all, if we really loved animals we'd just go ahead and do it (another comment I've heard before).  If the client can't pay and we decline to treat for free, somehow we are the ones letting the pet die, not the client.  It's our fault that we won't give away hundreds or thousands of dollars in services, but it's not the client's fault that they don't have any funds in a savings account or have such horrible credit that they can't qualify for a payment program.

I really think many people don't realize that we can't operate a veterinary practice without charging.  There are so many little things that people never think about....payroll, rent, utilities, liability insurance, worker's compensation, taxes, and many dozen other items that quickly build up and take up any revenue.  We as vets have our own personal mortgages, student loans, and other debts, as well as families to support.  And most vets aren't driving BMWs or Lexuses while living in 4000 square foot homes.  If we give away too many services, we can't pay our bills.  If we fall behind on our bills, we have to fire staff, cut services, and eventually will go out of business.  In fact, such discount practices are the number one reason veterinary practices close, and it's much more common than anyone outside of the profession realizes.

It's also not smart for most vets to set up their own in-house credit system.  I've seen this done, and more times than not clients fail to make payments appropriately.  Practice consultants routinely say that this is a bad idea for vets to do.  And if someone doesn't have good enough credit to have credit cards or Care Credit, this means that their revenue and ability to repay people is below acceptable standards.  In other words, they are very poor risks. So why should the vet take those risks?  I know that everyone says "Oh, don't worry, I'll be the one to make payments on time."  Call me cynical, but in my personal experience that is rarely the case.  Which is why most vets don't take payments, especially for first-time clients (which this dog was).

So what happens in these situations?  Unfortunately, the pet suffers.  But who is responsible for that pet's care?  It's the owner, not the vet.  The vet is the agent of treatment, but we can only advise decisions.  Ultimately the client must agree to the treatment plan, and the client is also ultimately responsible for the pet's well-being.  If the client can't pay, it's simply not the vet's fault or responsibility.  And most of us have learned not to let the client guilt us into doing it anyway.

In this case the client had enough money to afford euthanasia, which was the best decision if they couldn't do any diagnostics or treatment.  The dog didn't have to suffer for long.

It's about personal responsibility, folks. Something I think that much of American society has forgotten.  Too many people want to blame others for their failings and hard situations, when the huge majority of the time the fault is really with the person themselves.  People need to take responsibility for their own actions and for the care of the people and pets entrusted to them.

May The Bark Be With You

I don't typically share videos, links, and similar things on this blog just for entertainment purposes.  That's what Facebook is for.  However, this time I simply couldn't resist.  As a geek, Star Wars fan, veterinarian, and dog lover, I have fallen in love with this commercial.  Many of you may have seen this, as it's going viral on the internet.  Enjoy!