Your Pet's Best Friend

Heart failure and fluid accumulation

This is Toby with a blow-by oxygen tube in front of his face.  Toby is 14 years old.  As often happens, in the earlier stages of his disease a lot of his clinical signs were  chalked up to "just getting older".  When he began having difficulty breathing, his mom sought help.  This is a lady who loves her cats and is committed to their care, and it was quite a shock to see Toby with a belly full of fluid, swollen limbs, and seriously thin.  Part of this was his hair "filling in the gaps" early on, part of it was the gradual transition, and part of it was that "just getting older" thing.

Here's why he was having trouble breathing.  I'm sure it was a little difficult moving his diaphragm with that belly full of fluid, but having a chest full of fluid really made it hard.  His lungs are compressed down to about one-fourth of the space they usually occupy.  His heart cannot be seen here because it is obscured by the fluid around it.   An ultrasound examination showed that the right side of his heart was stretched out of shape, weak and flabby.  The inability of his heart to pump fluid forward was causing it to back up in the veins, and this back-pressure was causing the fluid to seep out of his veins and accumulate in his belly, chest and limbs.  His other organs were also suffering from poor circulation.

You can't really wait for medicine to take care of this, so we stayed late last Friday.   Thoracocentesis means sticking a needle (or in this case a flexible catheter tube) into the chest and draining off the fluid.  This was only about half the fluid in the chest, but it was all we could get without undue stress and trauma.  He was breathing much easier afterwards.

The next step was support with diuretics to help with the fluid reduction (which also reduces the heart's workload) and enalapril to further reduce the heart's workload.  He tolerated his medicine well, and has been eating well, but we aren't getting optimistic yet.  We may have to add more medicines to his program.  After his first week, his legs aren't swollen anymore, but his chest had refilled with fluid.  There was a little less fluid than last week, and we were able to remove about twice as much this time.

Toby is feeling halfway decent after the second round of drainage.  It's day by day now, and a consultation with a cardiologist.  Yeah, he's got a failing heart and he's 14 years old, but we're going to see if we can't give him some more good days.

Chronic Ear Infections

Last week we saw a lovely (if overlarge) cat named Baby.   She didn't look quite so bedraggled then.  This picture was taken as she awakened after her ear-cleaning procedure today.

It was Baby's first visit to our hospital and I was unhappy to learn that she had been suffering from chronic ear infections "for years".   She had been treated for various diagnoses of ear mites, ear infections, and ear polyps with every thing from long-acting cortisone injections to antibiotics to the current treatment of twice weekly home ear flushes.

Her ear canals were full of extremely hard debris.  Several passive flushes (just instilling a cleaning solution and letting the cat shake it out) removed virtually nothing.  I had to wonder how long it had been since someone actually LOOKED into these ears.  The canals were very hard, not flexible at all, and swollen so that you couldn't get a scope into them very well.

We gave her enough cortisone for about a week, and sent home drops with cortisone and anti-fungals and antibiotics, hoping to get the canals to open up a bit, and maybe soften that debris.

Today we anesthetized her and removed LOTS of junk, including this honker, which is as hard as a rock.  After cleaning this long-standing accumulation of crud out of her ears, we could see her ear-drums on the video-otoscope and were surprised to see that they appeared intact.  They were a little macerated (like your finger gets under a wet band-aid), but no obvious holes were present.  This was surprising because probably 80% of animals with long-standing ear infections no longer have an ear-drum.  A little closer observation revealed air-bubbles rising from her right middle ear and appearing through the ear drum to float up to the scope.

Fortunately, despite this small hole in the ear-drum, her middle ears looked great when we X-rayed her skull: no change in the bone, no crud on the inside.  Bottom line is that her prognosis is good to be FREE of ear infections "for years".   You have to really examine these thoroughly and really get them clean in order to effectively treat them.  "More ear drops" is not the answer.

Falling dog rises again

Does he look a little brighter here?  He sure acts that way.  After being totally hand-fed, hand-watered with a syringe, and receiving lots of oxygen, this guy is back on track today.  He's eating well and running and playing.

I had a terrible time getting a picture of him because he'd keep running up to me and I couldn't get the camera to focus fast enough. I set him down, ran back thirty feet and started shooting.  He's still a little out of focus here, but I'm okay with that.  The picture may be out of focus, but his life and lungs are nice and clear at the moment.  I love a happy ending.

Falling Dogs

"The bigger they are, the harder they fall."  You know, I think that's generally true. Of course, I also believe that the older they are (or the older I am, anyway), the harder they fall.  When I was a little kid and made accidental dismounts from the horse, it seemed like a longer distance to the ground than it does now.  Despite the reduced distance vs. my height, the impacts are a great deal more solid now.  I don't check the weather report, I check the gravity report. "Things gonna be heavy today?"

Newton's second law says that force equals mass times acceleration.  That's why when I was a tyke and supposed to be napping, I didn't get hurt when I played "magic carpet".  I'd hop off the top bunk with a pillow under me and be amazed when I didn't die -- of course, I only weighed about 20 pounds.  Now (in addition to being a fragile old geezer), I weigh more, so more mass.  Add more acceleration, like the time I leaped off the loading dock chasing a dog, and the force of landing was enough to break my heel.  A word of advice: if you're going to make some sort of gravity-defying leap, get a stunt-double.

This mass times acceleration thing is also important when little puppies fall off tables, or get dropped, or fall down stairs, or out of cars.  Little puppies don't weigh much, and this low mass often results in avoidance of injury even when the puppy has taken a rather appalling fall.  Unfortunately, if you're going fast enough (like in a moving automobile), you can still get enough force to be fatal. 

Even when you're going slowly, you have to consider your point of impact.  It's possible to land just right and dissipate your energy by rolling, and I've seen dogs that bailed out of pickup trucks at forty miles per hour get away without a scrape.  I've also seen them climb out of the window of a parked car and break a leg on impact.   

Most of the time when a kid is wagging the dog around, the distance to the ground is so short and the dog weighs so little that drops are pretty minor traumas.  Sometimes, you hit "just wrong".  Back in 1978, I saw a puppy that only fell 3 feet, but he hit his head on the edge of concrete step.  He was in a coma before they picked him up again, and he didn't last an hour.

Today we're treating a one-pound puppy who got dropped and whacked his chest hard enough that it bruised his lungs inside.  He was unresponsive and not moving much air when he arrived.  Fortunately, with some anti-inflammatories and several hours under oxygen, he's starting to come around a little.  He's still having some breathing problems, but you can hear the air moving in his chest now.  Plus,  he's walking around his little oxygen chamber instead of just lying there like a lump.

He's still not out of the woods, but he's thinking about looking for the path now.

My First Orthodontic Appliance

Well, not actually my first braces or retainer (that was 44 years ago, after all).  I mean the first one that I've applied to a patient.  In a previous post we talked about how retained baby teeth can lead to malocclusion: teeth that grow in where they don't belong.  On little Cocoa here, I failed to get a good "before" picture of that (before I did anything, that is).

This is a "before picture" as far as the teeth are concerned.  The white blob is the acrylic appliance I built up in the roof of Cocoa's mouth.  You can't see the  grooves that are cut in the wedge sticking down, but they are there.  What you can see are that the lower canine teeth (bottom fangs) are coming straight up so that they were hitting the roof of the mouth.  See how straight up and down they are?  They should have been angled out to wind up between the upper teeth.  As Cocoa closes her mouth, those teeth encounter the wedge now, and the grooves direct her teeth outward.

Here's a side view, showing the acrylic blob that covers part of the roof of her mouth, anchored to her upper teeth.  It's pretty thick in this picture.  After two weeks, the teeth had moved enough that the wedge wasn't hitting her teeth anymore, but was hitting the bottom jaw.  We shaved the blob down and cut new grooves to direct her teeth.  I was in a hurry that day, and didn't make time to get pictures of stage two, unfortunately.

Here she is at four weeks, minus her appliance (i.e. blob of acrylic plastic).  You can see that the lower fang is now directed outside her upper teeth and into the groove where it belongs.  This is pretty cool, and much less uncomfortable than having her bottom fangs poking her in the palate.  I'm glad I got the chance to do it, but if I'd gotten the chance to extract those funky baby teeth back in March, Cocoa wouldn't have needed this repair.

Watch out for those baby teeth when the permanent teeth come in.  If they aren't getting loose by the time the permanent tooth is halfway in, it's time for a visit to your veterinarian.

Interesting Cases

Back when I was in veterinary school, Dr. Larry P. Thornburg was a lecturing pathology professor (as opposed to the hands-on pathologists who worked with us in the laboratories).  One of my favorite Thornburg-isms was "This is a very interesting disease -- we don't know a thing about it."

When we moved on to the clinical aspect of our training, one would occasionally hear the clinician (the instructor/doctor in charge of the case, as opposed to the lowly student in charge of all the work on the case) say, "This is a very interesting case."   It didn't take too many of those pronouncements to realize that interesting cases were living on borrowed time. 

The thing is, if you're an expert, and you know all about the regular stuff, seeing the routine, run of the mill disease or injury is just "ho-hum, seen it all before".  For things to get interesting, it has to be something really unusual, something that is hard to figure out, something that maybe nobody has ever seen before.  In other words, it may take a while to figure out what's going on (maybe such a long while that you're too late to help), and you may have to invent a new treatment, or there may not BE a treatment.  In a teaching institution, that translates to a very interesting case report, complete with post-mortem results and microscopic analysis of the deceased's diseased organs.

I'm telling you, you don't want to be an interesting case.  When the doctor starts calling in everybody to look at you because your disease is so cool and unusual, it's not a good thing.  You want to be Mister Dull, Mister Boring, Mister See-these-everyday.  It's like the old Chinese curse: "May you live in interesting times." [Read your history books -- "...and there was peace and prosperity for 100 years." versus plague, pestilence, war, famine and other interesting things.]

Don't get me wrong, now -- I love an interesting case as much as the next guy... just not at five o'clock (or six o'clock, or any o'clock when I've had a long, full day and would like to go home, for heaven's sake).  Of course, I love it a lot more when I figure it out in time and the patient gets well. I'm batting .500 this week.  Monday we had a really interesting case that has gone on to that great litterbox in the sky.  Tuesday we had a really interesting case that is a whole lot better today. Both days had me working till eight o'clock, and back here again until ten.  It's never dull around here, but today was a little less interesting.  I'm okay with that for a while.

The trebuchet's maiden voyage.

Set the  Way-Back, Sherman.  About ten years ago, I was flipping the channels and came across a guy in England who had built an enormous trebuchet: a counterweight-driven catapult that uses a sling to further extend its throwing arm.  He was throwing small automobiles and upright pianos, among other things.  He like to see things "blow up" and dynamite is not legal for recreational use in England, so he had built this alternative.  I was captivated, and soon built a small working model.

Without doing much research, I decided I could just extrapolate the dimensions of my model and build a larger scale device.  Sixteen inches in the model became eight feet in the construction, and so forth.  The catch was that I wanted it to be easily transported in "knocked-down" form.  Why?  So I could take it to watermelon fields at the end of the season.  They just plow under hundreds of watermelons that are past their  "sell-by" date.  You could haul your siege engine out to the field and throw watermelons until you got tired of seeing them explode.

Charlie's Welding did some metal fabrication for me.  I used steel pipe for the cross members and wood for the uprights and runners.  Charlie Jackson made pipe collars to hold things together and I spent a lot of time drilling holes and bolting things together.  I was too ambitious, though.  Eight feet tall, eight feet wide, eight feet long, and a sixteen-foot throwing arm.  I only got it put together one time, and the enormous weight needed to move the throwing arm caused the axle to bend.  Plus, it was just too big to handle, even with a crew of four men (myself and three high-school kids).

I disassembled it and did a lot more research.  Then I re-engineered: six feet tall at the four-foot, double-thick axle, with outriggers still keeping the base eight by eight.  I never got it assembled again.  It never threw a missile, much less a watermelon.  My poor baby languished in a pile for the last eight years, four of them outside at my brother's house, where I was going to work on it someday. It was just too big for one guy to handle by himself.  I needed a crew.  I also needed some fresh enthusiasm, as I was fresh out.

I tried to interest the Venture Crew in taking it on as a project, but the former leader wasn't interested.   Ah, but now there's a new event at the Fall Fun Rally at Beaumont: Pumpkin Launching.  The new leadership and crew ARE interested in a working trebuchet.  They've spent several days re-assembling and modifying the beast, and today that rascal is throwing like a champ.  There's still some tuning to do -- maybe even some fine-tuning.  It was sure great to see it throwing.  I hope to get some video up on You-tube.  They've done a great job making my vision finally come to life.

I think this must be what Dr. Frankenstein felt like when the monster finally stirred and sat up.

What makes a "Real" Veterinarian

One of my high school classmates became a veterinarian as a second career.  When she (and I) went to college the first time, women were not exactly being encouraged to apply to veterinary school (the dark ages -- sometime between the Norman Conquest in 1066 and 1980).  She became a teacher, despite really always wanting to be a veterinarian.  She went back to school, got some science courses as pre-requisites, and graduated from veterinary school at the tender age of 48.  Six years later, she confided to me that "... sometimes I don't feel like a real veterinarian. My boss does most of the surgery, serious cases get packed off to the emergency clinic after five..."   On the other hand, she has had the experience of being on night call every other night and seeing her own emergencies... and she didn't like it.

So what is a "real veterinarian"?  I think that whether we admit it or not, a lot of us have that James Herriott gentle doctor as our role model.  This is not a bad thing, but it requires you to be all things to all people, which is a mighty tall order.  Too tall for 24/7, 365 days a year, not to mention that you can hardly be an expert on everything. I've been on the front lines for a long time, seeing "all comers" as their primary care veterinarian.  I am very glad to have the opportunity to consult with specialists and to have specialists to refer my patients to when it is possible for the clients.  In years past, because of my rural location, I've been forced to learn procedures that I'd have never touched if we were thirty minutes away from the university teaching hospital.  That's made me stretch and learn and given me the confidence to try new things.  I can't say that it's always been the best for that "first patient" (though, truthfully, their alternative in those situations was to have NO treatment).

Of course there's more to the Herriott model than simply seeing whatever species and problem walks in.  It's also about being part of the community, being "the vet", being available when your clients need you, even when it means some sacrifices in your personal life.  This can bring great satisfaction, but it also can bring great fatigue, which brings me to how I got started on this: being the day guy and the night guy.

Last night (this morning?) at midnight-thirty, I got a call from the police station.  "These two ladies have brought in a dog they just hit, and I didn't know who else to call."  [Me neither, or I'd sure give you his number.]  This little gal had no I.D. and no visible means of support.  While she was generally pretty stable, she was not too conscious.  That, along with constricted pupils and a little nose-bleed, suggested a cerebral concussion (brain-bruise).

She was better this morning, and continues to improve, though I reckon she's still got a headache, pain medicine or no.  We're optimistic about her full recovery and finding a home for her.  That's a good thing.  Feeling like I was out all night -- not such a good thing.  Does it make me more of a "real veterinarian" than my classmate who doesn't like surgery and night emergencies?  I don't think so.  You find a niche where your talents satisfy a need, and do your best.  That's real enough, I think.

Here is where I am, and this is what I do.  It's not for everybody, but if you know a nice young doctor who would enjoy small town life, I'd love some help. 

Grief upon grief

Old Yeller Alert

It's always hard to give bad news, but sometimes it's harder than others.   Today I had two old patients with kidney failure.  Everybody's pets are special to them, and saying goodbye is never easy, but today...

The first one was a cat whose kidneys were so large and misshapen that I could feel them like a couple of tennis balls when I picked him up.  When I mentioned this to the owner, she simply replied, "You're going to fix him.  This is my boy."  Pretty clear instructions.  Unfortunately, his ultrasound and lab-work make it pretty clear that we are not going to fix him.  We may make him feel better for a while, but with both kidneys cancerous, we're not going to fix him.  His time is short.

The second patient was a dog whose mama did not need another loss this year.  After major emergency surgery on herself, she lost her father in the winter.  In the spring she lost her adult son to an industrial accident.  There's no question that she cares about her dog and would not wish to confront it's passing,  but this latest link on her chain of losses was a cruel blow indeed.

We all suffer losses and deal with it as best we may, packing the experience away in our emotional garbage bag.  We put them behind us, but we don't totally get rid of the experience.  Each similar loss forges a new link on the chain, and in the process pulls the whole chain of losses out to wrap around your neck.  When we confront the impending loss of a pet, it is not uncommon to have to do so through the haze of a lifetime's sadnesses: all the griefs of lost loved ones, animals and people, from our last dog to grandma.  Usually it's not so obvious as it was with my poor client today, but it is an undercurrent that runs through every euthanasia I have to perform.  I have to recognize that and acknowledge it. 

Clients frequently say they are "ashamed to feel this way about a dog".  Not only must they deal with their grief, but they feel as though they are abnormal into the bargain.  "I'll never have another pet.  I can't stand this again."  Again, I have to acknowledge their feelings, but also let them know that they are not abnormal, and far from alone in their feelings.

Those who can feel no loss cannot feel anything.  As hard as these bereavements are, who would wish for a life where he cared so little for anything that he could not feel a loss?   So we go on, and open our hearts again when the time is right. 

Labor Day thoughts

People make a lot of jokes about not working on Labor Day.  Drive around town and you see plenty of people working, though.   I typically cover the clinic chores on holidays. I feel that I need to check on the patients that are here, so I might as well clean up after them, too and let the staff have the day off.  They'll cover for me sometime when I can't be here. 

I've only had a couple of emergencies today, so I got much of the day off.  Labor Day is one of my favorite holidays, simply because there's no agenda for the day.  I don't have to get to or help host a family dinner, no trip out of town, no gala celebration or concert to set up.  I actually take part of the day off and catch up on some things just for myself without having to shoe-horn them into stolen hours.

The diabetic cat will still get it's insulin injections on time, but I was able to start tinkering to find out why my running lights are not working on Old Red.  So far, I only know some things that aren't the problem.  That's a little too much like being back at work.