Entropion, the Feline Version. Why A Cream Can't Cure Everything.

Most examinations start the same way; Patient and clients escorted to an exam room by technician. Technician gets history, weight, temp and a summary of presenting need. This appointment was a little different from the get-go; cat on scale, parents waiting, and scribble in chart reads, "Client wants eye cream." I entered the room with an open mind and a blank exam chart page.

On the other side of the exam room door I was greeted with; "Doc, we are just here for a cream." Not much of a "hello," and straight to business.

But let me go back and set the stage. Sitting before me on the exam table was a cream colored rather tawdry looking fellow. Standing in front of him were his parents, an elderly coupe who also doubled as his muscle and protection. They were not here for a chat, they simply wanted an  eye cure cream,. They appeared to be on a tight schedule, and had no desire to meet me or start this relationship with a silly nicety like, "Pleasure to meet you Corky, I'm Dr. Magnifico. what brings you in to see me today?"

"OK, what kind of cream?" I replied. It is sometimes better to meet short and direct with the same and those routine examinations can get a bit mundane.

"Well, our friends had a dog with the same condition and their vet prescribed a cream which cleared it right up." Sit, sigh, fasten your seat belt. There is some mysterious illustrious miracle cream out there that never has a name,, yet people seek to find again,,perpetuate its elusive existence,  and the legend lives on. Much to the chagrin of every veterinarian there is not a cream that has magical powers. We treat a condition after it is diagnosed, then maybe after there is a cream. And, I promise we do not withhold the "miracle creams or pills" for the other clients.. After I explained this hey stepped away from the table and allowed me access to their cat, Corky.

"We saved the goop in the eye so you could see it." (For those of you out there who do this I would like to add a small polite humble side note; We know what goop looks like, and we believe you. And, personally, I am going to wipe it away becausse no one wants to sport goop in public. That's just embarrassing).

They rambled on for some time as I stood scribbling the important tidbits of information sprinkled between the miscellaneous stories of past veterinary experiences. It also seemed that they didn't see my white coat as bringing much to the proverbial treatment table..something about the "eye had been this way for years",,,"the goop gets bad and then a cream (still didn't know what cream we were referring to) gets it better,"  "Corky is an indoor only cat," and they "wanted the best for him." OK, common ground, I felt a bit more empowered and they took a pause.. (I think just to see if I was still present).

We are trained to start with a history. A good listener makes a good veterinarian. But the path to greatness is paved with good intentions and a thorough examination. 

This is what I saw..

Can you see Corky's problem?

 Maybe if you compare the top photo to this one?

Corky has entropion. His bottom eyelid rolls in and the hair on the lid brushes the cornea every time he blinks. This is painful and traumatic to the cornea. In an effort to reduce the irritation the eye produces excessive tears. The only way your eye knows how to get rid of an irritant is by flushing it out.

After a brief discussion and a tiny bit of  reinforcement that I was comfortable with both the diagnosis and treatment plan Corky's parents eagerly signed him up for his corrective surgery the following week. Turns out their initial gruff demeanor was just a case of over protective parents.. I have a very big place in my heart for people who adore their cats, and  they truly wanted nothing but the best for their Corky.

Corky left the exam with eye ointment to help heal the abraded cornea, updated vaccines and some pre-op blood work. His initial consult was $260.00. He was scheduled for surgery the next week, pending normal blood work.

Here he is on surgery day.

Entropion surgery entails correcting the eyelids so that they lay normally over the eye. This requires removing the slack or excessive skin so that it can open and close normally. This allows the tears to be evenly distributed, thereby keeping the eye clean, lubricated and protected. Corky had too much skin on the bottom lid. To tighten up this he needed an elliptical piece of skin removed.

 Corky also had an excessively long bottom lid so I shortened it.

Post-op Corky's right eye looks better already!

As with most patients with entropion, the condition is bilateral. Although Corky's left eye was not goopy it did roll in a little bit, and a little piece of lower lid was reoved to keep him squint free on the left side all of the rest of his days.

Post-op Corky has incisions under both eyes and an eyelid correction for the bottom lid on the right side outside (lateral).

Post-operatively Corky also needed an e-collar. Never over look this important medical device. A cat will lick or rub something that hurts. It is very important to keep the eyes protected from the paws rubbing, especially in light of needing to apply ophthalmic ointment every few hours. I know every pet hates an e-collar but they can save you both time (not needing to re-do the incisions), and money (again, not needing to re-do the surgery).  We place the e-collar on before they wake up completely as it can be difficult to do when they have all of their faculties and weapons on stand by.

Corky's surgery cost was $378.00. This included an i.v. catheter, i.v. fluids, anesthesia, entropion surgery bilaterally, pain medications post-op for three days, an e-collar, and ophthalmic antibiotics. 

Here is Corky at one week post-op, still a little bit of discharge but the cornea looks good, The eyelid is not red, swollen nor is it inverted and rubbing the eye.

The other important finding is that Corky holds his eyes open and they appear calm, quiet, and comfortable.

This is Corky at two weeks post-op. I do not charge for post-op re-checks. For me it is about encouraging compliance and monitoring, and assisting my clients and patients with an optimum outcome.

I spoke to Corky's parents today. It has been about a six weeks since his surgery. They reported that there has not been any eye discharge and that he is doing very well. Their only concern was that the hair we shaved for his i.v. catheter and around the eyes wasn't growing back as well or quickly as they had expected. I told them that sometimes this happens, we don't quite know why, but over time it should.

So, what I am most Thankful for this Thanksgiving? Having a job that I love, clients who love their pets, and a family to be surrounded by. Happy Thanksgiving Everyone!

If you have a pet question you can find a slew of helpful generous people at Pawbly.com. Pawbly is a free resource for pet people to ask questions, share advice, build relationships and we are always centered around how to provide better care and resources to pets. Pawbly is free for everyone.

If you would like to talk to me about my pet services at the clinic, Jarrettsville Vet, in Jarrettsville, Maryland, you can find information here. Or visit me on Twitter @FreePetAdvice.

Custard's (Almost) Last Stand. The Blocked Cat Meets Tailio

The cases I fear the most  arrive as quiet still patients who are oblivious to the fact that they are in the vets office. The cat who lies in their moms arm barely able to lift a head to face the barks and bustling of a busy veterinary clinic. Such was the case for Custard. He appeared to be sleeping soundly in a carrier on his moms lap. A cat never sleeps in a carrier when they arrive at the clinic.

With every pass I make through the waiting room I am always scanning for the still beast in the box, the swaddled pup in the blanket, or the sobbing person waiting. There are intuitive glances, postures, and the abnormal sounds of experience that I am always keeping my subconscious listening and looking for. You see I know that there should always be a look of concern, curiosity, some element indicating engagement in this is foreign place. We are a veterinary clinic a land of odd smells, unfamiliar noises, and a sixth sense of wonder and reservation. For the pets who arrive without this I worry and I jump in without pause.

I went to Custard immediately. I gave a very quick "hello" to his mom and without permission opened his carrier. He gave no response, and with that I told his mom I needed to take him to the treatment area right  away. In the second of her glance I knew that she was realizing her worries were just solidified.

A lifeless barely conscious Custard.
I am removing as much urine as possible before we
try to pass a urinary catheter to relieve the obstruction.

Custard barely responded to being taken out of the carrier, carried away and had no movement as he was placed on the exam table. I was certain that when my hand found his belly I would discover a large hard bladder.

Custard was what we call a "blocked cat." He was unable to urinate to empty his bladder. He was also very close to death and his chances of survival without immediate care were nil. I immediately removed as much urine as I could, about 100 mls of dark urine, while my associate started to prep to place a urinary catheter.

With this diagnosis time is your nemesis. You do not have a second to waste and everything in the building is put on hold until the bladder is patent. Unblocking a cat is about returning them to a place of homeostasis. This includes the ability to thermoregulate, free from infection, blood loss, build up of toxic levels of potassium (toxic to the heart), and puts a significant (although usually temporary) insult on the kidneys.

There are a few instances where veterinarians will act quickly and directly, a perceived blocked is one of them.

Here are the signs you should be aware of that might indicate your cat has a urinary blockage;

1. Repeated trips to the litter box
2. Crying or vocalizing in the litter box
3. Only producing small amounts of urine
4. Straining or posturing to urinate
5. Lethargy, acting tired, or painful, or weak, or even vomiting.

A blocked cat is an emergency. They can die if they wait for help. Custards mom was not surprised when I returned to tell her that Custard was blocked. She had lost another cat to this a few years ago, and Custard was acting just like the other one had. She brought him in to see us as soon as she realized this.

With the diagnosis comes the treatment plan. To treat a blocked cat requires about three (or more) days of hospitalization and care. The estimate we gave her was about $800, if everything went without any obstacles. 

Custards chance of lifesaving care depended on our ability to meet a very tight budget. We didn't have resources to do blood work, or any diagnostics of any kind. 

This is Custards urine collection bag,
his urine is significantly hematuric, (very bloody).

Custard arrived at about 5 pm. He was lifeless, cold, and barely clinging to life.

By 8 pm (closing time) we had gotten Custard warmed up but he was still very poorly responsive. I secretly hate these moments; when a pet is dying in front of  you and your back is to the wall. Our clinic closes at 8. There is no overnight staff, and we still had Custard bundled up unconscious and barley alive. I was stressed, worried and knew that he needed to be closely monitored, kept on fluids, and I couldn't walk out the door, turn off the lights and sleep tonight. I still take these cases to heart, I still can't convince myself that someone else's financial struggles, declining to transfer to the ER and a cat on the brink are not my problem.

I swaddled him up in blankets and placed him in a cat carrier to take him home with me for the night. I wasn't going to be able to sleep anyway, so I figured that I might as well give him the best chance that I could. And if he tried to die I wouldn't have to live with regret that he suffered by himself. The husband at home, 4 other cats, and 2 dogs wouldn't be surprised or upset with me arriving with an unannounced overnight guest.

At 9 pm I was still shielding myself from being too hopeful that Custard would survive. He wasn't looking like he was improving and he had arrived in such terrible shape.

By 1 am he could lift his head and open his eyes. I was so elated and relieved! With these guys better is significant. If they can get to better they can walk out of the hospital,,

IF they have enough time and monitoring. Here are the important monitoring points;

1. Fluid therapy is vital. Intravenous fluids keep the bladder flushing. Whatever caused the blockage needs time and fluids to flush it out, crystals, red or white blood cells, crud,, whatever.
2. Pain management. These patients strain, lick and posture because it hurts to hold urine.
3. Antibiotics. Even if the cause of the blockage isn't caused by infection shoving a plastic tube up the urethra can introduce infection, never mind still having to deal with fecal output happening in very close proximity to the urinary genitalia.
4. These guys benefit significantly from 24 hour supervision. There is an iv catheter going into one foot and a urinary catheter from the penis. They can, and do, get tangled. Also, the urine is still so bloody or infected that the urinary catheter can become occluded and they become blocked again.
5. Warmth, feeding, adequate oversight to monitor for changes is also vital. For instance, Custard was on three different antibiotics, a bladder muscle medication, and was montiored for fever, and bladder tone every few hours. Then he decided to stop eating, (don't quite know why), so we had to start force feeding as we started to guess why he was no longer interested in food. He also had terrible diarrhea to complicate the treatment.

It took about 4 days of iv fluids, urinary catheter flushing, and TLC to get Custard back to being able to urinate a normal amount of clear urine. He needed antibiotics, pain medications, constant i.v. fluids, and even force feeding for a week. He was one very sick kitty. But Custards incredible story doesn't end there.

You see Custard came to us as an unneutered cat from a colony of cats that lived in a barn. He was the first (and so far only) unneutered cat that I have ever unblocked. His caretaker provided the funds and permission to let us treat him. (For those of you who know me I have a very difficult time NOT trying to treat a treatable pet, I wasn't going to accept a "no" easily). There are very few people who care for a feral colony with this much love and dedication.

After a 5 days of treatment Custard was still spiking a fever (evidence of residual infection) and was reluctant to eat. In an effort to get him well enough to leave the hospital we offer what we call "the endless cat food bar." I sent a tech to the grocery store to buy him some unusual options.
Here are some of my recommendations for picky cats;

1. Baby food. Try the meat flavors. Super stinky to get the nose thinking.
2. Canned tuna. The traditional feline favorite.
3. Cooked chicken.
4. Junk food cat food. The only time I recommend buying those cartoon caricatured, day-glo colored cat foods that you find at the low end of the price range.
5. Kitten food wet and dry.
6. Cat snacks from the normally forbidden grocery store cat food section.

How is that for options? We label the many samples in the hopes of finding one he might take a liking to.

Signs that we still have an angry bladder. A tiny spot of urine is produced.

Another sign of a urinary condition, licking at the genitals.
A cat licks what hurts.

After a week Custard was healthy enough to start his vaccines, be neutered and begin a life as a loved kitty. Can't you see the love and gratitude in  his eyes?

Custard came back to visit a few weeks later to finish his kitten vaccines. He has earned himself a spot inside with a family and remains a very calm, confident, sweet boy.

Many would have dismissed Custard as a difficult case. He had no vaccine history, a litany of complicating factors, and a list a mile long with reasons to not try to save him, but he also was a cat with a person who cares and wanted to give him a chance, and it wasn't just me this time.

Here are my take home points when it comes to blocked cats;

1. They can be expensive. Our estimate is about $800. They usually require about 3-5 days of hospitalization.
2. They are usually treatable.
3. They need immediate medical intervention.
4. They can be treated affordably and reasonably. Ask for an option that is affordable. If nothing more unblock them and take it day by day. It is not advisable, but we started treating without any vaccines or any diagnostics. I know the blood work and urine are going to look awful when I start treating a blocked cat, it isn't going to change what he needed immediately. FeLV/FIV status is relevant to the discussion of long term care.
5. If they block once, there is a very good chance that they will block again. You need to change what you are doing to help avoid recurrence. The food is almost always the culprit..

This common ailment has early detection signs, like frequent trips to the litter box, frequent straining, producing only small amounts of urine, and excessive pawing at the litter once inside the box. There is a new tool to help pet parents identify when these are occurring. The ingenious tech device is called Tailio. Tailio works by collecting information from the litter box and it can then be used to understand subtle changes in your cats behavior. They like to describe it as a tool to help pet parents evolve from "Reactive to Proactive to Predictive." In essence they can put more knowledge and subsequently more power in your own hands,, They are in their first round of raising funds, visit them and pitch a nickel on KickStarter here.

And for the rest of you pet loving people, please visit me on Pawbly.com. Pawbly is a place dedicated to helping people and their pets by providing a free unbiased platform for the open exchange of information. You can ask a question, share a story, or even just be a beacon of hope and compassion for others.

You can also find me on Twitter @FreePetAdvice, the clinic Jarrettsville Vet in Harford County Maryland.

Never Surrender Your Voice..

My first contribution to Everyday Health..

Debarking: Cruel and Unusual Punishment for Dogs

By Everyday Health Guest Contributor

Published Nov 18, 2014

By Krista Magnifico, DVM, Special to Everyday Health

(Abbreviated blog)

In case you’ve never heard of it, debarking used to be considered a permissible and reasonable practice for vets. If a client complained of an incessantly disruptive pet, the vet would surgically remove, or damage, the dog’s vocal chords. A muffled, throaty whisper of a woof would result, like a lifelong case of laryngitis.

Why am I so opposed to debarking dogs? If it is important for us to remember that we each have our own voice and must be true to it, why isn’t the same true for the rest of our family members?

Dogs bark for many reasons, and they only bark for reasons they believe are completely justified. It’s not like singing in the shower, humming a little tune to make ourselves happy, or whistling on a sunny day. Dogs only talk with purpose and intent.

There are no stupid dogs, there are only dogs trying to tell us something. Like “beware,” “intruder,” “far-off dog barking,” “I hear a storm coming,” or “I’m bored/lonely.” Dogs talk when they need to tell us something. Muffling that voice is denying them their purpose, their protection, and their voice.

We all have a lot to say..

For my entire article on debarking please visit Everyday Health here.

Post script;
I received a few comments to this blog from veterinarians. Overwhelmingly they all felt as if they did not want to perform this procedure but thought it was an acceptable option when elected as a last resort to surrender or euthanasia. I hear the same thing from the vets who believe that declawing is acceptable if it will save a life and place a pet in a home. Do I think that anything is acceptable in the face of death? Well, I suppose that life is always more valuable than death, but I also hold all of us to a higher standard of compassion and humanity and I still see parenting as an elective choice fraught with responsibility and an expectation that you will be a better person if only because someone else depends on you to be. How is expecting someone to conform to what I expect them to be a way to honor the beauty of an individual?

Krista Magnifico, DVM, is the founder and chief creative officer of Pawbly.com, overseeing creative vision and user experience. She earned her veterinary degree from the Virginia-Maryland Regional College of Veterinary Medicine in 2005, and has had her own practice in Northern Maryland since. She has a strong interest in animal welfare and educating and inspiring people to take better care of their companions. Follow her on Twitter @FreePetAdvice.

This article was published on Everydayhealth.com. Everyday Health is creating a pet health column for pet health and I am honored and excited to be asked to participate in their quest to provide columns to inspire, educate, and provoke their audience. Their audience is 40 million users, 50 million newsletter subscribers, and 5 million social media followers. They provide helpful, credible content on a wide assortment of health topics. Give them a peek today, check out the recipes!! (and if you find a good one could you bring me a small sample)? Thanks!

Related Blogs; Twitter Trash Talk

There Has To Be Mercy Before Money. Why are we failing our clients at the expense of our patients?

Loon, our resident house cat mans the front desk.

I have become almost completely obsessed with the idea of creating a place that both helps and changes the world. I suppose it is a lack of disorder in the few quiet times of my day. I watch my sister go from the chaos of work (much of which I have dumped on her) to her home of 2 kids, three dogs and two cats (one being 90% feral) and I realize that she only has time to sleep when her batteries flag red, flicker and cut power to the rest of her body. There is nothing outside of her immediate sphere of responsibility that she has much time to chew, ruminate, and ponder. Secretly, I think her empire will likely long out live mine. But, yet, I ponder away....how can I create a place of meaning, a work of compassion, and change the way we care for our pets?? Not only am I trying to build this on a community scale with my practice, I am trying to build it on a global scale with Pawbly.

Dr. Morgan works her magic.

I suppose I have earned my self appointed entrepreneur title. I see a problem and I immediately pick apart the opportunities to improve upon, or, resolve it. I actually don't look for how things are working well or efficiently anymore, I look for the hitches in the machine.

I am completely determined to disrupt (also obsessed with that word) the current flawed system that discourages people from seeking, diagnosing, and treating their pets. I would normally place a current stat about what percentage of pet people I am referring to, but (small thanks from my soul) no one keeps track of that*. From my own clinic I would guess that 80% of my clients are reluctant to seek after hours emergency care, 50% refuse to ever go,  (many based on previous experiences), 60% cannot afford specialty clinics, and when I speak about the entire pet population in my community I would estimate that 30% of the pets don't get any care outside of food and shelter and a rabies vaccine, and 20% aren't even considered a pet (feral cats).

That's a lot of pets falling through the cracks and in need of additional help.

Coot, (Loons brother), strikes a pose.

Where are the cracks? Well, they exist in every community, every facility, and every pet centered business. We have become a nation of haves and have-nots, and the gap grows larger with time. As my practice grows and persists I am reminded daily that for every pet I see I know there are at least 2 who need care but will not get it. It is my veterinary practices goal and motto to not turn away a pet in need. Sometimes that service is in the form of a free euthanasia to relieve suffering, a payment plan, a donation from our generous donors, or a free moment of my expertise. There has to be mercy before money.
For my clients I have an ear, a hand, and options. It is very important to have a relationship with your veterinarian so your pet has an advocate in their corner. I now am seeking to extend this relationship to the other care facilities that we refer to. This referral network goes up the financial spectrum, for instance, specialty facilities like surgeons, cardiologists, dermatologists, and down the financial cost lifeline, like, rescues, shelters, fosters, etc. Between all of these there needs to be an open communication network AND a safety net.

Of course it's time for a disclaimer. I have many clients who are very happy with the care they receive elsewhere in the wee hours of the night when my clinic is closed, dark and quiet, or those who are seeking a specialist to guide their pets care. In fact, while preparing for this blog I asked my clients what their experiences were. I received many emails from clients who had excellent experiences at all of the facilities we refer to. Many felt that the emergency and referral clinics were compassionate, flexible, and provided outstanding life saving care.

Unfortunately, I also have a few clients who live pay check to paycheck. For those with disposable income there are more options and more favorable outcomes. Everyone might think that I am crazy to care, or chase the smaller spare change when there are enough big spenders out there.. But I see too many pets with neglectful parents who are stuck between being able to and wanting to and I refuse to believe that there isn't a way to make a difference in the life and health of every single companion animal.

Finishing up a cruciate repair with a our amazing staff.

I believe that much of the root of the problem lies in differences in our perspectives. I own a small rural practice that has been in existence for 80 years. I am a part of a legacy that I intend on passing on to another person in a few decades. I know that my clinic serves families who came here with their grandparents pets. I hope to see the same children with their grandchildren. I have to build strong relationships based on trust. I live and I die by it. I am not a one time stop for a once in a lifetime tragedy, and I am invested in the care of my clients and patients. This concept of trust and building long term relationships is becoming more and more foreign and will cost more and more veterinary facilities. It is not the low cost vaccine clinics, spay/neuter clinics or online pharmacies that will be  the undoing of you, it the your inability to be a part of your clients family.

I believe that all of us who love pets as family members need more options. I also believe that veterinarians are generous, compassionate, and genuine.

Here is the key; Figure out a way to disrupt the current system to provide better oversight and assistance for  the people and pets that my clinic serves AND use that system to build global assistance. You see, I might truly be crazy, but I still care even after I turn on the closed sign. And, I care even if you live a continent away and think no one else does.

Stay tuned.. I have a plan....

So, I want to hear about your experiences. Your concerns, and where you think we need to be paying more attention so that we can help you take better care of your pet 24/7/365.

* There have been some studies done, most notably by Bayer, focused primarily on cats, but, I believe a HUGE portion of the cat population remains unclaimed, unseen, and certainly uncared for. Homed cats and dogs are not the only small animal companions that matter or deserve care.

I can be reached here, at the clinic, Jarrettsville Vet, on Twitter @FreePetAdvice, and anytime for any pet question, or pet health care epiphany at Pawbly.com.

Listen To Your Client! Zippy's Polycystic Kidney Disease

This is Zippy's story.

Zippy is 6 year old indoor only male neutered cat. He arrived calmly and quietly cuddled up stoically next to his mom. Zippy is one cat who lives a life worthy of his majestic ancestry. He is a loved integral part of his family. At every examination his family escorts him. They sit worried and concerned with his health and they invest every ounce of effort into maintaining his health for as long as humanly possible. Few are as lucky as Zippy is.

How I wish all of my patients were this relaxed.

Zippy came to see me because his family was concerned that he "was not acting like himself and losing weight. They believed he was eating and drinking normally, but had bad breath, and was licking a lot."

One of the most important lessons to learn as you attempt to master veterinary medicine is to listen to your clients. One of the biggest mistakes that I see consistently with new graduates is that they want to diagnose (you quickly learn to accept that there is not always the luxury of this), before they listen and look. Neophytes read the notes of the computer scheduler, confer with the tech after they put an appointment in an examination room and seek out a book of 'differential diagnosis' before they greet and meet their patient. In the real world the 'common things happen commonly' and your best diagnostic tools are your ears, your hands, and your brain.

I listened closely to Zippy's family. They were great help in understanding Zippy. He did after all look perfectly normal sitting on the silver examination table all confidence and Cheshire cat pose; secretly studying his surroundings and his potential white coat threat. He was serenely in command, (as every cat is), and I know to let them always believe what they rely on as truth. A cat is always in charge, the rest of us simply wish coercion in their direction.

After a discussion of subtle and self-doubting recollections I was left with a few strong impressions; 

• These people truly loved Zippy. Listen to those people! 
• This cat was king. His vibe was one of complete command. Listen to those cats! Even if your expert eyes tell you that this cat looks fine, Listen to the true experts, his family.

The technician had gathered her preliminary data. His family was concerned about weight loss but the scale reported the exact same weight as the last time we had seen him. We say it often; "the numbers don't lie." A question mark followed her notes in the chart. Was this yet another client reporting a wrongly perceived problem? Zippy did live in a mulit-cat household and they were not monitoring food intake for each cat closely. This happens pretty frequently. It is one of the reasons I like wet food for cats. Portion control AND patient monitoring. Your cat won't be able to tell me their last decent meal, I rely on you for that.

I calmly and slowly said my "Hello," to Zippy. He barely opened his narrow gaze, his breathing pattern stayed quiet, and he ignored me as insignificant. Mom stayed very close to protect and calm him. He had his family and me quickly accommodating him. He just had that presence that made you think it was appropriate. 

My examination always always proceed in the same manner. I start at the tip of the nose and work backward. (A helpful tip from a professor in vet school). It has served me very well. If you pinpoint a targeted area you will forget something, or worse yet, you will miss another important clue. Always proceed in the same manner. Zippy's front half of his exam was all very normal. 

Onward I proceeded to explore the back half. My hands knew instantly that we had a problem. Zippy had a very large mass in his abdomen. It was so large that it resembled a water balloon and it encompassed his whole abdomen. I was unable to identify any normal structures around it. 

An x-ray was the next stop. 

Zippy appeared to have bilateral (both sides) large soft tissue structures from the ribs to the pelvis. A small empty stomach is visible and a colon, intestines are pushed ventrally (down).

I remind people often that x-rays are best suited for bones. For soft tissue structures an ultrasound is far better at displaying the internal architecture and features of organs. Ultrasound was scheduled next. Thankfully, we have an ultrasound and a very skilled veterinarian who can read and diagnose much of the disorders we suspect through this modality. 

Even upside down Zippy proves himself to be one cool cat.

Through the use of an ultrasound we were able to confirm our suspicion. Zippy's kidneys are both significantly enlarged and the functional integrity of the renal infrastructure is compromised by cysts. Zippy has polycystitic kidney disease.

Instead of the normal soft tissue structured  cortex and medulla which are responsible for filtering the blood to remove unneeded waste and recycle water and maintain correct fluid levels in the body, the kidneys are gradually replaced by large bubbly air/fluid filled pockets that are non-functional and compress . Instead of being a few inches long they are about ten times the normal size.

He is also showing the classic signs of renal failure;

• Excessive drinking and urination (they had not yet recognized this until I asked about the size of the urine clumps in the litter box), 
• Bad breath (build up of the toxins that the kidneys aren't excreting through the urine.
• Muscle wasting and weight loss. (His kidneys were getting larger with fluid but Zippy is losing muscle mass)
• Lethargy, or reluctance to play, jump, interact.

Polycystic kidney disease is the most common inherited kidney disease of cats. It is most commonly seen in purebred cats like Persians, Himalayans, etc.

It is a slow progressive disease where the elaborate internal architecture of the kidneys becomes full of non-functional cysts. As the disease progresses the kidneys start to show signs of failure. All slow progressive kidney failure causes the typical clinical signs of kidney disease to become apparent. For the astute clients they will notice an increase in thirst. As the cat consumes more water they will also start to produce more urine. We call this polydipsia (drink more) and polyuria (pee more). At about 66% kidney loss pets will drink and pee more. At about 75% kidney loss they will reflect kidney impairment in their blood work. Therefore, there is some period of time between 66% and 75% kidney loss that you know before I know.

Zippy will be monitored very closely at home. We instructed his family on a better kidney friendly diet, providing subq fluids to help flush out the toxins the kidneys cannot, and supplements to help bind and remove the excessive phosphorus. But most importantly we will help Zippy stay eating and happy. Polycystitic kidney disease is a congenital disease. It is not treatable outside of kidney transplant. 

Life is never about quantity it is always about quality. Few cats are as loved and cared for as Zippy is. I wish him many happy years ahead, but I know that even if fate isn't as generous to him as this, that he lived a loved life in spite of the cards he was dealt.

If you have a pet question of any sort you can reach me at Pawbly.com. Or find me at the clinic, Jarrettsville Vet, or on  Twitter @FreePetAdvice.

What Are You Building?

Annie.

As a veterinary practice owner I see the world a bit askew. I am a private practitioner who is dedicated to helping pets and their families, but because I am also responsible for providing a future for my staff and my business I view each and every decision as both maintaining and supporting our collective mission of helping AND economical for our long term growth and viability.

Growing a healthy business is much like raising a child. The task of a practice owner is to prepare your business kid to stand on it's own legs and live on without you. There are long term goals that you have to be planning and preparing for and a whole lot of bumps and obstacles you will meet along the way. You can try to instill a sense of your values and vision but you must be prepared to intervene and take charge at every step along the way. If you ignore your responsibility, or neglect to nurture the minute and monumental needs, you and your baby will suffer for it in the long term.

At some point you also learn that things run better if you have a tiny bit of emotional detachment while you make decisions that may be unpopular. For a female invested in a business whose whole  purpose is to care for others this is a tough lesson to learn. There has to be some zone of detachment. You cannot be the friend, the mentor, the boss and the proprietor when you are trying to meet and deliver every need and want of every being in the mix. You simply can't. You can try, and you can do your best, but ultimately your businesses viability in many cases will require to to put a poker face on and be a hard ass. If you fail to make hard decisions, fail to deal with conflict, fail to provide a clear and consistent vision for a long term success, you will be undermined and fail, perhaps in tiny fragments over years, but the end result will be the same.

I often reflect on how my leadership abilities result in the unforeseen consequences that arise.

Here's what I have learned;

Responsibility;
You are responsible for the business that you build, and are a part of.  I, just like all of my associates and staff, can either help foster and grow us, or we can undermine our own permanence. We are all responsible for the business we build. Theft, gossip, bullying, rudeness, cruelty, and mistakes cost us all.

Trust;
I say it over and over again, without this there is empty wasted time and space. Life is to short for that.

Genuineness;
Be the model that you want others to reflect; Scrutinize the message you are portraying. Don't apologize if your life's passion is not someone else's. Either grow together because you have diversity in your viewpoints or move on. The little voices of dismay in your gut will become a chorus of angst if you dismiss it. Make hard  decisions to better your and your staffs quality of life, and move on ahead. Don't take it personally. You can be different people but you have to steer your ship in a unified direction.

Nurture;
Nurture a place that reflects your mission and purpose. If you ask for something listen to your mothers voice in your head and end each statement with a "Thank-You." Every good deed and every exemplary effort should be met with an accolade. Your team will never be paid what they are worth, therefore, the value of their time needs to be supplemented with a reminder of the reason they stay with you. They make you and your practice better than the next guys down the street, (who, by the way, might need to pay more because he is an ogre to his staff).

Protective;
Shed the craziness: If it makes you crazy, or if it appears to be going looney-tunes in spite of your best efforts to contain it, let it go. Encourage and seek help for those on the fringe of their emotional and/or financial stability and move on. You can remain a friend and a support system but you cannot tie your future to the anyone's dilemma, disease, or demise. A leave of absence is often a chance for everyone to regroup and re-analyze the situation. Over the years I have had to intervene and challenge staff to seek resources outside of my business oversight and jeopardize infringing on the privacy of others. At these  times I have to ask myself the same questions that I ask when a desperately needy pet walks in without the funds or foundation to care for them.
"What might happen if I don't care? Or, don't intervene? Can I live with that?"

Remember your path;
It is important to know who you are, where you came from, who you wanted to be, and who you are becoming. This isn't a dress rehearsal and regret and shame are voices that you only suppress with excuses that other people can see through. Life will keep you humble or it will remind you that you are alone.

My goal is always the same. I have to care. I just have to care about more things, more beings, and I have to view it as a collective whole where each piece intertwines and is interdependent on each other. It is the goal of maintaining the whole organism while we understand what each piece contributes to it. Losing an appendage or limb to save the greater good is a hard decision but you can't die waiting for the limb to decide whether or  not it will ever help you ambulate again.

What am I building? On every step and scale I am building a place of people who have a purpose. There will never be a time where you don't find a kitten/cat/puppy/dog in need under our roof. This place is a reflection of our  purpose to help those who need us. There is no purpose that can be sustained on purely profit or without heart and integrity.

We are all a reflection of our mission. We say "hello," we smile, and we genuinely live to perpetuate healthy life.

Annie is a six month old Black Mouth Cur.
She is an energetic, happy, people centered pup.
She is bred to herd cows, or lead people by the hand.
She's charming and endearing,
 I loved her at the first inquisitive romp and stare.

Life is a series of small steps to an end. You can choose to look up, smile, be grateful and contribute, or you can choose to chase a figment of what you think you need to be someone else's definition

There will be an end. You can't take the dollars with you, and all you will be is a reflection of a purpose with or without meaningful intent. It's all your choice.

If you have a pet centered purpose, or a pet centered heart, please join us at Pawbly.com. Pawbly is an open online platform dedicated to promoting a safe, credible place to share and exchange pet information. Pawbly is free to use and open to everyone who wants to help pets and their people.

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