World Domination Proceeding

Over the last several months to a year I have seen this blog grow, have appeared on television twice, have done several on-line interviews that have been published, and now have been published in a major US veterinary journal.  A blog post I made several months back was noticed by one of the editors at Veterinary Economics, and he thought it would make a great "Hot Button" topic for the magazine.  We went through an editing process and I just received the latest issue, which has my article on the back page, with a mention on the cover (though you can't see it in this small image...it's just to the right of the main logo)! 

You can check out the issue online if you don't subscribe to it or are outside of the US.  Here's a direct link to the article, which regular readers will probably recognize from this entry back in May.

I'm particularly excited about this article because it's in one of the most widely read veterinary journals in the country, and will probably surprise many of my classmates and colleagues whom I haven't kept up with over the years.  Since this blog is mentioned in the bio at the end, I would also expect that I'll see a bump in traffic on this site. 

It looks like my plan for world domination is proceeding along just fine!

Titers Vs. Vaccines

Over the last 10-15 years veterinarians and clients have become increasingly concerned about the possibility of over-vaccinating.  This has led to changes in vaccine protocols, studies to determine longer durations for vaccines, and investigation into other methods of preventative care.  One of those potential other methods is measuring titers, something that I get asked about every now and then.

Let's first talk about titers, especially for those without a background in immunology.  When we give a vaccine we stimulate the immune system to react.  In order to help fight off an infection the body will produce antibodies specific to the invader.  These antibodies help immune cells recognize and destroy the organism.  Once the infection is defeated the body wants to be ready in order to repel a similar invasion in the future.  So antibodies against that given organism will remain in the blood stream for a period of time, allowing the body to respond quickly if it is infected again.  Each type of antibody is specific to only a single organism, though some may be similar enough that they will aid in fighting off very closely related organisms.

A titer is a measurement of antibodies in the blood stream.  It's not uncommon for us to measure titers as a diagnostic test when trying to determine whether or not a patient has a given infection.  Some people have been advocating measuring antibody titers to determine immunity before giving a vaccine.  The idea is that if the titer is high then protection is still adequate and vaccination is unnecessary; if the titer is low then immunity has waned and re-vaccination is needed. Sounds pretty simple and makes sense, right?

Unfortunately, it's not so straight-forward.  In fact, top immunologists don't recommend routine titer testing as an acceptable alternative to vaccination.  In the early 2000s the American Veterinary Medical Association published data from a Vaccine Task Force study that had been looking into vaccine protocols for several years.  More recently I read a summary article by one of my professors in vet school, Dr. Richard Ford.  There are numerous reasons why titers aren't a good idea.
1.  Antibody concentration and levels does NOT equal immunity.  A very high level usually indicates protection.  However, a low level may not indicate a lack of protection.  And in the "gray area" between the extremes there is no consensus on what level indicates adequate protection.  So just because a lab report states a given level it doesn't automatically correlate with any degree of protection.
2.  In the US there is no standardized method of measuring serum concentrations of antibodies for vaccine antigens.  Therefore the measurement reported by one lab can be very different than the measurement reported by a different lab!  You can't compare results between labs because they may not be measuring them the same way.  So if one lab gives a "high" result but another lab gives a "low" result, is the pet protected?  Honestly, there's no way to tell.
3.  There are no lab tests for most of the vaccine antigens on the market (currently only for canine distemper, canine parvo, and feline panleukopenia).  However, even if other antibody tests are developed, because the correlation between antibody levels and protection is so poor, results will be meaningless.
4. Vaccines are far cheaper than titer testing.  Most vaccines cost less than $30, yet titer testing for a single antigen may cost $80-100, sometimes even more.  For most cost-conscious clients it's better to give a vaccine rather than test for antibody levels. 

Now I know that there are those out there who are strongly against vaccines and are very in favor of titer testing.  However currently the evidence is against doing testing.  Vaccines have prevented disease for over 100 years and we are improving their quality while decreasing their reactivity.  Vaccines have saved lives and caused minimal problems.  There have been far more problems prevented than caused by immunization, and most of the concerns about them have not been proven despite studies.  So until studies show otherwise, I will continue to advocate for vaccination and against routine titer testing.

God And Veterinary Medicine

Ready for a very long post?  Buckle in, because we're going places I haven't gone since I started this blog.

Anyone who has followed my blog over the years or has perused my profile or some of my older entries will likely know that I am a Christian.  I deliberately do not make a big deal about it as that is not the main point of this blog (for something more along those lines check out my other blog, The Christian Ninjate, which isn't updated anywhere nearly as frequent as this one).  However, I've also never hidden my faith and do believe in being openly Christian.  Today I want to talk more about my Christianity in regards to my workplace, all because of an email I received from Rachel...

I'm been interested in becoming a veterinarian since I was very little and always had a deep passion for pets.
Now that I am about to become a senior in high school and have prayed much about it, God seems to have confirmed to me that I should pursue a career path in veterinary medicine.
I came across your blog and the stories that you mention are so interesting and always make me smile :)
Plus, the fact that you are a growing Christian while having the life of a veterinarian shocked me SO much!
All of the veterinarians/pre-vet/vet tech/etcetc. seem to be so avid about animals that they push God away- many speaking against "religion" (especially those who are staunch about animal rights!)
Many people who choose to make animals a critical part of their life even treasure them above people!
I get very discouraged about this, and sometimes think that I'm not "passionate enough" about animals if I value humans and my beliefs higher.
So my questions are...

-How do you glorify God through your job?
-What pushed/motivated you through the hardship of schooling?

In answer to Rachel, let me give a little more of my background, as it's pertinent to the topic. I was raised Lutheran and in what would be considered a pretty typical suburban background.  We went to church, I went through Confirmation, but it never really meant a lot to me.  It was something that we did, not something I really felt.  By the time I was through high school and into college I had started questioning things and became a full-blown agnostic.  At one point I even looked into other religions, including Islam (which was presented in one of my college texts as a religion of peace and inclusion).  While in college I spent part of a semester in London and had an experience there that suddenly made me strongly believe that God was real.  I had no doubts at all.  However, I didn't read or really believe in the Bible, and didn't take its lessons to heart.  I went through graduate school and veterinary school living my life selfishly and in a way that God wouldn't be proud or accepting of.  I treated people horribly and did many bad things.

That turned around in 1998, when I reached the lowest point in my life.  I don't want to get into all of the particulars, but some things happened to me and I felt my life falling apart, or at least going down a track that I didn't want to see.  One evening in my apartment I felt utterly hopeless, and suddenly remembered a few things that my mother had said about being able to turn to God.  So right there I got down on my knees and asked God's forgiveness.  The next day I started looking for a church, finding one close by.  I started studying the Bible, looking at it and life in ways that I never had previously.  About a month after that I met the woman who would become my wife, who was a Christian and someone I never would have considered prior to giving my heart and life to Jesus Christ. Since then I've tried to turn myself around, have changed my attitudes, and don't think that I'm the same person I was back in the '80s and '90s.  I've also tried to listen to God's guidance and have looked for ways to serve Him.  I have been involved in helping to grow churches, have spoken in front of churches, and have become a leader in a "Christian geek" ministry, Fans For Christ, where I organize and lead church services at sci-fi/fantasy/comic/anime conventions.

So that's the short version (believe it or not) of my story as a Christian.  Now to Rachel's points and questions.

I have also seen a decidedly anti-Christian bias among many scientists, who often put science over faith.  I am a very educated person who was trained as a scientist and have published in the scientific field.  I have also taught Biology and other science-related courses, so I have a firm grasp of these fields, evolution, and so on.  I have seen too many people feel that science and religion are mutually exclusive.  I have also seen people hold onto their faith and believe in science as or even more strongly that some people hold onto their faith in God.  And I have lived on both sides of that fence, as I used to be one who valued science over religion.  I have a unique understanding of both viewpoints.

Rachel, I completely understand what you are saying about some people putting animals and humans on equal footing. I also have seen it happen, as well as people viewing their lives and profession without any religious thoughts at all.  I believe in what God teaches through the Bible, that humans are a special creation given rights and responsibilities over the plants and animals of the world.  While animals should be cherished, humans should always win out over them when a choice has to be made.  I love my pets and treat my patients with the best care I can, but I always feel that the needs of the humans in the family take priority. Don't feel like you aren't "passionate enough" if you're not like these people.  Your passion is in a different area, but that doesn't mean that you can't be a great veterinarian.  In fact, you'll probably be more compassionate and caring by following the words of Jesus.

How do I glorify God? Like on this blog I don't beat people over the head with my Bible, but also don't make a secret of it.  I've learned to believe in the old saying that I may be the only Bible that people will read.  So as I go through my day I try to conduct myself in a way that God wants to see.  I don't use curse words, I don't tell off-color jokes, I try to give my co-workers, staff, and clients respect, and I make it well-known that I'm involved in church and so won't work Sundays regularly (my clinic is open seven days a week).  If a client brings up something about God or prayer I use it as an opening to share my own faith and have even prayed with them.  Mostly I try to live by example, showing a Christ-like servant-leadership as best as I can.  Some days it's harder than others, and I'm certainly not perfect (only Jesus ever was).  I want people to see that I'm not hypocritical (most of the time) in my Christian beliefs versus my life.  I also want them to see something in me (the light in Christ that the Bible talks about) that makes them want something similar.  I pray for strength and guidance in difficult cases, and often quietly ask for God's hands to help me through tough times, surgeries, and clients.

The hardship of schooling....I wish I could say that it was my faith, but I didn't have it when I was going through college and veterinary school.  For me it was sheer stubbornness and determination, nothing more or less.  I actually think it would be easier for me now, as I have God to turn to and rely on, something I didn't have back then.  He has helped me through some equally tough times since then, and I am so glad to have Him support and love me.

Rachel, hang onto God with both hands.  Don't let others discourage you.  And believe it or not there are others out there like you.  There is an organization I've been involved with called Christian Veterinary Mission.  They have veterinarians who do mission work in various parts of the world, using their veterinary skills as a way to get involved in a community, looking for ways to share Christ with others.  They also work with veterinary students and would be a good way to fellowship with others going through the same things (look at the "Students" section on the web page linked above).  I'll pray for your success as you follow the dream that God has given you.  Always listen to Him!

Non-Vets Doing Surgery

Sal sent this to me today....

Question:  Is it legal for someone other than a Veterinarian to perform surgery
to spay a dog?
I ask because walking out of my vet’s office, I overheard the receptionist
talking and she said that the vet would not be coming in.  However, I was had
just dropped off my dog to be spayed.  I just want to make sure she isn’t in
harm’s way.

I can't speak for outside of the US or even in every state.  However, I've been licensed in 6 states in various parts of the country and in all of those states, as well as any I've ever heard of, it is absolutely, positively NOT legal, or a good idea.  The owner of that practice could be sued for malpractice and end up with jail time for allowing it.  Also, the person who did the surgery could go to jail for practicing medicine without a license.  Even though spays are routine surgeries, they are NOT simple, and required a skilled hand.  I know experienced vets who aren't comfortable with doing spays!  It took me years of doing spays every day to get my surgery time down from about an hour to my current 20 minutes or so.

Unfortunately I have known vets who will allow their staff to do things like this, even if it's illegal.  Here in Georgia only a vet can legally give a rabies vaccine, but I recently had a client who went to a vet recommended by a local pet store and the vet's receptionist gave the rabies (without an exam!) because the vet was busy. Some vets really don't care about laws or quality medicine and that makes a bad impact on the view of the profession as a whole.

Interestingly, castrations are normally specifically excluded from the practice of veterinary medicine.  This is done because most farmers castrate their own livestock since getting a vet out to do every steer, pig, goat, etc. would really drive up the cost of animal production and therefore food and other animal products.  So technically someone who wasn't a vet could castrate their own dog or cat (or someone else's) and it wouldn't be illegal.  I still wouldn't recommend it because then you get into ethical issues of proper pain control, anesthesia, etc., but it wouldn't be "practicing medicine without a license".

Sal, I would talk to the vet about this, as it is a legitimate concern.  But I would also make sure that there wasn't some other reason for the comment, such if there were a few vets working that day and only one of them wasn't coming in, or if the receptionist was talking about the vet not coming in until later and you missed part of the conversation.  Also, maybe the normal vet wasn't coming in but they had gotten a relief vet who was going to fill in for the day.  Since you only heard part of the conversation you may have missed parts explaining what was really going on.  Give the vet a chance to explain and you may find a very reasonable answer for what you overheard.  However, if the vet does admit that a non-vet did the spay, I would immediately place a call to the state veterinary board and report that practice.

Reasons Regarding Regurgitation

Please excuse my alliteration in the title, but it just sounded fun.  Here's an email from Stefanie....

I have recently taken on a second foster dog. She is only about a year old and is a border collie cross. A high energy dog - which is fine - I'm learning how to channel her energy. I've noticed though that she will glurp out water as she is walking or running around. She also even glurped (my non-technical term for regurgitation) out dog food and water about 6 hours after her last meal. It's not a lot and while she has actually vomited a couple of times - it's been different objects she's chewed on around the house - it's more the regurgitation that has me puzzled.
Is regurgitation a few times a day enough to warrant a vet visit? She doesn't have any other symptoms other than what I've described - still has plenty of energy and is bright-eyed. I am fostering for a rescue so ultimately the decision to take her to the vet is at their discretion, but your advice on when to have her examined is greatly appreciated.
 
I would most certainly take her to the vet, and plan on having x-rays taken.  As you've indicated, regurgitation is different than vomiting.  The former is passive, with the stomach or esophageal contents spilling out because of a lack of tone in the sphincters or muscle walls.  Vomiting is active, involving contractions of the abdomen and stomach.  There are very different indications for each, so we can't treat them similarly.
 
The biggest concern I would have for chronic regurgitation would be megaesophagus.  This condition occurs when the esophagus is significantly dilated for some reason.  Anything swallowed can sit in this expanded area rather than passing into the stomach, and after a period of time can suddenly "glurp" back out.  In younger dogs this is most commonly caused as the result of a birth defect where a vascular arch near the heart stays around the esophagus, essentially causing a stricture and eventually dilation of the esophagus.  There are causes of megaesophagus that are more acquired than a vascular abnormality, but they are not as common.  A hiatal hernia or problem with the cardiac sphincter of the stomach (the one between the stomach or esophagus) could cause similar problems.  But I would consider megaesophagus until shown otherwise.
 
Megaesophagus is a big concern, as there is a high risk of food or water running backwards through the esophagus getting down the trachea and into the lungs, causing what we call aspiration pneumonia.  This kind of pneumonia can be life-threatening and the risk shouldn't be ignored, even if it hasn't happened yet.  Even if it's not megaesophagus, anything being regurgitated can be aspirated into the lungs and therefore should be checked out.
 
There is no cure for megaesophagus, so efforts are put to management.  I have known dogs successfully managed for many years, but it involves being very careful about feeding and drinking.  These dogs always need to have elevated bowls so they do not have their heads down while they are trying to swallow.  Essentially we are letting gravity work with us rather than against us.
 
So see a vet about this before something worse happens.  Good luck, Stefanie!
 
By the way, I love the word "glurp" and may use it myself, if you don't mind!

Attacked! The Good And Bad

One of the hardest things we as veterinarians have to face is the enmity of our patients.  Most people probably don't realize the real danger veterinary staff are faced with on a daily basis.  Take today for example.  I saw around 20 pets, mostly dogs, and ff those pets I had five try to bite me.  Most of them made really serious attempts to the point that we had difficulty getting muzzles on them and one we had to give an intramuscular sedative to knock her out.  Though none were likely to truly maul me, several potentially could have ended me up at the emergency room for stitches.

This isn't a rare occurrence.  In fact, it's a rare day when I don't have a pet try to bite or scratch me.  It's one of the least favorite aspects of my job, especially on days like today.  I get really tired of having pets try and take a piece out of me, but it's not like I can put a sign out saying that I'll only see nice patients (tempting though it may be).  As long as I practice I'll be faced with situations like this.

What I much prefer is how I am "attacked" when I come home in the evening.  Once I walk in the door I'm greeted by our two dogs, Inara and Yvaine. They jump all around me and seek my attention.  Then they seem to suddenly notice that I have scents all over me and before I know it I have noses running up and down my legs.  Sometimes I have a hard time moving because their faces are pressed up against me and I have two 60 pound dogs curved around me.  I don't mind this kind of attack at all and wish my patients behaved more like this.

Identify The Critter

Here's one from Andrea that I'm hoping my readers can help with...

I'm a norwegian vet tech student currently working part of my internship at an animal clinic in Denmark. There are a lot of heart and lung worms now in the summer, so we do a lot of worm tests daily. Today I was microscoping a sample from a pug and didn't find any larvaes. But there was something else. Without the microscope I could see a lot of teeny tiny white "rice". I know they're not tape worm segments! Which seems to bee the only answer people get when they find white things in their dogs feces. I can't find anything on the internet that looks like it. I've attached a coulple of picture I took with my phone. None of our vets know what it is. There is nothing similar in our clinical parasitology book. In the microscope they look kind of like a butterfly pupa. They have spikes on their "body" and I can see a lot of, what I believe is blood vessels. They didn't move, but one of them "spit" out some grainy stuff. I'm so curious to find out what it is! Can you help me? 

I only took pictures using one of the lenses, so I don't have one where you can see the spikes.

I can't identify these, but I do agree that under the microscope they aren't tapeworms.  They look like they could be maggots of some sort, and I'm curious as to whether this sample came directly from the dog or if it was collected from the yard.  If it was the latter, then it could be environmental contamination and not a parasite.  Honestly, I can't think of any intestinal parasites that look like this, but I'm not sure if there are some in Europe that I don't know.

So, all of my international veterinary readers....any clues?