Tiny Surgery

Last week I had a very unusual case.  A young bearded dragon had somehow gotten its leg stuck on an artificial rock in its enclosure.  In trying to free itself, it had ended up twisting its left hind leg around several times, ending up with a complete spiral in the leg.  The tissues were obviously damaged beyond healing and the only choice was amputation.

However, this was a very tiny patient.  Its entire body was no longer than the length of my palm and it weighed only about 2 grams.  I've done surgeries on exotic pets before, but never on one this small.  I knew that he wouldn't survive without the surgery, but I also worried whether or not he would survive the surgery itself.  On such a small patient we can't take standard precautions of using monitoring equipment, intravenous catheters, tracheal intubation, and so on. It's also difficult to do surgery on reptiles because their body temperature affects their metabolism and cardiovascular system.  Under anesthesia the temperature naturally drops, which can suppress breathing and other vital functions in these animals.  A small pet like this only compounds the problem.

So knowing the risks, we did the surgery.  I amputated his leg in the middle of the femur and closed the wound with a few small sutures.  I worried for a while as it recovered, because its breathing was so shallow.  But he slowly did wake up, and after a few hours was standing well on its own.  With the first hurdle passed (surviving the surgery itself) I knew that the next step was the most crucial.  Would it begin to eat by itself?  Would it heal properly?

Yesterday I check on the little beardie's progress and found that it was eating mealworms on its own.  Success!  I was so happy and excited to hear this news, as its survival at this point was beyond my ability to manage.  The tiny little thing isn't out of the woods yet, but if things continue to go well for another week, we'll likely have a healthy but three-legged lizard that can live to grow up normally.

Waiting Too Long?

A common complaint heard in veterinary offices is the clients being bothered by how long they have to wait.  Being in a room for 30 minutes is too long.  Having to wait several hours to pick up their pet is too long.  Waiting 15 minute for the fecal exam to be read is too long.  Yet those same people are more accepting of waits for their own doctor.

All of that went through my mind as I was doing my own waiting today.  My son was running a fever yesterday and complaining of a painful neck.  This morning my wife took him to an urgent care center to be examined (it's Sunday, so no doctors' offices are open, and we wanted to avoid the Emergency Department at the hospital).  The doctor easily determined that he has strep throat, but was concerned about the fact that his neck hurt so much.  Though he didn't think it likely, the doctor thought there was a small possibility of meningitis, and wanted my son evaluated for a spinal tap.  So we ended up at the hospital anyway.

It took over an hour and a half of waiting after we checked in before anyone took him back to an exam room.  Then it was probably close to another hour before the doctor came in to look at him.  She spent about 5-10 minutes examining him, determined that he didn't have the signs of meningitis, and just had a very bad case of strep.  It was probably about another 30 minutes before the nurse finally got our discharge paperwork and we left.  The day started at 11:00 with the visit to the urgent care.  By around 3:45 we were leaving the hospital with merely a case of bad strep throat.  Almost five hours involved.  Thankfully, it wasn't serious and he's perking up and doing well now.  By tomorrow he should be pretty much back to normal.

Even with all of that waiting, I'm not upset.  I feel that we were treated politely and respectfully.  Both doctors were very nice, and I can completely understand slight differences in diagnoses between doctors.  So even though I hated having to wait, it was important for me to make sure that my son was going to be okay.  I also think that most people would understand that kind of a wait on a Sunday afternoon when everything else was closed.

But what would happen if that same situation was in my own office?  What if a client waited a couple of hours after checking in before I walked in the room?  What if their total day was five hours of waiting and it turned out to be something simple?  Yes, many clients would understand, but I would argue that more would be upset and would feel inconvenienced (just remember the story earlier this month).  For some reason, it seems that people expect quicker service from their vets than they do their physicians.  Yet we vets have many of the same situations with different types of cases and having to triage to put the more serious ones first.  Waits can happen, and are unavoidable in many circumstances.

But I can't be too upset today, because my little guy is feeling better.  By tomorrow, I'll be wishing he was back in school!

Yes, It Can Happen To Vets

Today I took my dog, Inara, to work with me for her annual vaccines.  She received a rabies vaccine, distemper-parvo, leptospirosis, bordetella, a fecal exam, and a heartworm test.  All of the things I recommend to my clients I also do for my own pets.  Inara was a trooper and handled all of it well.  I did her services first thing in the morning and then put her in a kennel while I started to work on morning appointments and surgeries.

Two hours later I was in the back getting a patient and decided to give Inara some attention.  To my great surprise I saw that her whole face was inflamed and puffy.  Yes, my own dog was having a vaccine reaction.  She had received these same vaccines as a puppy, and these were her first annual boosters.  When she was younger she didn't have any problems, so I had no reason to suspect a reaction this time.  Unfortunately, reactions are individual and unpredictable.

Thankfully, most vaccine reactions are merely uncomfortable and not life-threatening.  In 13 years of practice and having given untold thousands of doses of vaccines, I have only seen three pets have a truly anaphylactic reaction.  Inara wasn't one of these severe reactors, and was wagging her tail as I started at her swollen muzzle and eyes.  A quick exam told me that she was very stable, but had some discomfort in her face.  I couldn't blame her, as all of her subcutaneous tissues were inflamed!

I gave her some antihistamines and antiinflammatories and continued to observe her through the day.  Over the course of the day her symptoms improved and she was still her normal self (except for some itching at her face).  Tonight she is resting comfortably, had a normal dinner, and looks almost completely normal.

Now here is the point where many people would panic.  "Oh, my gosh!  My dog almost died!  She can't ever get shots again!" As I said before, most reactions are not potentially fatal, and simple precautions can help prevent many mild reactions.  Her distemper-parvo and rabies vaccines have a duration of three years, so I won't have to booster those until 2013.  However, I will most certainly give them when they are due.  I'll premedicate her with antihistamines, place an IV catheter in case any future reactions are more severe, and will keep her in my clinic for the day.  All of the same things I would do for any of my clients' pets.

I try hard to practice what I preach.  I don't recommend any preventative care that I don't do for my own pets.  And I treat my pets like I do my patients.  This is the first pet I've ever owned that has had a reaction to vaccines.  However, it's not a crisis, and I trust my ability to vaccinate her in the future.

Disolcated Hip

Last week I saw a dog for some vaccines.  The owner happened to mention that he had been limping for a few days (often seems to work that way..."Oh, by the way, doc...").  When I was looking at him I quickly noticed that he didn't want to put any weight on this left hind leg, and some manipulation isolated the problem to his hip.  I was able to put a finger of each hand on the point of the femur and noticed that my fingers were uneven.  So my first thought was that somehow he had dislocated his hip.  A quick set of radiographs confirmed my suspicion.

Looking at the images you can see that the hip is completely out of the socket and displaced slightly dorsal ("up") and cranial ("forward").  It takes a pretty good injury to move a hip this far, as the femur is normally very tightly held in the socket.  There is a short, tough ligament connecting the bones, as well as a capsule around the joint. Displacing a hip this far requires a tear of that ligament and likely a tear in the joint capsule.

Depending on the severity of the injury, it can be possible to put the hip back into place without surgery.  However, extensive damage to the connective tissues can mean that the hip will dislocate again easily.  In cases like this, surgery is the only option for a cure.  In this case it seemed like a pretty bad dislocation so I referred the dog to a specialist for a further consultation.  With proper treatment, these cases can have a very good outcome.

What Voice Mail?

Does anybody bother checking their voice mail anymore?

Here's something that's happening with increasing frequency. I call a client to let them know that their pet is ready to be picked up. I end up getting their voice mail and proceed to leave a detailed message with any findings, treatment plans, and other information. Now, I'll only do this with routine cases, not ones where I really need to get more information or discuss something at length. But I do this in cases where I just need to pass on some quick details and don't need to speak to them directly.

Then the client calls back shortly afterward...."Yes, I received a call from your office."  But they don't know what the call was about.  What?  Obviously they simply saw the number on their caller ID and never bothered checking their voice mail.

Now, I don't know about everyone else, but when I see that someone has called and left a message, I listen to that message before I call them back.  After all, there might be something in the message that would make me do something else or I would see that I didn't need to return their call.  To me, that's common sense and something everyone should do. But obviously not everyone sees it this way, and for the life of me I can't figure out why. 

So if you ever get a call from me, check the voice mail before calling me back!

Dogs & Cats, Living Together...

It's a great line from one of my all-time favorite movies...

Dr. Peter Venkman: Or you can accept the fact that this city is headed for a disaster of biblical proportions.
Mayor: What do you mean, "biblical"?
Dr. Raymond Stantz: What he means is Old Testament, Mr. Mayor, real wrath-of-God type stuff. Fire and brimstone coming down from the sky! Rivers and seas boiling!
Dr. Egon Spengler: Forty years of darkness! Earthquakes, volcanoes...
Winston Zeddmore: The dead rising from the grave!
Dr. Peter Venkman: Human sacrifice. Dogs and cats living together. Mass hysteria!





The implication is that the idea of dogs and cats living in harmony is pretty ridiculous and isn't likely to happen under normal circumstances.  However, many of us know better.  And obviously the writers of Ghostbusters never visited a home like mine.  I have three cats and two dogs, for the most part living together well.  But one of the closest bonds is between one of my cats, Ash, and my oldest dog, Guinevere.

Guinevere has always been a very sweet girl, and is friendly towards pretty much any person or other animal.  She loves getting to know new pets, and is very low-key for a Labrador retriever.  When we first brought Ash home a couple of years ago she was curious but willing to let the newcomer be.  Ash was a bit freaked out by this big yellow dog, and would hiss at her for the first few days in our home.  But he quickly became used to her, and somehow they became friends.  That bond continues to this day, when we will see them laying together and see Ash grooming his big doggie friend.  It's really heartwarming to see how closely these individuals from traditionally antagonistic species have bonded.

Unexpected Hernia

Here's the case that kept me from getting to the dog I mentioned in yesterday's blog.

A client of ours had found a little stray kitten and brought her in for the first exam and vaccines.  At first glance she seemed a little dirty, but overall a sweet little four month-old kitty.  We proceeded to collect blood for a feline leukemia and feline AIDS test, ear swab to check for mites, and a fecal sample.  As I started my exam, things seemed okay until I listen to her chest.  Very quickly I noticed something strange.

Like humans, dogs and cats have hearts that are in a position slightly to the left of the midline of the body.  This means that in a vertically-positioned chest, the heart sounds louder on the left side of the body.  When I used my stethoscope on the kitten, I found it very difficult to hear the heart at all on that side.  As I started listening to the opposite side, I suddenly heard the heart much louder than it should be.  The more I listened, the more it became clear that the left side of the chest was very muffled and the heart was pushed to the right.  There are only a few things that could cause this, especially in a young kitten.  I knew that there was something that was filling up the left side of the chest and pushing organs to the right. The most likely possibility was a herniated diaphragm with abdominal contents in the chest.

The main purpose of the diaphragm is to allow movement of the chest to facilitate breathing.  But the diaphragm also separates the chest from the abdomen, keeping organs where they should be.  A sudden trauma can put enough pressure on the body or abdomen to "pop" the diaphragm, similar to a full balloon being stepped on. Once the it has ruptured, the contents of the abdomen can spill into the chest.

Here are the kitten's radiographs.

On the top image you can trace the line of the diaphragm and see the place where the normally sharp border becomes distorted and indistinct.  If you look at the left side of the bottom image you will see compressed but otherwise normal lung tissue.  The right side of that image is very hazy and opaque.  The astute observer will notice patterns of gas from the small intestines.  So it was very quickly evident that small intestine and possibly liver and stomach were sitting in the left side of the kitten's chest.  Such an problem compromises the ability of the lungs to inflate, making it difficult to breathe.  There is also the risk of some of the abdominal contents becoming "pinched", cutting off blood supply.

Surgery can be done to correct this type of injury, but it is risky and expensive.  I've performed this surgery successfully several times, once on a kitten this small.  However, the client didn't have the money and didn't want the kitten to suffer, so they elected to have her euthanized.  Her two children were in the room as we talked about this and they began to cry.  I was trying to help her explain to them that as sad as this was, putting the kitten to sleep was the best thing for her.

And it was while I was handling this case that the shih-tzu owner I talked about yesterday came in all upset because I didn't have time to come right out and speak to her.