Understanding and Diagnosing The Limping Dog, Why To Probe The Paw

This dog was brought in for limping.
Her foot hurt so badly she refused to walk on it.
Can you see the bruise on her pad?

There are a few conditions that are relatively simple, benign and resolve quickly but often present as a dog who refuses to bear weight on the leg.

For any dog who is either lame, or worst yet, carrying a limb, the best place to start is with a calm, relaxed, slow methodical hands and eyes on 'every-tiny-inch of the leg' approach. I see a whole lot of lame dogs, and I thought it might be helpful if I explained how I approach these cases.

Here is how I approach the pet who presents for "lameness."

When I am trying to determine the cause of a limp or lameness I always start with watching the pet ambulate. The best place to do this is in a closed, quiet, open room with as little furniture or hiding places as possible. In the exam room I will stand at the far corner and ask the owner to place the pet on the floor and calmly walk over to me as they coax the pet to follow. The pet will in most cases follow their mom or dad if they and this which allows me a few moments to watch them walk.

Analyze the walk
How much weight will they put on the leg? I scale lameness out of 1 to 5. 0 being normal, 5 indicating they will not put the foot on the floor.

This is my pup Jekyll. Grade 5, yesterday.
I corrected his cruciate rupture a week ago, on the other side.
Time for this one to be done is now ASAP.
And you think your dog has bad luck?

How much do the flex or extend at the joints? I want to see a good range of motion in every joint from the top to the bottom.

There are many subtle clues to a walking pet. They give me some hints about the bones, joints, muscles, and the nerves. When it comes to getting what you pay for an experienced eye from your vet can help your pet in innumerable ways. When a client calls me at 10  pm wondering whether their pet needs to go to the ER or whether they can wait until we are open I always tell them to send me a video. I can usually tell them with 30 seconds of a good walking clip.

The Physical Exam
I then try to take an educated guess where I think the problem is. If I think it is in the toe I look at the opposite leg from the shoulder down. Then I examine the lame leg from the shoulder down. Your hands do much of the work in veterinary medicine. We palpate for muscle size, lymph node size and number, bone pain and irregularities, joint swelling and range of motion, muscle size and sensitivity, etc. I try to palpate every muscle belly, every nook and cranny, and every anatomical structure in the leg. I also have to remember that some lameness results from an injury to the spinal cord.

When I think I have found the source of pain, (remember we are lame usually because we are painful) I then focus on what the root cause is.

Here's a tip from experience; For almost every single lameness exam, after I have watched the pet walking, I warn the parent that I am probably going to have to muzzle their pet. I know that people hate muzzles, for some reason they think they are cruel punishment devices?, or that it is a reflection of their parenting skills (sometimes there is a hint of truth to this), but I am looking for clues for the source of the discomfort/pain and I am asking the pet to respond. We all respond to pain differently, and when I am restraining them prohibiting their ability to flee that only leaves them with one other option. And so, I expect that in almost all cases the pet will respond with their best defense, a snip, a bit, a growl, and a harsh warning to back my inquisitive annoying self off. I don't blame them. I would bite the hand that hurts me too!

Remember when it comes to assessing the leg for lameness you have a cheat sheet. Use the other leg/foot to help identify differences. Subtle clues like;

• How much weight is being placed on the foot (a flatter foot has more weight on it).
• How long the toe nails are. Indicates how the foot is used.
• How the toes touch the ground. Is the pet reluctant or unable to place the foot correctly.
• What is the muscle mass from one leg to the other. A loss of muscle mass indicates dis-use, and more atrophy indicates either severity or chronicity.
• Is there saliva staining. A black/rust colored foot is a clue the pet is trying to tell you something.

My other pup, Charlie, who licks between his toes on his left foot.

Can you see the difference between the two feet?
The hair on the right foot is white, on the left its brown, from saliva staining.

This is Peanut.
Her mom noticed that she was intermittently carrying her back left leg.
Can you spot her boo-boo?

Peanut has a blister between her middle two toes.
For those of us who suffer walking around in a new pair of high heels we know how painful this is!

This pup was at being watched by a relative while her family was away on vacation. They are familiar with her seasonal allergies an have learned how to best manage them at home.The pet sitter didn't recognize that her allergies were flaring up. When her parents returned they were shocked to see how itchy, painful, and discolored she was.

Ellie Mae hands me a sore foot.

Ellie Mae's feet are brown, the toenails are dark brown at the base.
She has been sitting around all week licking her paws.
They ITCH!

The last place to look is the toenails. A broken toenail can be incredibly bothersome and most pets will lick at it incessantly and limp on the foot until the nail falls off or is removed.

Lorelei's nail is almost broken off at the base of the nail.
Every time she tries to stand on the foot the raw skin and jagged nail hurts her sensitive toe.

After a topical anesthetic was applied we quickly and pain-freely removed her broken toe nail.

Even though the toe is now bloody, the nail is removed and the toe can now heal without any pain.
We gave her a pain medication, something to soak the raw foot in to keep it clean and prevent infection.
A bandage to the foot and an e-collar an she will be right as  rain in a few days.

Quik-Stop to stop the bleeding.

Another happy, pain-free, limp-free customer.

My point is that limping pets arrive for a multitude of reasons. A good exam, a thorough history, a watchful eye, adept hands, and maybe even an x-ray or two, and most of our limping pets can be treated quickly, easily, and alleviated of their discomfort. Most limping pets are not an emergency. But the identification of the root cause, and a plan to assist the pet parents in understanding the consequences of waiting, and helping them to curb it in the future all help to find a quick end to a common presenting complaint.

The Treatment Plan

This should always be tailored to the patient and should address the following items;

How do we alleviate the pain?

How much time should it take for the lameness to resolve?

When should the problem be re-checked?

What are signs of the problem not resolving?

And, one of the most important, and frequently over looked parts of the treatment pan is; 

How can we prevent it from happening again? Understanding how this occurred and how you can prevent it will hopefully keep your pet pain free and out of the vets office. (Almost ALL of the toe nail problems occur because people are not keeping them trimmed).

If you have a question about your pet, or want to share your personal pet experiences with a community of pet loving people please visit us at Pawbly.com. Pawbly is always free to use and we welcome your questions and comments.

You can also find me at the clinic, Jarrettsville Vet, in beautiful Jarrettsville Maryland, on Facebook, and on Twitter @FreePetAdvice.

Advice To New Vets. My Top 10.

Pickles prep for neuter. Scabby Katie watches on.

I have owned my clinic, Jarrettsville Veterinary Center, for 12 years. I have hired about a dozen veterinarians in that time. Had anyone ever told me that I would be assessing so many vets over such a short period of time I would have never believed them.

Why we got to where we want to be.
Penny Lane sits pretty for a treat.

I remember vividly sitting in the large senior veterinary student lecture hall days before graduation about to be shoved out of the safe veterinary college nest, ready to test my wings, full of new life, vigor, lust for cases, and hungry to put books skills into real-life cases. We were getting a few last minute words of wisdom from the college Dean, who humble and genuine as he was, had never worked a day in private practice in his long tenured career. He stood above us lecturing on about “the world being our oyster and the horizon limitless.” I’ve no doubt it was the same sending off speech he had given dozens of times before. Each of us sat listening with our bloated with a stomach full of butterflies, the unknown of it all, and the anxiety of change upon us. I had been a college graduate before and I had a small suspicion that I would be heading to some suburb of Maryland to save dogs and cats. I knew myself well enough to whisper out loud that I wanted to own my own practice. Still I listened. Eager for any tidbit of sage advice to stuff in my pockets before I headed North to hang my vet shingle.

The advice I got was about "planning". He reminded us via poetic euphemisms about "picking a path along a road map of dusty dirt packed streets, and, not being afraid to follow previously paved roads established by our elders, and toll road speckled interstates we were about to embark upon." He also illiterated about using the knowledge we had been given, sharing the skills we were still sharpening, and keeping our minds open to new innovations, new advances, and the magic of medicine.

Lucy waits for her next puppy vaccine.
Safely between her mom and aunt.

Now I understand many new graduates probably don’t think much of listening to others advice, but, I should have taken the time to listen. It is tragic that each new generation is doomed to repeat the same mistakes simply because we think we are "too smart to listen." As someone now with an honest degree of private practice credibility I’ll put it into words for you few who might take heed and listen my advice on being the fledgling  about to leave the vet school nest;

1. Be humble. That’s a big one as you march forth with your wet diploma. Your client has a pre-conceived notion of what a great vet is. Humble is a part of that.

2. Be kind to everyone. Even the A-hole you want to drop kick when he yells at you for not giving his “rescued” cat a free neuter. It will pay itself forward I promise. And you will someday look back on all of your accomplishments and realize these cases were the most difficult and the most rewarding.

3. Be true to who you are. You don’t have to be anyone’s veterinarian except your own. In the end, and there is always an end, you will walk away alone. Just like you started.

4. Make decisions with a clear conscious and not an ultimatum from a client or a boss. You will retire with some ghosts and skeletons in your closet. Accept this, and relieve your burdensome conscious by at least knowing that in your heart you did what you thought was right and good, and not influenced by anyone or anything else. Other peoples definition of what or who you are supposed to be are whispers in the dark and rarely guide you in the direction you are meant to travel. If you show fear, doubt, or indifference you will build a persona of being the vet to the one timers. Transient people who make decisions based on coupons in newspaper inserts and will leave you as fast as they arrived.

5. Be brave. If you get out of school feeling a bit overwhelmed, under prepared, and over wrought with expectations, jump in anyway. If you don’t you never will. A year will go by and your reluctance to perform that emergency GDV surgery will become your crutch to refer these cases to specialists. Become a second set of hands to every single surgery that happens under your roof. Put term limits on apprenticeship regardless of the self-doubt and jump in.

6. Be an advocate for something. A rescue organization, a cause, a disease, a political figure, your community, something outside of your family and your paycheck. You will need a pocket full of favors somewhere in life. When life is firing you challenges from the muzzle of an M16 lean on these people. They will be your support and get you through the darkest days. We live in a profession where grief, despair, and suicide lurk. Keep a secret army under your white coat and use them. Your friends need to feel the same sense of purpose and empowerment that we get to feel every day. You save a parvo puppy you feel empowered, share that sense of purpose, let someone save you, it is the meaning of a veterinarian’s life.

7. Understand your clinic’s mission statement. You won’t know which way to paddle if you don’t know where the clinic is trying to go. If every new vet had a clear understanding of this cornerstone of their employers purpose the BS associated with negotiating CE, and every other line item of the employee contract would be avoided. Stop being focused on minutia details like 'modern vet equipment', 'time off', and 'allowances'. If your practice in solely rooted on a profit-loss statement then everything in your professional life will be too. If you are a vet who is more than the practices mission statement move on. A bad fit is never going to be anything at better than a 'tolerable' fit, and even that will at some point become intolerable. You can do better.

8. Understand your colleague’s motives. They are your best key to success and enjoyment in practice. Understanding the core of every person affords you the ability to build strong healthy relationships. You don't all have to be great at everything, but, it is super helpful if you are diverse in skill sets and work like a team. Not everyone can be the lead singer, or quarterback.

9. Understand your bosses perspective. You will be asked to make decisions when they are not around. Ask for guidance as often as you can so you can make the split second decisions solo when the time comes.

10. Don’t burn any bridges. This is a small tight knit community and word gets around. People will respect you for being opinionated but never vindictive or maniacal.

And when all fails, find a critter to love.
One of our TNR kittens sums it all up.

Related Posts;
Why Would I Hire You? My rant on hiring a technician.

Compassion Fatigue. When the candle you are burning at both ends consumes you.

Taking A Stand And Facing Consequences. 

If you have a pet question you can find me on Pawbly.com. I am happy to answer any pet related question, or you can assist others in their pet care needs by contributing your time and expertise. We are always free to use. If you would like to learn more about us you can find us online at JarrettsvilleVet.com, on Twitter @FreePetAdvice, or on Facebook, where we have inspiring stories about pets and vet life. I also have a YouTube channel where I discuss cases, conditions, and what to do if your pet needs help.

The Audacity To Oppugn The One Armed Bandit, And The Importance Of Good Leadership

I remember sitting in the lavish Captain's Office back on the old cable ship when the office was a spacious auspicious chamber worthy of a time when ships were built to reflect a certain elevated status. With magnificent views of the sea from 100 feet up both fore and aft you were pressed to just gaze out the portholes, but back then I knew that I was merely a fleeting guest. I never felt at ease on the Captains deck in spite of his upholstered armchairs, massive oak desk, custom painted ship oils on the walls, and I never stayed longer than my five minutes of dialogue required.

We were in the midst of a contentious debate about the risk and rewards of seeking a new crew member.

You see in those days it took about 120 people to perform all of the duties of laying fiber optic cable round the clock for three months to connect one side of the Atlantic Ocean to the other. The cable ship housed five departments; deck, engine, steward, transmission, and splicer/joiners. I belonged to the deck department where there 3 Thirds, 3 Seconds, a First Mate, Chief Mate and the Captain. The deck department, as we were collectively known, maintained every ship board requirement that took place above the water line. The ships were always at sea and we had a difficult time retaining Thirds (the lowest ranking Officer position) because it was a demanding job where you frequently out on a cold, wet, hard steel deck performing a boring monotonous task with someone who out ranked you always looking over your shoulder barking orders. It was an intensely hustling-bustling high pressure job as compared to the rest of the Third Mate jobs in the other merchant going fleets. A Third Mate on a cable ship had to have a brain, a back, computer skills, work 12 hour days, and you were at sea for the majority of your rotation time, versus the traditional cargo ships who were quietly at sea or in a different port every few days. All of the old salty mates with experience in what the normal side of shipping looked like quit before the our ship ever left the dock. That left us with green, right out of school, newly minted Thirds. If they were willing to stay after they got a day or two on the job the Captain was very inclined to settle for any warm willing body, than to take a chance on re-hiring someone who would quit and leave us one man short for a three month voyage.

Me, Third Mate, and Noah, my brother visiting in Portsmouth, NH.

I always argued this tactic.

My reasoning was that I would rather walk up to a slot machine pull the one armed bandit and take a chance on hitting the jackpot than to sit at a table where you know the house will never deal you a winning hand. If that bandit spits out a dud fire them at the first port of call, go back, sit down, throw in another nickel, pull the lever, try again. Until by chance, luck, and sheer loss of numerous failures, one Third Mate walks up the gangway that measures up to the rigorous standards you assign. Why keep lowering your standards, settling for sub par and jeopardize the project, the crew, and the already long voyage?

My home for 7 years.

I left the cable ships after 10 years, but I still remain stuck in this mind-set. I am not afraid to try to find someone who measures up no matter how long it takes me or how many people I send packing down the gangway. What I am unwilling to do is waiver on my expectations and jeopardize my crew and my clients.

The Engineers, the heart of every ship and always the most entertaining.

So here I stand, now Master of  my own veterinary clinic, in charge of the hiring, firing, and course we take.

My obligation to my crew remains what it always has been;
I am responsible for the integrity of this business, the safety and well-being of every member and guest aboard, and I know that there may be days of stormy winds, treacherous seas, and forces beyond our ability to predict, but no matter what life or the sea throws at us I will never leave the bridge and will never abandon the souls I am entrusted to care for.

First Mate, on work boat buoy ops.

How do I explain to my clients why there is a change in my crew? Why do I go through so many Thirds? Well, just like on those ships, I have rigorous high expectations, and sometimes it just doesn't work out. There are a few great long time staff members who remain with me, and a few who are happier on ships with different articles, ports of call, and Captains.

After a decade with the same shipping company and almost a decade at Jarrettsville Vet you realize that these two places are like many of the rest of the places we all work at, your job is your home away from home. I have a family of people who I love dearly, some who I no longer sail with, but who will always be a apart of who I am, who I learned from and who shaped me into the leader I am now. And now I have a family that I work with under a roof cemented to terra firma who I remain fiercely loyal to keeping and maintaining in a place that  fulfills their purpose, passion, and is a happy, healthy,  on a daily basis.

I know that most veterinary consultants recommend that anyone thinking of owning their own veterinary clinic take a few business classes, and yes, having some business acumen is incredibly helpful, but I think that after 9 years of own practice I would say that leadership skills are paramount to any other.

If you have a pet question please ask me on Pawbly.com.

If you have a dog or a cat that needs exemplary veterinary attention please visit me at Jarrettsville Vet,

And, if you want to find me on Twitter I am @FreePetAdvice.

And if you think that the cable ship sea going life is the life for you, here's some information on it here.

For information on how to become a ships Master visit my journey here.

The Skeletons You Can't Take With You

We all have baggage. Those little skeletons we try to keep hidden away under subconscious lock and key in the desperate hope that no one uncovers our secrets.

For every veterinarians proverbial medical bag there is an unseen dumpster full of regret, self-doubt, and lost cases. I suppose that at some point we either get so busy that we don't have time to sit and reflect on these, we decide we in fact have no idea of what we are doing, or we try to remind ourselves softly, kindly and gently that we are indeed human, we do not know everything, and that sometimes fate decides for you, in spite of you, and without consulting with you. Boy is that frustrating.

If you truly can forgive yourself and keep plodding through the day to day life of cases you learn to get better at recognizing the subtle clues a pet gives you. If you trip and march on long enough you can occasionally give fate the finger and save a pet from following in the footsteps of a case that got you screwed in check mate before. Boy is that liberating.

Stubbornly blind determination can be a good tool to help you get through those dark days. Your good clients will be grateful for it, and your bad cases might actually live to see another day. It is the flip side to ignorance is bliss, but the only way that you can walk away with a clear conscious should fate decide to throw you a fastball.

For all of my most painful cases this one trait has gotten me through the darkest of days.

Saying goodbye, losing a case, and the feeling that fate stole another soul from my clutches is a difficult task that never gets easier. But for every face whose eyes have stared back at mine begging for a release from the pain and suffering I always say the same thing, "I am sorry, I am trying, and I am on your side."

There is great humanity in humane euthanasia. There is great grief in not understanding how fate can keep you at the poker table, bluff you, break you, and keep trying to bankrupt you. And yet we stay at the table, deal another hand, and tell ourselves "maybe I can win this one?"

If you have a pet question, need, concern or a desire to help other pet people please visit us on Pawbly.com. We are a free open online community dedicated to helping pet people by exchanging information to better pets lives.

You can also find me at the clinic, Jarrettsville Vet, in beautiful Harford County, MD, or on Twitter @FreePetAdvice. 

The Skeletons You Can't Take With You

We all have baggage. Those little skeletons we try to keep hidden away under subconscious lock and key in the desperate hope that no one uncovers our secrets.

For every veterinarians proverbial medical bag there is an unseen dumpster full of regret, self-doubt, and lost cases. I suppose that at some point we either get so busy that we don't have time to sit and reflect on these, we decide we in fact have no idea of what we are doing, or we try to remind ourselves softly, kindly and gently that we are indeed human, we do not know everything, and that sometimes fate decides for you, in spite of you, and without consulting with you. Boy is that frustrating.

If you truly can forgive yourself and keep plodding through the day to day life of cases you learn to get better at recognizing the subtle clues a pet gives you. If you trip and march on long enough you can occasionally give fate the finger and save a pet from following in the footsteps of a case that got you screwed in check mate before. Boy is that liberating.

Stubbornly blind determination can be a good tool to help you get through those dark days. Your good clients will be grateful for it, and your bad cases might actually live to see another day. It is the flip side to ignorance is bliss, but the only way that you can walk away with a clear conscious should fate decide to throw you a fastball.

For all of my most painful cases this one trait has gotten me through the darkest of days.

Saying goodbye, losing a case, and the feeling that fate stole another soul from my clutches is a difficult task that never gets easier. But for every face whose eyes have stared back at mine begging for a release from the pain and suffering I always say the same thing, "I am sorry, I am trying, and I am on your side."

There is great humanity in humane euthanasia. There is great grief in not understanding how fate can keep you at the poker table, bluff you, break you, and keep trying to bankrupt you. And yet we stay at the table, deal another hand, and tell ourselves "maybe I can win this one?"

If you have a pet question, need, concern or a desire to help other pet people please visit us on Pawbly.com. We are a free open online community dedicated to helping pet people by exchanging information to better pets lives.

You can also find me at the clinic, Jarrettsville Vet, in beautiful Harford County, MD, or on Twitter @FreePetAdvice. 

Charlie's Life Saving Lipoma Surgery. (Warning graphic surgery photos.)

Helplessness is despair with a straight jacket on.

When you are in this place mercy is your only prayer.

We saw it four times in four separate patients two weeks ago.

People can call me a "sucker", a "bleeding heart", a million other things, and yet, each case was a miracle disguised as a pathetic plea, and every case walked out of Jarrettsville Vet's door with a second chance and a grateful parent. It is what we do here. It is who we are, and it is part of the reason people drive from far and wide to get to us. Am I tooting my own horn, absolutely! Why?, well because I believe that there is always hope and always a chance, IF you try. I believe that part of my job is to help people, remind myself that I am just an interpreter of disease, and that the biggest failing I can ever have is to remove hope.

This is the story of Charlie. He arrived two weeks ago to be euthanized. But, I just didn't feel right about it. My gut couldn't accept that his only option was death. That story here.

I stuck my neck out, I donated my skills, and together the staff at JVC saved Charlie's life.

Before Charlie came to us he had been to three other vets. They were correct in warning his family about all of the possible outcomes of his condition. There were a ton of unknowns. That's what life and medicine is. That's why medical advances and the luxury of diagnostics came into existence. On the human side doctors have been beaten by angry, bitter, entitled, victims who have sued or harassed enough doctors that they now will only make a decision after appropriately covering their butts by performing every diagnostic possible to be able to proceed with a clear defined treatment option. It is certainly the ideal way to practice and save lives. But, this has come as a terrible trade-off. We get so frightened to allow ourselves to be vulnerable that other patients suffer. There are now well documented "minimal standards of care" for everything. These are the protocols and practices we are required to recommend. These also give us the protective excuse to dodge our clients ability to pay for treatment. We have yet another convenient excuse to remove ourselves from the case. No dirty hands, no weighty guilty conscious, move on to another paying customer. The reality is that most people cannot afford all of the diagnostics we want to do before we assist a patient. The other reality is that many treatable patients suffer or die because of this.

The decisions made from this point separate the mavericks from the meek, and save lives. It is that simple.

Have we lost the ability to practice the kind of medicine our forefathers did decades ago? When diagnostics were a rumored luxury, when medicine was half gut guesses, half attempts at swinging the bat to try to hit one out of the park, and attempts to help without all of these was the norm?

Charlie was a risk on almost every front. There were no funds to run diagnostics, (every vet before me had drawn their line here and walked away with a clear conscious). The imaging that he had done years ago was not available for me to reference. He had an ENORMOUS mass in his leg and I had to go by my gut and my skill set to determine if this surgery was likely to allow a possible improvement in his ability to function. But, then again,,

He was at the clinic to be euthanized. His parents believed there was no hope and he was losing his ability to walk, urinate, and defecate.

When it comes to basic life functions my list includes;

1. Ambulate. A pet must be able to ambulate, with or without assistance. Few pets are happy or content to simply remain paralyzed and lie in their own excrement.
2. Eat and Drink. 
3. Pee and Poop. 

If you can't do these the question of quality of life needs to be discussed.

For all the money that they had spent previously they had been filled with words of discouragement, too many worst case scenarios, and believed that their only options were to perform more expensive diagnostics which they could not afford. So, here they were at my door in deep despair feeling like there weren't any options available, and that he would be better off dead.

Except for the fact that running around the room wagging was Charlie. Charlie wasn't anywhere near ready to die. I wasn't ready to abandon one of my primary veterinary guidelines, "The pet always decides. They always tell you the answer if you listen."

I called my surgery specialist friends for advice. What I got was a list of diagnostics to do, information to gather, and a pep talk about how to proceed based on a every possible scenario. They were incredibly helpful, supportive, and a bit envious that I could try to help when the facilities that they work for would never allow them to.

I had many conversations with Charlie's owners. They understood what might happen  and they were willing to try. It all starts with that. You have to care enough to try.

Charlie's grossly abnormal leg, camouflaged in a wiry coat.

Last Tuesday morning we tried. Charlie had the most successful outcome imaginable. His surgery was relatively easy and any first year grad could have successfully cured Charlie with his lipoma removal.

As the hair is shaved off the leg reveals itself.. and no one is left to wonder why he was having such a hard time walking, peeing, and pooping.

Shaved of his wiry hair, you can now see what Charlie had to deal with. His leg is about four times the size it is supposed to be. To the touch this is firm and solid. 

Veterinarians use their hands as we do our eyes. Your hands can feel size, texture, and tell your brain what your eyes can't see. To the normal by stander Charlie looked normal. If he was standing still there was a mildly detectable abduction (away from the body) of his back right leg. At a walk there was also a mild limp. Not until you put your hands on his thigh could you understand the magnitude of his dilemma. When I was palpating his leg my hands couldn't tell my brain what was under this pups skin. Clients often don't understand why the vet wants to run so many diagnostic tests, but it is a guessing game without them. Charlie was a whole bunch of unknowns for every single step we took with him..until we got him to surgery.

There has to be a plan for every treatment strategy. It should be discussed as best case AND worst case scenario. Everyone should understand the consequences, even the most remote, and the plan should always be agreed upon before the first swipe of the scalpel. 

Charlie's surgery contained too many unknowns, (based on a lack of resources to run diagnostics, and the position of the husband), therefore, his pre-op plan was even more difficult to  address.

I knew that Charlie likely had one shot. One attempt to go under the knife, one chance for this dilemma to be resolved or he would be euthanized. I also knew that if this was NOT a simply removable lipoma that the next best option for palliative relief would be an amputation.

Amputations are fraught with emotionally charged discussions. Of all of the treatment options that I discuss with people this is by far the most reluctantly agreed upon option. Most clients will drag their feet, procrastinate this decision until the pet is about to be put to sleep. It is also my least favorite surgery to do. I hate them. They are long, exhausting, and cumbersome. 

Charlie's mom did not want to talk about this, but I needed her to. I needed to hear that she understood the case  had possible unforeseeable unwanted outcomes. I also told her that for me to try, on this first surgery was me getting myself emotionally invested. I did not care to stick my neck out to be told that there were no future options. I understand that this is a selfish thing to say, but I had to say it in the beginning. I had to be honest. 

Charlie, like every case, was hope for the best, but plan for the worst.

This is what best case scenario looks like;

Using my fingers to probe from a small incision under the most superficial muscle lay... a soft squishy mass.

The emergence of a large fat pad.

In the hopes that the entire mass is a fatty tumor I probe the mass all the way around the leg.

Four large fatty tumors (lipomas) merge to form one large circumferential mass that has been growing for years. Because they lay under the muscle they did not feel as if they were the normal soft fluctuant superficial mass that most of them are.

The immense size of these space occupying lesions is evident as they lie on the surgery table.

Even with the fat being consolidated there are still numerous vital structures that reside deep in the thigh. Dissecting these out (think blood supply and nerve function to the foot) requires careful finger tips, (nothing sharp belongs in here!). I had warned Charlie's mom that there might be some decreased nerve function (often manifests in the form of dragging the foot, or not righting it normally to place the toes at the step/walk), but as long as you don't sever the nerve they often improve with time to a normal walk. 

The large pocket the fat left behind. The muscles of the leg are small, flaccid, and not in their correct anatomical position.

There is also a large pocket of dead space left behind.

I can remove the extra stretched skin, but the rest of the leg will heal and re-find its normal position with time and resolution of normal range of motion and ambulation.

Lots of extra stretched skin.

The extra skin removed so the incision closes normally and the leg retains its shape.

The leg profile after.

Almost 4 pounds of fat were removed from Charlie's (pre-op) 24 pound body.

Charlie at his 3 day post-op check. He has exceeded all recovery expectations. I feared he would have difficulty remembering how to use a leg that had encumbered his ability to move for almost a year. I also worried that there would be nerve damage to the nerves that tell the foot and brain how to walk because I had mucked around the area they reside in as I peeled the fat out of the muscles that protect the arteries, veins, and nerves. But there he was walking around perfectly.

At two weeks post-op Charlie's body perfectly reflects the demeanor he has never flickered from. He is a beaming bubbly boy with a long happy life left to live.

Some stories do have a "Happily Ever After," 

I wish Charlie and his family many happy wagging days to come.

Here is Charlie in 2018;
Still the same happy, unstoppable boy he always has been;

If you have a question, concerns, or just want to share your pet knowledge with our pet enthusiasts please visit Pawbly.com. We are a free pet community with a big heart.

You can also find me at the clinic, Jarrettsville Vet, or on Twitter @FreePetAdvice.