Second Guessing

It's not easy being involved in literal life or death situations on a daily basis.  Honestly, I think this is one of the biggest sources of stress in my career, and I can't imagine what human medical professionals go through.  Multiple times per day I have to make decisions that will affect the life and health of my patients, sometimes in life-threatening circumstances.  I always try to use my years of knowledge and training to the best of my ability, but I'm an imperfect human and there is no way I can be right 100% of the time.  I know this may be a rude awakening for some people, but there is no doctor on the face of the earth that hasn't made mistakes or misdiagnosed cases.  Simply put, nobody is perfect and nobody can always be right.  Hopefully, though, with care, training, and a little luck the mistakes will be few and far between.

But doctors aren't the only ones who wrestle with serious decisions.  I can't make choices for my clients.  Instead I have to give them enough education and opinions that they can make their own decisions for their pets.  In the end, it comes down to choices from the owner, not from me, even though I can guide those thoughts and options.  This means that in many cases the client is ultimately responsible for the case outcome, as I can't do anything they don't approve.  Many clients know this and wrestle with tough decisions, such as whether to treat or euthanize.

On both sides of the issue this can lead to second-guessing yourself.  I'll often come home worrying about decisions I've made in cases, wondering if I prescribed the right treatment or handled it appropriately.  It drives my wife crazy, and honestly isn't the best thing for me mentally.  I know that some of my clients wrestle with similar thoughts, trying to figure out if they picked the best options.  When you're passionate and you care about something, you always want to do the best.  But because we're imperfect people, we realize that whichever option we pick may not always be the right one.  So after the fact we re-analyze things and may doubt our initial decisions.

Yes, recent cases brought this to mind.  I have recently been treating a case of nodular panniculitis, an immune-system disorder where the body attacks the subcutaneous fat, with a strong immunosuppressive drug.  The dog has been doing fine on the medication for a month, but developed sudden and severe anemia within the last week and ended up being euthanized as the emergency clinic yesterday.  When I found that out I scoured the record and the dosages, double-checking to make sure that I had made the right choices and calculated dosages correctly.  Yes, I had, but I still have to wonder if there was something else I could have done.  When I talked to the owner this morning, she was also second-guessing herself, wondering if she should have brought her pet to us sooner, when she was just starting to act a little strange.  I feel that I handled the case appropriately and the client made good decisions in the end, but we both still worried.

Another case came in today for some odd behavior and a possible ear infection.  We ended up diagnosing a life-threatening anemia due to destruction of the red blood cells by the immune system (yes, odd that both cases had similarities, but they really were different).  Treatment would have been costly and extensive and there would have been no promise of a cure; at the same time the pet couldn't survive without therapy.  In the end the client opted to euthanize her dog, but she wondered if she was making the right choice.  I tried to assure her that she was, but I'm sure there was still part of her that didn't listen to my words and doubted her decision.

Second-guessing yourself is human nature.  However, it doesn't help much and can lead to anxiety and depression.  Believe me, I know this first-hand.  But it's one thing to wonder if you locked the door to your car.  It's another thing completely to wonder if you chose the right diagnosis to start treating.  I wish I had great advice to give on how to overcome this problem, but I'm still struggling with it myself.  Really, this is just another peek behind the scenes, showing what goes on in the mind of a vet.

When Vomiting Really Isn't

Believe it or not, vomiting isn't always vomiting and it's something that vets really do have to worry about.  Let me give you a quick lesson so you can help your vet determine what is wrong with your pet.

Producing fluid or food from the mouth generally falls into two broad categories:  vomiting and regurgitation.  The distinction is important because each can point to different disease processes.  Few clients understand this difference (which is what I'm hoping to correct) so most people simply think that their pet vomited.  In a nutshell, vomiting is active and regurgitation is passive.  But let's look at the two in a little more detail.

Regurgitation normally involves stomach contents coming up and out through the mouth without active muscle contractions.  If the esophagus is enlarged and dilated (such as in megaesophagus), food can come back up because it sits in the esophagus rather than making it to the stomach.  It can also happen if the upper sphincter in the stomach (the cardiac sphincter) is loose, not sealing food in the stomach.  When regurgitation happens the pet usually just stands there, opens its mouth, and fluid or food comes out.  Because there are no muscle contractions it just sort of falls out and there is no force behind it.

When a pet vomits, the esophagus and cardiac sphincter are functioning normally, pushing and keeping food into the stomach.  When the nausea centers are triggered the stomach and abdominal muscles contract, resulting in the contents being expelled from the mouth.  The difference is that there is force behind vomiting.  You can see the abdomen contracting and the vomit may be "projectile", covering some distance.  It's not uncommon to have multiple episodes of vomiting close together, which is much less common with regurgitation.  You can often see a "lead-up" to the actual vomit where the pet feels the nausea and contractions then gets into the position to expel.  Regurgitation more typically involves a sudden "splort" (my word) without any real warning.

We vets do try to differentiate between the two because the things that cause regurgitation are usually different than the causes of vomiting.  It's kind of like trying to tell the difference between "dry" and "wet" coughs.  So the next time your pet seems to vomit, try and pay close attention so you can give more information to your vet.  It may actually make a difference with your pet's diagnosis.

A New Look

Every once in a while you need to shake things up a bit.  I noticed that Blogger had some new templates, and was thinking about changing the look of my blog.  Partly this was to alter the width of the posts so I could include bigger pictures and videos.  Well, I accidentally clicked on "apply" too early, and lost my old template.  I found it and was getting ready to put it back when I realized that maybe my mistake was an opportunity in disguise.  So I took this time to completely rearrange the blog, add some new features, and make it a little more personal (such as including my dogs, Yvaine and Inara, as my background). 

Hopefully you folks will like it, or at least not be too annoyed by it.  Comments are welcome!

Body Language Masters

Regular readers will know that animal behavior is a strong interest of mine and I've done a lot of study in this area.  Often I point out to clients that dogs are masters at reading human body language.  Much of their own communication is non-verbal and a lot can be "said" with changes in posture.  Because they are hard-wired to pick up on these cues, the notice a lot of the signals we send without realizing it.

Though this is generally accepted and well-understood by behaviorists, there hasn't been much scientific evidence.  That is, until now.  Today I just read an article about this subject, describing how dogs will follow a person's gaze in the same way that human infants and toddlers will do.  Though it may seem simple to us, it's proof that dogs really are aware of us and in tune with our movements.

Why does this matter?  Because we need to keep in mind our non-verbal signals in relation to our pets.  The volume and tone of our voices, our posture, the strength of our gestures, and a hundred other little things communicate various things to our pets.  When talking to clients who have dogs with behavioral issues I will usually ask about any stresses, arguments, or changes in the humans of the household.  Arguments among the humans can cause problems for the dogs as well.

In client service training I've been told that about 80% of communication between humans is non-verbal.  However, most people don't pay conscious attention to this even if they still pick up on it.  The animals around us are more consciously aware of these cues.  If we pay attention to such communication when we're training and teaching our pets, we can have better behaved dogs and cats and closer bonds with them.

Owners Giving Vaccines

Controversial subject?  We'll see.

Most vets don't recognize vaccines given by breeders or owners and most boarding facilities I know of also will only accept vet-given immunizations.  This can cause some disgruntled people as they have to get vaccines done again through a vet if they want to board or groom their pet.  Some vets may also not allow unvaccinated pets to stay in the hospital for simple things like spays and neuters without proper vaccinations.  I've known a lot of owners and breeders who have gotten upset in circumstances like this and I've had to try and explain it to them.  There really are very valid reasons, and it's not about the vets trying to squeeze more money out of people.

I will be the first to admit that giving a vaccine isn't rocket science and I can train someone to give injections just as well as I can.  It's also common for most people with horses, cows, goats, and other livestock to give their own vaccinations rather than going through a vet.  In most states of the US the rabies vaccine must by law be given by a vet, but other vaccines are not legally mandated.  So yes, legally an owner can give their own vaccines (other than rabies) without breaking the law.  You can easily purchase distemper and parvo vaccines at feed stores or online, so they are available to clients.

With this in mind, what is the problem with owners giving vaccines?  Why bring it up now?

Yesterday I had an 11 month old Yorkshire terrier come in and within an hour die from parvo virus infection.  A few days prior to that a littermate died at home from parvo.  We managed to treat and save one of the dogs in the litter.  This is a good bit older than most dogs are when they succumb to parvo.  And the owner was the one giving the vaccines.  In fact, the only adult dogs I've seen who have come down with parvo had their vaccines given by the owner.

If vaccines are so available and so easy to give, why are breeder- and owner-given vaccines not effective?  Usually it comes down to inappropriate administration.  Vaccines must be started at a certain age and boostered at proper intervals in order to stimulate long-term immunity.  Vaccines must also be mixed properly and stored at the proper temperature in order to be effective.  Mix them wrong, store them for too long at too high of a temperature, or otherwise mishandle them and the vaccine will not work.  Also, not all vaccines are equally effective, and owners usually don't have the information available to make those decisions between manufacturers.

I routinely see breeders starting vaccines at four or five weeks old, when the minimum age should be six weeks (this is due to proper immunology).  I have seen pet stores giving vaccines weekly, when a duration shorter than two weeks doesn't do anything to booster immunity.  I've had clients who give one vaccine and think the pet is protected.  One time I had a client bring in the bottles of the vaccine given by the breeder, where the breeder had used the diluent liquid and the dry powder from two different company's vaccines.  Anyone who is in the veterinary field knows exactly what I'm talking about.  For anyone who hasn't worked in veterinary medicine, please believe me that these sorts of things happen much more commonly than you realize.

When we see a vaccine record from a breeder or an owner, we honestly have little to no idea if the vaccines were administered and handled properly.  Many of them might be, and I've known breeders who give the same vaccines I use and do so in a very medically appropriate way.  But based on some paper or labels we have no idea whether or not that is the case.  It is in the best interest of the pet and ensures the best health for a veterinarian to be the one to give the vaccines.  Can vets mess things up?  Sure, we're only human and as prone to failings and lies as much as the next person.  But you are much less likely to have improper vaccination through a vet than through an owner.  Vets simply have more knowledge and training than the huge majority of pet owners and breeders, as well as have their licenses and careers on the line when it comes to medicine and record-keeping.

I know that money is tight for people, and many give vaccines to help their budget.  But you are potentially leaving your pet open to infection, as well as preventing them from getting full exams to look for other issues.  It's simply in your pet's best interests to let a veterinary medical professional be the one to do vaccinations.

Post-Traumatic Stress In Dogs

Post-traumatic stress disorder (PTSD) is a well recognized phenomenon in people.  Though most commonly thought of in relation to military personnel (and at one time called "shell shocked" during my father's generation), this problem can affect anybody who has been through a sufficciently traumatic event.  But humans are not the only ones who can suffer after trauma.

Recently I've seen a few articles on this subject in dogs, specifically military dogs (for example, see this article from the New York Times).  As someone with a strong interest in animal behavior, I found myself really thinking about it.  Apparently it's a growing concern in dogs serving in the military.  From the article....

By some estimates, more than 5 percent of the approximately 650 military dogs deployed by American combat forces are developing canine PTSD. Of those, about half are likely to be retired from service, Dr. Burghardt said.

It may sound a bit strange to people, but it makes perfect sense to me.  Every vet knows that our patients often quickly develop an aversion to the office, often showing signs of anxiety as soon as they pull into the parking lot.  Formerly friendly dogs can develop fear-related agression towards veterinarians after the patient has undergone extensive and potentially painful treatment after a serious injury or illness.  We also commonly see phobias and anxiety develop after a traumatic experience.  For example, a dog has a ladder fall near them noisily during a storm and from that point on is afraid of thunder.  Or a cat develops an aversion to the litterbox because it had pain when defecating and the cat associated the pain with the litterbox.

All of that makes sense, right?  So it surprised me that the article mentions that the topic is being debated.

Though veterinarians have long diagnosed behavioral problems in animals, the concept of canine PTSD is only about 18 months old, and still being debated. But it has gained vogue among military veterinarians, who have been seeing patterns of troubling behavior among dogs exposed to explosions, gunfire and other combat-related violence in Iraq and Afghanistan.

Frankly, as a behaviorist (though not a specialist), I'm surprised that we haven't recognized this problem sooner.  It's a well known behavioral principle that traumatic events can lead to future anxiety when presented with similar circumstances.  Perhaps the difference is in the current state of military affairs, with more improvised explosive devices and urban warfare than in the past, presenting dogs with situations that may more closely resemble their home life and environment.

Treatment is possible, and the techniques appear similar to what we use in treating any phobia or aversion.  I've used similar methods many times in storm phobias, and desensitization techniques are used to train hunting dogs not to be afraid of the gunshot.

More serious cases will receive what Dr. Burghardt calls “desensitization counterconditioning,” which entails exposing the dog at a safe distance to a sight or sound that might set off a reaction — a gunshot, a loud bang or a vehicle, for instance. If the dog does not react, it is rewarded, and the trigger — “the spider in a glass box,” Dr. Burghardt calls it — is moved progressively closer.

Some dogs are also treated with the same medications used to fight panic attacks in humans. Dr. Burghardt asserts that medications seem particularly effective when administered soon after traumatizing events. The Labrador retriever that cowered under a cot after a firefight, for instance, was given Xanax, an anti-anxiety drug, and within days was working well again.

It's an interesting subject, and I'd recommend the article to anyone with an interest in pet behavior.  I also think it's important to reconize that the men and women in the military are often supported by canine soldiers, and we need to honor their service as well.

Happy 2012

Welcome to 2012.  No flying cars or moon bases yet and the world's supposed to end on December 21st, so we'll just have to make the best of things.  In the spirit of the new year, here's something that all vets and pet lovers can related to.