Wednesday, March 31, 2010

About the dog

Heidi continues to settle into the house. She's an exceptionally good girl. She's learning the heel right now, although training is frequently interrupted by my work schedule. I'm on my 9 days off right now, so I can focus more on training.

She doesn't bother the cats or the birds.

We take her everywhere we can with us. If the weather is cool enough (which - in spring - it is), she can hang out in the car while we shop or do whatever. She even got to go with us while we car shopped. (Caveat: Be very cautious when leaving pets in the car during spring. Even though the temperatures are very mild, I don't leave Heidi if the temperature is above 70. Even then, the windows are down, and I check on her and the temperature of the car frequently. Once it's consistently above 70, we'll either have to leave her home or go to exclusively dog friendly places.)

Her limping is improved with regular exercise, and she is filling out some finally. She still looks raggedy to me, but it's improved. Her appetite is still ravenous...but it might have slowed down a little. We go to the park nearby a lot and walk. It's not an off leash park (and frankly, off leash parks scare the bejesus out of me)...and I hate that I can't let her run like a puppy. Also, our yard isn't fenced, so she pretty much has to be on a leash at all times. Hopefully, she'll respond well to recall training, and she'll be able to be off the leash one day.

So far, the integration is going very well.

Tuesday, March 30, 2010

Why take it personally?

Sunday night, a disheveled woman comes in with her cat that is acting oddly - he's meowing loudly and painfully. She makes it clear on the phone beforehand that she ONLY has the $92 to be seen by the doctor, nothing else.

OF COURSE OF COURSE - her cat was blocked (see sidebar for explanation).$92 ain't gonna cover that, no way, no how.

Here's my dilemma:

In a best case scenario, I run bloodwork to look at kidney values, place an IV catheter, anesthetize, unblock, run a urinalysis, leave the catheter in for 24-72 hours while the patient is hospitalized, continue pain medications and fluids, and eventually discharge the patient to go home. This runs between $800-1500 depending on the length of the hospital stay.

There ARE other possible treatment scenarios. For instance, although I hate to do so, I can eliminate the bloodwork and urinalysis. This isn't a great idea, because I can't tell if the patient has gone into renal failure from the obstruction or not, and thus, I have no barometer for measuring if fluid therapy is effective...but if it's euthanasia or that...I'll cave and give the animal a chance. Or, if I'm feeling particularly bold and money is extremely tight, I will anesthetize the patient, unblock it, and send it home. This is a recipe for disaster - I'm not going to lie. Most cats unblocked this way and not put on fluids, will reblock within 24-48 hours (in my experience). Many cats when treated with the Cadillac plan will reblock at some point in the future anyway.

So, Mom is not happy with our "no billing" policy. It's either pay or we can't help you. I know that sounds heartless, but if we extended credit to everyone who said they couldn't pay, we would quickly be bankrupt and no animal would receive emergency care.

Mom tries to guilt trip me - and that's where I almost got angry. She calls her 15 year old daughter, hands me the phone, and makes me explain what's going on. She's trying to BLAME ME for her lack of funds, her inability to qualify for credit (CareCredit), and her inability to find one single person to loan her $500. If I needed $500, there are at least 10 people I could call off the top of my head that would loan it to me, no questions asked.

Daughter becomes hysterical. I calmly inform her (all the while seething inside at mom's underhanded maneuver) that her mother is deciding to euthanize kitty because of funds. I made it HER decision, NOT mine.

Mom starts ranting about how "if only Obama had gotten health care for animals, too." And yes, I bit my tongue so hard it might have been bleeding.

In the end, Mom came up with $200. I was able to sedate the cat, cysto to empty it's bladder of some very bloody urine, and dispense Buprenex (an opioid pain medication). It was 11pm, and her vet opened the next day at 7:30am. She swore she would be on the doorstep at that time.

She signed an "against medical advice" form saying that she was taking her pet home against medical advice. At the bottom she wrote, "I am not choosing to do this. I didn't have money, so I got no help."

At the end of our interaction, she said "hurry up, so I can get out of here, and you won't have a bad conscience."

I looked at her levely and said, "ma'am, I did a humane thing for your cat, emptying his bladder and getting him pain medications. I did what I could given the limitations you had. My conscience is clear."

She shut up after that.

Monday, March 22, 2010

You win the stupid award for the week!

Sunday afternoon, a couple brought in a very small dog (5 pounds) due to difficulty birthing.

She'd gone in to labor around 8am. A puppy foot came out ... and then just hung around. No puppy followed. For 2 hours, mom pushed and pushed. No puppy - just 1 forlorn foot.

That's when the owners took things into their own hands (literally). The owner tried to pull the puppy out. Guess what happened? The puppy came out. Well, at least the puppy's body came out. SANS HEAD.

So, they showed up and told me that they'd pulled the puppy out, and the head had come off. It was still in the dog. When I palpated the abdomen, I was horrified at the size of the skull. The dog weighed 5 pounds. I estimated the puppy at around 1-1.5 pounds - monstrous for this dog (and the only puppy I could palpate).

Of course, the owners declined treatment due to cost. They told me several times that they'd had a c-section done a mere 2 years earlier at our facility, and it cost them only $600. When I checked the records, it was true. They'd had a c-section. Whatever doctor had done it had done it at a discount - likely because the owners were financially strapped. Here they were, 2 years later, expecting the same hand-out treatment again.

That immediately got my blood up, I won't lie. It was coupled with the fact that despite previous breeding problems, they'd bred again. This mother dog was unvaccinated (never had rabies vaccine, which isn't legal), she wasn't on heartworm preventative, and she was absolutely emaciated. She was in no shape to be having babies. Yet, she was.

Infuriated, I decided that I wouldn't be doing these owners any favors. I prescribed antibiotics and pain medications. The owners made an appointment to see a vet first thing the next morning for a c-section.

In the end, I never feel good about these things. The dog had to suffer for another night due to owner ignorance. She should never have been bred in the first place, as she was absolutely so thin that every rib and vertebrae stood out. I could have done a "budget c-section" - but that would only reinforce the owners' idea that they could receive cheap/discounted medical care for their dog every time they made bad, bad decisions.

And I still feel like a crappy person.

Sunday, March 21, 2010

Baby, when it's love, if it isn't rough, it isn't FUN!

Around 9am this morning, I was presented with a youngish male dog. He was not neutered. His chief complaint: bloody urine.

On physical exam, he was in splendid health and body condition. As he walked, small drops of hemorrhage fell from his penis. This was no bloody urine, this was pure blood.

I went to talk with his owners, and the story came out...he'd tied with a female the previous day. He'd never tied before, and the owners described his lovemaking skills as significantly less than gentle. In short: it was extremely violent, and the female dog that wandered into the yard was a less than accommodating partner (YET ANOTHER reason to spay/neuter your pets).

Since then, he'd been extremely lethargic, dripping blood from his penis.

Based on his physical exam and history (absence of a large or painful bladder on abdominal palpation), I suspected he'd suffered penile trauma during the tie. I recommended sedation to his owners so that I could fully extrude his penis and examine it.

I don't know how many of you have looked at a dog penis fully out of the sheath, but they are shaped like a lipstick, for lack of a better comparison. At that base on the penis is a bulbous area (called the bulbis). There are glands that live there that secrete fluids into the ejaculate and whatnot.

At any rate, as I pushed the penis out of the sheath, I was almost blinded by the amazing freshet of blood that came spurting up and out. Apparently, this poor dog had lacerated the entire base of his bulbis, including a large supplying artery and several smaller veins. AS soon as the penis was out of the sheath (which was acting as a decent tourniquet), blood began spewing!

I was horrified, as were all the males present. The whole base of the penis was bruised and swollen. It needed surgical repair, given the extent of tearing. I administered a dose of steroids to help with the swelling and inflammation, placed small, absorbable sutures in the vessels to stop the bleeding, and recommended hospitalization to the owners.

Due to finances, they took the dog home for the night. Hopefully, they'll follow up with their vet - as they promised - first thing in the morning! I can't imagine how uncomfortable that poor dog must have been.

Tuesday, March 16, 2010


She picked out the green toy herself at PetSmart today.

Heidi is a very timid girl. Today, we worked a little on socialization. The husband and I took a trip to PetSmart to pick up a 20 foot training lead (I'm starting with teaching her how to heel). When she first got out of the car, she was a giant ball of nerves. She didn't know where to look first, and she kept spinning and weaving around. Finally, I had her sit, got down on her level, and rubbed all over her body while talking calmly to her and telling her what a good girl she was. This was amazingly effective and served to center Heidi. After that, she was fine. I introduced her to some other dogs, as well as some children. The children made me nervous - they moved too fast around her, and sometimes didn't listen to what I told them. My heart was in my throat the whole time, despite how carefully I was supervising. She did fine, but she was terrified. She shook. I'll probably back off a little on the hand's on contact with children for now and just work on having her around them consistently. She did fine with our nephew last night, but she avoided him like the plague.

We're doing well otherwise. She continues to limp, and I'm concerned that her joint problems may be something more sinister than a life on concrete -- something like polyarthritis or the like. I'm taking her to work with me tomorrow (both for the socialization and to give her a good physical exam).

Mis(sed) diagnosis

I have lots of interesting stories to tell - about great saves, surgical miracles, and other "I'm a fabulous veterinarian" tales. Instead, I want to bring attention to a problem all ER doctors (and GPs too) struggle with - the time crunch.

A couple of Saturdays ago, I was swamped with cases. In the midst of this, I was confronted with an almost 200 pound patient. He had developed swelling of one of his front legs and was limping badly (almost non-weightbearing).

At first glance, I thought an orthopedic problem. Palpation of the leg did not elicit any specific areas of discomfort. Further, the swelling of the leg was not centered over a joint or particular area. The entire antebrachium (forearm) and carpus (wrist) were swollen and slightly warm to the touch. I could not find a puncture wound anywhere. His temperature was 104.7...but he was 200 lbs, limping terribly, and we'd had a spurt of spring-like weather that day. He'd walked almost a mile on 3 legs to get into the car, and he was panting very heavily. I attributed the high temperature to heat/exertion stress. It improved to normal with acepromazine and hydromorphone, something a true fever usually won't do.

I wrote up sedation orders for him so that we could take xrays, and turned to the other 7 patients awaiting my attention.

When I reviewed his xrays later, there was no evidence of a fracture - just diffuse swelling of the leg.

In any other circumstance, I would have thought about cellulitis/abscess formation (infection of the tissues below the skin), but I was overworked, overwhelmed, and busy. The dog was otherwise doing fine at home - eating, drinking, and attempting to walk.

I dispensed pain medications and advised the owners to follow up with their vet on Monday if there wasn't noticeable improvement.

Monday came round, and the owners went to their veterinarian because the dog had not improved, and the leg was significantly more swollen. Bloodwork revealed a white blood cell count of 60,000 (!!!). Normal for a dog is between 5,000-17,000. The vet diagnosed cellulitis and started antibiotics.

Where was my mistake? As I review the case in my mind, there are several.

1) I was biased in my thinking. A 200 lb outdoor dog with sudden onset of swelling in one limb, I assumed orthopedic or soft tissue trauma - based on many other patients I see.

2) I assumed the 104.7 temperature was heat exertion/stress based on the fact that it improved with sedation and decreased respiratory rate. With the combination of the swollen leg - I should have been thinking infection (although I'm still not sure whether it was a true fever or not).

3) Busy - I was too busy and overloaded at the moment to take a step back and really assess the case. In my head, I had put the pieces together: diffuse swelling of the leg not centered over one particular area, acute lameness, no specific areas of bad pain, and a possible fever...these equal cellulitis...or at least, they should have!

The dog is doing fine on his antibiotics, but this has been bugging me for the entire week. I had intended to call the owner on Sunday and relay my suspicions about cellulitis, but then I got swamped again, and by the time I looked at the clock, it was well past 11pm. I had fully intended to ask them to come back in for a free re-examination....and then...time got away from me.

It's frustrating when this sort of thing happens, because the patient doesn't receive optimum care. The owners feel cheated, because they spent $300 to see me, and I didn't make a diagnosis. I feel like a failure as a doctor because I was tired, overworked, stressed, and made a mistake. Nobody wins in that situation.

Monday, March 15, 2010

More on Heidi the wonder-dog

So, her story goes something like this:

Heidi is 5 years old. She has not been spayed. Her coloring is due to a color dilution gene(color dilution alopecia).

She was purchased for breeding. At some point, she became a strictly outdoor dog. Her home was a concrete floored doghouse. All winter, through temperatures in the single digits, Heidi lived outside. Her hair coat is very, very thin due to her genetic issue (color dilution). She was ignored. Her health deteriorated due to bad diet, lack of exercise, and no interactions with people. Her carpi (wrists) developed pressure sores and became very swollen and extremely arthritic (again, due to lack of exercise and malnourishment). She was eaten alive by fleas.

One of my big-hearted technicians was finally able to get her turned over to us. She has been at the clinic for the last 2 weeks. She is gaining weight on a puppy food, her fleas are gone, her open sores are healing, and she is limping less and less. Her manner is extremely eager to please, and she wags not just her tail but her whole body. In short, she is the sweetest thing I have ever seen.

I've wanted a dog on and off for the past many years, although I am a self-confessed cat (and bird) person. I didn't want to deal with the destructive puppy behavior and house soiling - although I have no qualms about obedience training. Heidi is already house-broken and knows some basic commands (sit, lie down, wait).

Now I know a good deal about Dobermans - personally I have always been a fan. Dobermans have their fair share of diseases - notably von Willebrand's disease (lack of a crucial clotting component) and dilated cardiomyopathy (a terrible, inevitably fatal heart disease that some researchers estimate 50% or more of Dobies will develop). On top of that - they develop hypothyroidism. She's also intact - so I have to fret about pyometra until she's recovered enough for me to spay her. She's a big, deep-chested dog, so I'll pexy her too - to hopefully prevent her from having a GDV. Likely, Heidi will be arthritic for the rest of her life and will require medications to keep her comfortable, as well as regular exercise.

All that said, I think she is worth the time and effort. I am already so in love with her that it's a little ridiculous.

I'm more than 3/4th of the way through How to be Your Dog's Best Friend written by the Monks of New Skete, and which I highly recommend to anyone interested in dog/pack psychology and training. My closest friend used it to train her dog, and it's amazing how effective their methods are. They take a holistic, "big-picture" approach to training - incorporating understanding of how your dog thinks and feels into the training.

I'll keep ya'll posted on her progress - yes, with pictures!

Sunday, March 14, 2010

I am so in love

Smitten doesn't even begin to cover it. I am in love, love, love, love.

Saturday, March 13, 2010

I must be crazy

Soooooo...since I've been married, I haven't owned a dog (going on 11 years now). I love my dog patients, and there are some breeds that I am particularly fond of. I love a pit bull. Granted, the breed has its issues, but I love them. I'm also a big fan of Dobermans.

We have one at work. She's been there for about a week. She was turned over to one of our technicians for terrible neglect (but not physical abuse - no beatings). She's malnourished, has malformed joints, but is absolutely sweet - and in time - she will be beautiful. Once her hair grows back from flea infestation, and she gains some weight, she will be a lovely Dobie.

Currently, her head is in my lap while I type this. She circumnavigates some of my concerns about dog ownership - she's not a puppy, she doesn't chew/tear up stuff, and she's already house-trained. Sure, I have more training to do - but the hard stuff is done for me. I also need to spay and pexy her. She's somewhat intimidating looking (being a Dobie) - which is a plus - because she's a big, big lap dog. So, when Jim is out of town, I will feel much, much more comfortable.

Ok, so this is strictly a trial. If she shows the slightest bit of too much interest in our other household denizens (namely the parrots), she goes back to work to await another home. For now, though, she resides with us.

Friday, March 12, 2010

Books and covers

Last Saturday night, I had another important lesson reiterated (seems to be the theme from last week). I was down to a nub. I was exhausted (sleeping poorly), we'd been busy all week, so I hadn't slept on any of my working nights, and one of my technicians was giving me the silent treatment (more or less). Basically, I was finished. My judgment can be admittedly hazy in these situations, but I was still caught off guard.

At around 9pm, an absolutely beautiful, purebred show dog walked in. She was pregnant, had produced 2 puppies over 13 hours, and was now very, very lethargic, feverish, and still having intermittent contractions. Diagnostics confirmed a retained, very dead puppy. Seeing that this was a gorgeous, well-loved show dog, I popped into the room certain that I would be doing a c-section. Much to my horror, the owners barely had the money to cover the diagnostics we had conducted. They euthanized.

Later that night, a 70 pound, extraordinarily pregnant pitbull walks in. She'd had a puppy stuck for 12 hours, the head hanging out of the vulva. She was so pregnant, she could barely waddle into the clinic. The puppy, of course, was long dead. This pitbull had home-cropped ears (she actually had NO ears, really). She was dirty, wearing a large chain collar, and she was very aggressive. Her owners were...........Well, they didn't look like the type of people to plop down $2000 for emergency surgery.

After 20 minutes of pulling, rotating, lubricating, etc., my tech was able to get the puppy out (he used every inch of his not inconsiderable height and weight). I gave mom a shot of oxytocin and crossed my fingers. Twenty minutes of pregnant dog screaming later, I figured c-section was the only good option.

The owner barely glanced at the estimate for $2000-2500, says "well, it's gotta be done," and signs the form.

Repeat lesson of the day: never judge a book by its cover.

(As an interesting sidenote: the pitbull weighed 67 pounds on admission. After c-section, she was 46 pounds!! Yup, her uterus weighed 21 pounds. The actual c-section was an utter nightmare. I think there was uterine juice on the ceiling when I was done. I had a good cry afterwards, because I was so tired and stressed.)

Wednesday, March 10, 2010


Hey, if you're out there, and you're a regular reader - become a follower. I'm trying to really get this blog out there in the mainstream, and it would help having some idea how many people actually read me. Thanks :)

Primary differential cont'd

So...yes, cancer was my first differential.

I discussed this with the owner. I told her that I could not explain exactly where the small clusters of bacteria were coming from. My guess was that there was likely GI cancer that was causing leakage of the GI tract.

That was where I made the mistake. If you've ever read any of Atul Gawande's books (Complications and Better)- you'd probably be familiar with this mistake. I assumed that my primary differential was the right one - based on previous experiences. I did make sure - however - to tell them that I wasn't sure - and that the next step would be abdominal ultrasound or exploratory laparotomy.

They elected to euthanize, and because I am always, always trying to learn and improve, I requested a necropsy. The owner consented.

When I opened the abdomen, the omentum was so diffusely inflamed and erythematous that I was quite astounded. There was fibrin floating around in fluid (quite a bit of it). I examined the intestines and found nothing grossly out of the ordinary. I pulled the stomach out and found the omentum adhered to the pylorus. I pulled it away and stomach and upper small intestinal contents spilled into the abdomen. There was a hole in the pylorus about the size of a quarter. I cut over the hole with a scalpel and out popped a wood chip. I stared, amazed. The dog - instead of having cancer - AT THIRTEEN YEARS old - had a FOREIGN BODY. It had led to necrosis and perforation of the pylorus. The reason the bacterial numbers in the abdomen were so low was because the perforation was an upper-GI one - there is very little bacteria in the stomach/pyloric region - especially compared with the small intestines. Those unusual cells I was seeing were reactive mesothelial cells (reactive due to the abdominal inflammation/peritonitis).

I called the owner and let her know - feeling terrible. I had let my certainty that the dog had cancer cloud my judgment and clinical knowledge. The dog had peritonitis with some free bacteria - that screamed GI perforation. Unfortunately, I thought the perforation was secondary to cancer. It was not.

On the other hand, the dog was 13, had a whomping heart murmur, was very, very sick, and needed abdominal surgery, which the owners had already said they wouldn't go put him through.

But still. It was a vital, vital reminder to watch for the Red Herring (capitals courtesy of a friend) and to always, always remember that differentials are just differentials until you hold the answers in your hand! A 13 year old dog is certainly capable of a foreign body, just as a 1 year old dog is certainly capable of having cancer.

Thursday, March 4, 2010

Primary differential

I know that title sounds like something out of Star Trek, but it's not. When fledgling veterinarians are learning how to diagnose disease - we are taught a "problem-based" approach. As in - list the problems your patient has - then list differential diagnosis.

An example: an un-vaccinated 5 month old puppy comes in with loss of appetite, vomiting, and bloody diarrhea.

Simple enough, the problem list is: anorexia, vomiting, bloody diarrhea.

The next step is formulating a differential diagnosis list i.e. what could be causing these signs based on the age, sex, vaccination status, etc of the patient.

In this puppy, my differentials would be as follows: parvovirus, GI parasites, foreign body, GI intussusception, dietary indiscretion, HGE, etc - in that order. When formulating a differential list (Ddx in our parlance), it should be done in order of most likely to least likely.

So, this was what went through my mind when I was presented with a 13 year old dog at 3am on Tuesday night. He belonged to a technician from one of our local DVMs. He had been going downhill since the previous Thursday. No vomiting or diarrhea. He was just progressively more lethargic and depressed. He had woken up the owner that night crying in pain and then he vomited twice. Bloodwork at his vet on Thursday had been unremarkable. He was on tramadol for pain control.

When I examined him, he was extremely depressed, dehydrated (his gums were dry), with a moderately distended, painful abdomen. Rectal exam revealed no abnormalities other than scant loose stool. He also had a fairly rocking heart murmur.

Since he'd just had bloodwork 4 days previously, I elected to start with abdominal xrays. It only took one glance to diagnose an abdomen full of fluid. Ultrasound confirmed this. I tapped the fluid for cytology (slide for microscopic examination). I saw peritonitis - gobs and gobs of neutrophils. Bacteria were surprisingly scarce - although here and there, I found intracellular rod bacteria. Certainly not as many as I've seen with previous septic abdomens. There were also occasional clumps of large, irregular, darkly staining, multi-nucleated cells that looked like this:

So, veterinary students and vets alike and anyone else: what would your primary differential be? What other differentials should you consider?