VMDiva

I received a call the other night from a distraught pet owner who sheepishly approached our conversation about his 5lb puppy. “I did something really stupid.” Uh-oh. I have heard a lot of crazy things so I was prepared for just about anything he was going to tell me. His voice cracked as he slowly said, “I can’t believe I thought this was a good idea.” I started to squirm then he admitted he gave his puppy “a few tablespoons of wine” and now realized it was an idiotic decision. Lethargy, and probably a drunken stupor, hit the puppy hard.

I decided the puppy, who was then walking around as the effects of the alcohol wore off, seemed stable. We spoke about what to expect and what clinical signs required emergency care. I’ve never heard back from him. After I hung up and realized I didn’t even ask him why he did it. Truthfully, I don’t think he even knew. I gave this guy the benefit of the doubt. We’ve all made stupid, thoughtless decisions which weigh heavily in our stomachs as we mull the horrible decision and try to rectify it. He clearly didn’t think. Any rational person would know not to feed any animal, let alone a small puppy, alcohol. He at least redeemed himself by calling my office to find out what he should do. Perhaps I was too lax, but I trust this man will never make this mistake again.

I like tangents and this case got me thinking about how I could measure a blood alcohol content (BAC) in a domestic pet. Breathalyzer is out. A quick search on Google failed to yield any available bedside blood alcohol tests. Laboratory tests exist but shipment of blood for a BAC would take too much time. Any veterinarian should provide decontamination and supportive care to any alcohol poisoning suspect pending any bloodwork. The animal would most likely have either recovered or died while waiting for BAC lab results.

I then tried to calculate the puppy’s BAC using The Original Blood Calculator. A full 5 oz glass of wine would have given Fido a fatal BAC of 0.813%. Two tablespoons equal 1 oz of wine, so Fido’s BAC may have been closer to 0.16%. While it is clinically interesting to speculate, this value may or may not be close to accurate given varying metabolisms between humans and dogs.

Animals entrust us with their care. Be smart and don’t abuse it by giving them alcohol. For more information on alcohol poisoning in domestic pets, check out this article on VIN!

Admittedly, I stopped reading books for pleasure during college and had a long dry spell until I resolved to pick up the slack several years ago. My attention span is embarrassingly limited so a book really needs to peak my interest for me to even pick it up. I’m a sucker for stories narrated by emotive animals (can anyone say anthropomorphism) but I’m particularly vulnerable for insightful ones. Such was the case with The Art of Racing in the Rain.

Enzo, a lovable aging dog, tells the story of his owner’s balancing act between his desire to race cars and his commitment to his struggling family. His comedic and painfully accurate assessments of human personalities keep you laughing and cringing at the same time. He also offers a poignant perspective on his own impending death.

Laughter, anger, love, hope, introspection: It all made me fall in love with Enzo.  This book will leave you wondering what your own dog is thinking.

Highly recommended.

Faced with a leg amputation to treat bone cancer, dog owners can experience trepidation over their pooch’s outcome. This scenario is playing out for one couple at my practice who’s six year old golden retriever, named Goldie Hawn, has been diagnosed with bone cancer in her left femur.  Given their amazing ability to walk on three legs, amputation is the treatment of choice. Amputation will at least provide palliative treatment of her tumor and at best a cure. Amputation is permanent which makes the stakes even higher. Goldie’s owners have that knot-in-their-stomach nervousness but a little education can alleviate some fears.

From a veterinarian’s perspective, it’s easy to discuss the surgery, recovery time, and varying anticipated outcomes following a leg amputation. What we aren’t always ready for are those questions regarding specific parts of the dog’s quality of life. I smiled as Goldie’s owner asked how she would be able to “squat to pee” and if she would “have a stump”. I walked them through preoperative and postoperative care, glancing over the surgery itself when they told me they couldn’t handle the details. I recommended they watch videos on youtube.com of three-legged dogs to get an idea of what to expect. Knowledge is power.

Dogs never cease to amaze me with their ability to cope. Many dogs swiftly adapt to their tripod status. It seems hind leg amputees ambulate better than fore leg amputees but both still motor along with the best of them. Check out these videos!

Fore Leg Amputee Playing Frisbee

Hind Leg Amputee Competing in FlyBall

It disheartens me to see my alma mater struggle during the recession, especially when a portion of its economic strife is not under the school’s control. The Commonwealth of Pennsylvania has slashed its funding to the veterinary school so severely the school has been forced to eliminate numerous faculty positions as well as entire departments. It is evident these cuts affect the public and veterinary students as the repercussions funnel down to them. I have great concern for the future of Penn Veterinary Medicine, especially when the future is partly controlled by bureaucratic decisions.

Veterinary student debt is a common topic and I certainly don’t want to harp on something most veterinarians know about. With budgetary issues at the forefront, it only flows that student tuition will continue to rise.  At Penn Vet, the current cost of tuition for PA residents is $32,902. The current tuition for non-residents is $40,058. That doesn’t even cover cost of living during those four years. With debt soaring, students shouldn’t have to deal with another tuition hike. They shouldn’t be sitting on top of one another in class either. Class sizes are always increasing but have significantly risen in the past few years.

The public will ultimately be hurt by these cutbacks.  The Matthew J. Ryan Veterinary Hospital has eliminated its neurology and special species departments and rumors swirl about the elimination of more departments. Pet owners will need to go elsewhere for some types of specialized care, sometimes miles away from home.

Perhaps most concerning is the elimination of the Center for Infectious Disease Research, highlighted in the CNBC article. “Established to study diseases with the potential to move from animals to people (or vice versa), the center’s loss is “stunningly myopic” in the era of swine flu, [Dean] Hendricks said.” Veterinarians do not merely care for sick pets. They play a critical role in protecting public health by researching and preventing zoonotic disease and inspecting the US food supply though the USDA.  A slash to infectious disease control measures will put the public at greater risk for zoonotic disease and could affect our food supply.

I am generally not a fan of home-cooked diets for pets because, too often, I have seen pet owners fail to provide a balanced diet. Now, I’m not talking about the folks who do their research, provide a variety of nutrients, and add supplements. I am talking about the owners who report their precious Fluffy just won’t eat anything but roast chicken and green beans. Merely adding a veterinary or human multivitamin to a diet does not make it balanced as those products are labeled for use in addition to an already balanced diet.

The dangers of an unbalanced diet are multiple. Nutrient deficiencies can result in anemia, skin issues, gastrointestinal issues, nerve conduction problems, and immunosuppression among many other medical conditions. It is crucial that pet owners who want to make food for Fluffy do it well. Many of the home-cooked diet recipes that came out from companies like Hill’s Pet Nutrition about 10 years ago have since been deemed unbalanced and are no longer recommended although you can still find recipes circulating the web. A Google search yields pages and pages of scientific, non-scientific, and opinionated recommendations on what to feed pets. With all this information, it can be difficult for pet owners to know which recommendations to follow.

As a general practitioner, formulating a diet is something I could do with the guide of a nutrition book and many calculations but is beyond my comfort zone. When faced with folks who have questions on how to provide a diet for their pets, I state the easiest way to achieve a balanced diet is to feed a balanced commercial food. If the owner finds this undesirable, I talk about the other two options: Consult a veterinary nutritionist or use a veterinary nutritional website to find a diet that fits the pet’s needs.

Owners can search the American College of Veterinary Nutrition to find a veterinary nutritionist. If that seems like too much work then they should check out these two websites below. I like both of these sites because they personalize diets on an individual pet basis.

PetDIETS.com was developed by a veterinary nutritionist and can provide specific diets for healthy and sick pets. These nutritionists can recommend a home-made diet, a commercial diet, or both depending on the pet’s nutritional needs.

BalanceIT.com allows pet owners to choose the protein and carbohydrate sources they wish to feed their pets and creates a supplement based on a recipes the owner purchases. This is great for folks with pets with GI sensitivities or skin issues who have already been feeding an unbalanced diet. It allows them to continue feeding their current diet while adding supplements to make it balanced. I really love this one.

An appalling case of animal abuse occurred near my alma mater this week and it sickens me. The local news reported a 33 year old Philadelphia father, surrounded by his small children, decided to teach his young pit bull a lesson after the puppy nipped at him. His solution involved dousing the animal in alcohol and setting him on fire. The man’s children reported the incident to school officials. The dog has apparently survived but has a tenuous recovery from severe burns to his face and neck.

This type of cruelty stirs a nauseating anger that grows the more I think about it. Pennsylvania Animal Cruelty laws state “It is a Misdemeanor in the first degree if a person: “Kills, maims, mutilates, tortures or disfigures any dog or cat, whether belonging to himself or otherwise; or administers poison to or exposes any poisonous substance with the intent to administer such poison to any dog or cat, whether belonging to himself or otherwise”  This is punishable by a fine of not less than $1,000 and/or imprisonment for up to 2 years.” This particular suspect is facing many other charges such as child endangerment and arson.

Remove children from the situation and this guy (or a similar perpetrator) could get a slap on the wrist. A $1000 fine is insufficient for this type of malicious disregard for life. Imprisonment up to 2 years is reasonable, but very rarely do the courts drop the hammer on animal abusers. This confuses me given the known ties between animal cruelty and domestic violence. It has long been understood that animal abusers often graduate to domestic violence. Regardless of personal beliefs about treatment of animals, it would be prudent of the courts to look at “gateway abuses” critically. I wonder how this man responds to his small children when they misbehave.

We need to seriously consider the way we handle perpetrators of heinous acts of animal cruelty. Anger management, domestic violence classes, and compulsory prison sentences should be mandated. Psychological evaluations could help prevent future abuses and should be incorporated. Perhaps the courts should even  require community service in an animal shelter. A small fine for first time offenders equates to a slap on the wrist and does nothing to prevent further abuses of both animals and people. Drop the hammer. Please.

A recent article in the Wall Street Journal made me evaluate how my own pets affect my relationships. The article highlights how distorted priorities can lead to marital problems and dysfunction in the family. My husband knew what he was getting into when he married a vet, so I almost get a free pass when it comes to me lavishing my pets and treating them like the infallible monsters they are. With my own pet-to-husband balance in check (I admit to the occasional argument on who cleans the litter), I mulled on the ways my pets affect everyday life.

I just recently realized how disruptive the cats are to our sleep during their recent month of confinement. Both have been banished to the basement due to Winston’s inappropriate elimination (before you think I’m mean, it’s a finished basement with all the kitty amenities). With the cats safely locked away, there was no more waking up in the middle of the night to ax-like paws digging into my sternum. No more 3am howling in triumph after killing the toy mouse for the 1000th time. No early morning meowing alarm clock nervous we’d forget to feed him breakfast. I must say, I’ve been sleeping quite well.

In addition, the cats definitely affect the relationship with my in-laws. My father-in-law is dreadfully allergic to cats and despite my cleaning, vacuuming, dusting, and sterilization of the house, his visits can only comfortably last about 2 hours despite allergy medications. Summer visits lend themselves to sitting outside but winter visits result in trips to the movies or going out for dinner. I have no plans on ridding the house of cats in the future so I guess I have agreed to awkward visits.

I’m wondering how your own pets affect your day to day and extended relationships?

I’ve gotten a number of questions about Angels’ Eyes, the oral product that proclaims to rid little white dogs of their unsightly red-brown tear stains. Small breed dogs and brachycephalic cats commonly experience epiphora, or excessive tearing. Products like Angels’ Eyes promise to rid a pet of its tear stains with a daily oral supplement. I typically consider such claims nothing more than another gimmick. However, it seems as though this product might actually work for little Fluffy. I researched the miracle product and was surprised to find the secret ingredient is Tylosin.

Tylosin is a macrolide antibiotic commonly used in food animals but can also be used to treat campylobacter and mycoplasma spp infections among others in dogs and cats. It is also used as an anti-inflammatory to treat colitis, much like metronidazole. It is in the same drug family as erythromycin and azithromycin (Z-Pak). The company claims the product kills yeast, which they mistakenly call a bacterial infection, that are responsible for producing red pigment. Tylosin actually kills the bacteria that, when interacting with the yeast, cause the formation of pigment and subsequent stain.

I have some major issues with this product:

Tylosin tartrate is labeled by the FDA for OTC use in food animals. When it comes to use in dogs and cats, the FDA notes federal law restricts this drug to use by or on the order of a licensed veterinarian. This drug should not be sold OTC for pets. Period. Loopholes in the supplement labeling system allow companies like the manufacturers of Angels’ Eyes to sneak around FDA regulations with the disclaimer: These statements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure or prevent any disease. This disclaimer does not make the act of dispensing this drug legal, it merely allows the manufacturer to make the product without going through the expensive and arduous process of FDA approval. Because the FDA typically has bigger fish to fry, companies like this cruise under the radar.

Antibiotic resistance is a problem that affects all facets of medicine. Many common antibiotics have dual use in both veterinary and human medicine. While tylosin is a veterinary only drug, drug resistance to one drug can potentially result in resistance to an entire class of antibiotic.  I am concerned there are voices on the web who say that, because tylosin is a narrow-spectrum antibiotic, resistance is not a worry. Say what? First of all, tylosin has broad spectrum coverage against gram positive bacteria. Second, if an antibiotic has activity against ANY bacteria that bacteria can become resistant. Those same voices also claim tear staining leads to eye infections. Sorry, wrong again. Staining leads to unhappy owners; Improper tear production and tear flow coupled with shallow orbits, bulging globes, and underlying pathology leads to infection.

I also have serious concerns for any use of an antibiotic to treat a cosmetic issue. This is bad medicine no matter which way you slice it. Angels’ Eyes gets my stamp of disapproval.

I was recently unpleasantly surprised with the diagnosis of a bone tumor in a young golden retriever I was convinced had a cruciate ligament tear. The ensuing conversation blindsided the pet owners and I was reminded of the importance of delivering bad news properly. I’m not the most articulate person but as I travel along in my veterinary career I have learned invaluable lessons in the delicate art of breaking bad news. Below is a short list of insights that may help an unsuspecting new veterinarian.

Be honest and forthright.

I am not a fan of the question “What would you do if he was your pet?” While I offer my opinion when solicited, I always note that I have a bias. That bias is what makes me a veterinarian. My job is to cure and treat disease, alleviate pain, and want to find the diagnosis. If you think an animal is suffering, kindly say so. Veterinarians sometimes better recognize the signs of pain, discomfort, and failing quality of life.

Get to the point. Repeat.

When delivering bad news to an owner, like the diagnosis of a tumor, it is tempting to talk about normal results and how the animal arrived at this point before giving the diagnosis. It just doesn’t work. Most people are perceptive enough to sense something is dramatically wrong and their minds begin racing as soon as you don’t say everything is okay. I find the most effective way to deliver the blow is with a soft voice, caring personal tone, and preface the entire conversation with “I’m afraid I have some very bad news for you, it appears as though Fluffy has a tumor in his abdomen that looks as though it has spread to his chest. I know this is a lot to handle but I’d like to discuss it with you.”

Further discussion at that time is completely dependent on the owner. Some owners want to discuss all options then and there. Others need time to digest the information and will need to call or visit later. Determining what the owner needs is a skill a vet develops over time. Too many times I have tried to plow through a discussion of what we do next only to realize the owner hasn’t moved beyond the word “cancer”. Once you deliver the news, summarize the findings again. In a state of shock, owners may remember only a fraction of what you tell them.

Don’t Use Euphemisms

It may be tempting to sugar coat findings to try to spare emotions but you will do a disservice to your patient if you fail to adequately explain the dire situation to its owner. A gentle apologetic tone prevents you from sounding too calloused. For suddenly deceased pets, using terms like “moved on”, “passed on”, and “no longer with us” are not definitive for a reeling mind. Use the terms “death” and “died” at least once in conversation and supplement the conversation with the other terms.  For the terminal diagnosis, terms like “life-ending”, “end-stage”, and “not recoverable” are warranted. In addition, “uncomfortable” does not mean the same thing as “suffering” to most owners so choose your descriptors wisely.

Offer Follow-Up

Once you’ve delivered the news, acknowledge there will be more questions. Suggest owners write them down, sleep on it, and call you the next day with questions. Make yourself available for a consulation appointment as some owners prefer speaking in person.

Be Compassionate

You’ve just rocked someone’s world. Remember what it is like to be confused and stunned. Don’t be afraid to reach out and hug a client in need.

Apparently only one. At least that’s what the civil court said in a recent civil complaint against my practice. Let me give you some history.

Mrs. Notesta brought her young cats to our clinic years ago, well before I worked there. At the time, she declined Felv/FIV testing saying, in what typically amounts to a “never”, she wouldn’t test today and that she’d have to think about it. Thankfully, the veterinarian at the time noted this in the record. She declined testing the other 2 cats as well. Fast forward to eight years later when one of Mrs. Notesta’s indoor only cats, Lucky, becomes very ill. She is seen at a local referral center where, over the course of a couple of days she deteriorates and is euthanized. Lab results revealed she had Feline Leukemia Virus (Felv) and it was believed this lead to her death. Felv is not curable or even treatable, leaving cats with a compromised immune system and more likely to develop cancer. Fortunately, none of the other cats in the home were infected.

Mrs. Notesta wrote a letter to the hospital with accusations of negligence and malpractice because her cat was never tested for Felv. She contends that, because Lucky wasn’t tested, the hospital is liable for all medical bills incurred at the referral center, loss of salary for her time off, and other bills accrued during the cat’s illness. Despite having copies of the records with multiple documented refusals and repeated telephone conversations with the practice owner, she announces she will pursue a civil suit against the practice to recover her expenses.

A couple of issues come to mind with this situation:

1. Had the original veterinarian not recommended testing or failed to document her refusal, would Mrs. Notesta have a case?

• Consider how the cat’s medical care would have evolved had veterinarians known she was Felv positive. Perhaps she would have received more aggressive antibiotic treatment when infections were evident. More aggressive treatment early on may have staved off inevitable illness a little longer.
• Would Mrs. Notesta have pursued expensive diagnostics and treatments at the referral center had she known the cat was Felv positive and likely suffering complications of endstage Felv? Probably not. Even if the cat was not tested, testing would not have necessary affected the overall outcome. In the above scenario, is the hospital responsible for her bills if it failed to recommend testing?

I don’t know the answers to these questions but I sure look forward to hearing your opinions

2. How many times should you ask an owner about a specific diagnostic or treatment modality, especially if they say “I’ll have to think about it?”

• The civil court judge  in this case ruled that one instance of documentation of the owner’s refusal for Felv/FIV testing 8 years ago was enough even though there were multiple documented refusals. The lawsuit was dropped, the owner paid her bill to the practice, and we haven’t heard from her again.

I think one additional inquiry about testing is warranted from a medical standpoint, if not a legal standpoint, especially if the owner left the conversation with “I need to think about it.”

3. Can clients construe repeated questioning about testing be construed as bullying?

• Maybe. It depends on your approach and the client. If a client senses you’re uncomfortable pressing for an answer they usually become uncomfortable themselves. If a client says no, a reasonable response is “Well, if you ever change your mind and want to do that test let us know” or at an annual visit “Are we still holding off on that heartworm test like we did at your last visit? I certainly recommend the test for Fluffy.”

I am not legal expert and can rarely predict which way the court will rule, but I think veterinarians are probably “safe” recommending testing one time for diseases like heartworm and Felv/FIV provided the recommendation is recorded. Informed owners are key; It’s not enough to merely suggest a test but to explain why that test is important. I talk about heartworm disease in depth at least once, typically at a puppy’s final vaccine appointment. I still recommend testing to owners who have repeatedly declined heartworm testing for their dogs. I also discuss the long term affects of Felv/FIV with new kitten owners prior to recommending testing. I am sure to mention testing twice (if needed) and recommend the test strongly for all strays and all never-previously-seen cats.

Perhaps my approach is overkill, but I feel confident that when Mrs. Notesta writes me a letter, I have myself adequately protected.