Tuesday, June 28, 2011

Weekend Highlights

OK, so not the post about Guess and Maybe as planned but thought the highlights of the weekend might prove somewhat entertaining.

We had planned to go down and help sort out some of my brother's mess this weekend and to that end I rearranged my schedule to be off Friday, drop Guess off at the dentist Friday to spend the weekend, leave the dogs that need to be watched while we were to be gone, etc. At the last minute, the trip was canceled which turned out to be a good thing.

I took Guess on Friday to be worked in for is implant adjustment and was well on my way to Birmingham when I got a call that a tree had fallen on the fence separating some of the dogs during the storm the night before. As a result, Thumper and Yoda had crossed into the fence with Tag and Maybe, trying to start a fight with Tag. Mom got all that sorted out while I was gone and when I returned, I found that pretty much everybody was upset, probably due to the weather; we're having a lot of pop up thunderstorms over the past few days. I promptly practiced better living through chemistry and slipped the kids that needed it a mickey.

Saturday was not bad with the effects of the drugs still lasting and not as bad of weather. Sunday dawned with Thumper and Yoda back over the fence. With a little work and a lot of shuffling, I got them back where they needed to be and got the fence fixed. More drugs because of the weather and a necessary trip to the clinic to pick up a refill (we usually don't go through quite this much, it's been a rough storm season for the kids and now we have the dreaded firework holiday approaching, too!!)

Monday, I was off due to our planned trip and I started the day by sawing into pieces the rather large dead pine that fell several weeks ago and has been trapped on a limb but hanging over another portion of fence (quite stable, but needed to be gotten down and this was the first chance I found). After getting that down, I gave Chief, my old Chow / Rotti mix a little tranquilizer so that I could shave him down. I typically brush him out but with the weather, his coat was well on its way to a disaster.

Afterward, I got a much needed shower then cooked supper. Then I loaded the recyclables into the truck to drop off on my way to work today. On the way in, I tripped going upstairs onto the porch and took a nosedive, landing on my hands and knees and using the top of my head to slam the half open screen door shut. It was one of those moments when you just sit up, wiggle all pertinent limbs and verify no broken bones, then shake your head and wonder how it even happened. With that, I closed my day.

Now it is time to start all over in the hair department of the herd; sometimes it's a little depressing...

Saw a funny / interesting case last Wednesday. Little pup I helped deliver; the new owner had found his mother abandoned and pregnant in the house next door. As the pup was running around and playing like an idiot, the water bowl was knocked over and spilled. In another run, he hit the water and slid then hit a counter resulting in severe lameness. When they brought him in, it was immediately apparent that he had a broken humerus on the right front. Since he was bearing weight on the other 3 legs, I did not pursue other investigation at the time but splinted the leg (nice fracture that will heal well with a splint over the shoulder. It wasn't until the next day that he became lame on the left rear; after another x-ray, I discovered a greenstick fracture of the tibia. Now he has 2 splints... Fortunately, he's still young and will likely heal in 2-4 weeks.

Today it was a 4 month old Maltese mix with a broken jaw. The mandible had a fracture near the lowest point of the ramus. The puppy was kicked in the jaw by a 4 year old neighbor child who walked over into the owner's yard while they were out playing with the puppy. Even a child that young knows better. It's disgusting!!

The highlight of last week was the spaying of the wrong dog due to the ineptness of the help that I was complaining about recently. The one who did kennel the weekend before mixed up cage cards therefore the dog labeled boarding and spay while here was anesthetized, put on the table, and opened only to realize she was spayed. It was at that point that we realized it was the wrong dog. The owner's were very understanding at first (dogs belonged to same people) but apparently did not pay attention to what was said since when they picked up the dogs the following day they started screaming that I did not tell them I actually opened the dog and demanded their money back; in entirety.

That's about it except that I still owe the post on Guess and Maybe. Maybe next time; I Guess...

Monday, June 20, 2011


Had to take a moment to comment on an article in the June 15 issue of JAVMA. There is a very nicely put together article criticizing the role of corporate freebies given to veterinary students throughout vet school as well as to veterinarians and physicians written by a lawyer who is (or was at time of submission) a second year vet student at Colorado State. This is what happens when lawyers go to vet school...;)

In all seriousness, she had many good points but I have to refute from a practical standpoint. Had we not received free or very cheap pet food, there is no way I would have been able to afford to feed my kids. Additionally, the free lunches, dinners, etc. often provided made many of us actually eat a meal when we might not have done so otherwise. To eliminate this would be another step toward making veterinary a privileged profession only available to the elite people who have money or a spouse or parent to support them. There is already enough politics out there that limits admission to many worthy folks while allowing admission of people who really don't deserve to be there. Speaking for myself who grew up on the "wrong side of the tracks" in a family with a very low income due to having my father pass away when I was extremely young and who paid for my entire education through scholarships, grants, and student loans (NOT parent loans, by the way), I for one appreciated any help given.

The author makes a valid point that gifts can influence later recommendations and that the meetings, lectures, etc. are biased. While this is true, I always walked into the corporate sponsored lectures with that prior knowledge therefore listened with an even more critical ear than usual and, believe me, I am very critical probably in part due to my natural cynicism. This exposure as a student can but benefit when one reaches a private practice job in which the boss prefers not to pay for good CE hours and forces at least some of the hours to be through local chapters that are, guess what, corporate sponsored events... Additionally, I viewed the food as a chance to get a personal working knowledge of the different companies and availability. Now, when an owner asks me if the food works or is palatable, in most cases I can actually say I have used it for my cat or dog and this was my opinion. This is one reason that I have a personal preference for Purina HA versus Hill's Z/D for allergy dogs; I tried both on mine.

I believe that a better approach than eliminating this practice would be to better educate students on how to critically examine evidence and make a non-biased decision. Realistically, this practice is something that everyone deals with on a daily basis in real life - wouldn't it be better to learn how to handle it while there are mentors available to question and from whom to learn? Oh, but I forgot, to teach students to critically examine evidence would be to expose those clinicians who are deficient in their knowledge, etc.

It took me a while to recognize that those who laughed at my questions, blew them off like I was asking something stupid, ignored them entirely, or handed me a pat answer really didn't know what they were talking about and didn't want to admit it. I had the privilege of working with many great clinician's in vet school as well as a few during my other experiences since but my absolute favorite by far was the man whose lectures were beautifully put together, took the time to find a way to connect, and who responded to my first weird, out there question to him with "I don't know; why don't we look it up." This describes a person who is secure enough to admit they don't know everything (who does?!?!?) even to a (gasp!) underling such as a lowly student. This is in direct contrast to the other type that I previously described who are definitely too insecure to admit a lack of knowledge or confidence in front of a student.

Perhaps it is partly my nature that makes me take this stance on this issue. I'm admittedly a questioner; always have been, likely always will be. I'm sure I drove mom crazy with the endless string of "Why's" throughout childhood. I even remember playing softball in high school and failing to run home when the coach told me to because it made no sense to me. Much like Smalls in The Sandlot, I think too much, never really fit in with kids or people of my own age group, and am not great at just letting go and having fun. Needless to say, I got pulled out of the game after that but the coach knew me well enough that he also took the time to explain his reasoning on why to run. Unfortunately, I still have not developed that trust in anyone just to blindly run when told hence I don't blindly trust just because someone said so; even if it is a boarded specialist. I probably drove many of them crazy as well with my questioning and looking things up that I was told just to verify that it was truth...

Anyway, I do not disagree with the points in the article I just disagree with the solution. It's time that we really advocate evidence based medicine in vetmed. (I did a great presentation on this last year; I'm not sure that it went over that well with the folks listening but I had a blast doing it and used some of my more sarcastic cartoons to help illustrate the point.)

On other topics, my brother is still in a mess. He got his wife out of jail and 4 (!!!) days later they were both arrested for drug possession. He seems to rationalize that it is ok because the drug they are using is "technically" legal in his state. It doesn't matter that they both are killing themselves slowly by using it. The whole problem started after they had a really bad car wreck about 17 or so years ago. Due to their injuries, they were placed on prescription pain medication, slowly began to abuse it, then reached for illegal substances, and it has escalated from there. He's trying to play the guilt trip on mom to get him out and he's really good at it. I hope she stands strong because at least he is in out of the heat with food, water, shelter, and hopefully no drug availability. It's so sad seeing them throw their lives away; their kids won't even associate with them at this point.

The herd is doing well overall (big sigh of relief!) and I'm working on being intentional about spending more time with each of them, especially the geriatrics in the group. I still don't have an answer on my poodle but am looking into atypical Cushing's. Not that I'd treat it yet if it is that but I'm really a type A driven personality when it comes to finding answers and explanations. I liked the suggestion about age related changes, too. Maybe it's a combination of things; I'm comparing him to my Cocker/Poodle that passed away a couple of years ago at 18 and he's not really quite like she was (definitely a cognitive dysfunction syndrome) but does show some similarities. Abdominal ultrasound was boringly normal but I do caveat that at this point I have to rely on a human ultrasonographer to do scans since we do not have a machine and it's not really kosher for me to take the probe from her (besides, he turns into Cujo if I don't hold him...) to do the exam.

Have done some self diagnosing again and determined I'm definitely dealing with some major compassion fatigue as well as some burnout. Partly disillusionment factors in ranging from the disappointment of not obtaining the surgery residency that I worked so hard for primarily due to politics and very much because of the reluctance of many clients to allow me to practice good medicine. As a quick example, I recently repaired a cherry eye (prolapsed third eyelid gland) in a Beagle. He's being brought in tomorrow for my boss to remove the gland because the owner is not happy, it was not the same as before and doesn't look as good. It was a huge prolapse and had some inflammation; she has not given it time to heal or allowed me to even re-examine it to see if there is anything else that needs to be done. I cannot bring myself to remove the gland since it was beaten into my head that doing so is akin to malpractice due to the association of development of dry eye after removal (I'm also really enamored with eyes, therefore it is a double whammy to try to talk me into doing something I feel is wrong.) but that is what my boss was taught and he is no convert or lover of eyes... What's the point in trying to do it right? Not that my driven self would be able to do differently but it is very frustrating!

At work, my boss has hired 2 teenagers, 18 and 19, to do the kennel in the afternoons and to work as a receptionist. I hate running a nursery. They don't listen to me and he hasn't helped by undermining any authority I have in front of them. I've lectured, explained, yelled, griped, and pleaded for the same things over and over. One of the worst is the importance of maintenance of a proper medical record. INK. DON'T SKIP LINES. NO INAPPROPRIATE COMMENTS. ETC... What do I get last Friday?? 2 lines skipped followed by presenting complaint "boobs too big, tee hee =)". Dead serious. Another recurrent issue is to completely fill out rabies certificates. I even took time to write down in 2 places the vaccine info but it still fails to appear in the appropriate place. But, at this point, they sign my boss's name all the time anyway so... I told him it was amazing how many vaccines he does when he's out of the office.

The other issue at work (besides the ongoing ones) is the controlled drug log. I've inherited the problem and it is making me more crazy than usual. The few people that have access refuse to cooperate and short of myself pulling up and recording all drugs used, I have no solution. Couldn't do that anyway since I'm not there every day. The boss hints about my working more since we are very busy with the advent of summer but, although I could certainly use the money only barely stretching paychecks to pay student loans and other needs, I just don't know if I can physically and emotionally handle it right now. Besides, he wants me to be there but doesn't want to pay for my time.

That's about all that is new for me. I've been trying to find a way to send a kitten to CantSpell to make her feel better and smile a little but haven't found a way yet. Maybe airmail...hmmmm.

Planning a fun post about Guess and Maybe but need to get a picture first to help illustrate. Hopefully in the next few days I can get it done. Also working a lot on my cartoons which are a major source of stress relief. Have considered posting them before but have not figured out how to post and maintain legibility. Need a better computer guru than I am, I guess.

For now, I must go because I have more than plenty to do that I'm putting off for a little bit...Me? Procrastinate?? NEVER!

Wednesday, June 8, 2011

On a roll

So now I'm posting about losing a pet. My beautiful, smart, and annoyingly affectionate cat Riley (he was only 9) passed away this morning after a week long battle with something. At first I thought he had a chronic herpes flare up- he did that periodically. Then he went into hepatic lipidosis- yes, I should have started syringe feeding him earlier. But then how does one go from a white count of 46,000(!) to 6,000 in two days? And a RBC of 8.something to 3.something? With no bleeding?!?!?!?!? It shouldn't have ended that way. And I'm sorry it did. And I'm especially sorry I didn't say bye to him last night when I left the clinic he was at because I was so sure I'd be back this afternoon. He was happy to see me last night then I did mean vet things to him and then I left him... and now I won't get to say goodbye. I can only hope he knew how much I loved him.

Tuesday, June 7, 2011

A Quick In and Out Procedure...

I have a word of advice to everyone in the veterinary profession and especially to veterinary students - Never, and this means NEVER, go into any surgical procedure (or for that matter any procedure at all) needing to go to the bathroom regardless of how quick it is supposed to be done.

Today, I broke my own rule that I've had since before vet school. It was an extremely busy and frustrating day; everyone seemed to have gotten up on the wrong side of the bed and no one wanted to pitch in and help the day go better. In the late morning, after having been delayed by worried owners with 1000 plus questions, a harried boss who was freaking out because there were 2 sick patients and 2 rooms waiting (I don't know why he was so freaked out, he's been doing this for over 30 years now), and routine surgeries that were not going so routinely, I was asked by my boss if I could go ahead and get the prostatic biopsy done next. Sure, no problem. It should just be a quick in and out procedure...

The story as was told to me was that the poodle had a large prostate, suspected neoplasia but not sure yet so a biopsy was to be obtained. Radiographs had been done, not too helpful, bloodwork was overall boring except an elevated white count. I examined the dog and he did, indeed, have a large, firm caudal abdominal mass. The whole thing started to prove not quick and easy when hitting the dog's vein became a multi-person challenge.

I opened the abdomen only to discover the bladder that ate Manhattan as the source of the mass. Slight, gentle pressure did not yield voiding but resulted in the bladder trying to tear. I requested assistance so that we could pass a urinary catheter; it would go no farther than the proximal end of the os penis. With a little manipulation, I could then palpate a tiny stone in the urethra. Try as we might, the stone would not move. I had already opened the bladder and could not pass a catheter that way either, running into obstruction past the prostate slightly.

The prostatic biopsy became a cystotomy, urethrotomy, castration, and scrotal urethrostomy. Needless to say, it was not a quick in and out procedure. Got 2 small stones out and the dog passed two more that were smaller during recovery that apparently I did not get flushed out. The prostate was normal, by the way, as was the rest of the explore. And, much as I love surgery, I was rather glad to be finished because the bathroom was sure calling my name...

Blog Roll

I went through the blog roll and took out anybody that hasn't posted for more than 9 months. If I took somebody off that should be back in please comment below and I'll fix it!

Monday, June 6, 2011

Kittens For A Cure

It all started due to one of those impulsive decisions for which I'm so well known...

April 5, a client came in with a pregnant cat that had been dumped at her house. My boss saw the appointment. The cat had been in labor for over 24 hours with no kittens produced. I was doing surgery that morning and the cat was brought to me at which time I was told that regardless, there were to be no live kittens at the end of the procedure.

I'm not fond of spaying pregnant animals. I know that there are a ton of strays out there (believe me, I know! where do you think the herd came from??) but it still doesn't make me happy. In this case, I figured the babies were likely dead and decided to go ahead with her next, altering the pre-planned schedule.

I made no special precautions as I would for a C-section but anesthetized her and opened her abdomen, doing a routine spay. I set aside the large, distended uterus and closed the abdomen. As I was closing the skin, I noticed the uterus twitching and a small body emerging from the uterine body...

Now, let's be honest, I would have opened the uterus anyway 'cause I'm just wired that way but I really didn't expect to see a kitten complete with placenta begin to wiggle out while I was still finishing the surgery. I tied the last knot, got mom off the table, and got out the two babies, both of whom were alive.

So we went from no live kittens to 2 struggling newborns which we promptly began to resuscitate. The little boy responded quickly, crying and wiggling, the girl seemed to quit on me. She came within inches of the garbage pail, quite frankly, because I thought she was through but then she took another breath. After a bit of work, both kittens were pink, breathing, crying, and wiggling. Now I had to tell the owner and my boss - oops...

With a little sweet talking on my part, the owner agreed to let the babies stay with mom until they were ready to wean then bring them back to the clinic for us to place in homes. Since they have been back, I have reached the conclusion that kittens could cure the world of its misery. I would prescribe a kitten to all depressed people and those with diseases that make them feel miserable because a kitten just can't help but make you smile.

Notice I did not say puppies. They involve way too much work. Kittens just make you happy.

Mystery Case

OK, for all you veterinary types that read this. Yeah, this means all, what, maybe one loyal follower left?? I have a case to see if anyone else has good input on that may be helpful. The children of the herd are overall doing well but the poodle is being a puzzle and any comments or suggestions would be appreciated...

12-13 year old, NM, miniature poodle. I adopted him in 2005 as an adult supposed to be about 8 at the time. Historically, he had terrible skin and was treated with a lot of steroids, antibiotics, and sensitive skin food. When I adopted him, I changed him to Purina HA and his skin cleared with only occasional outbreaks during really bad "allergy weather" and he has had no steroids since 2005 other than the small amount in ear ointments on occasion (rare). He has grade II/IV bilateral medial luxating patellas with associated osteoarthritis, asynchronous growth of the radius and ulna bilaterally with associated elbow dysplasia and osteoarthritis (too late to fix when I got him) resulting in right fore being slightly shorter than left, and luxated his left coxofemoral joint in 2007 this was repaired via closed reduction but he has a good bit of osteoarthritis in that joint as well. Neurologically, he had a presumptive episode of herniated cervical disk material in 2010 with clinical signs of neck pain and root signature that resolved with conservative therapy consisting of meloxicam, buprenorphine, and exercise restriction.

At the time of adoption, he was severely overweight and we have managed to reduce him to a consistent 14-15 pounds although he is still slightly overweight (BCS 6.5/9). He acclimated to the reduced diet and, while still more than willing to pick up an extra bite here and there, was not miserably hungry. When I feed him, I pre-soak the food then add water to help make him feel more full.

Lately, over the past 5-6 months, he is polyuric and polyphagic. He is not drinking any additional water than what is added to his food (measured out it does not exceed his expected daily intake) typically and is not getting any different food (i.e. increased sodium, etc.). He will urinate a huge puddle (as in imagine twice his size spread on the floor) then often a smaller puddle 5-10 minutes later. And yes, as indicated, he is breaking his housetraining when this occurs. He often needs to go as frequently as hourly but this is not a daily occurrence; very intermittent. During these periods, his abdomen will appear distended but not just with a large bladder. Non-painful, no palpable masses, then just as suddenly it appears normal again. Additionally, he acts as if he is starving constantly even pacing and unable to settle down at night to go to bed. I have not managed to measure the actual urine output yet.

Physical exam findings are boringly normal, no coat changes, prostate small and non-painful. Thoracic and abdominal radiographs taken in March were normal (need to repeat). Bloodwork from 2 weeks ago unremarkable, mild elevation of ALP, triglycerides. Thyroid values normal. I even did an ACTH stim reaching desperately that was totally normal. Have not done a full abdominal ultrasound yet (checked bladder about a month ago, normal) but that is next on the agenda.

So, given that complicated history, etc. any ideas floating around out there?????

Flying High

First I wanted to say thanks for the kind comments and condolences both through the blog and e-mail / text, etc. I have 3 or 4 posts in my head that I'm going to try to catch up if the sleeping dogs will lie...

This is primarily an update but you'll have to forgive the necessity of a little family history to help it make sense. My mother and dad adopted my brother (aka the prodigal) shortly after they were married when she was 17 or 18, having just graduated high school. My brother is the biological child of my aunt, mother's sister. My other brother and I came along somewhat as a surprise years later, in fact, my adopted brother is 20 years older than I am. He married when I was around 2 years old and had been married before for a very short period of time therefore I have a niece (who I have never met) that is older than me and 2 nephews and another niece who are only a couple of years younger than I am. Shortly after the second marriage, he moved to his wife's home state and he and his family have lived there ever since except for a very short stint during which they attempted to live here near the family - that didn't work for her at all.

OK, maybe that condensed version will help the update and prior story make more sense. At this point in time, brother dear is back in the wife's home state and she, in theory, got out of jail today. My aunt had talked to him a couple of days ago and said that he sounded good then mom and I spoke to him yesterday...not so good. It amazes me that my mom and aunt have reached their age and are still so naive about some things; particularly him! I know that part of it is simply that they don't want to see it but how can you possibly try to help if you fail to acknowledge the problem?? Brother dear was flying high when we spoke. Sure, he sounded like he felt good but it was the drug induced good before a crash. And, as usual, he wants money and is lying about what he plans to do with it but they just don't see.

It's hard to know what is true with him at any point, especially when he's on something. He swears he hasn't taken anything but, call me cynical or whatever you want to, I don't believe him. That comment allows an easy segue into another post topic I intended to mention anyway.

Glass half full or half empty? Optimist or pessimist? I find it mildly amusing that different people who know me, mostly fairly well but at different levels all have different perceptions. Can'tSpell says I'm a pessimist. I have other friends who say I'm an optimist. Maybe I truly do have a split personality as I've often joked...