Emergency Kit. The Veterinarians At Home Kit.

I was asked by a follower on Twitter for "my best pet advice," so I had to think about this open ended question for a moment and decided that one of my best pieces of advice was that every pet owner should have an at home emergency kit.

Here is what I think it should have in it;

1. A list of emergency phone numbers. 

I give out business cards so that my clients have one for their regular vet and also a card for our emergency clinic. (It has their number in very big NUMBERS so even in the emergency you see it). I also want the directions to be on the card. When you get stressed you forget to listen or pay attention to anything.

Pet Poison Hotline. Their number is 1-800-213-6680, a fee applies for their services.

2. A big blanket. 

It can act as a straitjacket, a warming blanket, and absorb fluids if needed.

3. Thick absorbent bandages and Tape. 

Some people actually use women's maxi pads. They are cheap, and highly absorbent, and pre-packaged. Vets love Vetwrap. You can find it pet supply stores, or stores that sell horse products. It sticks to itself but not your pet, or their fur.

4. 3% Hydrogen Peroxide. 

If you are concerned that your pet ingested something toxic or dangerous you need to have this on hand. Call your vet or the Pet Poison Helpline BEFORE inducing vomiting. Their number is 1-800-213-6680, OR call your vet, OR local pet emergency clinic. DO NOT WAIT. Seconds count, and hours can kill. (For more information on when to use this please see my blog, To Puke Or Not To Puke, That Is The Question..)

5. Benadryl (generic is called diphenhydramine). 

You need this anti-histamine for bug bites, (or if you are my dog Charlie, eating frogs) or any other allergic reaction. If your pet gets red skin, or hives, or is even having a worse allergic reaction it is your go to drug to try to slow or stop the progression of the reaction. If your pet is having trouble breathing, get in the car and go immediately to the closest ER.

6. Eye wash. 

Over the counter generic eye wash, sterile saline, is fine. Cheap stuff. Use it to flood the eye if the eye looks inflamed, has any abnormal discharge, or is being held shut (squinting). If the eye doesn't appear to be improving after an hour, or if it is painful, or you see yellow or thick discharge you need to go to the vet ASAP.

7. Thermometer and Lube. 

Please use a digital thermometer. The old mercury ones are too dangerous and fragile. What would happen if your pet sat down while you are trying to take their temperature? The normal temperature of a dog or cat is about 100.5  to 102.5 degrees F, or 38.5 to 39.2 degrees Celsius. If your pet is below 98 or above 104 degrees F go to the vet immediately. DO NOT WAIT! It is very likely the temperature is on its way to worsening, and seconds count!

8. Nail trimmers and Quik-Stop.

It is important to have the right trimmers for your pet. Ask your vet to show you what they use, and how to use them. Kwik-Stop is the product we use to stop the bleeding if we accidentally cut the nail too short. Here is my primer on How To Trim Nails.
I swear I have had this same bottle since 1995. It is still full, it takes forever to go through a bottle, and you get better at trimming nails with practice.

I also have very definite opinions on nail trimmers. Don't buy the cheap guillotine kind. Buy spring loaded heavy duty nail trimmers if your dog is over 30 pounds. ALWAYS have quik-stop standing by JIC.

9. If your pet has any medical issues you may need other drugs in this kit. 

I keep an NSAID, (old dog pains), and ear wash for floppy eared Beagle-pup. Along with previously prescribed drugs, ointments, etc. Always ask your vet before using old medications. many expire, and often clients inadvertently use the wrong drug on the wrong species or at the incorrect dose. I also keep heartworm, flea and tick preventatives close by in a locked container.

Please remember to not use prescription medications, (or ANY medications) without your Veterinarian's "OK" first. Many clients over use and abuse the prescription ear medications and over time make the ears much harder to treat.

Always use the medications given to you completely and exactly as directed on the label. I also have unfortunately seen many owners give their pets "human drugs" that are toxic to pets. I have actually lost pets due to owners giving medications that are toxic, and/or giving doses of drugs that are way over what a pet can tolerate. If you are in doubt, "Don't give it!"

10. I also keep my pets medical records with the medical kit. 

So if you need to run to the emergency Vet you have your pets records.

11. A Leash, Harness, Collar, and/or Pet Carrier.

If you need to get your pet somewhere fast it really helps to have these things at your finger tips.

12. Something to use as a Muzzle.

Also, some dogs do not do well with shock collars, or invisible fences. Please seek advice before purchasing products that might be potentially harmful and/or not work for your pet.

In the event your pet is hurt, or scared be prepared with a soft cloth muzzle. You can make one yourself with a long scarf, leash, a necktie, or pantyhose (if you use this don't pull it too tight this stuff is hard to get off and can act like a tourniquet) or length of gauze. I promise you your pet will bite if they are in pain and you are trying to do anything to them. When you are in pain you are not the same individual. Ask any woman who delivered a baby what came out of their mouth in the delivery room. A dog, or cat, or anything reacts without thinking if you touch them, and they are in pain. So just put one on and then don't get upset if they resent the muzzle. Improvise your own muzzle by making a noose by tying a loose knot in the middle of the length of the strip, leaving a large loop. Approach the dog quietly from behind and slip the noose over their nose. Do not block the nose, they need to breathe through this. If your dog is really struggling to breathe then do not tie the noose so tight. It should only be tight enough to not allow their mouth to bite you. Put the noose about mid-way on their muzzle/nose. Pull the know tight with the know on the chin, then pull the ends behind the ears and fasten a bow.

 The following picture is from "The Dog Lover's Companion," Fog City Press, a great resource for all dog owners.

Here is a picture of Savannah, my dog, modeling, (unhappily) an improvised muzzle.

And here is Joe, my husband, being a goof, because I asked him to show me how put it on ( a little quiz to see if he was paying attention), after I had put it on Savannah.

Here are some of my pets. I promise you that I have used my emergency kit on every one of them. (Did I ever tell you about the time my whole staff came over to our house to go fishing and my dog Charlie bit into the 3 pronged barbed fishing hook? That was emergency sedation, first-aid, and surgery. I'll tell you that story later.)


Ms. Pig just saying "hello"

Miss Pig, Ambrose, and Savannah on a perfect summer day. That's Ms. Pigs house. It is insulated and cozy year around.

Here is Squeak Box, DC, and Donner. We only go out on supervised outings. They are indoor kitties. But they love to go for walks with us and think of themselves as vicious predatory jungle lions.

Ambrose looking for attention.

Lilly, my moms dog. She's another story. In this photo she has Cushings disease. It was not treated at this point. Now she's an Addisonian. I'll explain her saga someday.

Breeders, My take on them

I know that I am supposed to try to be very PC (politically correct), but I am honest. It’s sometimes hard to be both. So when I question which side of the line to fall on, I always look deep down and ask myself, “what is best for my patients?” Because when it comes right down to it, that’s my job. To take care of your pets*, (I always add a little asterisk here because I also have to look out for my clients health and safety too, but short of that I am here to take care of your pets).

Today I thought I would throw in my two cents about breeders. If you look in the vet publications you will not find any veterinarians writing about this topic. Vets are viewed by the public as being well respected and having integrity, but I would add sometimes we are cowardly too. For too long we, the shepherds of care for animals, have let public opinion and prejudice decide whether or not we will take a stance. I challenge any vet to argue factory farming and puppy mills with me at anytime. 

I know a lot of clients who spend a lot of time researching breeders to find the pet they want to purchase. I have to admit that almost all of them come to me with their new pet and say that they “spent a long time researching the breeder before they purchased.” I will now admit that many of you with the best of intentions want to believe so badly that your breeder is fabulous, when in my opinion MOST of them are merely good at looking like they are what you already want them to be, great breeders. Now I will clarify and admit that I think most of these breeders truly care about their bitches/queens, etc., but MOST of the breeders I know do not bring their pets to the Veterinarian regularly. So when you go to purchase your next pet from a breeder I would recommend that you ask for references. Those references should be from an owner (preferably 3) who purchased a pet from their last litter, and the Veterinarian that the mom and dad go to for their annual physical examinations.  

Then when you call the vet(s) have these specific questions:

Introduce yourself first,

Ask the veterinarian if they would be willing to answer some questions about one of their clients because you are interested in purchasing one of their kittens or puppies, etc? Many will say "yes", but some will say "no". If they say "no", explain that you are trying to decide if they are good breeders/owners because you are interested in buying a pet from them. If they continue to say "no", then ask the vet if they will talk to you after the owner gives them permission to talk to you. Vets often don’t want to talk about clients without the owners’ consent. Any good client will happily give consent, and most Vets are upfront and honest. We Vets don’t want to be affiliated with bad breeders either. You can always ask the Vet or their staff members “If you were looking for this breed of pet would you buy one from this breeder?” that way you aren’t asking the Vet to say anything potentially hurtful about them, but you will get a straight answer.

When you talk to the Veterinarian try have specific “yes” or “no” questions ready. (Once again we don’t want to be accused of slander, so a "yes" or "no" is more comfortable for us to answer).

The specific questions that I think you should ask the Veterinarian are;

                Did this breeder bring the mother of this pup/kitten to you before breeding?

                Is this mother up to date on all of the vaccines that you recommend?

                Would you recommend this breeder to a family member?

                Do you feel that this breeder takes excellent care of their personal and breeding pets?

Do you feel that this breeder is providing all of the necessary care needed for happy healthy pets?

If they do not answer “yes” to all of these questions find a different breeder. I will admit that the further away from your home the breeder resides the more likely you are to not know the full story on your pet. Unless you have first-hand personal knowledge of them.

Ask the breeder to provide you with copies of the medical records of the parents of the pet you are thinking about purchasing.The “self-proclaimed wonderful breeders” are few and far between

I am also saddened to hear clients coming in to say “we got her from a puppy mill, once we saw her we couldn’t leave her there, we saved her.” To this I reply you saved her to have another poor puppy or kitten fill her shoes. These places will never stop unless they don’t have any customers to buy their “goods” any longer. The buck speaks louder than the law. “Don’t feed the greed” is the new catch phrase. I know it is hard and heart breaking to see an animal in deplorable conditions, but please don't purchase them, please report them to the appropraite authorities if you think an animal is being neglected, cramped, mis-treated,etc.

In closing, a great breeder invests about $1000 in each puppy, and $300- $500 in each kitten, if you aren’t paying double that then the breeder can’t cover their costs and they are skimping something somewhere.  For many it is a business, and they are in this business to make a profit. The pups and kittens are a product. There are some breeders in this business for the love of the breed. They will stand behind their pup/kitten and offer a full refund, (for any reason). They will also stand by you in the adjustment of having a new pet, allow you open access to their medical records, have any and all of the recommended tests done, (many breeds suffer from specific diseases which can be checked before they are breed, therefore lessening the chance that they will pass this disease onto their young), and you should never have one odd feeling or red flag when you meet them or see what their facility looks like.

I am also a huge advocate of adopting from a shelter. Most of the sweetest, gentlest, loving, healthy pets I have ever known were cast-aways. So please always shop at the shelter first. Then there is the whole shocking, cruel, unbelievable statistics of how many pets we euthanize every day of every month of every year. It is truly appalling how many people love animals and how many pets still die because we don’t have enough homes for them.

Sharing your life with a pet is one of the greatest joys of life. It is a big decision and a life-long committment. Do your due diligence in making a smart decision fro your lifestyle, your budget, and your beliefs. And as always, don't be afraid to ask your Vet for help. That's what we are here for, every step of the way.

Daisy the Bassett

One of my favorite aspects of my job is to meet a client with their new pet. Especially if that new pet is a puppy or kitten. In many ways veterinary medicine mirrors human medicine with the exception of the degree of specialization that is very common place on the human side. In the last few decades we have seen an eruption of specialty veterinary practices but for many clients they are too expensive or too far away to be utilized. This dictates that the private general veterinary practitioner needs to stay adept at all facets of pet care. Much too many a Vets chagrin we can’t specialize in pediatrics. What could be better than having every appointment be a puppy or kitten? Really, nothing could be better. Every time you open the door and enter a room a bounding mound of fluff and furr waddles over to you with the smiley, waggy optimism of youth. That smell of puppy breathe and that rhythmic comforting purr at every visit. Well, the daydream fades and the reality that everything grows up remains (long sad reflective sigh of disappointment).

So when a new baby bounds into the clinic we smother them with kisses and enthusiasm. We know the joy of entering our building is short lived and the bliss of youth is fleeting. Hard as we try to make coming to the Vet a good experience we all know that in time most of our patients will fear and resent us. Most clients apologize for the fear and hiding and nasty faces that our patients give us, but I always reply, “I understand, and I don’t take it personally. Nobody wants to go to the doctor.”

We each have our own personal favorites, the favorite breed, color, size, sex, even personality. Pets come in every size, shape, color, energy level, and personality. And like everything else in life those personal preferences evolve over time. I used to be a full blown Border Collie junkie. I also love NYC. Both for the same reasons. I like a fast pace and sense of being consumed by a job and a lifestyle, the constant go-go-go action. And I can be a little obsessive-compulsive. It just seemed like the perfect combination for me, work, work work, or herd, herd, herd…run run run, bark bark bark…need a job, need a sheep, gotta go..can’t be late, can’t miss a moment. Then after the sun goes down and all of the rest of the action goes to sleep you sleep. If I can make it there, I’ll make it anywhere, it’s up to you New York, Neeeew York!” Well that was my fun filled take no prisoners twenties.

I’m not in my twenties anymore and my favorite dog breed has changed. I get older and my dogs get smaller. I used to be a 60 pound dog girl. Now I am a 25 pound dog girl. I want to be able to pick them up, carry them down the stairs, and load them into the car with ease. When they get sick and need constant care I want to be able to take them up to my bedroom so i can watch them all night long, put them in a cage if they need to be kept quiet, be able to provide the care that I am trained for. I want portability. Instead of small erect ears I have been wooed by the big and floppy. I like short legs and long ears.

In walked Daisy. In case you haven’t had the priviledge of having seen just about every breed of puppy  then let me assure you that the cutest thing in the world is a Bassett Hound puppy. (a close second is a pug, but I like the ears). Daisy was 8 weeks old when I met her. Her parents were in their early twenties. They were almost as cute as she was. They coddled her, and spoiled her, and she worked them hard. They were college students, I am guessing in some sort of Ag school? The jeans, cowboy boots, baseball (not the professional team kind of hat, but the John Deere green kind of hat), big belt, bigger belt buckle, and the worn cotton plaid-ish tight fitting buttoned down collared shirt. They loved her more than just the "another farm dog" kind of love. She was their idea of "getting an apartment together" kind of relationship next step thing to do.

At 8 weeks she would trip over her ears everytime she came barreling over on her way to come greet you. It was hilarious to see her trip and stumble everytime. I do not think that there are nerve endings on those floor length velvety drapes. I know they bleed when they are injured, but there doesn't seem to be any feeling when you trip over them, drag them through the gravel and mud, freeze them to the ground, lay on them and cut off the circulation, or tie them ontop of the head for a little respite on the abuse.

I got to see her every 3 weeks from the time she was 8 weeks old to 4 months old. The ears stayed long and she still trips over them, but her enthusiasm for us has diminished. It is hard to convince her that I am still worthy of a kiss.

Maybe by next year she will have forgiven me for the plethora of vaccines I administered? And maybe by then I can get another kiss?

Daisy at Halloween, 2010, at 3.5 months old
"The Constable"

If you would like to learn more about Bassett Hounds please follow the link below;

http://www.akc.org/breeds/basset_hound/index.cfm

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.

my last week

Hello Everyone,

Hard as I try to get a post posted every other day I seem to have these bumps in the road that cause me to de-rail.

I had three terrible days in a row. It all started last week when a friend I had'nt seen in 15 years dropped in for a few days. It was wonderful to see her, and I really tried to take some time off. But last Wednesday I saw a 1.5 year old spayed female Akita that had been ADR (vet term for Ain't Doin' Right, (its one of my favorite terms, so gritty and ole timey)). Her owners were in their mid-twenties. All smiles and full of new life. It was palpable the minute I walked into the exam room. They very quickly spilled the beans that they had just gotten hiome from their honeymoon. They had left their dogs with their parents and their parents had reported to them that Bailey's (Akita's name) had been lethargic, not interested in food, and had had white gums for the last two weeks. I very quickly gasped and interjected, "Ok, in the future white gums equals immediatley get in the car and drive to the emergency hospital or here." They went on to tell me that they had been very busy and thought she might recover on her own, (small gasp again). I looked at her gums, and they were a pale muddy slightly purplish color, aka crap-ola. I palpated her abdomen and there was an enlarged mass in the area of her spleen. I took an x-ray and reported back to them that she needed her spleen removed ASAP. I scheduled her first thing the next morning. Problem was I had my friend coming in, had a very messy house to try to get ready for compoany and i was exhausted.

It was the beginning of my cascade of avalanche of disasters that has kept me from posting. I will finish Baileys story soon, stay tuned. It's a goodie!

Back to my tumultous week. My poor friend Marta showed up at the clinic whike I was in the middle of trying to get things wrapped up so I could go spend  some time with her. She ended up assisting us with Wren my "worst case ever kitten" (I have a long story on him coming soon), and Momma Kitty with the worst polyp ever, (she's coming up to), and the turtle, Bailey, and a few others. Sorry Marta, and Thanks for all of your help.

I did spend a great Friday and Saturday with her, Diedra, (sister) and Joe (husband). And then we left on Saturday afternoon for Philadelphia to run the Rock N' Roll 1/2 marathon. It was a blast! The run is flat, the weather was great, a band plays music to cheer you on every mile. We all finished together and had a concert to dance to at the end. It was a great day. Needless to say I was tired on Monday.

The event of Monday are the last blog.

But this is my real-life. Crazy, insane busy, drama life and death, and I love it!

Ok, Here's a few pictures of Bailey,

Here are some pictures of the three of us at the Philadelphia Rock N' Roll Half Marathon

A day in the life, (a bad day)

This is supposed to be about my real-life. But sometimes my real-life gets so out of control crazy busy that there is nothing else in my life. It is part of the reason I love what I do. But it is also part of the reason that I have no children, few hobbies, and a diet no one should be proud of.

So I thought I would describe what my day yesterday looked like.  Yesterday was Monday. Mondays are notoriously bad. They are insane busy from the moment the doors open. I opened the clinic for appointments on Sundays just to try to reduce the volume of bad cases that we see on Mondays. It has helped marginally.

I don’t know if people are too busy to notice that their cat hasn’t peed since Thursday night. Or that their dog that was having trouble with stairs and walking is now paralyzed and unable to control their bowels.  Or that the cat that has been crying since Wednesday and now won’t let you touch him, and has blood erupting out of a wound on its back needs to be” dropped off right now because you have to go to work.”(And, oh yeah, you can’t go near him even on his “good” days). Or the morbidly obese Shih Tzu that just walked in with his whole family because they think that the dog is having trouble breathing and they “think it’s time.” Those were some of yesterday’s cases. This is my real-life. And this is a bad day.

About a month ago I tried to cut back my work schedule so that my routine crazy insanely busy days might be more bearable. I have been scheduling my Mondays and Wednesdays for surgeries for the last couple of years. I was waking up on Mondays like the rest of the world and dreading the drive in to work. Mondays were becoming too busy to get my scheduled surgeries done, and everyone was suffering for it. So I decided that I wouldn’t schedule anything on Mondays with the hope of being less stressed and better able to provide the time and care the patients needed. I am not really sure how I can still not schedule anything, show up to work and still be here for 13 hours but it happened yesterday, and it still happens most all of my Mondays.

I woke up early like I always do, called into the clinic to see what was already on the books from the overflow of the last week and was told that I only had three cat neuters scheduled for today. I thought “Great! 3 cat neuters takes about 30 minutes, I will have no problem getting them done! I don’t need to rush into work.” Then I asked how the other Vets on the exam schedule looked and Lindsay, the receptionist, told me that they were full. That means I needed to get to work ASAP to help cover any walk-ins/disasters so the Vets on the exam schedule don’t get behind. As I was getting out of the shower Grace from Animal Rescue called. She had three small dogs that were trying to rip each other apart and all needed emergency neuters. She also had three other dogs that needed to be either spayed or neutered. I told her I would fit the emergency neuters in but the other guys would probably have to wait. She said she would meet me at the clinic in 45 minutes. I started to apply make-up faster and ditched the idea of blowing my hair dry. Another day with wet hair drying in a ponytail it was. The phone rang again. Could I come in earlier and help with the emergencies that were already calling? “Yes, I will be there soon.” Throw bag of belongings into large book bag, throw three dogs into car, remember to give Midnight her thyroid medicine, put little baby Wren in his carrier, grab coffee, and  go.  Get to the clinic unload the garbage, three dogs, one small sickly kitten (Wren) pick up my bag and trudge into building. Deep breath, good thoughts, and jump in. Open staff entrance door, survey scene. First face I see is my very well trained, lots of experience, long time Licensed Veterinary Technician. She looks up from the rubble, and the first thing out of her mouth is “why are there 3 more dogs to neuter?” I think to myself, “oh my god, I just got here, the anxiety level can’t be at a 10 already? We just got here.”  She came back at me before I could reply, “ I still have all of the treatments to do, and we don’t have enough people for all of these surgeries.” It’s hard to walk into a hard day with complaints at the onset. I put my stuff down, reminded her that they were the rescue’s dogs and we didn’t have to do them first thing, and that we would be ok and get through this. It is a hard stressful incredibly busy job and my poor techs bear the brunt of it.

I only thought I had three little quick cat neuters to do. I was sooo wrong it was soo beyond an easy day. That busy crazy Mondays cases started with Daymin. I had Daymin to look at all day. Sitting in up in his cage panting , trying to get up but unable to. Trying to get up because his brain told him that this place, this hospital, is not a safe place, so his front feet try to dig into the un-grippable stainless steel cage, and his unresponsive back end just lays there like dead weight. He cries when you try to move him and he involuntarily urinates and defecates. It is the bodies response to pain, flight or flight, and the mixed up incorrect nerve responses that happens when your spinal cord is damaged. Because he was so miserable we gave him morphine to try to ease his pain and provide some sedation. This caused him to vomit a huge amount of…stuff… I think it was eggs and chocolate? Didn’t his owners realize that his back problems were in part caused by his obesity? He was covered in poop and urine and we couldn’t clean him up without causing him more pain and thus producing more poop and urine. While we spent the day trying to convince Daymins owners that he had slid steeply downhill and needed emergency neurologic intervention we kept Daymin sedated, listened to him moan in his dysphoric morphine slumber and waited. At 6 pm I told his owner that I could no longer watch or partake in his cruel care. I told his owner that the only options left for Daymin were to refer him for the spinal surgery he desperately needed or to end his suffering with euthanasia. Daymins owners consented to letting him go and for the first time in over 3 days he wasn’t in pain.Concurrently I was trying to help Simba. A sweet purring machine of a long haired domestic tabby and white cat who had not been able to pee for days. His bladder was hard and it was painful when you touched it. He needed to pee and he needed it bad. I have seen more than one cat die in the process of trying to unblock their bladder. I went through all of the steps in my head. Remove some of the urine via cystocentesis (poke bladder with needle and pull off as much urine as possible) gosh you feel soo much better after that. Retain urine sample, (in his case very very bloody), to submit to lab, pull blood to submit to lab, place i.v. catheter to start fluids and correct electrolyte imbalance,then place under general anesthesia because its bad enough to be blocked butrtheres npo way any animal will lay still as you try to skewer their penis. (Although I have had more than a few blocked cats be soo bad off that the anesthesia wasn’t needed, and would have probably been the last nail in their own coffin). Then start the arduous process of trying to thread a small piece of plastic into a very small, and plugged up, little hole. God I can’t even explain to you how many sweaty brow hours I have spent trying to thread that hole. I have figuresd out a lot of tips. Here are some of them for you newbies; try a catheter (22 gauge minus stylet), try lidocaine in your catheter, try the ultrasonic scaler. Its like a rota-rooter on your sensitive delicate urethral lumen but it busts that cement plug up like TNT. And god bless the tomcat catheters that everyone says not to use, but damned if I can ever get one of those red rubbers in. glue tomcat in with tape and Chinese finger trap. Tape and sew collection bag to the tail and don’t forget the e-collar, or you get to do the whole process over again tomorrow.  I also think that an important tip to remember is to give the cat some SQ fluids before leaving at night and then disconnecting their i.v. fluids. I have come in the next morning to find a big birds nest of i.v. line because the cat spun around all night and twisted the lines to the point that either the i.v. or urinary catheter gets pulled out. Luckily Simba did great. And luckily for me it only took an hour to unblock him.

Then there was Mac. Mac is a big outdoor cat who hates anything that isn’t done exactly on his terms. He was brought in this morning. His owner literally passed the carrier (with him in it) over to the technician and said “he has been gone for a few days and now is bleeding on his back”. “Ok”, my technician said, “let’s take him out and take a look.” “No!,” the owner blurted, “I don’t want to see him, and he’s not a nice cat.” “Can’t I just leave him here for today?” “You can’t touch him, even on a good day.”  And for some reason he was left for me too look at when his mood changed. I called the owner and got permission to sedate him before I lost a hand or needed plastic surgery. After ten minutes with some hard core drugs surging through his veins he was placid and cooperative. I liked Mac like this. We started shaving off of the furr covered in pus and blood. The more we touched the wound the more puss erupted. And when I say FOUL smelling, I want you to think dead fish rotting in the sun. bad doesn’t make you think you are going to throw up. does it? I wanted to. But I had three other cases waiting for me, he was already under anesthesia, so you just swallow, and keep plugging along. One hour later he had a 6 inch long drain running the length of his back. I called his mom to explain what we had done, and she of course asked me “ what o you think did that?” I told her that “ I couldn’t be sure but in most cases it is another male cat trying to get him to move to another block.” He was a mean mean pistol when he was awake. We let him wake up in his carrier. He spent the rest of his day hissing and spitting and swearing at anyone and everyone who dared to come close to his cage. His mom picked him up at the end of the day still afraid to look into his carrier and see what his wound looked like. she swears he is angel at home. I hope so, he is the devil outside his house. Bon voyage and good luck Simba!

Lastly I got called out of the back surgery area to look at a walk-in client with an older Shih Tzu who they think “is having trouble breathing, and it might be his time.” Lovely. I escorted mom, dad, daughter, and obviously obese older Shih Tzu into an exam room. Turns out their dog is morbidly obese, was groomed a few days ago, and now is soo painful he won’t eat or move. To think that these owners were contemplating euthanasia due to sore back is scarey. The appointment didn’t take long and I was happy to have this bullet dodged.

I left 13 hours after I walked into the building. I watched two shifts change. And I was exhausted. Little did I know that today, Tuesday would be worse.

the lessons we are told and the ones we learn the hard way

 In the long process of getting into vet school (my process has to be the longest on record, I sound like I am proud of that, really, I am chuckling, it was so ridiculous), I had to meet the stringent, grueling, and  exceedingly high expectations set forth by the Veterinary Admissions Committee. I needed to have high grades (another story in itself), a few letters of reference, a GRE score that was almost unattainable, a work history that was longer than the other applicants I was up against, and some experience in a laboratory setting for the purpose of research. It took me many years to get that small list up to par with the rest of the hopefuls. To help bulk up my work history resume I started calling all of the veterinary clinics around me. I had to make a lot of calls. I am sure most of the clinics thought I sounded like a loon. I was asking if I could come in and volunteer my time at their clinic. But there were few stipulations and problems that I had before I could start volunteering. Like, for example, I still had a job, a crazy unpredictable job.

I went to sea for a living, as a merchant seaman. (I know not a common transition, Merchant Mariner to Veterinarian). I was working for AT& T on their fiber optic cable ships stationed in Baltimore MD. I was worked on the ship 7 days a week from 8 am to 4 pm, and then I would head off to the veterinary clinic. But the ship was on standby, which meant that if any undersea cable in the Northern Atlantic Ocean needed any fixing we had 24 hrs to get our ship shipshape and lines aboard, and be heading out to sea. We never knew how long we would be gone, and we never knew when the call would come. In other words I wanted to help but I might be very unreliable. After a few random calls I landed an opportunity to volunteer at a vaccine clinic. It was at that time a very novel idea. The clinic was open 2 hours three times a week for walk-in appointments. The clinic could only provide minimal services, primarily vaccines and examinations, but  I immediately loved this clinic. The medicine was fast and furious. The clients were from all sides of the spectrums, (because I guess everyone is always trying to save a buck?) and the cases were just as varied. Sometimes, most of the time, it was just “hello,” “nice to meet you,” happy healthy cat/dog, place said cat/dog on the examination table, pop vaccine in the butt and then call out “Next!”  It was fast, and furious, and fun. But there wasn’t a lot of intense medicine involved, (not that the admissions committee was going to find out).

The owner of the vaccine clinic was Dr. Lou Applefeld. He was a tall, dark, handsome, smart, witty, and friendly man. I loved him instantly too. He was great fun to be around, and a great mentor to have. I got lucky. I stayed volunteering there for about 3 years, and I actually learned as much about veterinary vaccines as I did about being a veterinarian and business owner. He was patient, kind and generous with both his time and advice. He loved veterinary medicine and his patients but he was tired of struggling between the ability to make a living reflective of a doctor/veterinary expert, and the pressures owners placed on him to give away his time, expertise, goods, and services. He told me over and over that the amount of time, effort, and money you had to put into the process of getting a DVM wasn’t worth it in the end. He pleaded with me to change my mind. He was trying to save me from the internal frustrations and challenges that his 40 years had given him. It was a lost cause. I had wanted this for too long and I had invested too much into it already, that and I am destructively stubborn. I had to learn this lesson on my own.

In 2001 I started vet school at Virginia-Maryland Regional College of Veterinary Medicine. I was so proud. It seemed like it was the culmination of a lifetime of effort. (I was an old lady comparatively speaking to the rest of my class, 31, (grimace, shock, horror).  It was four long hard years of school. And let me tell all of you who are debating starting vet school it’s really hard to do anything else while you are trying to get through.

 I had the support of a wonderful man that I had just met 3 months before vet school started. The odds of any relationship, especially a new one are not stacked in your favor, but it turns out he is almost as stubborn as I am. So he stuck with me for the 4 years of vet school, drove 4 hours each way every weekend just to hold my hand, hand me hankies, clean my house, and buy the weeks’ worth of groceries. He really helped me get through vet school, and I am not sure I could have done it without him. (Thanks honey, I owe you a million).

Fast forward 10 years or so and now I am in about the same position Dr. Applefeld was, (well minus the 30 years of experience) and I now understand why he harped on me as hard as he did. And damn him if he wasn’t right. It is a difficult career to pick. Juggling the pressures of making a living, looking into the eyes of a patient whose life depends on someone intervening on their behalf, and in many cases an owner who cannot, or will not pay for their care. Veterinarians either stop caring, stop listening, go broke, or burn out. I struggle to stay standing as I walk the high wire in between all of these. I tell myself everyday that the last part of me that I will let go is my sanity, followed by my compassion, and lastly my business. (But if my husband asks please tell him the reverse order). 

Here is one of the stories where I got burned by my desire to do the right thing, take care of a critical pet and learn another lesson the hard way. One of my technicians came to me one day to tell me that her boyfriend’s ex-wife had her dog in the emergency hospital and she could not afford the care there that her dog needed. I told her that if she couldn’t afford the emergency clinic and her dog needed care she should bring it over for us to look at. A short time later I met the ex-Zaremba and her very sweet pit bull mix dog Freckles. Freckle’s was in a terrible state when I met her. She was obese, unable to walk, lethargic, and very ill. She was one of those cases that break your heart in 5 minutes. For as sweet and gentle as she was she had essentially been ignored all medical care for at least 4 years. The list of possible diseases that could be causing/contributing to her current state was long and the investigation to get to her diagnosis was not going to be cheap. I discussed all of this with her owner and she explained to me that she would do whatever it took to get her well. We began the long process to identify the cause(s) of her condition. Within 30 minutes we knew the following; She had a terrible case of Lyme disease (if left untreated, or if found in the advanced state, this will often be fatal), She had a very large distended urinary bladder that might burst at any moment and could kill her if not resolved immediately. She was not spayed (leaving the real possibility of having a pyometra, or infection of the uterus, another big killer is not treated immediately). A very low protein, (also life threatening), and she had a severe case of both whipworms and hookworms. I made it very clear to her owner that she needed immediate emergency care and that regardless of all the treatment and care she was given she may still not survive. Her prognosis was grave and her condition severe. Her owner Ms. Zaremba pleaded with me to do everything I could for her and she pledged to pay for her care even if it meant making payments on her account for months to come. I provided her with an estimate of about $1000 which I hoped would take cover of her three days of hospitalization and care.

After three intense days of aggressive medical care, multiple x-rays, blood work, a urinary catheter, and hospitalization Freckles walked out of JVC a happy healthy dog. We started her vaccines and spayed her a few weeks later. Everyone was relieved that she was such a wonderful success story. She remains one of the happiest patients we have ever cared for. It was wonderful to see how incredibly resilient and miraculous her recovery was. That kind of case is the payback all vets live for. For as many terrible endings it is the one or two miraculous cases that keep us going.

But back to Dr. Applefeld. After Freckles received all of her care, she had amassed a bill of over $1500 dollars. In the very beginning, when Freckles still needed follow up care, Ms. Zaremba followed through with her established payment plans, but after we stopped seeing Freckles we also stopped seeing payments. To this day I have not been reimbursed for her care. Do I regret it? No, I did the right thing for a wonderful dog. Do I do payment plans anymore? Hell NO! They don’t work, and I need to maintain some tactics to preserve my burn out potential.

So Ms. Zaremba I know that you are still out there, (there are also a few others, you know who you are, that took advantage of JVC) I hope that someday your sense of responsibility and descency bring you back to our door to make things right. And I ask myself do these people exist in every small business? Yes, no doubt. Do I expect people to be fair and descent still? Yes. I still believe in people, I just don’t put the staff’s payroll on the line for them.

 It is an ever evolving process to figure out how to walk the line. I wish I had Dr. Applefeld around to get advice, but very sadly he passed away a few years ago. He had 6 years of retirement, which he enjoyed much more than working, and I feel that the words of advice and his life lessons live on with me. I remind myself to enjoy the successes, learn from the failures, love my patients as if they were my own pets, and follow my heart. That and I never deny care,( because I won’t let myself become a hardened uncompassionate soul), but these days I take collateral, multiple forms of id, signed promissory notes and I have a great collections agency. Or you can sign your pet over to JVC and then we can provide all of the needed care without the frustration of trying to collect payment afterwards. So far it has worked. But it means we always have a pet up for adoption, and jewelry in the collateral bag. If you see the neon sign in the door with the three balls and the “pawn broker” words in the window you know that I have fallen one more tier down the ladder of desperation. I hope that it is still a long way down. I miss you Lou, and I say a big loud “THANKS!” I am a better person, veterinarian, and business owner because of you. I am very grateful.

Puppy Mills Cruelty

Puppy Mills

I got a call from Grace at Animal Rescue asking me if I would look at a 7 year old Golden Retriever that they had rescued from a shelter. Animal Rrescue takes in so many dogs abnd cats that they provide spays and neuters to all of the pets that they adopt out at their shelter. When they were preparing to spay this dog they injected her anesthetic and proceeded to try to pass an endotracheal tube into her esophagus to provide her the oxygen and anesthetic gas to keep her under general inhalant anesthesia. For the Veterinarian we approximate what size endotracheal tube to use on the pet based on their size, weight, and breed. I have seen some toy breed dogs take a tube used routinely for cats. And I have had to use a tube three sizes smaller than I estimated on a bulldog.

As a side note: There are a lot of helpful anesthesia tips for brachycephalic dogs. I always have a long discussion with these owners prior to placing these guys under sedation or anesthesia. You should expect to pay more and be asking questions if you are not.

In the process of trying to pass the endotracheal tube the Veterinarian noticed that her vocal cords were abnormal. She also noticed that the size of the lumen (the opening of her airway) was significantly smaller than it should have been. As I have said before your body will respond to an insult (fancy medical term for damage) by scarring. Scarring in a tubular structure is called stricture. A stricture causes the tube to narrow. Her vocal cords were unable to open normally, (they open like drapes around a window) because she had been brutally de-barked.

When Grace called to ask me about this dog she was calling to ask if I could use our laser to try to remove the scar tissue that was like a webbing holding her vocal cords together. It is always very difficult to give an opinion on a case over the phone. I need to see a pet and understand not only the condition about which they have come in, for but also assess the pet, and in many cases the owners ability to follow through with any post operative care. I told Grace that I needed to better understand this dog’s condition by seeing her. I also told Grace that I wasn’t sure what she was talking about when she explained to me that she had a 7 year old dog that had been de-barked at the puppy mill. I had never heard of a de-bark being done by anyone other than a veterinarian. (This is a procedure that used to be done pretty routinely in the “old days,” thankfully it has fallen out of fashion).  Grace sent me a drawing of the dogs larynx as the Vet had described. She also went on to say that the way puppy mills de-barked was to “shove a pipe down their throat, to break the vocal cords.” I wanted to vomit. I couldn’t believe that people could be so cruel. I also couldn’t believe that I had been doing this for as long as I had and never heard of this. (Something about ignorance being bliss ran through my head).  I told her that I was appalled to hear about this girl but I would be happy to see her.

Thankfully she did well under anesthesia and recovered without any problems. It was decided that based on her age, her lack of clinical signs and how well she seemed to be doing that we would take a “watch and wait and see” approach.

My hope is that she will never need another surgery and that she will be with a family that loves her. She may have started out with a terrible cruel person who didn’t care about her, but hopefully she will end up with the exact opposite.

Puppy mills only stay in business because there are people willing to buy a pet from them. If you don’t know the breeder and you haven’t met and visited their facility personally please don’t support them by buying a pet from them. They will only stop abusing when there isn’t someone buying their product.

There is not much information available on de barking, but here is an interesting debate;
http://tinyurl.com/3rdfugb