Your Pet's Best Friend

Pain is Nature's Way of saying "Don't do that."

When one of my patients isn't using a leg, it's usually because it hurts.  If something hurts,  I try to stop doing it.  That pain is a signal that I'm making it worse, and I'll slow down the healing (or prevent it).

Hey, but what about those times when you know something is wrong, but it doesn't really hurt?  Once I tripped on the steps and fell to my knees. It hurt right then, but seemed okay afterward.  I did my cardio workout later that day, and one of my knees blew up like a balloon.  I had damaged the blood vessels, but not actually broken them.  Then the increased blood pressure when I exercised caused considerable leakage.  It hurt then, sure enough, and I took  a few days rest.

I'm a doctor and should know better.  My right middle finger developed a little swelling on Tuesday, slightly resembling a pregnant guppy.  My physician says, "You've broken a blood vessel."  Maybe so, but I don't recall any trauma.

Since it wasn't hurting, I went ahead and did my weight workout on Thursday evening.  No direct pressure on the hand, as I used Flexsolate wrist straps.  Unfortunately, as with the knee, the exercise increased the pressure, and by Friday morning the pregnant guppy had turned into a sausage.

Believe it or not, it's a little better this evening (but not much).  There's enough pain now that I'm getting the message "Don't do that." I could use one of those medical-grade leeches right now.

This is the problem that I have with my patients.  I do want them to be pain-free when they have injured themselves.  The problem is that then I'm taking away some of Nature's little voice saying "Don't do that."  That's why it's important to confine those patients so that they don't overdo it as soon as their pain is relieved.  They just don't know any better.

I know better, and I did it anyway. They may be smarter than I am, but you can't count on it. When your pet has been injured, you'll have to be his conscience when you start those pain meds.

Arthritis treatment alternatives

This question showed up on the Pelvic Fractures post today:

> My precious Schnauzer/Yorky mix was hit by a car & broke her hip 7 years ago. She has healed and walks on her leg from time to time but I have noticed great sensitivity when I touch her leg lately.(nerve damage?)She goes under the bed a lot which tells me she is in pain.I would love to find a natural alternative to help her with pain and possible arthiritis. I did have her on Previcox at one time but it seemed to upset her already sensitive stomach.Somebody recommended a joint pill by Drs foster& Smith.i would love to get your input on this. Any ideas or suggestions will be greatly appreciated.

Hello, Celeste,

With the history you have given, I would be very much surprised if your dog did NOT have arthritis.  Arthritis is defined as inflammation of a joint. Pain is included in the definition of inflammation. Any dog may experience wear and tear on the joint with age, but when there has been an injury, it will almost certainly be worse. 

The injury usually produces an irregular joint surface or an imperfect mating of the two bones in the joint.  This will cause more wear and cause it sooner than one would expect in a normal joint.  Irregularity and loss of the flexible,smooth cartilage coating will lead to bone-on-bone contact and this is painful.

Previcox is one of a large group of drugs referred to as NSAIDs, short for non-steroidal anti-inflammatory drugs.  In other words, they are drugs to relieve pain and inflammation that are not some form of cortisone.  Cortisone is a great anti-inflammatory drug, but has many other side-effects in the body.

The NSAIDs have fewer side-effects than the cortisone, but they still have side-effects. Most common are GI problems, ranging from loose stools, to blood in the stool, to vomiting, to bleeding ulcers.  If a big overdose is given, they can damage the kidneys.  As with any drug, you can also have idiosyncratic reactions, meaning that some individuals just cannot tolerate the medicine, even though most do fine with it.

Over the counter NSAIDs include aspirin, ibuprofen (Advil), and naproxen (Aleve).  You really should consult your veterinarian before giving ANY of these to any pet.  There have been reports of a bleeding ulcer after a dog receiving a single dose of ibuprofen.

There are numerous potent NSAIDs approved for dogs.  Phenylbutazone used to be a mainstay, but the new drugs are much safer and give more relief.  In addition to the Previcox you mentioned, I personally use Rimadyl, Deramaxx and Metacam.  There are others available.

As with people, sometimes an individual has poor tolerance for one NSAID, but does well with another.  If your dog did poorly with Previcox, Rimadyl might work fine.  You just have to try it and see.  It is important to do this in cooperation with your veterinarian.  Do NOT combine the drugs, as you can cause serious, even fatal, side effects by doing so.

There are also many supplements sold to help with arthritis.  Most of these contain glucosamine, chondroitin sulfate, or MSM, among other ingredients.  There are several studies on this, with conflicting results as to how effective they really are. I believe that these are beneficial for a lot of dogs, and they rarely have any side effects.  You generally have to take them for a month before you can really see any improvement, though.

Some dogs really respond great to Adequan (polysulfated glycosaminoglycan) injections.  These are given at 4-day intervals for four to eight injections.  No side effects are likely, and some patients have miraculous results: i.e. they do great for six months without other medicines.  Unfortunately, other patients may show no benefit whatsoever.  Personally, I can't predict who is going to get the miracle, and who is going to get nothing out of it.  It's a pretty reasonable cost to take a chance on a small dog.  It's pretty expensive for a big dog if it isn't going to work.  I wish I could predict who will get the miracle.

In summary, to answer your question, I would recommend starting some type of glucosamine supplement.  I think Adequan would be definitely worth trying.  I would also consider trying Rimadyl or Metacam to see if your dog does better with those than with Previcox.

Non-medical alternatives include physical therapy, acupuncture, therapeutic laser, massage, and veterinary chiropractic.  It is often difficult to find access to a veterinarian with expertise in these areas, though.  My friend, Dr. Ava Frick is one of the best.

Good luck.
 

De-clawing Cats -- What do you mean, you "don't think he's hurting?"

Some days I think I am a great communicator.  Heaven knows, I love to listen to me talking.  Then there are days like today.

De-clawing is a major surgery for the cat (pretty routine for me).  I don't feel it is something to be entered into lightly, or to be considered "minor" in any way.  You are amputating the last bone (digit, third phalanx, whatever you want to call it) on every toe that is being de-clawed.  This is not crippling to a cat, as they walk on the next bone up, with that last bone and claw flipped up out of the way -- the old, retractable claw business.  On the other hand, just imagine having the ends of all your fingers cut off...  Ouch!   Okay, you can stop imagining now.

There are definitely times when de-clawing is indicated.  Sometimes either the claws have got to go or the cat has got to go.  I don't want the kitty to lose his home, and I know that it won't be long before he's able to walk normally and pain-free again.  Sometimes you just have to make the best choice you can. The important thing is to make the surgery and recovery as pain-free as possible.  In addition to general anesthesia, we use local anesthetic to block the nerves to the paw.  This prevents some of the pain perception mechanism from ever getting triggered.  We use a lot of buprenorphine post-operatively.  It's a mild narcotic that cats tolerate well, and you can give a tiny volume simply by squirting it in the mouth.  They don't actually have to swallow it, as it absorbs across the cheeks and tongue.  We send home enough to give every 6 to 8 hours for at least three days.

It's unusual to de-claw an adult cat, but when folks have adopted a cat who needed a home desperately and the cat starts shredding his new home...  This was a big cat: fourteen pounds.  We talked about what a major surgery this is. I told the folks that he would stay in the hospital an extra day with his bandages on to protect his paws, and that we would be using extra pain medication to be sure that he had enough when he went home.  An adult doesn't heal as fast as a growing kitten.

When we called to check on him, we found that they weren't giving him his pain medicine.  "Well, we didn't think he needed it.  We had a cat before, and when he was hurting, he did a lot of panting and crying."  [As cats have a strong tendency to conceal signs of pain or illness, I wish we had had the presence of mind to ask what was wrong with their previous cat to get him panting and crying.]

Here's a predicament for you: If the people listen to me now, they have to admit they were wrong and were letting the cat suffer without his meds.  To be right, they have to hold on to their previous mindset and wait for him to pant and cry.  The best I could think of was to remind them that some cats try very hard to conceal their weakness.  It's a survival instinct.  Don't show your weakness, as other predators may take advantage of you.  "Just in case he is one of those cats, let's go ahead and give the medicine... just to be on the safe side, you know.  It won't hurt him." [Since it's, whaddayacallit? ... pain medicine]

It's just another reminder that animals (and people) don't always show their feelings in the same way.  One cat purrs only when happy, the next purrs like a machine when he's about to come unglued and take the room apart.  I have to keep falling back on, "Would I be hurting if this were me?"

Pain control takes empathy.

There's an old cowboy saying: "Don't tell people about your troubles -- half of 'em don't care and the other half are glad you've got 'em."  If you've looked at my bio links and old posts, you know that I'd be interested in old cowboy sayings.  Still, if someone asks "How are you?" I'm likely to respond as if they really want to know.  None of that "Fine, how are you?" stuff for me.  No, no, brother; now I've got this place in my lower back and sometimes... well, you're not interested in that, are you? See, I know that, so when I talk about my sacro-iliac [say it like Jimmy Durante would], just bear with me, because there really will be something significant coming up later.

While I do my cardio workout in the mornings, I listen to a lecture on tape, and I turn on the FitTV channel and watch the yoga chicks with the sound off.  Watching is where I should have left it. Those gals are supple, and I'm not.  I decided to stretch my hamstrings a little, and wound up tearing my right S.I. (sacro-iliac) joint .  That's sort of like spraining your ankle, only in your back, with tearing and stretching of the ligaments that hold your pelvis on to your spine.  It hurts quite a bit, for a week or two usually (I've done it before, alas, several times, though not in this precise way).  Those yoga chicks are for watching, not emulating.  Sort of like in "The Outlaw Josey Wales" where Lone Watie holds up his hard rock candy and says "... But it's not for eatin'.  It's just for lookin' through."

So the next day, I'm taking Aleve, I'm using the alpha-stim, and I'm putting the ice to my injury, and I'm still hurting... all the time.   Lo and behold, here comes a dog who has been hit by a car.  He can't stand on his hind legs, and they think he might have to be euthanized because of a broken back.  The good news is, while his spine is broken, the break is way back where his tail hooks on, and really will only keep him from wagging his tail.  The bad news is, he can't walk because his pelvis is fractured in many places.  Both of his S.I. joints are torn loose from their moorings on the spine, and the pelvic bones are broken in several additional places.  Fortunately, his leg-bones and hip-joints are NOT broken.  The good news is that there is so much muscle and tendon around the pelvis that it acts as a "self-cast".  Since his hip joints are okay, the odds are very good that the pelvis will heal without any surgery.  In fact, in two to four weeks, this kid will probably be walking pretty normally.  Complications are certainly possible, but the odds are very good that he just needs a lot of good nursing care, cage rest, and pain control, which brings us to the topic of the post.

I gave the kid a sedative and narcotics so that we could do a better examination and X-ray without hurting him so much.  I mean, he was hurting plenty from the injuries already, much less from me tweaking things around.  After finding that his injuries gave him a good prognosis, and explaining the above to his folks, all that remained was to explain the nursing care, and get the pain meds fixed up.  Here is where that empathy thing comes in.

I'm fixing him up a nice big prescription of Rimadyl (a popular NSAID, or non-steroidal anti-inflammtory drug -- like Deramaxx, Metacam, aspirin, etc.).  Twenty years ago he probably would have just gotten the cage rest and nursing care prescription, but now he gets Rimadyl, too.  What a nice doctor I am!  Then I'm thinking, I have a mildly torn S.I. and the NSAIDs are not really cutting it.  This guy has both S.I.s torn loose completely, plus multiple fractures.  What am I thinking of, just sending him home with NSAIDs?  So, we wrote him a prescription for a generous dose of Tramadol (narcotic pain reliever).  He seems to be doing okay with that, but you know that dogs are great at concealing their pain.

I just hope that karma doesn't require me to experience every injury I'm going to see next week.

Why NOT give pain control medicine?

In my last post, one might have a tendency to interpret my comments as being critical of the dog's regular veterinarian.   While I do think there is some lapse of logic in sending home a barrier collar instead of (or without) pain medicine, you have to consider this in light of the back-story.  Don't judge too harshly.

As hard as it may be for you to believe, routine pain management after surgery has not always been the standard for our profession.  As a reformed sinner myself, I must admit that our commitment to routine pain management is only about seven years old.  Prior to this, pain medication was only given when the animals were crying.  This was sadly inadequate, as it is a non-survival behavior to exhibit how weak you are.  Animals are not stoic out of some misguided sense of macho, but rather because the primeval ancestors who advertised themselves as helpless victims did not produce many descendants.  So "big girls don't cry", and waiting for the animal to cry is waiting too long.

How could we have had such a callous attitude toward animal suffering?  I graduated from veterinary school in 1978.  When I took my surgical training, we were told to be very sparing with pain medication, if we gave any.  "If you get them feeling too good, they'll run around and tear up your surgery."  We were paying good money for our education, and these professors were the best in the west, and so we believed them.

Now you might say, "Have you ever had surgery yourself?  Didn't you need something for pain?" I'd answer yes, and yes.  HOWEVER, when I had my shoulder reconstructed about one week before starting veterinary school (I was in a sling for the first six weeks), they didn't give me much pain medicine.  In those days, being a drug addict was considered "a bad thing".  If you got to liking those pain meds, you just might become a drug addict.  So, I lay there hurting like hell all day long, and then they'd give me some Demerol at bedtime so I could sleep.  That's the way it went for three days, after which the pain had subsided greatly.  I don't know whether I'd have become addicted if I had received medication during the daytime, too, but I was sure glad to drift away on my little pink cloud at night. 

Since they didn't give people much pain medicine, and the instructors told us not to give pain medicine, it's not so hard to understand how this attitude became pervasive.  Attitudes have changed greatly in the past few years.  In 1997,  Dr. Bob Paddleford talked about pain control, and spent half his time apologizing for recommending it.  He knew the old-timers would think he was a sissy.  Now we're concerned with multi-modal analgesia (in other words,whether you are using enough different approaches to be sure the pain is under control).

If you have major surgery now, chances are good that you'll have a little "pain pump".  If you start hurting, you just hit the button and get some more medicine.  In retrospect, I find that when I received post-surgical pain medicine, it hasn't made me want to get up and run around -- it let me rest. 

I don't know how long it would take a pet to learn to operate a "pain pump".  I do know that I can't wait for them hit their nurse's buzzer.  Certainly, when you know a particular individual, you can be alert for changes in attitude, restlessness, and so forth.  For practical purposes in the hospital, we just have to look at what we're doing with that animal.  Would this be painful if it were happening to me?  Then I'll treat my patient as I would wish to be treated (not like I was treated in 1974).

If you KNOW it hurts...

Why not do something about it?  My dentist friend tells me of patients who come to him with terribly painful dental problems, such as broken and abscessed teeth, that have gone untreated for weeks to months.  When they tell him this, they add, "I just couldn't stand the pain any longer."  You might be thinking, "Why were they trying to stand the pain for so long?  Why not just get it taken care of?"  It might be money, but more often it is the perception that dental procedures hurt worse than the tooth-ache.  This is untrue.  I have (sad to say) had a lot of dental work done, including several root canals, and the tooth-ache was a lot worse, by far.  Yet, I can tell you that there are many people for whom just hearing the words is enough to send shudders down their spine.  If you want sympathy, don't tell folks you have a broken leg: "But this will just take a minute!"  No, if you want them to leave you alone, tell them you just had a root canal.  They will start back in horror, "OH....no hurry...uh, I gots to go now." Then they carefully tiptoe away in an attempt not to catch whatever it is that placed you in that predicament.

There are times when it's not so clear-cut.  I have a friend who had terrible degenerative arthritis in his knees.  It hurts to stand or walk, so he wasn't doing much exercise, and he's a guy who really enjoys his food.  That combination put a lot of extra weight on him, which made his knees hurt a lot worse.  "Well, he just needs to lose that weight."  Sure he does.  But he can't do aerobic exercise because his knees hurt so much, and his knees hurt so much because he's so overweight.  Oh, yeah, he could starve it off, but that's easier said than done, even if you aren't a person who really enjoys food.

I've talked a little about pain control in a previous post.  Here's what stimulated today's diatribe.  On my Saturday afternoon off (when I went to lunch at 2:00), I had just sat down to read the paper when the phone rang.  "We're here visiting this weekend and our little dog was spayed on Monday and now her incision is bleeding.  Could you take a look at it?"  I could, I did.  One end of the incision was draining some nice pink pus.  Well, that's not supposed to be happening.  The sutures seem to be holding fine, but she obviously has gotten it infected.  "Is she licking it a lot?"  "Oh, yes; we can't keep that hood on her."  By hood, they meant an Elizabethan collar.

Here's Queen Elizabeth the first of England.  Note the fashionable collar, or ruff.  That's not what I'm talking about. 

This is what I'm talking about. 

Or maybe this.  It's a device to keep the dog from getting it's mouth onto anything but the food bowl.  Sometimes it works.

"It's been five days since her surgery, so I guess she's probably out of her pain medicine."  "They didn't give us any pain medicine.  Should we have asked for some?" 

Let me get this straight, now: we send home the E-collar because we're afraid that the dog will lick at the wound.  It is apparently common for that doctor's patients to lick their incisions a lot.  Could this be because the incision is painful?  I know any incisions on me have been painful (but I'm not flexible enough to lick them, even if it would help, which it doesn't.).  If you KNOW it hurts, wouldn't it make more sense to give pain medicine than to just try to block the dog's attempts to assuage the pain?  Hmmm?

I'm not against the E-collar.  There are definitely times when you need to restrain the dog's mouth, even though he's full of pain meds.  Some dogs feel that they can chew out whatever's in there hurting them, and that ain't right.  It doesn't help, and it screws things up.

I'm not too big on taking drugs as an answer to all of life's problems.  Taking a pill because you're shy at parties is not a good thing.  On the other hand, if you've just had a painful surgery, I think it's okay to take pain medicine for a few days.  If you have just performed a painful surgery on a pet, I think it's mandatory to send home pain medicine for a few days.  You can't wait for the dog to ask for it.

It feels so good when you stop.

There's an old joke about someone finding the simpleton hitting himself in the head with a hammer.  When asked why he would do such a thing, he replied "It feels so good when you stop." 

When I was a boy, we used to camp at Alley Springs State Park for our family vacation.  In those days you could camp right on the spring "branch", the exceedingly cold, clear stream leading from the spring itself to the nearby Jack's Fork river.   We waded in this knee-deep stream and our legs and feet would become quite numb from the cold after just a few minutes.  It was much too cold for swimming, yet every evening my father would immerse himself briefly.  He would jump up and out to land on the bank, shaking like a wet dog and exclaiming about how great it felt.  One evening, I decided to emulate him and received the shock of my life as the icy water closed over me.  "Dad, why do you do that?"  You guessed it: "It feels so good when you get out."

There is some truth to this, of course.  "Hunger is the best relish", meaning that you really cannot appreciate how good some simple food is unless you've been really hungry.  Thankfully, I've never been starving.  The closest I've come to this was my apprecation of a simple stew after a long day of working the rappelling cliffs with the Scouts.  It may not have been the best meal I ever ate, but I remember it as being so.

You can appreciate the true beauty of being warm after being chilled to the bone.  One night, I lay prone in the snow, in short sleeves, delivering a calf down in a wooded gully.   I got pretty wet in the process, and it was a fair hike back to the truck.  When I finally arrived home, I opened the damper wide on our wood-burning heater, took a hot shower, wrapped up in a blanket in front of the stove, and ate hot soup.  Good is not a strong enough word for how I felt then.

When we took our hiking trip at Philmont Scout Ranch, we were ten days on the trail.  We wore one set of clothes and carried a spare.  There were streams to wash them in, but it wasn't sunny enough to dry them.  You could change clothes, but not into clean ones. In ten days, I got one shower, and one sponge bath.  You cannot imagine the exquisite pleasure afforded me by a hot shower and clean clothes at the end of the trek.

By the same token, the relief of a pet's pain is a wonderful thing.  Sadly, animals often conceal their pain.  Their instincts tell them not to advertise their weakness.  You have an abscessed tooth?   Don't let anyone know you can't bite them.  Chew on the other side.  Don't cry.   You will never know how much your pet is hurting until the pain is relieved.  The arthritic pet who was "just getting older" -- after five days on an anti-inflammatory, his owner calls to say "I have my dog back".  The pet with abscessed teeth (for six months) --who has a personality change after the teeth are extracted: "We can pet her now.  She doesn't bite us and  she wants to be loved on."

Certainly we can use some rules of thumb.  When surgery is performed, just think: "Would this be hurting me?"  Your pet is no different in the amount of pain he feels.  He is just more stoic about concealing it.

Sometimes we just don't know what's going on to depress the pet so much.  When in doubt, try relieving the pain.