A Vet’s Guide To Life

It’s hard to be a doctor. There are a lot of decisions you have to make that affect your patient’s life and well-being. Test results can sometimes be interpreted in different ways, and different combinations of results can mean different things. Not every case is clear-cut, and many are difficult to figure out. Many decisions have to be made on the path to a proper diagnosis and treatment. It’s never an easy thing to do. It’s even harder when its your own pet.

My oldest cat, Perceval, is 16. The summer before I started vet school I was working for a veterinarian in my home town. A litter of three kittens was dropped off for routine leukemia testing and vaccinations, and we did those services. The “owners” never came back for the kittens, and we quickly discovered that all of the information they provided was completely bogus. I ended up keeping one of those kittens, and he’s been with me ever since. He has moved with me across the country several times, and has lived with me in seven homes in five states. In his 16 years he has seen us add two cats, two dogs, two kids, and a wife (not in that order!) to the family. He has taken these changes with quiet grace, and is older than any pet I have ever had.

Over the last couple of months he has started vomiting with increasing frequency, beyond what a cat normally will do. In the last several weeks we’ve started noticing that he has seemed very thin, quickly getting worse. He’s always been a thin, lean cat, but this has been much worse. He is normally around 9 pounds, and last year was as low as just over 8. Today he weighed in at 6.6 pounds.

I took him with me to work today and ran a battery of tests. I ruled out kidney and liver failure, heartworm disease, hyperthyroidism, and several other diseases. Unfortunately, I wasn’t able to make a specific diagnosis, and am still scratching my head. I have it narrowed down to two likely possibilities, and a host of lesser possibilities. One is inflammatory bowel disease (IBD), which is very treatable with steroids and diet. The other is cancer, especially intestinal lymphoma, which will require surgical biopsies for a definitive diagnosis. I’m beginning treatment for IBD and will see how he responds before taking the next step.

Situations like this are very difficult for a vet. No matter how close I am to a patient or a client, there is always a clinical objectivity that I can maintain. That’s much harder when it’s my own pet, especially one that has been my friend for a decade and a half. I’m faced with the prospect of possibly only having a few months with him or even less depending on what happens in the next few weeks. That’s not easy, and it makes any decisions even harder. I’ve been faced with this on my own pets in the past, and it’s never easy. At times like this, a vet is more of a client than a doctor, but has to play both roles. Vets can definitely sympathize with our clients because we are faced with the same decisions with their own pets. As I make choices about Perceval, I will have to weight the chances of successful treatment versus the cost. And yes, I do have to pay for services and medicines even if it’s discounted, and I’m far from wealthy, so I do have to worry about money.

When it’s personal like this, it’s not easy. But I also don’t want to turn over his care to anyone else, even though I completely trust my associate. I just need to go through the diagnostic process, try various treatments, and pray.

The longer I practice, the more surprised I get at certain things.  One of them is the number of people who think that their pet has something stuck in their throat.

The situation normally begins something like this.  A client brings in their dog because he has been coughing.  The pet may or may not have been chewing on a bone or a stick or paper or something like that.  The cough is sporadic and not constant and has been going on for a few days.  The main concern that the client has is that the dog has something stuck in its throat and that’s the reason for the cough.

In order for something to cause a cough, there needs to be irritation in the trachea.  Yes, things can get caught there, but it’s not a simple thing.  If some sort of object is stuck in the trachea it is VERY irritating.  This won’t cause several days of occasional coughing.  This will cause pretty frequent and pretty severe coughing.  It may also cause difficulties breathing depending on how big the object is.  However, this situation is very rare.  In 12 years of practice I have never seen a coughing pet that actually did have something stuck in the throat, yet I frequently have clients who think this has happened (including today).

Now that’s not to say that it isn’t possible.  I’ve read cases of tracheal foreign bodies or obstructions, and have spoken to colleagues who had to deal with such a case.  But it’s definitely not a common occurrence.

So if your pet has problems with coughing, definitely take him or her to your vet.  But don’t automatically assume that something is stuck in the throat.  Odds are that this is NOT the case and there is another cause.  Listen to your vet and follow the recommended diagnostics and treatment.

Tonight my wife and I were sitting on the bed, each of us on our computers, with the movie Eight Below on the TV.  For those of you who haven’t seen it, I highly recommend it.  The story is about an Antarctic researcher and his sled dogs.  He has to be flown off the base, and the dogs end up getting left behind to fend for themselves for an entire Antarctic winter.  Much of the movie follows the dogs on their struggle for survival.

As is typical in our household, both dogs are up on the bed, almost crowding us out.  Guinevere was very relaxed and just about asleep.  Then we hear a little growl, and then see Inara’s head and ears perk up.  For those of you who have seen the movie, this was during the scene where the dogs are facing the leopard seal.  Inara was watching it very intently, and started barking at the TV.  Every time the dogs were not in a scene or it was on a commercial, she didn’t seem to care.  But when the dogs were prominently featured, she was watching the movie more closely than my wife and I were.  It was one of those moments that comes along rarely, and we were cracking up laughing at her interest and antics.

It really is fascinating to me how different dogs can have different reactions.  One of my dogs when I was growing up would sometimes do this, but I don’t remember it being as consistent in one evening as with Inara.  Guinevere has never done this, and really doesn’t even seem to notice that the TV is even on.  For whatever reason, this movie really grabbed Inara’s interest, and she was responding to the dogs.

Now we’re going to have to try this with Snow Dogs or 101 Dalmations!

I did an entry on misconceptions about pets several months ago (in December), and thought I would address a few more.

Cats need to drink milk.
Dairy products aren’t inherently harmful, but also aren’t good.  A dog’s or cat’s digestive system changes after weaning.  The structure of the lining of the intestine alters to no longer be able to absorb lactose, the main sugar in milk.  So once a pet has weaned (about 5 weeks old in dogs and cats), they develop a sort of lactose intolerance like some humans have.  A little cheese, milk, or ice cream isn’t a big concern, but enough can cause problems.  Thankfully, these aren’t serious problems, and are usually limited to diarrhea or vomiting.  So the old image of a cat drinking from a bowl of milk or cream isn’t really proper, and is nothing that a pet owner should be doing.

Giving garlic to a dog will repel fleas.
This is a common recommendation, and you can find many internet sources and discussion groups that will talk about it.  The problem is that there is no scientific basis for this.  In fact, studies have checked the effectiveness of garlic as a flea prevention, and found that it does absolutely nothing.  I have read more than one scientific study that confirmed that garlic supplements do nothing to keep fleas off a dog.  While it won’t hurt, there really is no benefit at all to it, and there are much more effective ways to prevent fleas.

Have you ever wondered if those old remedies, recommendations or stories are true?  Send me your questions and I’ll answer them!

Sometimes one of the hardest things to deal with is a patient with numerous problems at the same time.  Like my patient today.  Actually, I was filling in at a different location than I normally work, but I had good notes from the other doctor to follow.  Spice is a 12 year old poodle who has had chronic ear infections, a low-grade heart murmur, and has recently started having seizures.  Oh, and recently he had some pretty dramatic increases in the liver values in his blood tests, indicating that there was something really wrong with the liver.  On top of all of that, he has some pretty bad arthritis and needs to be on pain medication daily or he can’t easily get around.  Think this little guy has enough problems?

Let me give you a better idea of the specific problems and decisions that he and his owner face.  His seizures are controlled by phenobarbital, and if he doesn’t take this medicine every day, he will seizure multiple times per week.  Phenobarbital can have several side-effects, and a large part of that relates to damage to the liver.  When a patient is on this medication, the liver values need to be regularly tested.  Most pain medications fall into a category called non-steroidal anti-inflammatory drugs (NSAIDs).  In humans these are things like acetaminophen, ibuprofen, and naproxen.  Pets take medications like Rimadyl, Etogesic, and Deramaxx.  One of the problems with NSAIDs is that they can cause damage to the liver.  When we start a patient on either of these medications, we check the liver values first to make sure there aren’t any pre-existing problems.

When Spice was first evaluated for the seizures, his blood tests were normal, but they didn’t stay that way.  Two of the main values we look at are alkaline phosphatase (ALKP) and alanine transferase (ALT).  Normal values for ALKP are about 70-212  and for ALT are 10-100 (these normal ranges can vary depending on the lab or equipment being used).  When Spice’s values were checked in January, they were normal.  A month later, the ALKP was over 1200, and the ALT was almost 400!  A really, really big jump, and a pretty scary one.

The dilemma is that he needed to be kept on phenobarbital to stop his seizures and needed Etogesic to control his severe arthritis pain.  However, either of these could have been affecting his liver.  Now, we didn’t start the Etogesic until after the lab results were run, so that wasn’t the initial cause.  But the doctor at the time was hesitant (and rightly so!) to use any NSAIDs.  She decreased his dosage of Etogesic, hoping to find a balance between controling his pain and not hurting his liver.

Today we rechecked his values.  His ALKP was 388 and his ALT was 109.  Those were considerably better than before, and were almost 1/4 of the previous values!  However, they weren’t normal.  I talked with the owner about the options and the risks.  Analgesics other than NSAIDs weren’t a good option, as they could cause an increase in sedation, especially in conjunction with the phenobarbital.  The Etogesic at a full dose did help with his pain, but could harm his liver.  We couldn’t take him off the phenobarbital or he would start seizuring again.  Really, there were no easy solutions.

This is the kind of difficult decision that we sometimes face as doctors, as well as pet owners.  We want our pets and patients better, but somtimes that’s not easy.  Do we take him off pain medication to help his liver, leaving him in unmanageable discomfort?  Or do we put him on the analgesics, controlling the pain, but potentially shutting down his liver?  Definitely between a rock and a hard place.  And I can’t say that there was a single right or wrong answer.  Any choice could be a good one or could be a wrong one.  And I’m not here to tell you that we made the right decision, because we really don’t know yet.  I wanted to bring this up as a case where there really is no easy or clear-cut choice, and we have to just do our best.

What we ended up doing was increasing the Etogesic to a dosage that will control the pain and hoping for the best.  He will have his liver values checked in two weeks.  If they haven’t gone up considerably, we’ll keep him on those medications and try to manage any side-effects.  If they go up dramatically again, the owner has a hard decision as we can’t keep him on pain medications.

Nobody said medicine was easy.

God works in some pretty cool ways sometimes. The Bible talks about the little ways that God talks to us, but we’re always looking for the big things.

Last week I was really struggling with my life and happiness. Without going into the details right now, work and life were really getting to me. I’ve been trying to work through it, and do pray and seek God’s guidance, but it isn’t always easy. I know that He has plans for me and that He is always watching me, but it’s hard to feel that sometimes.  I often say that I’m not worried that God has something good in mind for me…I just wish He would let me in on the plan.

That’s why I was surprised when I was finishing up with a client and happened to look down on the ground. Against the wall in the exam room was a pen. I picked it up and noticed the crosses and “Jesus fish” on it. I asked the client if it was hers, and she said no. So I ended up keeping it. I had been wanting to have a new pen that showed my Christianity, and this one was perfect.

But what was really cool was that the pen had a clear “window” in the barrel. When you click the pen, it rotates through four different scriptures. All of them are very encouraging and uplifting, and all talk about how God is always with us. It came at just the right time, and really reminded me of God’s love.  I have no idea where it came from, or how it ended up on the floor in my exam room.  But I am 100% certain that God arranged for it to be there.

Sure, it’s not your typical way for God to speak, but it is quite fitting. It’s so nice to know that he really does pay attention to us!

Oh, and here are the scriptures on the pen. Remember them whenever you think that God isn’t with you.

Be still, and know that I am God. (Ps 46:10)
Lo, I am with you always, even unto the end of the world. (Mt 28:20)
I can do all things through Christ who strengthens me. (Phil 4:13)
The Lord is my shepherd; I shall not want. (Ps 23:1)

If you’ve been following this blog for a while, you’ll have seen me mention that everyone should have several hundred dollars set aside in an emergency fund for their pets.  Today I saw yet another validation of this idea, as well as a validation of my policy against unnecessary euthanasia.

A client had a 3 year old female rottweiler mix that had received a nasty gash on her leg.  She had already been to the local emergency clinic earlier in the day, and they had quoted her around $700 to suture it up.  She came to us for a second opinion, concerned that they were a bit high on their pricing.  When she first called, she seemed to downplay how bad the cut was, so we didn’t know what to expect.

The dog was very calm and nice and overall looked to be in very good health.  The owner didn’t know what had happened, but Lady did go outside in the woods on her own, and it may have happened then.  When I looked at the wound, I was surprised at how huge it was.  The laceration was on the inside of the left hind leg, and was at least 8 inches long.  It was straight and smooth, so something very sharp had cut her.  She was a very, very lucky dog, as it was extremely deep, almost to the muscle, and the wound ran directly over where the femoral artery and vein lie.  Another 1/2 inch deep and it would have had a good chance of slicing through these major vessels, resulting in pretty rapid death from extreme blood loss.

As deep and bad as it was, it was something that was completely fixable, and would heal well with stitches and antibiotics.  It was a bad enough wound that a sedative and local anesthetic wouldn’t be good enough.  This dog needed full general anesthesia and a pretty long time to sew up.  I gave the owner a quote of about $670, not far off from the emergency clinic.

This hit the owner pretty hard, as she simply didn’t have the money for the procedure.  We bandaged the wound to help protect against further contamination and were going to give the owner a few days to figure things out.  However, she knew she wasn’t going to be able to come up with even part of the money, and asked my tech about putting Lady to sleep.  When I found out about that I was very startled.  This was not a terminally ill pet, but one that was in great condition and with a problem that could be easily fixed.  All it would take is some money.

Remember the idea of a emergency fund for your pet?  This is a perfect example of when it would come in handy.  But because she didn’t have any money available, the owner was looking at making the hard decision of putting a young, healthy pet to sleep.

I simply couldn’t bring myself to do that, and told her that we would refuse euthanasia under these circumstances.  However, we also couldn’t leave the wound open, as it would be very difficult to heal without stitches.  We have a policy that is used rarely, but I felt applied in this situation.  We offered to have her surrender the dog to us, relinquishing custody.  Thankfully, she agreed.

Instead of being put to sleep, my associate will be stitching up her wound in the morning.  Lady will be staying with us for at least a week as we try to find her a home, or possibly turn her over to one of the local no-kill shelters for adoption.  It’s not a great option, but her wound will be treated and she won’t be put to sleep.

Remember, folks.  Be prepared for the unexpected with your pets.

Last year I wrote an entry about heartworms not just being a problem in dogs (if you weren’t here then, read it right here).  I swear, I’m starting to get extremely paranoid about heartworm disease.  In the past two weeks, I’ve had five different dogs that have tested positive.  That’s more than I think I’ve ever had in such a short period of time.  Today it got worse.  I had my first heartworm positive cat in 12 years of practice.

I’ve known that cats can contract heartworms since veterinary school, so it didn’t totally surprise me.  I’ve also tested cats over the years, and have always had negative results.  But this one was most definitely postive.  Want to know why he came in to see me?  Sporadic vomiting for the past three weeks.  And as surprising as it may seem, vomiting is one of the leading signs of heartworm disease in cats.

Here’s a quick review of heartworms in cats.  Felines are many times more resistant to heartworms than dogs, and so are much less likely to get it.  However, when the become infected, they had fewer worms so it’s harder to detect.  In an average infection in a dog there may be 30-50 worms.  In a cat it may be 1-3.  Even if we find it, we’re still a bit up the creek.  There is approved treatment protocols and medications for dogs, but not for cats.  So cats are less likely to contract heartworms, but if they do it’s harder to find and we have no way of treating it.

The worms live much shorter lives in cats than in dogs.  So the goal is usually to control any symptoms and hope that the cat outlives the worms.  This isn’t a very satisfying answer to be able to give a client, but I had to have just that kind of conversation today.  Thankfully the cat doesn’t seem to be too severely affected, so we’re hopeful for a good outcome.

Remember how I’ve been up in arms about owners not putting their dogs on prevention?  Now I get to do the same thing for cat owners.  The larval heartworms are carried by mosquitoes, so even indoor cats are susceptible.  Spend the money and put your cats (and dogs) on heartworm prevention!  And if your cat is vomiting and your vet recommends a heartworm test, please do it!

One of my favorite memories from veterinary school involves a little puppy with a severe heart condition.  The puppy had a patent ductus arteriosus (PDA), which is a very serious disorder.  When the fetus is in the mother the blood bypasses the lungs since the lungs have no oxygen in them.  Instead of the blood pumping into the lungs, it passes from one side of the heart to the other.  When the baby is born, this ductus arteriousus is supposed to close down, allowing blood to flow completely into the lungs.

In rare cases the ductus arteriosus remains open.  Some of the blood bypasses the lungs, not picking up oxygen.  So the puppy’s blood has less oxygen than it should, potentially starving the body and tissues.  If this continues for long enough, it can be life-threatening.  The only cure is surgery.  The most common way is to open the chest, get to the heart, and tie off the PDA.  This will allow the blood to completely flow through the lungs instead of bypassing them.  In recent years there is another procedure where a mesh is passed through the vessels without open-chest surgery, closing the PDA internally.

Well, back to the story.  This puppy was brought in by a man who looked like a stereotypical biker.  He had a leather jacket, big bushy beard, and numerous tattoos.  If you encountered this guy on a dark street, you’d be very worried.  And you definitely wouldn’t want to get on his bad side or get into a fight with him.  In other words, a potentially intimidating person.

You certainly can’t judge a book by its cover.  He was an extraordinarilly nice and caring man, especially when we found out why he was there.  You see, he had adopted this puppy from a shelter knowing that it had a PDA, and knowing that the surgery would be about $2000 (at that time….more expensive now).  He knew that the puppy would die without surgery, and knew that most people wouldn’t adopt it knowing it had such a serious condition.  So he adopted the puppy because nobody would take it home and have the surgery done.  He truly wanted to help this little puppy who had a bad heart.  Thankfully, the biker guy had a very, very good heart.

The puppy had his surgery (one of my favorite surgical experiences, as I was allowed to ligate the PDA!), recovered perfectly, and went home with his new owner.  That man taught me how someone could love a dog unconditionally, and how much generosity a person could show.  I also learned that you need to talk to someone and not judge them based on appearances.  I sometimes wonder what he and the puppy are doing, or even if the puppy is still alive (this was 13-14 years ago).  But I have every confidence that he continued to give that little pup a great, loving life.

This is one that many people may not know about.  Last week a client called because her dog (about 16 pounds) got into her purse and ate an entire pack of chewing gum.  She thought she had remembered something about it being poisonous, so she called my office.  We had her check the package, and indeed it did carry the toxic ingredient.  Thankfully, we were able to help her induce vomiting right away, managed to get the gum out of the stomach, and after some observation the dog was fine.

Xylitol is an artificial sweetener found in many products, but most commonly sugar-free chewing gum.  In dogs it can cause a sudden drop in blood sugar, sometimes as  quickly as 30 minutes, but also as long as 12 hours after ingestion.  The hypoglycemia often appears as stumbling, weakness, incoordination, or other neurological signs.  However, vomiting is usually the first sign of toxicity.  There is also evidence that xylitol poisoning can lead to liver failure.  In fact, liver disease and death are emerging as the more severe consequence.  The affect on the liver can also cause severe disfunction of the blood’s ability to clot properly.

Xylitol is also found as a sweetener in other products, so it’s not just limited to chewing gum.  The ASPCA Animal Poison Control Center has reported this poisoning after eating cookies, muffins, and cupcakes.  What is interesting is that other artificial sweeteners such as saccharin, aspartame, and sucralose are generally considered safe.

This is a prime example of how animals metabolize things differently than humans.  Something that is perfectly safe for people, can be potentially deadly in a pet.  At first it seems like something as simple as chewing gum couldn’t possibly do any harm.  But this is a serious risk, and should be treated as a real danger.  If you see your dog chewing gum, it could be more than just a lark.  It could mean a sudden and expensive trip to the emergency room.

Here is an article on xylitol poisoning from the Animal Poison Control Center.  Be warned that it’s designed as continuing education for veterinarians, so a layperson may get lost in some of the language.

Xylitol Poisoning