IVDD. Dr Kelcourses' Advice.

Matthew Kelcourse, DVM commented ...

Hello Sara.

I have managed hundreds of spinal patients in my years - from conservative home therapy to surgery; so I am copy pasting my client education handout I provide to my clients when the earliest signs of IVDD are evident. (I don't know well it may copy/paste but I could not see a way to attach the handout to this post.

Dr K
Intervertebral Disc Disease (IVDD)

What is IVDD?

IVDD is a degenerative condition that affects the cartilage discs that act as shock absorbers between each of the boney vertebrae of the spine. Degenerative means that over time, the daily stresses of normal activities take their toll on the cartilage discs, causing them to become more resistant and less resilient to the mechanical forces endured while running, playing and jumping. The condition is commonly referred to as a bulging disc, a slipped disc, a herniated disc, or a ruptured disc.

Who is Affected by this Condition?

Chondrodystrophic breeds such as the Dachshund, Shi Tzu, Lhasa Apso, Miniature Poodle and other small breeds (including mixed and designer breeds) that are known for having short legs in comparison to the length of their spine make up the majority of patients affected by this condition.





Why Does This Condition Affect Some Breeds More Than Others?

The shorter legs of chondrodystrophic breeds do not have the ability to absorb as much of the high impact energy of running and jumping as the larger, longer legs of some other breeds and this excessive impact energy is passed along to the spine and intervertebral discs. This excessive energy absorption the spine needs to deal with adds up; and the more they jump, the faster it adds up and the sooner the symptoms of IVDD begins to affect the patient.

The act of a dog jumping down from a height results in two very different but damaging actions:
• The high impact energy we discussed a moment ago is focused solely on the front legs when landing (instead of sharing the load with all four legs) and this energy is passed along to the spine and intervertebral discs.
• Upon landing on the front legs, a dog will arch its back while bringing the back legs down to the floor and this arching of the back will focus a lot of the impact energy in the middle of the arched back and neck.
• Simply said; the more often a dog jumps off the furniture or out of a car, the faster the spinal discs will degenerate and the sooner symptoms will begin to become obvious.

What are the Symptoms of IVDD?

The symptoms may vary for each patient, but the symptom first noticed by most guardians is pain and this pain may actually seem to manifest in many different ways:
• Poor appetite and/or decreased water consumption: back pain may cause nausea but may also be preventing a pet from comfortably bending over or leaning down to the food or water dish
• Not defecating on a normal schedule: the back may be too painful to position properly for defecation; so a patient may hold it in or sometime just release it while laying in their bed
• Difficulty finding a comfortable position for sitting or laying down
• Arching their back or neck as if their stomach is painful
• Noticeable decrease in activity levels (including playing, jumping, greeting at the door, etc…)
• Crying out in pain when picked up
• Excessive salivation (drooling)
• Vomiting
• Panting
• Whining
More involved symptoms in order of increasing urgency of medical attention are:
• Drunken Sailor Syndrome: the pet is walking around on wobbly limbs as if they got into the liquor cabinet. This is actually an indication that a bulging disc is pressing on the spinal cord and causing an interruption of communication between the brain and the limbs; causing a kind of balance disorder known as proprioception deficits.
• Dragging the limbs occurs when the interruption of communication between the brain and the limbs is severe enough to cause partial or complete paralysis of one or more limbs.
• Drooping Tail Syndrome: is when a bulging disc has traumatized the spinal cord to the point where all, or nearly all, communication between the brain and limbs has been interrupted and the pet is now dragging their limbs while also being unable to use a limp tail.

What are the Treatment Options for IVDD?

There are three stages of treatment options for intervertebral disc disease and the recommended treatment is determined by the the severity of the symptoms.

I. Conservative Outpatient Therapy: is ideal for those patients who present with early and minimal symptoms such as back pain and only mild proprioception deficits. Treatment begins with the use of NSAIDs (non-steroidal anti-inflammatory drugs); pain-relief medications; and sometimes a muscle relaxant while resting quietly at home.

II. Conservative Inpatient Therapy: is a 42 to 48 hour inpatient therapy necessary for patients who have moderate to severe Drunken Sailor Syndrome and treatment involves receiving an intravenous anti-inflammatory steroid medication administered through an IV catheter (called a constant rate infusion; or CRI); pain medications; muscle relaxants; and other medications that may be required.


III. Surgical Decompression Procedure: is reserved for patients with severe Drunken Sailor Syndrome and those having difficulty moving their limbs. Spinal surgery will always come with intrinsic risks and is therefor performed only when a surgeon believes the patient will not be able to walk and play normally again without surgical intervention. This treatment may require a few days in the hospital and entails the Inpatient Therapy described above (II.); performance of a myelogram (or other special imaging technique) to locate the exact position of the bulging/ruptured disc; and surgical decompression of the spinal cord at the identified location by performing a laminectomy to remove some of the bone covering the spinal cord to release pressure from the spinal cord.

What to do if You Suspect Your Pet has IVDD

The best thing to do is to contact your veterinarian as soon as possible to set up a physical examination. If the symptoms are more serious – such as Drunken Sailor Syndrome or worse – contact your veterinarian or your nearest veterinary emergency hospital immediately. This is important because the sooner treatment is initiated, the better the prognosis for a patient suffering with IVDD.

How do You Minimize the Risk of Your Pet Developing IVDD?

1. Keep your pet in a healthy body condition; feeding a proper diet and getting plenty of low-impact exercise – obesity is one of the major contributing factors increasing the risk of IVDD.
2. Prevent, or at least minimize, jumping off furniture, out of cars, etc…. You can help by placing pet steps at the edge of furniture: even if your pet doesn’t use the steps, it’s important they are there just in case they decide to use them some day.
3. Use a daily joint supplement like Glycoflex Chews that help maximize joint health; including the joints in the spine.

The original Pawbly question can be found here.

Dr. Kelcourses bio from Pawbly; Graduated from Tufts University School of Veterinary Medicine in 1992. Special interests in orthopedic and spinal medicine and surgery.

If you have a pet question about IVDD, or any other pet related question please come visit us at Pawbly.com. It is free to use and open to anyone who loves animals.

Related IVDD blogs can be found here;

IVDD. The first few days of diagnosis, treatment, options, costs, and encouragement.

IVDD. A Tale of Two Outcomes. Surgery vs Cage Rest.

IVDD A tale of two outcomes

We have these weeks where the storm clouds swirl above you and the seas rise around you and your boat gets rocked hard. It is in the middle of the looming disaster that you test your abilities, and truly get a sense of where your strengths lie and where the weaknesses are cracking your hull. There was a time a few years ago where we literally did 12 splenectomies in a 2 month period. Before that first splenectomy I had been out of vet school for two years and not seen one. In the four years since I haven’t seen 2. So weird, but completely true.

In the last week we have seen two dogs with acute intervertebral disc disease cases. I thought their cases would be a good story to help you understand this disease and how easily an outcome can sway in the balance.

Today is Wednesday the 21^st of September. It is the day that Porter had the disc that was putting pressure on his spinal cord at Lumbar vertebrae 2 and 3 removed. The intervertebral disc in the spine can best be described like a jelly filled donut. Those little jelly filled donuts are the pillows between the vertebrae that protect your lifeline; the spinal cord. The bones that makes up the vertebrae, (your backbone), are like the cars of a train. Once one of those cars gets loose in the track the rest of the cars are more vulnerable. It is an amazing framework of engineering, but one small problem has devastating consequences. If you injure your back to the point that the jelly is extruded from the donut the jelly can only go into your spinal cord space.  Any tiny amount of jelly in this very narrow place is painful and causes pressure and damage to the very sensitive electric wires that are your spinal cord. Too much pressure for too long causes paralysis of these fibers and then the messages your brain is trying to send to the body get slowed down or stop completely. It’s like losing your power to your house because a tree fell on the electric lines between the power plant (your brain) and your house (or say your leg). IVDD (intervertebral disc disease) is common in the dogs with the long backs. The most common dogs we see suffering from this disease are the dachshunds. I also see it a lot in beagles. The obese dogs seem to also have weaker backs.

In some cases we see this disease as a result of dogs playing to hard, or from trauma, like being hit by a car. And in some cases it just creeps in slowly and silently and persistently. Clients will walk in with their pet complaining of not wanting to walk up or down stairs, or not wanting to jump up on the bed, or not able to urinate or defecate. Sometimes it is that they aren’t eating. All of these complaints areyour dog telling you that they are in pain. I have had owners tell me that they think their dog has a belly ache because when they tried to pick them up they screamed. A dog with a “slipped disc” is painful. Sometimes they are painful everywhere, sometimes they are very good at hiding their pain. There have been a few patients that make me have to search hard to get them to elicit where their sore spot is. IVDD can happen in the neck (cervical) or lower back (lumbar). When it happens in the neck I see these dogs reluctant to walk, unwilling to move their head, (think whiplash) and then scream in pain when you try to move their head while holding the rest of them still. Sometimes we also see the four legs not responding normally to basic functions. A dog with lumbar disc disease will not want to jump, or walk up or down stairs, or not wanting to get their butt off the ground. In the end stages of this disease the disc cuts off the spinal cords ability to talk to the limbs ability to ambulate (move), and the body’s ability to urinate or defecate voluntarily.

The tale of Porter and Daymin is about lumbar IVDD.

On Thursday the 15^th of September Daymin was brought to the clinic to be evaluated.  His chart read simply, “Exam, can’t get up, has $ issues.” That was written by the receptionist as was stated by the client to them at check-in.  The technician then wrote the following; “ owner thought he was constipated,  so they gave him an enema. Was fine, normal, all day, sat back, then fell over, urinating on himself.” I was not the vet that Daymin saw that day, but as I read his chart I am once again dumbfounded how many times clients think that their pets are constipated. I know that I shouldn’t make these broad sweeping general statements, but here I go.., “People! Dogs are hardly ever constipated!” As I think back, I have only ever seen one or two constipated dogs. (Now constipation in cats is a real problem, so my statement doesn’t apply to cats!) Perhaps constipation is a big problem in people?, so that’s why they think their dog is constipated? I don’t know? But darn it, don’t give anyone an enema without a Dr’s ok. Enemas can cause big big problems. The veterinarian who saw Daymin stated in her physical examination findings that Daymin was panting, painful, and unable to use his hind legs. Daymin was also very obese. Daymin is a Labrador Retriever and these guys don't typically get this disease, BUT, the fat ones are all susceptible. He had urine and feces on his hind end. The owners had enough money to run blood work and take x-rays. After these were run his preliminary diagnosis was IVDD. Based on the severity of his clinical signs the veterinarian recommended he immediately be sent to a veterinary neurologist specialist. Based on the cost (estimates range from 1700-8000+) the owners declined and sought conservative medical treatment. Based on my experience if deep pain is still present in their back legs (a test your vet will check) and strict cage rest for 8 weeks I would say that 40 to 50% of patients will have a return to function. For dogs without deep pain present this conservative approach has a poorer prognosis, and little chance of return to function. (When I say return to function I mean able to ambulate on four legs.) If the disc material can be taken out quickly the spinal cord can heal and I have seen many dogs go down (paralysis) and be looking normal a few weeks later. Daymin was given a barrage of medicines to try to stop the swelling, protect his stomach from the steroids he was being given, pain relief medications (opioids are the only thing with any chance of relieving this kind of pain) and strict orders to bring him back tomorrow for a re-check.

On the 16^th Daymin was dropped off for the day for us to observe him. his medical record stated; “able to sit up, ate a little, unable to support his weight. No proprioception in the back legs, (this is a test that we do to see if his feet can talk to his brain and then his brain tell his feet that they are in the wrong position to stand). Does have superficial and deep pain present (this means his feet can feel a tickle and a hard pinch, or the nerves in the feet feel a sensation and tell the brain that they can feel something. Deep pain is one of the most primitive functions and the last thing the nerves let go of).  When this is gone there is complete paralysis and without relieving the cause little hope the nerves will talk to the leg again.  At the end of the day his progress report read “eating and drinking normally, leaking urine, but seems more comfortable.” The owners were given directions to keep him in a small confined enclosure, continue the treatment plan provided the day before, re-check on  Monday, or sooner if worsens, owner was told there is a 50% chance of recovery. Owner declined referral to neurologist.”

9/19 entry, “patient here for observation, seems painful.  Unable to support weight on hind legs, no superficial or deep pain. Prognosis poor.” Daymin was not getting better and he needed a neurologist. The owner also gave the Vet a handwritten letter. Dr. E held the letter up to me and gave me her “I don’t know what to do about this, and the guilt is crippling me” look. She summarized that the letter was written to her, because they liked her and trusted her.  “Dear Dr.  Daymin did good over the weekend, he peed and pooped and we kept him clean, like you asked us to. He drug himself around with his front legs. I’m not asking you, I’m literally begging you to please see if you think acupuncture is worth a shot. I just don’t wanna give up yet…please let’s just try a little longer. Please. Thank you..”  I don’t know how the acupuncture thought came into play, but this poor dog was waaay beyond the point of this helping. I am a big supporter of alternative therapies but he needed emergency veterinary care NOW!

Daymin stayed in his cage heavily medicated all day. At the end of the day the owner sent two friends to come pick Daymin up. The owner had made an appointment at the neurologists on Wednesday. He would have to wait until then. When we tried to move Daymin out of his cage he tried to bite the technicians, he also urinated and defected everywhere, despite being medicated, having a morphine patch on, and really no sensation to his whole back half he was in excruciating pain. I went outside to the friends of the owner here to pick him up and explained just how bad Daymin was. Medical management was not working in spite of every effort to provide him relief. His suffering was too great and I knew it wasn’t fair to him to wait and get even worse. The owner elected to euthanize him. it is a hard terrible thing to put down a sweet dog who may have had another outcome if the expense wasn’t so great.  I am in no way trying to pass judgement or assume that his outcome may have been different. It may not have regardless of finances or circumstances. There are many cases whose outcomes are decided by some intangible force no vet, no human, and no amount of money will change. It is the lesson your learn in medicine if you stick around long enough to not grow frustrated or indifferent no matter how hard you pray and want a patient to walk out with a "happily ever after."

Porter and I at Jarrettsville Vets Pets with Santa 2013

That evening my good friend Janet called me to tell me that her 13 year  old mixed Dachsund-ey looking dog was having trouble and reluctant to go up stairs. (Remember how I explained the splenectomy cluster we saw a few years ago? this week was disc disease bonanza).  I told her to bring him in right away. She arrived a short time later. Sure enough Porter was painful in his spine and his radiographs showed some narrowing in the spine at the level of L1 to L3 and L5 to L6, (top and bottom of his lumbar vertebrae). Because it was late in the evening I gave him some pain relief medications, told her to keep him calm and quiet and call me if he worsened overnight. If he wasn’t better by morning she was to bring him back in. at 10:30 pm I received an email saying that he was no longer walking. I told her I would see her first thing the next morning . Before I left for work that next morning I advised her to have a “worst case scenario” talk with her husband. I was pretty sure that Porter had ruptured a disc in his back and based on the fast progression and worsening of his clinical signs he needed to be transferred to a neurologist ASAP. When I saw Porter that next morning he was significantly more painful and would not support his own weight. We started calling to transfer him.

The next day he was examined by a Veterinary Neurologist and then was given an MRI which confirmed everyone’s suspicions. He has ruptured a lumbar disc. He immediately went into surgery. In the 48 hours between him being reluctant to walk up the stairs, he lost deep pain in his back legs. It was the worst case scenario. Luckily for Porter he received all of the care he needed in almost the shortest time possible. He is recovering at the neurologists over the weekend, but so far he is eating, comfortable, and has regained some sensation in his back feet.

I expect, and hope for, Porters full recovery. I will keep you all posted. His final bill will be somewhere in the range of $7000. I jokingly told his mom that they can check off the box that says “Most expensive thing that can happen to your dog”, box now.

Here are some post-op pictures of Porter with his mom giving him his post-op PT.He is doing great! He is a strong, determined, stubborn dog, and I have no doubt he will make a full recovery.

My expert general practitioner advice is to have pet insurance, especially for the predisposed IVDD breeds like dachshunds, Shih Tzus, and beagles. IVDD is uncommon in other breeds as long as they maintain an optimal weight and refrain from dare devil activities. 

For anyone in a financial predicament DO NOT GIVE UP ON YOUR DOG! Follow the vets conservative management guidelines. The most important of which is;

• ABSOLUTE CRATE/CAGE REST FOR 4-8 WEEKS.
• Leash walk only to go to the bathroom.
• Use the pain medications prescribed.
• Don't freak out in the first 3-5 days. They are the worst, but, things will get better.
• Monitor for eating, drinking, urination, defecation. Call the vet with questions. You will need a helping experienced hand. They can help.
• Be strong, be brave, have faith, and try. Your pet is an amazing soul who can beat almost the most impossible of things, IF, you give them a chance and a helping hand of love.

If you would like to learn more about IVDD please see the links below;

The leading source for IVDD help online; Dodgerslist.com

Dr Kelcourse's advice for IVDD patients.

IVDD. Getting a diagnosis. What to do once you have it and associated costs with each option. Encouragement for the first few days (hardest days) after the diagnosis is made. 

Update; Porter did very well with his slight stagger, and somewhat torticollis-sway back stagger for his remaining 4 years! He needed carpet to help him keep his feet from slipping, and he could not climb up stairs, but he never seemed to be in pain or distress and loved his walks with his mom up until his last days at the end of 2015. He lived to be 19. He will always be missed.

In an ideal world resources, financial stability, and access to experts is reality. For the rest  of us lean on your vet, get help where possible, follow directions explicitly, and be patient. There is the other side of this disease, and many pets will shock you at their degree of recovery. I never, ever give up on a disc disease pet. It may be hard to watch, difficult to manage and heart wrenching, but it will pass, and most will dramatically improve IF you can get through the first few days.

If you have a question about your dog with IVDD please find me on Pawbly.com. I am happy to offer assistance and encouragement. Pawbly is free to use and open to all pet lovers across the globe.

If you have a pet that you would like me to see you can find me at Jarrettsville Vet in Harford County Maryland.

I am also on Twitter @FreePetAdvice, and I have a YouTube channel with lots of helpful videos.

IVDD. The days immediately following the diagnosis. Recovery, post-op problems and how to conquer them all.

Without a doubt the fear, apprehension and sense of dismay is thick and overwhelming for most clients dealing with IVDD (intervertebral disc disease). It is persistent and pervasive at the time of diagnosis and for the first days to weeks of recovery, regardless of whether the patient is recovering post-op or with conservative care. With each case there are always many questions, with many remaining unanswered left to the decision of time, circumstance, and luck. It is the equivalent of sudden decisions, life changing odds and prognoses, and fate in some unnamed higher power's hands who refuses to show their face to claim responsibility. 

For these cases I try to reiterate and reinforce a few simple things;

1. Be Strong. Even if you don't know what to do or which end is up. Just stand, breathe, and believe you and your dog can get through this. We have wonderful tools to help heal, but giving up defeats them all.

2. Listen to your pet. They will look at you for help. They will wag. They will try. Take heed in them. They always decide, and they rarely give up. 

3. The first 48 hours are hard. The first week challenging. But if you can get through the first week and if things have gotten easier with encouraging signs of interest in food, better understanding of bathroom needs, a routine with a friend who needs a little more TLC, then you can get through this. 

4. Lean on someone as much as you feel you need to. Ideally this is your vet, your neurologist, your vets staff, your friend and fellow pet lover, or even those of us at Pawbly.com. Ask lots of questions. 

Don't leave the vets office until you have been taught and are comfortable with the following;

1. How to pick up safely. I like one hand on the sternum and the other behind the back legs supporting the pelvis. Hold on don't squeeze and don't let a nervous pet make you nervous. If you are worried about wiggly use a towel to wrap like a burrito and be safe.

2. Know how to check for a full bladder. Learn how to palpate, express and monitor. Yes, it takes practice, and yes! you can do it. (I promise, you can).

3. Learn how to monitor defecation, and keep it soft so it can pass easily. Every client gets worked up about lack of poop. I am usually not too worried. Even after 3 or 4 days. If your dog has a disc protrusion/extrusion they have a very painful time even sitting. They usually aren't eating for a few days. If your pet isn't eating there won't be feces for days. Also, posturing to defecate is painful. They either won't try, or they can't push the feces out. Every IVDD dog is placed on wet food and given an oral laxative to keep the feces from becoming dried and impacted in the colon. Use the wet food and laxative to desired effect. The dose is never set in stone, it is used when, if and as much as needed.

4. Learn how to safely use a sling. I want you to keep encouraging and challenging your dog to be a dog. Walk, pee and poop. That's dog basics. Use a sling, place their feet correctly and encourage them to support their weight. As the foot righting improves encourage walking. Physical therapy is 10% putting them in the right spot (I like outside in the cut grass for footing and softness if there is a spill) and 90% giving them the opportunity to go back to the life they remember.

5. Obstacles happen. Don't get discouraged, stay active and have faith. Sometimes medicine comes down to faith, and it is always the better for it.

6. Cage rest is imperative. Not encouraged, but rather, required. If  your pet is not used to being in a cage it is often very difficult to keep them calm. Calmness, quiet, rest and rebuilding of the broken damaged tissue is what is needed. How can you discourage movement if you cannot cage them? I will warn you that they will move faster, try to do more, push themselves to doing what they did before, and if allowed to make decisions, they will make bad ones. Keep them caged and know it is for the health, well-being, and sanctity of having a rest of their lives.

This is Wrangler. His stumble in the recovery process was licking his left knee to the point of an open wound. In spite of his e-collar he was wiggling his nose to the point of his knee and licking obsessively.

Now I firmly believe that our pets are always trying to tell us something. Wrangler was telling me that there was a problem ad he was trying to point me in the direction of it. Wrangler was leaking urine. He knew he was leaking and no one likes dripping pee. 

He needed some laser therapy for his knee, another e-collar, and a medicated ointment for his prepuce. We also instructed his family to palpate the bladder with each trip outside. First to get a urine stream going, and second to try to make sure he was emptying his bladder completely. Residual urine in the bladder turns into a possible pool for infection. An overly full bladder will leak.

Double e-collar anyone? If we can't make Wranglers nose shorter we have to make the e-collar longer.

Laser therapy had the lick granuloma cleared up in less than 3 days.

A drying healing knee. 

IVDD is the one disease that comes on like a freight train and sinks a  pet parent to their knees. It is frustrating, painful, and often seems overwhelming to parents. Have faith, be calm, be patient and don't give up early on. It is a disease your dog can conquer, even if you cannot afford the neurologist, the MRI, or the surgery.

I always try to add associated costs of care with my blogs. All estimates are in USD for East Coast USA
Here is the break down;

Conservative care; Non-surgical medical treatment. Cage rest.

• initial exam to get a presumptive diagnosis. $40-$80. These cases are usually able to be diagnosed on the first visit and do not require advanced diagnostics like an MRI. They have a high incidence of suspicion that is usually accurate at presentation.
• x-ray $100-$200. Should be done at initial visit if the vet suspects IVDD.
• analgesics $50-$150. Includes NSAID or steroid, opioid patch, oral opioid. Do NOT decline these. Your dog needs them. There are lots of cost effective options (like a steroid at Wal-Mart is less than $10. Call me I will loan it to you. If you decline it is simply because you are an awful person.
• Elizabethan collar $20-$40. They can be made. Ask the vet for an old xray film to make your own.
• Sling, free, use an old shopping bag with the sides cut out, or use a towel. 
• Cage; borrow from a friend if you don't have one.
• Many places will recommend blood work. If you are tight on funds skip it. It is not going to make your diagnosis and it may not help with the treatment plan. It can be done later.
• Follow up care. Ask how your vet charges for rechecks, phone calls, and emergency care. Expect to see the vet about 3-5 times in the first week or two.

Gold Standard care. No expense is too great, or, I have great pet insurance;

• Includes referral to an emergency care facility for the first 24-48 hours. Usually $500-$2000 and for all of the items listed above.
• Referral to a neurologist for MRI and surgery. $3000 to $9000.
• After care at a facility to help recovery. May be 3-5 days $2000-$3000.

Personal Note; Nothing disturbs me more than a client being directed down a path they cannot afford to be on. If you cannot afford the decompression surgery and follow up care with a neurologist it is difficult for me to advise that you have an MRI done, UNLESS it is to rule out an untreatable life threatening condition like a tumor, blood clot, etc. If the vet or neurologist thinks it is a disc AND you know you cannot afford surgery DO NOT FEEL PRESSURED TO continue diagnostics. Elect cage rest (be compliant and follow up with your vet) and don't feel bad. Whatever you do, don't feel so bad that you give up and elect euthanasia.

For more information on this disease please see these related blogs;

IVDD. A Tale Of Two Outcomes.

Dr Kelcourses' IVDD advice. How to diagnose, how to treat. Tips from an expert.

If you have a pet in need you can find a community of helpful people at Pawbly.com. Pawbly is free to use and open to anyone who loves their pet and wants to help them.

I am also available for personal consults at Jarrettsville Veterinary Center in Jarrettsville Maryland. Or find me on YouTube or Twitter @FreePetAdvice.

Hank. Cervical Disc Disease Management When Surgical Treatment is NOT an Option. His journey and recovery blog.

Hank was a statistic no one wanted to happen.

He is a beagle who is middle aged, lazy and overweight. He also spends his time outdoors with a hyperactive over exuberant nut case of a brother, Moe. Moe has everything going for him. He is active, lean, muscular, and full of energy. This lifestyle has made him a powerhouse, it has also made him a liability to his brother, fat, old, slothy Hank.

Moe, Caleb, Hank

Hank was found laying on his side unable to stand, move, or walk on a Friday afternoon. He was shaking, trembling, and crying in pain. His family brought him to see me on a Sunday after it was apparent he was not recovering on his own.

Now I am just like you. I heard his story, looked at his pitiful pathetic desperate self and thought, "Oh God! why did they wait to bring him in?"

This is what I saw when I entered the exam room the first time I met Hank and Caleb.
I will never forget seeing them.
I feared the worst...

I have been wearing a white coat for a while. It has provided me some important life lessons. One is to not assume or rush to judgement. Hank's family was overwhelmed with caretaking for their son, Caleb, who has spina bifada. Caleb is 8 years old and preparing for his 6th surgery this year. It was very clear very quickly that this family was taxed beyond what many of us could handle on a routine basis and now Hank was down and out. When I discussed my concerns for Hank, how he needed to be transferred immediately to a neurologist and how the optimal care for his current condition would require an MRI and decompression surgery with its $8,000 to $10,000 price tag, his family went white with anguish.

Hank was Caleb's best friend. His lifeline, and his inspiration for all of his surgeries. At every surgery Caleb carried in a stuffed version of his beloved Hank to keep him company.

My bright idea of publicly posting Hank's condition in an effort to gain social media assistance to cover some, or all, of Hanks medical costs was abandoned when Caleb's mom quietly mentioned that they already had a GoFund me site set up to help pay for Caleb's next surgery. How could I ask for help with Hank's medical needs when Caleb's were in competition for those dollars? There was no way I was going to ask, or beg, for help and have it cost Caleb. So I did what I believed was the only option left. I took Hank's case on as my own. No advertising, no reimbursement, no discussion of anything except to say to his mom "You worry about Caleb and yourself, and I will worry about Hank."

And so it was. After two nights in the clinic Hank came home with me. I arrived at home late Wednesday evening with a paralyzed Hank and an almost absent ambivalent husband who now expects that I take the critical cases home with me. A few minutes of basic technician training and my husband was enlisted in Hank's care and understanding that verbal protests would only damage our relationship and fail at discouraging my maternal veterinary compulsions.

After 14 days with us, including a week of almost completely sleepless nights because Hank refused to sleep on a dog bed at the end of our bed, and would only stop crying, whining and bellowing when I put him in our bed. Which is a ridiculously dangerous place to be because who wants a paralyzed dog to fall out of bed? AND he is peeing and pooping at unforeseen intervals.

Hank required 24/7 care. Multiple baths at 2 am because had to go to the bathroom, multiple times getting up to try to figure out if the whimpering and discontent meant he needed something like, perhaps,, food?, water?, pain medication?, to go outside?, to sit up?, to get more attention?, to see the cat who believed she also belonged on the bed?, to cool him off?, warm him up?, etc. etc. There is no exception to these pups being an intensive amount of work with an unknown amount of recovery time.

There were days I went to work exhausted and cranky. There were nights my husband hated me for inflicting these restless nights upon our bedroom. And, there were the endless questions of whether this was all for naught? Would he ever get better? Would his family take him back? Would that be best for Hank? What would the rest of Hank's life look like? Would he relapse in a week? A month? A year? Would he recover the next time?

Here is Hank's YouTube diary.

There are a few critical things I hope that everyone leaves this blog with;

1. These cases are difficult.

2. There is no rule book for time and prognosis.

3. These cases need affordable options provided to clients,

4. Never surrender hope.

5. Or let anyone steal your faith.

6. These cases deserve an opportunity to provide and offer the fertile ground of miracles a chance. If any vet tells to you surrender your hope IF YOU DON'T have a couple grand available immediately walk out and find another vet. 

7. Managing pain is possible, and these cases have a chance at recovery. Hank was trembling and panting for a week in discomfort. It was hard to watch, and I tried very hard to keep him as comfortable as possible, BUT, I did not out him in a drug induced coma. 

8. We got through it together! Me, Hank, my husband, and the staff at the clinic. Provide a supportive network or encouraging helpful people. Death is not an option I considered. I understand this is on a case by case basis, BUT, I was prepared for a cart and a dog who needed help for as long as Hank needed help.

What does Hanks future hold? I am not sure. He is home with his family. We talk often and we will continue to do so. Caleb has his next surgery next week. Our best wishes and thoughts are with him. We have faith,,,, sometimes that is enough.

Caleb comes to visit Hank, day 3.

Hank and his family day 10

There is a whole lot more information on IVDD on my other blogs. Please visit them. I think they answer every question I have ever had on managing this disease.

Hank goes home, day 17

IVDD. The Days Immediately Following the Diagnosis.

IVDD. Dr Kelcourse's Advice.

IVDD. A Tale Of Two Outcomes.

If you have a pet in need, or a pet question you would like to ask, please find the helpful people at Pawbly.com. It is a free and open community for anyone and everyone who loves pets.

I am also available via Facebook, Twitter @FreePetAdvice, and YouTube. 

Baby Brea

I received a text message last night that Brea had passed away very early this morning at the veterinary neurology facility.

She had been referred by us to a neurologist because she had been experiencing some severe back pain that had progressed to her not wanting to move. She had come in last week with reluctance to move and we quickly thought that it might be her back.

Back pain is rather common in dachshunds and beagles. But based on Brea's recent history of illness I was concerned that she might have meningitis.

Meningitis is inflammation of the meninges. In veterianry medicine we usually mean inflammation of the covering of the spinal cord. It is very painful and usually the result of an infection, although many times we don't know how or why it decided to land there. It is a very serious disease and can be very difficult to treat. You see your brain and spinal cord are protected by a protective tissue that keeps the bad stuff out of our most important and most valuable place, our brain and its peripheral extension, our spinal cord. When disease gets in it is now sealed in. There aren't the same super effective defense mechanisms in place here so the infection can lie undetected by our body, but wreak havoc on our primary nervous tissue. To diagnose this disease we need a spinal tap. This is not a procedure general practitioners do. We like to send these tests to the neurologists. (Something about a big long needle piercing into the spinal column gets us spooked, although all of the neurologists I know tell me it's actually easy to perform. I'll take their word for it).

Brea's arrival with yet another disease had us all scared. It was just a few weeks ago that she left the hospital after a 3 week stay from one of the worst cases of pneumonia that I had ever seen. Now she has severe pain that seems to be coming from her spine? OMG! How can 1 little sweetest-dog-ever, have another terrible affliction? My first thought is that this episode MUST be related to her last episode. We ran blood work, took her temperature and looked for any sign of progressive infection. Everything in the infection category was negative. Yet her exam still looked like spine, inter-vertebral disc disease, (IVDD). I called the neurologist to ask for his opinion. I didn't want to deal another crushing blow of devastating and expense to treat disease to Brea's family.

He agreed that she probably wasn't a meningitis case, but also agreed that we probably shouldn't start her on a steroid initially. We sent Brea home last week with lots of pain medications and a plan that if she wasn't better in 2 days, or if she worsened that she would go to the spine center.

Two days later she was not better, and she was sent to the neurologist to try to identify her source of pain and to try to figure out how we could lessen it.

Brea had a myelogram and it identified a disc in her spinal cord at the level of her cervical spine at C2-C3. The "higher" your disc disease is the more paralysis it usually causes. A disc at the cervical area will affect all four legs, versus a disc at your lumbar area affects your rear limbs. Also the nerves that control your vital organs live high up to. If you injure your spine at the very top (high cervical area, right by the base of your brain) it can actually stop your ability to breathe.

At 3 am Brea died. The consensus is that she must have extruded more disc material or she was so pyrexic (elevated body temperature, can happen from pain), that her breathing stopped. She had done fine during her myelogram, and was at the hospital for observation and pain management, but slated to be discharged for home care in the morning.

As soon as I heard about Brea I called her family. They are wonderful, kind people who have done more for any dog than anyone I have ever met. The first time I saw Brea was within 24 hours of them adopting her. They knew she was sick, but they adopted her anyway. And even though I wasn't sure that she would live through the day from her pneumonia they decided to try to save her. They stuck by her despite needing three weeks of hospitalization. As she got better she blossomed into a happy energetic inquisitive beagle. They had gotten her to help ease the anxieties of their other dog, Beau. Beau only knew Brea for a few short weeks. Between being quarantined for her first and last illness Beau and Brea only had a few weeks together.

There wasn't anything I could say to comfort Brea's parents. All I could say is how sorry I was, and how incredibly unfair it all seemed.

I sat on the phone trying to hold back tears and telling them how wonderful little Brea was and how incredibly lucky she was to have found them. What I really wanted to say was, "How can this have happened?" Not to place blame, because I just don't think there is any to point at, but how can that little bundle of baby beagle who was so adorable, so irresistible, abandoned, almost died a few months ago, have died from this? How could she be so young, and have been dealt such a shit hand?"

I told Beau's family that we would help them find a new friend for Beau. That I know they are shell-shocked and don't even want to think about it, but I will help them find and foster a healthy friend for Beau, who still needs someone to keep him from being alone and afraid.

I know I get too emotionally involved with my patients, but "Why?" I just don't have the answer to "Why?"

I am heart-broken for baby Brea and her family.

Such is medicine, I just doubt I will ever stop asking "Why?" It happens when you get emotionally involved, but I guess I will never stop doing that either.

To read Brea's blog please go to:

http://tinyurl.com/8lyjxnh

Veterinary Pearls 2025 Edition

I just celebrated my 20th year in practice! Quite a milestone!

It has been speckled with so many memories, hopes, fears, obstacles, challenges, and, most importantly peaceful purpose. For everything that I ever hoped this place, and my place with in it, has cost me, (and be honest living, breathing, furious working, well, it costs you), it has paid me back twice what I put into it. I am exhausted almost all of the time, therefore with the current currency exchange, I still count myself the luckiest person ever.

There is now a calm sense of accomplishment to add to my dusty degree. Something that wraps the responsibility that weighed heavy with a hug of reassurance that it really did all work out just as it was supposed to. For me, that is what the Pearls of Practice are meant to convey. The outline of a recipe to make your magical creation, your legacy, your life's work, your own. 

I am adapting this to you, from this; it is the original version and it can be found here. 

I start every exam with a hello (to my patient first, of course).

I have been keeping a list of "veterinary pearls" since the day I started practicing veterinary medicine. It is intended to be the list of tips and tricks I have learned, (some the hard way), to help you become the best veterinarian to all of your patients, and to maybe avoid some of the missteps I have made. 

The best pearl I can offer is this;

Start with a moment about thinking of who you are. Who are you as a person, pet parent, pet care advocate, and a veterinarian. Hold on tight to that person. You will be challenged and tested and ultimately your ability to care for others depends largely on your ability to understand who you are and stay true to YOU. It takes courage and bravery to be a great veterinarian (and human). If you know who you are it is easier to defend your inner voices of conflict on the hardest of days. Stand up for your patient and yourself among the dark days that medicine invariably delivers. You are everything your patient, your profession, and yourself ever needs you to be right here and right now. It will never be an easy job, or a painless profession, but, all the hopes, dreams, and magic all lie right here. In this place. You should be as proud today as you are 20 years from now.

Cookie. Perfection in a purpose.

Start every appointment, surgery, interaction and crappy moment with pause. Take pause and sit on the floor with the puppies. Whisper into the frightened kittens ears that you are on their side. Take a moment to think about your surgery patient. How afraid you might be in their place. Never rush a moment that you need as much as they do. Euthanasias are sacred. It is about them, and their family.

Pearls are pivots posing as a overlooked routine. To help provide context to them let's start at perspectives. The 20 years of time and the macroscopic viewpoint it provides.

I have to start here. I have to start at the end. What life really needs to teach you is to start at the end. Make all of your small moves and tiny steps as a direction that started at the destination. Medicine should always start there. Every piece of advice, kindness, spirit and thought starts at the end. 

Hope for the best, prepare for the worst.

The ending for all of us is a goodbye. There are so many clients whose lives become arrested at goodbye. This one act, the one that vetmed allows as a true end to suffering that human beings cannot put themselves above, is a curse as much as it is a blessing. There is a time in my career where I am going to walk away from euthanasia. There are cases today I have to say no to. People hate you for the no's. They want you to make them feel good about the goodbye, when often it is hard to do when your allegiances lies with your patients who deserved a chance. A diagnosis. An analgesic. Another pet parent. (A string of pearls for another day).

Never euthanize a patient because it is;

•  Closing time.
•  Cheaper. Economic euthanasia is a business practice for practices focused on billing not building (borrowed from a colleague). Nothing costs you more than selling your patients short. 
•  Easier than a work up.
•  What the client thinks is the best treatment option and you feel uncomfortable with it. Looking back these were the times I wished I had become a nail salon technician, or florist. Truly, nothing has cost my soul more than feeling like I was abandoning my patient for the sake of the (non-existent) relationship with my client. There are days I wish euthanasia was no longer a "treatment" option. There are days that I know I love my patients more than their families do. This is what I love most about myself. This is who I am, and I never abandon her. Being the most liked vet doesn't amount to squat if you don't like yourself.  See more on this with Honeys Story here.

Seraphina. One of my WHY's

Live in “worst case scenario-ville” "WCS". There are times where this is what the world gives you. If you are prepared for this, and if your client understands this as a possibility, they won’t be blindsided. But, be careful, some people use this as an excuse to apply the brakes too early and bail. Worst case scenario lifestyle and vet med, (or any med), is about this. (Human medicine does an absolute shit job of this. They could learn a whole lot from this side of medicine if they just talked to people openly and honestly. No dialogue, no direction given to patients and a whole bunch of specialty focused volleying for ridiculous amounts of time). Here we talk to people, treat them like family, like the people who we will also be helping 10-20-30 plus years down the road. It took me awhile to realize this, that these new faces were faces who others before me knew, and cared for as they help guide through the quick/easy and long/tragic waters of pet care and veterinary medicine. 

Here is my advice for all of the middle parts of this life.

The best practitioners take pause, think about our goals, and then use all of the tools in their vet med tool box (thorough exam, look, listen, smell, feel), and then; remember to always listen first. (full transparency,, I have not mastered this one so I place it at the top). 

With a clear head  (try to) never formulate an opinion until after you listen to everything. Keep an open mind and open plan, as you listen carefully. Many clues lie here. Jot down a list of things to keep in mind,, then do your exam,, then narrow and focus the list.

My puppies,, reminding me to play

 A

      Help clients understand your thought process and concerns/fears. Medicine is about mediating a patients needs and constructively manipulating a clients wants. It is an art. It is the stuff we are left with as the challenge we seek when the medicine gets boring, (which on some days does happen). 

·       Always be accessible. Our JVC email is on every report card. For some patients I give my business email for better accessibility and a more timely follow up.

·       Always document a plan, and provide best and worst case scenario framework. Everything in writing. People get overwhelmed and confused, and too often our words, and thoughts aren't the same as theirs.

·        Report cards are part CYA, part summarize exam, (list presenting concerns, what we are doing about them, what we are doing today, what we will do tomorrow if needed, and what their responsibility is (i.e. recheck, drop off samples, follow up, “if not better by ___, then we ____ ) and 100% documentation to deliver intentions, investment in care, and accountability. I also list the items they declined as a reminder of where we chose to go, and where I am going to recommend we go back to if needed. 

I    It's ok to not know. It is ok to say that. How often do vets and their big britches say "cancer" and condemn a patient to a death sentence minus the shadow of diagnostics. 'Tis better to be honest than the lynchman wearing the crown. 

      Keep everything you do as a practitioner relatable to the rest who are not. Big words, big diseases, and the lofty pretense of knowing better than your client who "has done their own research."

·       Always close a report card with a personal note. For example;  “Thank you for bringing Fluffy in to see us today.” Or, “have a wonderful Summer, we are here if you need us.” Makes all the difference in the world. We always send home a report card. People can’t listen and comprehend everything they hear from us, and most of them do want to be excellent stewards of their kids needs. Gentle reminders, highlights of exam findings, and written plans (most especially for the late Friday appointments with the (likely feared) critical cases save lives, and help people who are emotionally over taxed.

·       Utilize and use the techs to help guide you. Ask their opinion, provide feedback, and help them to learn. They are as eager to learn something new as we are. The techs are your lifeline and your liability. Always hope for one and prepare for the latter. Never, I don’t care what the scenario is, use the excuse “the tech told me to” the state board fries you, not them.

Oliver.. A great reminder as to why I care so much

·       Every euthanasia is the most important moment of your day. Take the time it needs. Provide the guidance the client needs. Tell them your plan. Ask them their preference. Be gentle. Discuss the difficult cases before you have one. Don’t make it easier for you, make it easier for them. My personal opinion and protocol differs from others. Ask why? Ask yourself which you would prefer? Tell the receptionists to light the candle at front desk. Tell the other appointments waiting for you that you are taking your time to say goodbye. They will understand.

·       Understand your threshold. For me this is reminding clients that I am doing the best I can and dealing with a huge array of cases, including euthanasia’s. If they are being vocal, impatient and demanding I talk to them in person. I remind the complaining/impatient clients that the other case I am taking care of might be the most difficult moment a person ever has to face. Be patient and compassionate and ask them to do the same. They will empathize. If that doesn’t quiet them down tell them they are being referred to the ER so they don't have to wait for you any longer. We are about compassion first. Every single time. And I also usually remind them that at some time they will be in that persons shoes and I am an elephant I never forget. Your threshold exists on many levels; skill, expertise, ability, and emotional. 

      Do not ever allow anyone to influence the emotional well-being of our staff. Bad clients exist and they are excised,, like cancer, its curative. People can be emotional and have a bad day but they cannot, and will not cost us a staff member. I am very firm, and completely unafraid to get rid of toxic people. It is one of the most overlooked and vitally needed pieces in our profession. How many vet care members work with leaders incapable of controversy, confrontation and allow others to suffer from caustic interactions and behaviors (internal or external) as the price tag. Think about why the suicide rate is what it is and what your part in protecting the peace is?

My rabies quarantine kittens; Raffles and Birdie.
They remind me that the most rational, and expected decisions can bear the heaviest price tags.

          The courage to speak out when needed, and the compassion to put your patient first. 

·       Surgery; you will develop your own preferences and habits. Every choice has a consequence. Here are my mandatory requirements;

1.     Every patient gets a full exam and a full review of the medical record. Read the previous medical record notes. Look for reasons to not do the surgery. You will need these for some cases. It is not uncommon to have to call an owner the day of surgery to discuss a new PE finding, ex heart murmur, increase in estimate, overbooking, emergency needs to bump an elective, etc. The patient comes first. I would rather apologize and postpone vs call after bc the surgery went sideways.

2.       Every patient gets a planned course for surgery. If you need to change the plan call the owner to discuss. For example, I overwhelmingly request an iv catheter for each potentially difficult spay. I also use propoflo when needed. This is charged to the client and might double their bill. I explain why and get authorization before eating the charge which I will do, and allow all the vets to do if it helps your peace of mind and provides a better chance at a safer surgery.

3.       Intubate whenever needed. (For me this is everything, except maybe, the cats who are so fractious you worry about a safe recovery).

4.       Gown and glove for anything extensive or in a cavity.

5.       Cap and mask at all times general anesthesia is on. Techs included.

6.       Formulate an exit plan before you grab the scalpel. Don't worry about how to make it look pretty after you have a hole and no skin left to close. Closure is the devil to margins,, a patient with a rough post op recovery will negate all the work you did.

7.       Expect your mass before you schedule a mass removal. I run by the ethos that if you are asking me to do it you owe me the right to see what you are signing me up for. with that go to number 12.

8.      dentals are like pandoras box. if you aren’t ready for the booby prize don’t open the box. every dachshund dental sucks.. every single one. even the ones who are 2 years old. Know how to do an oral-nasal fistula repair (two ways) before you find a dachshund on the table and blood dripping from the nose.

9.       PDS is $$$$ know when to use it and when its too $$$ to use. Suture choice reflects ability. 

10.      Every surgery is documented with all relevant and needed details. We have a surgery form to help.

11. Post op care matters at the time of surgery. I rarely use staples. and I rarely have pets come back for suture removal. think about why. .

12. My favorite surgeries are the ones no one else wants to do and no other option exists. think blocked cat, foreign body, mass no one else wants to do. the life saving knife changing magic and miracles only happen if you try surgeries. Have I told you about Spencer, or Mufasa, or Maddie? 

•               Every ADR old/older dog has cancer. palpate palpate palpate,, then xray... blood work gives you less clues than the PE does. Do it last.

Saffie,, rehomed 3 times for inappropriate urination.
She had needs no one cared enough about to help resolve.
Another great example of my WHY.

      Who's hands belong where? I do not want anyone pulling medications off the shelf expect a vet. Mistakes happen. Have someone double check every drug, and label. we are going to start labeling our prescription areas with general doses to help avoid this. Further, I try very hard to run the fine line between encouraging people outside of their normal duties to learn and grow, but, I cannot put them in a place where they cannot manage the WCS consequences. think about a jugular on a cat that causes a tear in the trachea.

      Cystos are a big worry for me. Never do a cystocentesis on a pet with a possible neoplasia of the bladder "seed the abdomen". What are other tasks beyond the techs ability to foresee disaster?

      Cremations. Have we ever talked about the catastrophe of mislabeling a deceased pet?

Hope,, and her pre-Christmas counter surf.

•         Rectals are part of a routine exam. You will learn this when the pet you saw 3 months ago presents for pu/pd and then you find hypercalcemia, and then you rectal. I see too many AG abscesses after the pet has been here for an APE within the last month. How do we explain that to an owner?

•         Never refer until you have done bw, rads, rectal, and offered u/s. do everything we can do here before you send.

•         Know what you are sending a client into before you refer. i.e. neuro ivdd, cost is about $10-15k. If they are not prepared to spend this, and do sx I am not sure what value sending them has? But,,

•         We always offer and document the benefits of referrals to specialists.

Rosie, first visit, first vaccine,, and a not so subtle reminder of the harm we can do,
even with the best of intentions and training.

•          Call people often.. after every sick patient visit, after surgery, and when you think they might benefit from hearing your voice. I am not the most talented diagnostician that ever got a DVM degree, but damn I am invested in my patient and clients care. I go to bat for them. I make hard phone calls. I demand help for them when they need it (and can pay for it), and I am very comfortable not being liked by my peers. I am not here for them.. I remind them of that when they challenge me. (Have we ever talked about my license threats?).

•         Know the cases that take extra TLC/emotional and physical burdens from clients. Like IVDD, MG, ME, DM, etc. these cases stay alive only if their parents can manage them, and because we hold their hands for the first two weeks (or as long as needed) of adjusting to the new life of a special needs pet. We are the clinic that takes care of our patients even after they pay and leave the clinic. 

Reminder; not all pet parents are created equally. I have some clients who cannot read, or write, or have language barriers, or physical limitations, or families that put pressure on them to dispose of the pet,, there are so many conversations outside of medicine that go on in exam rooms. (Have you realized that we are part vet and part phycologists/emotional support advocates).

•         No cosmetic surgeries here.. no excuses,,, no pressure from owners. If you are not sure why ask me.. I am happy to discuss. (small exception; the polydactyls who live outside and cannot retract their multiple stacked dewclaws. These eventually grow into the foot pad,, they should be removed at spay and neuter).

•         Hard work is our credo, heart-felt-compassion is our purpose in practice.

•         Give estimates to everyone. Document it on their go home report card and on the alert or appt        schedule. If the client seems uncomfortable about it discuss why and itemize. If it comes down to  inability to pay we will find them help. We have lots of options available for this. But we need to know before the fact. People feel like a failure if they cannot afford their pets care. We do all we can to provide support and guidance for pet care regardless of cost. Use the GSF if needed.

My Wren. She came to me a speck of a dying tid-bit. 
I refused to let her die. In some cases it takes medicine and a refusal to let it win.

There is an ethical obligation to being a veterinarian that I fear the profession is discarding. We owe every patient and every client the right to chose the treatment plan that is best for them. Many places offer "Gold Standard" care as the proposed "best" treatment plan. This is always the most expensive. There is no list of options given. There is one option. If it is refused a second, less costly, option is given. The amount of time, guilt, shame, and patients we lose from not putting the pets care at the clients/parents/owners choice is quite honestly unacceptable and unethical.

•         Take photos and add to MR if helpful.

•         Measure lesions, or have owner measure at home and keep track.

•         Have owners keep a journal for things like DM/BG, seizures, episodic events (v/d), litter box, cardio respiratory rates, etc. I love to give owners homework. It keeps them engaged, provides a way for them to participate in pet care, reinforces what I want them to focus on, and what clues I am asking them to search for. 

 Demos in the clinic are the best way to educate and owner and empower them to participate in their pets care. We have tech appointments for insulin admin, sq fluids, ear cleaning, nails, tooth brushing, ear hair, anal glands, etc etc. Charge techs do these. Arrange in advance and tell them what you need them to demo. No Qtips in ears! 

 Microchips are guardian angels. I scan for them at each visit and I expect every JVC patient has one. The  rare exceptions are the clients who "don't want their pet back if it gets lost?" I don't even know what to say to these people out loud.. they have a note made in the alert section.

•         The "vaccine only" clients. We have a few of these. They go home with a detailed description of why we  recommend what we do, and what they are not eligible for if their pet gets sick. Ex. KC, CIV and  boarding. Young children and HW RX. No one can decline rabies without your consent. If they do tell them you will call AC to notify. I always call AC to notify. (Its called professional CYA). Flip side, the "I don't vaccinate people" they are given a written statement that says "We reserve the right to deny services based on vaccine status." We do not board if the client declines rabies or lepto. 

•         Abuse cases. Document everything. Ask to take photos, ask to take a video. I always do this with the client present in the room. (PS ask me about the emaciated Coonhound case and the guy who went postal beating his dog at the front desk). These happen, sadly they happen in the cases you weren’t even considering this to be the case. The nurse who intentionally starved two of her dogs to death before we realized she had Munchausen by proxy?

River and Rosie,, who remind me why I love to be a small town vet.
I belong here because of these relationships. Some of the most meaningful in my life.

•         Cat vaccines and the tail. Read the AAFP guidelines. All cats get vaccines in the tail. 

     We have staff meetings every other month. I am hoping that you will add a “pearl” one from a recent case) for every meeting.

•         You can always give out my email. Initially it will help build client comfort as most of them know me, don’t take anything personally.. we built a co-dependent practice the flip side is people got a little spoiled.. they (everyone) is less confident with the new kid..

•        Always be humble. We are vets. We get peed on for a living.

Three view chest rads for every suspected neoplasia case. Rads for every case that your gut tells you to be worried about. Often clients need, and deserve, a quick answer to a tough, and/or expensive case.

TP always goes with PCV,, even if the techs don't want to, or, forget to do it.

Fat cat, weight loss, peripheral neuropathy, plantigrade walk, check BG first,, don't wait for that blood work to come back the next day. For the DM cats, I try to diet reverse them before start insulin. If they are not at DKA try canned DM, W/D watered down, no dry, and give them time to make their autologous insulin,,, or start at 1 unit and canned only diet. I have had a few that got off insulin for good, and lived much happier healthier lives.

Drugs.. ugh,,, the chasm of worries that these bring. Try not to give too many and overwhelm an owner, or drown out your ability to know whether the subsequent clinical signs are the patient or the meds.. and be careful for those seeking medications too often. When all else fails write a script and have the human pharmacies collect personal info. A client who wants too many refills, or pills, or is a new client with a drug addicted pet is a red flag. No one overdoses on valium... but we have  safer options for people to not abuse. Watch the staff and the drug logs. It is a nightmare every clinic has to worry about everyday. 

When all else fails and a client is getting to a place where we cannot predict or influence the outcome pull out your cell phone and push "record" and call 911.

Take selfies.. and laugh with the results,, then share them.
Joy is as contagious as it is inspiring.

Weird kittens can = rabies. We have stories to confirm. there is a fine line between helping all of the orphan kittens in HarCo and massive rabies exposure. Kittens with rabies die within 2 weeks, and usually within a few days. Don't freeze a rabies suspect. CYA if an owner refuses to submit for rabies. Tis better to lose a client because they don't like then then because they died after taking their rabies pets home. (We have a lot of rabies,, did I ever tell you about the TNR cat?).

Scan for a microchip for every new pet, or every pet period. We provide them at cost and I tell people "I hope you never need this, but, things happen. House fire, house is broken into, car accident with pets onboard, kids forget to close the doors, cats break screen windows, fireworks."

The Health Dept people and the Animal Control people will have your back. Lean on them whenever needed.

The use of a muzzle and removing a pet from a room need permission from the owner first.

Never argue. It's not worth your time, and it never solves anything. There is a place where we "keep them happy to keep them quiet" and, "pass the buck to someone else." Take a pause and remember your purpose. Always go back to that.

Offer a referral for everything. Its CYA and SOC. But, don't send anyone without giving them an idea of what it is going to cost them. Nothing worse than sending a referral to someone who cant do anything when they get there. (For both parties). In many cases I recommend going just to help them understand options, but they often can't afford treatment there. In some cases I send them to be given the bad news I am not sure of. No surgery outside of spay/neuter, or treatment plan should be without a written offer to seek a specialist, but, all of them should include some sentence about coming back to us if they cannot get help elsewhere. Humans have that rackett of CYA solved.

Eating charges for having peace of mind. I would much rather have you be comfortable in your plan than saving a client money. If you need a diagnostic to help you sleep at night do it. We will either provide it pro bono or use the good sam to help. Answers without compensation are how we learn and live with the cases we stumble with. Rx. give the agonal cat a free radiograph to help make a suffering pet have peace.

The pets that save our lives.

Step up for the staff anytime and every time they need it. No one ever gets bullied or intimidated. Ever.

Learn to pay attention to gut feelings and red flags. People are crazy. And crazy things happen.

One of the most important things to learn is how to protect yourself and minimize liability. What really helps is being likable, documenting everything, and knowing when to bail. A person who is unkind is never worth salvaging. Walk away. Call me, and let them go before they try to hang you.

Accidents and bad cases happen. Never lie. Always learn and be humble.You are human. The worst asset of anyone is to never admit failure and to not be honest. There are lots of vets who forget to be honest and have integrity. Admit mistakes. Apologize when warranted, and be kind. You can't expect others to do it if you can't.

Don't be afraid to jump in every single time. Be honest with your client, expect honesty back from them, and jump in.

A smile and a card save the day often. Learn to start difficult conversations with things like: "what do you think is fair?" "what do you want me to do?" "what is it going to take to make it right for you?" Write down everything. I prefer to have these exchanges via email to be able to add them to the MR without verbal interpretation or miscommunication. 

Remember yourself every day. Start with a plan for work life, end with a plan for home life. They are codependent and equally important.

Don't confuse vacation with CE. They are separate entities. They require separate packing contents and medications.

Know where your loyalties lie. Never confuse the order. It will lead you into places you can't explain your way out of. For me it goes like this;  

• Patients first. My passion and professional skills are centered on them.

• Staff second. These people will have your back everyday. they will sacrifice for you if they believe you would do the same for them.

• Client last. If they love their pet as much as we do they will understand and support your obligation to pets first.

• As with every rule there are exceptions. Public health is our responsibility too.

• Safety, patient, staff, client.. and always be ready for a mishap. Did I ever tell you about the time a technician got stuck with the sedation for a euthanasia, and then they called me as she was passing out? Or the time the feral cat got loose in the treatment area, hid under the xray and then attempted to be extracted by the only people in the clinic not vaccinated for rabies. Guess who was bitten? Guess what that led to?

A kiss for luck,, it can't hurt..

When I first started I had a tough time understanding the spectrum of presenting issues/diseases/severity. That took time. In general, (ok I am failing to think of an exception,, wait,, cardiac,, there's one!!), I am now much better at seeing the imminently dying as such. It takes time to know what the worst ear looks like vs the mildest. The dying of suffocation, (did I ever tell you about the kitten on the exam table suffocating and the new vet in the back looking at a textbook for orthopnea. I happened to be walking by the room and saw the cat on the table wide-eyed, open mouth blue and I just rushed in and took her to oxygen while we figured out the rest. She had been hung by her collar on a stair rail.. we did an emergency tracheotomy and sent to ER,, she lived there for 2 weeks trach tube in, and a nice phone call from the sx about how to place the tube better the next time. 

Did you ever hear the story of the 54 cats we saved from the hoarding case?

Edema (peripheral) look for cardiac.. but I have had a few that turned out to be cancer way down the line. Rutin 500 mg and massage and keep looking for the answer. Maybe old dog not moving, ie not circulating.

Lameness, the only emergency is a CF luxation.. time matters here, everything else can do rest NSAID (do SA055 for all suspected long term NSAID patients). People are much happier if you approach these in a cost sensitive manner. Offer rads and bw upfront, but set up a plan; 7-14 days rest w NSAID and then if not better rads. Small dog lux patella, mid-lg; cclr. Bilat CCLR’s look like hips. Cause significant lameness. Last note on ortho; in discussing CCLRs I have had people listen to me discuss the dx and tx plan (surgery is really the best and only way to restore best function) I have had people want immediate euthanasia. So, deliver gently. With this; be very careful with your words. Most people want their pet to be happy and healthy and not have any indication or permission to “suffer.” I never use this word unless I absolutely believe that euthanasia is the only and kind option. (remember the blue hypoxic cat). Eminently dying is one thing, guessing and recommending euthanasia is another. Tread very carefully. I honestly believe that the plague of SA vetmed is our non-chalant cavalier attitude in recommending euthanasia. Every pet deserves a diagnosis before we try to unburden ourselves from the detective work of getting this. 

Access to care and caregivers. The foundation of the community vet practices, the James Herriott model, is this. We are here through thick and thin and for both the short and the long haul. This isn’t a model of get what you can while they are here regardless of the bridges you burn. Where my fear in vet med lies isn’t in our ability to diagnose, or diagnose at any affordable price (seriously becoming an endangered species), but to retain the affection a parent has for their pet. This is where we are shooting ourselves in the foot. We are dismissing the importance of this in the longevity of this profession.

Hazel,, and her magnificent overbite.

These are from Micheal Shaer’s book, Clinical Signs in SA Medicine; they are timeless and precious;

1.     Treat for the treatable.

2.       Assumptions lead to trouble, therefore don’t assume.

3.       Always interpret clinical information within the context of the patients presentation.

4.       Avoid tunnel vision. 

5.       Treat your patient, not just its disease.

6.       Avoid overmedicating. (and be ready for these medications to change over time).

7.       Be honest with yourself. (and equally honest with your peers, pateints and clients. This is why I document everything, refer everything, and CYA in every single scenario.. its my healthy, be prepared for WCS (worst case scenario) paranoia).

8.       Don’t postpone todays urgencies until tomorrow. (i.e. exploratory, splenectomy, GDV, bloat, CF luxation, Addison's, hemoabdomen, blocked cat, humane euthanasia, analgesia in every single case!)

9.       Common things happen commonly. Look closely at your patient; they will usually tell you what is wrong. 

10.     Look closely at your patient; they will usually tell you what is wrong.

11.     Never let your patient die without the benefit of the silver bullet, (steroids). Human med does this well.

12.     When you hear hoof beats look for horses, but don't forget about the zebras.. (Addisons!, acromegaly, insulinoma, OSA vs CCLR, what about bilat CCLR vs hip dysplasia). 

13.     Never sell the basics short. (PCV/TP. BG, HR, RR, temp) so important! and go back and listen again, (pe, hx).

14.     If you don't think you won't find it. Cats are soo good at this.. every constipated cat is a bigger problem.

15.     Never let biological specimen go to waste. I.e. every sick pet gets a full cbc, chem (electrolytes and calcium are so important!) along with a fecal, urine (think ketones) and tick panel.. not knowing is negligence if you are not looking.

16.     Disaster lurks whenever a patients problem is "routine."  Ex. the patient who goes into shock after a vaccine. I have had two cats die after a neuter. 

17.     If its not getting worse, give it a chance to get better. Ex the URI kittens,, don't bombard them with abx. start with one ( I usually do clavamox drops, then doxy, then azithromycin), but, I give them a chance bn each to get better.. usually they need a little TLC, time, stability, deworm (first time you see them!) and good food.. their immune system will catch up. caveat; eyes worsening = asap meds! 

18.     Don't stray too far from the patient,, the diagnosis will eventually appear. (This is written by an IM specialist,, oh the bliss of always getting to a diagnosis! real-life tip here;; life isn't so blissfully easy in the trenches.. the patient often gets better and we often don't know what the problem/disease/diagnosis was). 

19.     Don't give your patient a disease it doesn't deserve to have. Be careful who you explain and describe your patient and their clinical clues.. ex; (for me) the "caution" dogs can be used in a court as documentation that they are "dangerous" also pit bulls as a breed. 

20.    Don't let technology make you decerebrate. Ex. Don't use amylase and lipase values to diagnose, same with T4. 

21.     The necropsy is the clinicians trial by jury. I am never afraid of the truth,, I just hope that I was kind, compassionate, and honest with all involved. We will someday leave our professional lives, it won't be without stories to tell, some we win and some we don't, but we are honest the whole way through. 

22.     The wisdom of experience should never be ignored. What we lose in mental acuity and new advances with age we gain in experience and gut to compensate. 

23.     The diagnostician should always ask themselves 2 (I say 4) questions;

1. Where am I with this patient,
2. Where am I going.
3. What does my client expect
4. What does the patient need now

24. If the patient isn't going where you expect it to be going, then go back to square one.

25. In order to successfully treat a cat, you must think like a cat. There is no anger, frustration, poor words or struggling with a cat,, (or dog). Stop, take a break, talk to the owner, try again later,, oral ketamine, oral gabapentin, kitty magic,, no one suffers here. The cat is always in charge,, we just try to convince them that they want to participate in our treatment plan

26. Avoid the pitfalls of the red herring. Labs are part of the story, the patient is the director, follow the patient, not the labs. Ex, every blocked cat has azotemia, often the worst you will ever see,,, ignore it. Same with hypercalcemia, it has to be repeated to be valid (except with Ag mass, thoracic mass, evidence of neoplasia elsewhere).

27. If they can't afford the Ivory Tower, then offer them a chance. Affordable care and access to it is every patients right.

28. Know thy patient. They are a whole package, with unique needs, and abilities,,, in my opinion it is more important to know your patient then your client,, and the best clients (parents) want for their pets then themselves.

29. Nobody wants to pay a big bill for dead animal.. while i agree in essence i do feel that it is better to accept a tragic ending with a degree of resolve that we all tried to the best of our abilities. 

30. What matters is not so much what you say to a concerned client, but how they perceive what you have said., (or "likability")

31. Diagnostic cloudiness will soon be replaced by clear skies - be patient. The difficult diagnosis patient can lead to frustration and sometimes wrong decisions. If it is not a life threatening problem, give the disorder time to unveil or refer to a specialist.

32. Better that the dying patient expire in the hospital than during the car ride home (or to the ER because you didn't see them). 

33. You must have cognition to be a competent clinician, (oh lord the number of things I can list with this one.. the utter exhaustion that makes you not competent to do that exploratory, or surgery, or even another exam,, the aging DVM who cannot perform at the level needed and needs to find another avenue within vet med, the elderly who need the techs to push the euthanasia solution)..

34. To prognose you must first be able to diagnose. Giving the wrong diagnosis will certainly cause a domino effect on all subsequent actions for your patient. Better to know why a certain action must be taken rather than to regret that it was taken. Me; Don't give a patient a death sentence you cannot back up from every single angle,,, we diagnose death sentences too often and with too much conviction. 

35. The toaster effect; Just as toast pops out when it is done, a patient will eat, bark, and be frustrated to be caged when they reach their turning point for recovery.. nothing makes my heart beam like a parvo puppy screaming for food and freedom!

36. To cut is to see; and to see is to do; to do is to cure. Get in there and try to save a life that is dying in front of you. There is great power in being a clinician if you are brave enough to jump in and try.

Never sink to the standards that make other people safe. Never surrender who you are because life hands you a challenge.

Get out alive and intact is more important than out of debt and liked.

Be vulnerable and find the strength in that.

You are never alone. We are all here for each other.. me, well, I am always here.

Be brave and know it will serve your patients in the best way they cannot ascertain without their freedom and liberty bestowed. It will serve you better than compassion. You cannot have one without the other.

Be the leader when you need to be, but always the student.

Be the ear before the professor.

Be the shoulder before the pen or the sword.

Be safe, you are your best advocate for those we are advocating to serve.

Hamilton,, let your heart decide

Analgesics accompany every patients peri-exam period and post-departure journey.

I have learned to never turn away someone without giving them something. Pain meds, nausea meds, app stimulant, my email, a resource page, a hug, a report card that says “we are here to help.” I have lost countless nights sleep over knowing a pet is FUBAR and telling them so, only to have them walk out without anything to help. Hospice, dying at home, and dying without medical interventions are all acceptable. Give them something for the sake of the pets suffering. “Tis better to die trying than to fail absently.”

Grin, smile, and jump in.
Let me tell you about Harper.

And to close I would remind you to think about your weakest link alongside your pet care goals. The one thing that you have to protect to get out alive (you and your patient). There are two to three souls in every case that need protecting, prepare to defend, fight, and even compromise the financial goals, the ideal care, and anything else you have to so that there can be an ending everyone can live with. Your weakest link might be the list of diagnostics that the owner cannot afford to do. Or, the list of diagnostics that don't leave you with anything treatable anyway. It might mean we lose the ability to run tests for the sake of saving funds to provide a treatment plan. It might be the time you don't have to sit with someone who needs reassurance that they are doing the best they can. It might mean the staff member who needs to be allowed the chance to fight for a case to help them feel a part of our cause. And in some cases it is you, losing sleep, feeling like an imposter-syndrome failure because life just isn't fair and the cutest, youngest, sweetest animals can die from horrible diseases that break your heart. Keep your heart on your sleeve and lead with conviction in the most honorable cause there is. Make magic happen with fierce determination and compassion coming first. 

...and good luck,, I am always here for you..