Your Pet's Best Friend

Little puppies need early check-ups.

In one way, these two cases seem similar: very young puppies who were doing lousy, and now they are on the mend (though hardly up to their potential -- they could, and will, be so much better).  In other ways they seem totally different, yet they still share one underlying factor: they waited WAY too long to seek medical attention.  I could call it bad veterinary care, but mostly because there was no veterinarian involved.

Angel was a freebie.  Her owners were puppy-shopping, and the breeder told them that they could have Angel at no extra charge, since "she may not live".  She was half the size of her littermates, had very little appetite, and was very thin.  Like most commercial breeders [breeders who raise dogs the way farmers raise pigs], these folks don't give the puppies much individual attention.  Everything is done on a herd-health basis.  When the puppies are two weeks old they get this.  When they are three weeks old, they get that.  It's all cookbook.  This is a practical way to handle things, and most of the pups will do okay (providing your cookbook has the right "recipes").  However, when an individual has special needs, the cookbook approach just doesn't get it.   

While her breeder had vaccinated and de-wormed her, she had not had any diagnostic testing.  A stool exam showed that she had coccidia (a microscopic one-celled parasite -- since it's not a worm, de-worming doesn't get rid of it).  We started treatment for the parasite, but she didn't respond very fast. In fact, she lost weight in the first ten days, from 1.8 pounds down to 1.7.  She required fluid therapy, as she had become dehydrated, in addition to being thin and under-developed.  She still had to be hand-fed, and just didn't get much better until we also gave her a jump-start with anabolic steroids (fortunately, she's not planning an athletic career, so we're not worried about her getting disqualified and losing her medals).  After her second 10 days of treatment, she's up to 2.5 pounds and getting better every day.

Without the individual attention (that she COULD have had weeks earlier), this beautiful little puppy just wouldn't have made it.

You can't really see how scabby and nasty Duke and Elvis are here. This is definitely their "good side".  What you can see is that they are wide-awake and interested in what's going on.  That's a far cry from four days earlier when they were presented with sub-normal body temperatures.  Elvis was laid out stiff and couldn't even swallow. We're talking weak. Besides having a lot of hairless, scabby areas (due to Sarcoptic Mange, aka scabies), they were also heavily parasitized with intestinal worms -- hookworms and roundworms.  They were the dog equivalent of cold, scabby raisins (shriveled, as it were)  If we had seen them a week earlier, treatment would have been quick, simple and cheap.  As it was, Elvis had to be gradually warmed to a normal body temperature before he could be treated with anything.  I was amazed to see him come around after about thirty minutes, as he looked so bad that I really feared he would die.  It is so great to see them looking fat and sassy (though still scabby).

With both cases, I have to give credit where credit is due.  Medicine only does so much, and these guys got intensive nursing care at home.  Their folks picked up the ball and ran with it once we got them started.

On the other hand, I have to admit that it makes me a little whacky to see these guys get critically ill when a simple check-up early on would have averted the problems.  Puppies should have their first check-up and de-worming at about 3 weeks of age.  Their second check-up and first vaccines at around six weeks of age.  If they aren't doing well, DON'T WAIT THAT LONG.  This seems so simple. Maybe it's too simple, and folks are looking for something more complicated.  Beats me.

Get a Second Opinion, revisited

A while back, I posted some thoughts on getting a second opinion, and today I follow up with some more.   The bottom line is (if you don't believe it, scroll down to the bottom): If you want a second opinion, let me help you get the most out of it.

Yesterday I examined a little Schnauzer who had been throwing up for a couple of days.  This breed is famous for being overly susceptible to pancreatitis, so that was my first thought.  Her outward physical examination looked pretty much okay, eyes, ears, mouth, heart and lungs, etc.  She had no abdominal tenderness.   The most striking findings were a high fever (105.6) and that she had lost a significant amount of weight since her last visit in July -- from 25 pounds down to 20.  I asked the owners if she had been on a diet (she actually looks better at 20 than at 25), but no, really they hadn't been working at any kind of a weight loss program.  A significant and unexplained weight loss is a little disturbing.  Put that together with the vomiting and you start worrying about a lot of potential internal organ problems -- liver disease, kidney disease, cancer (and pancreatitis, too, of course).

We did a complete blood count and biochemistry profile, revealing a high white blood cell count, with lots of immature infection fighters ("band cells" -- they're kicked out before they're ready when the body has a sudden demand for them).  Her kidneys were not functioning well, either.  Blood Urea Nitrogen was two times normal (which can happen pretty fast) and Creatinine was three times normal (which takes a few days).  This little gal was a lot sicker than I had hoped to find.   

At this point, I felt we needed to get a urine specimen for microscopic analysis and culture, and an ultrasound exam of the abdomen to get a better look at her kidneys (and whatever else; that weight loss may have other factors).  She also needed to be on intravenous fluids and antibiotics to flush those kidneys and get those wastes eliminated -- the high waste in the bloodstream was the most likely cause of the nausea she had been showing.

At this point, her owners felt that they were reaching the limit of their financial commitment, so I was compelled to stop the diagnostics and do second-best therapy, with subcutaneous fluids, and oral antibiotics to send home.  This is one of the unpleasant realities of veterinary medicine. 

I was definitely concerned about how well the dog would do on this second-best regimen, so we called to check on her this morning.  Lo and behold, while the dog does seem to be feeling better, the owners were at another clinic seeking a second opinion -- they wanted to be sure it wasn't an ear infection making the dog nauseated.

Now you might think that I would be hurt by this lack of trust.  After all, I did examine the dog's ears and they were okay.  We had clear evidence of other, serious problems, which we began treating as best we could within the limitations set by the owner.  And truly, I can't say that it made me feel good.

Here's the thing, though: I understand that any time you give someone an answer they don't want to hear (like "your dog is really sick and needs intensive diagnostics and intensive treatment"), people are going to be looking for a happier answer.  That is very natural.  Also, you don't have to believe something just because I say it. 

What is important in these situations is to do what is in the best interest of the patient, and seeking a second opinion can certainly fit that category.  BUT... if that's what you want to do, just say so.  That way I can give you copies of your medical records and lab-work so that the other doctor isn't operating at a disadvantage.  Making him or her see the case with no knowledge of what went before can give them a skewed picture of what's going on.  Aside from re-running tests you've already paid for somewhere else, the new results mean a lot more in relation to previous results and treatment than they do standing on their own.  [Fortunately, in this case we were able to fax copies to the second doctor.]

My job is to do what's best for your pet. That's the first priority, and delivering the service you want is the second.  If you want a second opinion, let me help you get the most out of it.

Get a Second Opinion.

Old Yeller Alert

"Doctor, doctor, my feet hurt all the time." "You're too fat. Lose weight."  "You quack, I want a second opinion." "You're ugly, too."

Nothing like starting a post with an old vaudeville joke, is there?  But, seriously, folks... If we are given a diagnosis that we don't like, or don't agree with, we are very likely to go to another doctor for a second opinion.  If we are offered a prognosis that sounds pretty bad ("You gonna die!"), we are almost certainly going to see another doctor.  If the recommended treatment sounds difficult, unpleasant or expensive, we're going to look for somebody else who will tell us something we like better.

But what if everything sounds pretty reasonable, and we're sort of doing okay for a while, and we like our doctor?  Only we're not really getting "all better again".  What if there were just a slow, very gradual deterioration, and that seemed to be in line with the original diagnosis?  And what if that original diagnosis was wrong?

It's not uncommon for me to see patients for a second opinion when the pet's owner is dissatisfied with how things are going.  I do my best to resist the temptation to criticize the first doctor's approach, for two reasons.  The first is that I don't know what things looked like on that initial presentation.  Sure, now that it's been going on for weeks and I know what didn't work the first time, it might look like the other guy really goofed up.  It might not have been so obvious the first time around, though.  The second reason is that sometimes the owner doesn't accurately communicate what happened the first time around.  I try to give that first doctor the same courtesy I'd want if I had been the "first doctor".  Again, that's a common situation, and people are working at getting their problem fixed.

On the other hand, maybe I've made a diagnosis and prescribed a treatment, and it all sounds reasonable.  As times goes on, the pet isn't doing all that great, but, hey, I'm sure Ol' Doc has done everything he could.  Have I? 

When I don't hear back from a client, I tend to think that the pet is getting better, that things are going well.  I'm saying that if your pet isn't doing that great, it's okay to get a second opinion.  Start by getting a second opinion from his regular doctor.  I guarantee that if I find out that the pet hasn't improved on what I recommended, I know that I need to take a second look at the situation. Let me take a second look; in fact, demand that I take a second look.  If I'm stuck in tunnel vision ("You've had this before? Well, you have it again."), don't feel bad about seeing another doctor, and asking for copies of your record.  Maybe the other doctor will find exactly the same thing, and we just have a bad situation.  Maybe...  maybe one of us will figure out something to fix your pet.

I looked at a sad case this week.  Two-years old Labrador Retriever -- looked like she was fifteen. She looked like a skeleton with a big belly full of fluid.  "She started having problems after she got run over last year.  They told us that the fluid was from kidney damage.  She has just gone gradually downhill since then."  The kidney damage explanation didn't seem very likely to me.  Be that as it may, the one patently obvious thing was that the dog had never gotten any better, had gotten much worse instead. 

She tried to stay in a sitting position.  If she lay down, she got back up again.  When I listened to her chest in a sitting position, I could hear air move.  When she lay down, no air movement.  When she lay down, gravity was putting something into her chest that kept her from breathing normally.   What could be falling into her chest?  All that fluid, maybe.  How would it get there?  Through a hole in the diaphragm.  This all started when she got run over.  Her abdomen could have been mashed, popping her guts into her chest.  That causes her organs to function poorly, she loses weight, has trouble breathing.  We X-rayed her chest, and sure enough, it's full of guts and fluid, which are squishing her heart and lungs.  Diaphragmatic hernia is the diagnosis.  That's fixable.

That is, it's fixable when you're still in good enough shape to survive a nice long surgery.  Not so fixable when you are severely dehydrated, haven't eaten in days, and look like a concentration-camp victim.  Her owners elected not to gamble on such a poor chance of success, and we euthanized the poor dog.  I'd rather have fixed her, but she was starving and suffocating, and her chances were certainly slim.

They liked and trusted their first doctor.  They should have asked him for a second opinion.  I suspect he might have had one.

Why don't you DO something?

You're familiar with the phrase, "a double-edged sword", as in something that cuts both ways.  That sounds like a good thing, but is usually used to indicate something whose desirable effects may be offset by other effects you don't want.  Somehow "double-edged sword" has edged out "back-firing blunderbuss" (which I believe more accurately conveys the intended idea).  I guess "double-edged sword"  doesn't sound as dumb as "back-firing blunderbuss".

When one of my clients is super-observant of their pet's behavior, it's a double-edged sword.  On the one hand, they pick up problems very early in the course of the disease.  This should make it easier to effect a cure, as the animal has suffered minimal damage and his body will be better able to respond to treatment.  On the other hand, these people notice when the dog "just isn't right" but doesn't yet have any specific signs and symptoms.   You really want to pat them on the back for being so attuned to their pet's health.  On the other hand, "just isn't right" doesn't narrow the problem down much.  When you can't tell what's wrong with the pet, what do you do?

This evening we looked at Radar, the Boston Terrier.  He's still eating, looks great, no fever, absolutely nothing out of the ordinary on his physical examination.  He's not vomiting, stools are okay, no straining, no sensitivity or other indication of pain.  He's just "not right".  So, whaddayagonnado?

For me, that depends on several things. First of all, how "not right" is he?  If his problem is virtually undetectable, then I have no rational basis for giving him any medicine.  What about diagnostic tests?  With no specific signs of disease, there's no way to narrow it down, so you'd just be running a huge battery of tests hoping to find something.  Again, hard to justify with somebody who may just be having a bad day because of a change in the weather.  In a case like this, if the owner doesn't have to drive too far, I feel the best course is to just observe him overnight.

If the pet is really pretty sluggish and depressed, I'd push harder for some diagnostic testing, at least a complete blood count and blood chemistry panel.  With the pet whose condition is more subtle, there may not even be measurable changes in the blood yet.

Many of my clients have a thirty-minute drive or longer.  It's not so easy for them to take off work again tomorrow or the next day if the pet needs to be re-evaluated.   If he's better in the morning, it's a non-issue.  If he's worse, that's a problem, particularly if his signs are still non-specific.

I believe that this is why veterinarians (and M.D.s) over-prescribe antibiotics.  The client wants you to "do something" and, hey, it might be an infection, and the antibiotics are unlikely to make him worse.  Unfortunately, if it is an infection, and the antibiotic is not appropriate, it may give you spurious results should you need to culture the problem (culture = take  a sample from the problem area and try to grow the bacteria living there.  If successful, you grow them again and test their ability to survive various antibiotics.  It's how you pick the right drug for sure, instead of just hoping you get lucky.)

Your dilemma is that you know you should wait and avoid subjecting the animal to unnecessary (or inappropriate) treatment.  BUT if you wait and he's worse, why didn't you do something?

That's where the art of practicing medicine comes in.  More importantly, it's why your relationship with the client requires good communication and trust.  "Doing something" too soon is not always the best thing to do.