Saturday, February 28, 2015

Diarrhea. The Very Basics, Canine Version

Most of my clients make appointments in hopes of my curing some clinical sign. They aren't so concerned on the disease that caused the clinical sign they would just,
"Very much like it if I could stop the diarrhea NOW!"

Diarrhea is always a consequence of something else.

"The good news," I tell my clients, "is that in most cases it is an acute self-limiting sign that will resolve with time."

Here's why:
The majority of cases that I see are caused by one of two things;

  1. Dietary Indescretion. Anther words, "I ate something that I shouldn't have." Poop, trash, the Thanksgiving turkey leg, a tainted piece of food that probably smelled irresistible to your dog.  Why the dog brain says, "Smells rotten, Yumm! Let's eat!" I don't know, but it does.

Friday, February 27, 2015

Uterine Prolapse. Canine Edition

These are 8 week old Central Asian Shepherd puppies and their mom,
Dixie Carter, when they came to visit us for their first set of puppy vaccines.
The puppies were about 40 pounds, and there were 8 of them!

Dixie was a patient mom who gave birth to 13 puppies.
Sadly only eight lived.
Even for a large dog this is a lot of puppies!

This is Dixie Carter when I saw her two weeks ago.

Can you notice her haunched back end? This is a classic stance of a pet with pain She is tucking in her pelvis under the abdomen... and here is the reason why.

That pink fleshy mass protruding from her vulva is her uterus. Another words, her reproductive tract is slipping out the vulva. This is painful and dangerous to her health.

Here's why;

  • The uterus is a structure meant to be living safely up inside your abdomen. The tissue is not meant to see the light of day. Every time Dixie tries to sit down the fragile tissue is touching the floor. This causes it to be traumatized, bleed and become further damaged.
  • Damaged tissue responds by doing two things; bleeding and swelling. 
  • The swelling to the tissue is made worse with  every passing moment until the tissue either becomes infected, necrotic (dead), or ruptures. Now her already bad situation is dire.
  • To add to her dilemma the vulva and vestibule (area just inside her vagina) is also being stretched, which allows more of her uterus to fall out.
There is no way to treat this without a veterinarians quick intervention. 

Placing an i.v. catheter pre-op.
Dixie arrived on a Sunday with her predicament.

She had delivered 13 puppies 5 months ago. At three years old her owners wanted to breed her again.

The conversation unfolded something like this...

"I am not a reproduction vet. So, I'm pulling this info from vet school about a decade ago. Uterine prolapse, (this was the only thing I was sure of), happens after hormonally driven reproductive tract weakens and relaxes so much that it can essentially fall out the back. It usually occurs in females who have had vaginal deliveries and/or straining against the pelvic floor muscles. It is not uncommon in farm animals who are bred frequently and repeatedly."

"What can we do to treat it?"

"My recommendation is to spay her."

"Is there anyway we can breed her again?"

"Well, I am not a repro vet, and I can only tell you from large animal experience. In large animals we replace the uterus, sew it in, see if it stays, rebreed them, and if they prolapse again we slaughter, spay, or euthanize them. In many cases they re-prolapse. Every prolapse is another opportunity for damage to the reproductive tract, systemic infection, and possible adverse impact on their health. The safest and best option for Dixie is to spay her as soon as possible." I recommended that she be referred to the emergency clinic for surgery and overnight care. They asked about cost for this and were given an estimate of about $2500.

They decided to wait for us to do her surgery the next day.

Dixie was started on i.v. fluids, i.v. antibiotics, and placed under general anesthesia. After careful cleaning of her uterus we gently replaced it in her pelvis. The tissue had been exposed for 5 days. It was incredibly swollen and took about 45 minutes to replace in its normal position. This is done in awake patients for horses, cows, sheep, and goats. The only humane and effective way for it to happen in Dixie's case was with her asleep and on her back. A technician had to remain holding it in place for the entire length of her spay.

Yet another glamorous task of a veterinary technician; "uterus holder".

It took 3 vets to spay this big dog!
Traction to the uterus via the abdomen was required. As the technician pushed the uterus into the pelvis I pulled it back into the abdomen. This is exactly why this is only resolved with a spay.

Pulling the reproductive tract back into position.

Dixie's spay and uterine replacement surgery was not easy. It took three vets and two technicians to replace the uterus, hold it there, tie off her orange-sized ovaries, and her massively thickened uterus.

Poor Dixie has a very stretched vestibule.
But there just above my fingertips is her uterus, almost back into its normal position.

Thankfully Dixie is a very healthy, strong girl. She did marvelously through her surgery! When she woke up we gave her opioids to keep her calm and pain-free. She also went home with a fentanyl patch to provide three days of slow release pain control.

A dog that walks home comfortably after their spay is a happy sight!

Headed home Monday night.
Not too surprisingly Dixie came back to see us on Tuesday morning...
..because she looked like this.

But, happily, her abdominal incision looked like this..

A quiet, healing incision.
I want to add a personal note based on experience. I think that checking an incision 24-48 hours post-op is one of the most beneficial things we can do for our clients and patients. I am happy to see any patient of ours at anytime post-op to check the incision, answer any questions, and help my clients provide the needed after care. I do not charge for this. I have a hard time justifying charging for this. I think it discourages compliance, and creates an unneeded potentially damaging barrier between myself and my clients. I know that this policy has benefited my clients, my patients, and my ability to sleep peacefully at night. For the vets that argue this point, for whatever reason (some valid like the cost of our time), I suggest that you add the fee for re-checks into your surgery fee, and then tell your clients that re-checks are free. They will appreciate knowing this, and it is an excellent marketing tool that builds trust and ease into their perception of both you and your practice.

Getting ready for the post-op procedure.
Because her uterus was prolapsed again, (very common and should be expected), we decided to protect it from further trauma of siting on it, abrading it, or exposing it to the frigid February temperatures by enclosing it within the vagina.

A Caslick's procedure was performed under a local anesthetic block. Three sutures were placed to close the vulva and hold the uterus inside the vaginal vestibule.

A little time and as much protection as needed are all that are required to resolve this.

1 day post-op

6 days post-op.
I will see Dixie again on Sunday. That will be almost two weeks from the day of her surgery. I expect that her vaginal sutures can be removed and the uterus will have shrunk to almost a normal size.

For Dixie's spay and uterine prolapse surgery the cost was $1600. This included; i.v catheter, fluids (a lot of fluids), spay, additional assistance from vets and techs, 3 hours of anesthesia time, antibiotics and pain management for the day and after care, e-collar, fentanyl patches and hospitalization and all re-checks. It was a substantial bill made significantly larger due to her size and the length of the surgery time. If this happens to your dog seek veterinary care as soon as possible. The longer tissue is prolapsed the more difficult it is to treat and the higher your risk of failure.

Dixie always reminds me of a Polar Bear.
Two weeks post-op re-check

Her abdominal incision looks wonderful!
Back to normal!

A big smile over not being the subject of more embarrassing photos!

Related blogs;

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If you would like to discuss your pets condition I can be reached at the clinic, Jarrettsville Vet in Jarrettsville Maryland. I am also on Twitter @FreePetAdvice.

Thursday, February 26, 2015

Dig Until You Get An Answer,, Even If You Are Fishing In Unfamiliar Waters. Isa's Canine Leukemia.

There are a few hidden talents to a vet who has been in the trenches for a few years. It is the simple accumulation of enough stories that allows you to see a common plot in a new patient with a particular shimmer of a tiny clue in the blink of their eyes. It is hard to explain, but the longer you practice the more your gut guides you.

I met Isa on a busy over burdened Sunday afternoon. She and another pup were waiting at the door twenty minutes before we opened with sobbing parents, (never a good sign).

Isa's vet visits had begun with diarrhea 5 days ago and progressed to include vomiting 2 days later. Isa, an older German Shepherd, was now lethargic, despondent, inappetant, and withdrawn. She was also pale, weak, and unable to walk.  Her mom was understandably emotionally exhausted and fearing the worst.

Over the previous two days blood work and x-rays had been done at the ER where she had been transferred for the weekend. And, yet, here she was back at the place that had been searching for her answers for over 72 hours looking like time was no longer on our side. We knew she was sick and we knew she was getting sicker... we just didn't know why.

That's what medicine is. A battle between wits, guesses, diagnostics, and determination. It can be frustrating. Sometimes you get a case that has minimal tools to help you through your puzzle, whether they be a lack of resources to chase down every possible disease, lack of free time to dilly-dally when your patient is making a run for the white light, or a client who lacks the patience to allow you to sift through the most likely culprits to get to that elusive rare disease hiding in the rule out haystack.

Isa had been tested and cleared of all of what we thought were the most likely "treatable" diagnosis scenarios. Yet, here she was still sick and now flirting with dying. Every seasoned vet will tell you that most likely scenarios don't have a name. They have a breed and an age and a prayer to build a wish upon. Terribly cold labels to paint on a beloved family pet. But, there is truth to those old broad sweeping, emotionally void labels. Isa was still an older German Shepherd  who looked like the first guess on the suspicion page and the least wanted scenario. She looked like cancer. We just couldn't find it. Everyone of us knew that we had to be looking for this, we just didn't know where it was lurking. She was now at the door, sicker, paler, and weaker than ever before.

The ER had suggested to Isa's family that she have an exploratory surgery. It was a realistic request, the problem was that this was a Sunday and an exploratory surgery requires more staff than we have on hand and an intense follow up after care plan. I tried to apologize to Isa's desperate mom, and I felt awful about it. I knew that there was a chance she wouldn't live another day, I knew the answer might lie in her belly, and I knew that even if I could open her up and reveal her mysterious illness she would have to go back to the ER.

I did what I always do in this pinch with my heavily burdened conscious. I left my phone number and told Isa's family to have her back with us in the morning. If they wanted an answer I was sure as heck not going to give up looking for it. There is truth to the adage "where there is a will, there is a way."

Isa, we believed, was in need of an exploratory surgery to remove a mass in her belly. The x-rays seem to suggest this, so we decided to confirm it with an ultrasound. Her ultrasound concurred there was something abnormal in the area of her stomach. As much as clients hope that we can come to a diagnosis affordably there are times that we have to run every single one we have in our arsenal.

By 10 am on Monday morning, after about a week of diarrhea, inappetance, and lethargy we were going to try to get an answer to Isa's woos. Isa's mom consented to the exploratory surgery she had asked for the day before. There was a new sense of optimism that we had her villain in the cross hairs.

Isa was on the operating table by 1030 am.

Her exploratory started out as good as one could hope. No visible bleeding in the abdomen, and doing well under general anesthesia.

 Isa's first big reveal. A very large spleen, and I do mean very large. 

The search widens..

And reveals,,,nothing. Another dead end.

Every inch of Isa's abdomen was inspected. Some by touch and some by visual recognition. But no organ, no area, no corner, nothing was missed. I reluctantly, begrudgingly closed her up.

And, damn it, as hard as you try, as much as you want it, there are those cases that stump you at every move. Isa was one of those girls. She was a shorter list of rule outs, a list of attempts, and a girl who still smiled, still wagged, and still wanted to be her families guardian. 

A week of every diagnostic option tried, and crossed off the list, and still we didn't have an answer, a reason, or guiding advise for Isa. There were three vets on her case and all of us knew the answer was out there. We also knew that when the easy answers are exhausted you sometimes get cornered into cancer. It was now at the top of the list. We needed Isa's family to allow us to keep digging, even after we admitted there was a slim chance that there would be a happy ending.

What do you do when you have looked and not found an answer?

You look again.. and you keep looking. I know it is hard to accept, infuriating to pay for, and yet it is real-life. So we started from the top. We re-examined her. questioned every decision over again. We talked about her case with every other vet in the building and repeated Isa's blood work. We were starting her on the only treatment option that we had left, steroids... massive amounts of steroids.

When your patient won't eat call in convincing reinforcements.
Isa's bloodwork now 2 weeks later was being sent to the lab again. This time the lab noted that there were significant unusual abnormalities and sent her blood to a pathologist for review.

And, there it was, finally an answer. Isa's diagnosis was confirmed by two pathologists at the reference lab. She had leukemia. It was a diagnosis we had feared and suspected all along, even if it took us a week to get.

Isa was started on steroids. It was her only option left. 

Her disease had quickly annihilated her bone marrow,, therefore she grew weaker and more anemic as the supply of her red blood cells collapsed. She, the prodigal German Shepherd was dying of a cancer we rarely see and more rarely have the opportunity to diagnose. She passed away two days later with her family who were grateful to know the answer to her illness and happy that she was with them until there was nothing left to do. She was loved. She was given every possible chance, and she was a smiling, gentle, majestic friend to all. I called her mom to send our condolences. A half apologetic somber extension of my grief, my angst, and my sorrow. Her mom just thanked us for never giving up on her, never being anything but kind and generous and always being supportive of her quest to save her girl. I told her how grateful we were to know her, to be a part of her life's journey. 

Leukemia, especially acute leukemia is a fatal insidious thief who steals life in about two weeks. Just like Isa the clinical signs are often lethargy, vomiting, weight loss, diarrhea, and anemia. It is most often diagnosed with a blood profile and bone marrow aspirate. There are no well documented treatment options with much measure of success. Here is the best article I found on more on this disease. National Canine Cancer Foundation, Lymphoid Leukemia.

I want to add a personal note to Isa's family. I will never forget you and Isa. She was a regal majestic sweet girl who reminded me to always keep focused on finding answers, fighting for every precious day and just being grateful to have them.

If you have a pet question, concerns about your pets condition or disease, or curious about what  might be happening with your pet please join me at the community dedicated to educating and inspiring other pet lovers, Pawbly is free for all to use and enjoy!

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I am hoping to make veterinary medicine more transparent. I know that cost is a significant barrier to many people in the care of their pets.

Here is Isa's treatment plan and associated costs;

First visit for diarrhea; Exam $50, probiotics $29, fecal exam $30.

Second visit; Ultrasound $200, exploratory surgery w anesthesia iv catheter, fluids, antibiotics, pain management $700. 

Third visit; steroids and inpatient care per day $50. Isa stayed for the day for four days. Repeat bloodwork $130.

Fourth visit; euthanasia and private cremation $350.

Monday, February 23, 2015

Nail Trim, Feline Edition, The Stress-Free Way

Here is the biggest and most valuable secret that you will ever get on cats. 

Never, ever be audacious enough to think that you are in charge. 
You aren't. You never were, and you never will be. 
If you can willingly surrender this notion everything will fall into place.

The beauty of the most precious relationships in life is the quiet moments you share just being a peace with who you each are. My cats, well, they rule the roost. They rule the dogs, the people, and the kingdom they call our home. I love them for their independence, their cunning intellect, and their kind purrs in my ear when the day draws to an end.

I would like to think of myself as their parent. A lofty hope with little reward to convince me that I have any influence on their day to day outlook, but a clear resolve to be responsible and insure that they receive the needed care of a living, thinking, soulful creature.

Of all of the needed care that our pets need one of the most challenging is nail trimming. It has become such an ordeal in so many homes that clients wait all year for the Annual Physical Exam day to arrive and then ask the veterinary staff to jump in and bail them out of the task they abandoned long ago.

Nail trimming should be done monthly. It should also be performed in a calm, direct, stress free manner. I know it sounds much easier said than done. But it can be easy and stress free.

Here's how;

  1. Start touching your pets feet at any and every chance.
  2. Start teaching your pet to surrender and relax in your arms. This can be done without actually doing anything. Just hold them past the point of struggling. Hold them a few seconds longer than they want to be held, and reassure them that they are OK. 
  3. Start keeping the nail trimmers around more often. A foreign object is more frightening then one they are used to. This also applies to cat carriers. If your cat is used to it as a piece of furniture they won't respond in fear when it magically appears out of nowhere. 
  4. Start with small simple motions and do one nail at a time. You don't have to do all of the nails at once and you don't want to push your cat to the point of  fear. It will only make the next attempt to trim them more difficult the next time.
  5. Also, pick your trim time wisely. An anxious, playful, rambunctious cat will not make a good patient. But a tired, content, resting cat might.
Here is my cat Wren. She is so gentle and so trusting that I can trim her nails on my lap with ease. It has taken time and practice, but she loves the quiet time alone with me and I get to safely and carefully trim all of her nails. We also get time for belly rubs and snuggles!

As your cat ages their nails will need more care and monitoring. I always recommend that you check them monthly, front and back feet. 

For related blogs and more information on nail trimming please visit;

How To Trim Nails.

Overgrown Nails in an Adult Cat.

Wren enjoys sleeping on my lap, as Magpie takes the coffee table.
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Wednesday, February 18, 2015

Recently Boarded Vaccinated Dog is Coughing? What To Do Now?


Just picked my dog up from boarding for a week and she has a bit of a cough and gagging sound. She was there for a week. I think this could be kennel cough. She had a Bordatella shot. Will this go away or should I call my vet?

Asked by Ellen, in Pleasant Hills, Maryland


Here is my answer;

Hello Ellen,

It certainly sounds most consistent with kennel cough. Even with a vaccination (no vaccine is 100%) a dog can get the disease they were vaccinated for. I use the flu shot analogy when discussing this with my clients. Just because you are vaccinated for the (human) flu you can still get the flu. The hope is that if you do become exposed, and even infected, your body can mount a quicker and stronger immune response and hopefully you either will not, (or at least not get as), sick. This has on occasion caused great  frustration with my clients who want to think of a vaccine as a shield of armor and either want us to reimburse boarding fees, or treat their dog at no cost. Hard as we try to protect every pet, it is impossible to thwart disease when you congregate a group of pets (or even humans) together.

The good news is that most vaccinated pets are covered under the vaccine manufacturers guarantee. This is applicable as long as your pet was vaccinated at the veterinary clinic, within the manufacturers suggested guidelines. So, yes, you should definitely call your vet to notify them. I want to know, and if one pet gets ill, I call all of the other dogs who boarded during the same time. I know my clients appreciate an honest proactive approach. If you were my client I would ask you to come in for an examination. We would take a weight, temp, listen to the lungs and discuss bloodwork, etc. In general, vaccinated healthy dogs will run the coughing course of the mild form of this disease and be fine in a week, or two. The biggest pets that I am concerned with are the very young, very old, or debilitated pets. They should be watched very closely. 

As far as treatment for this goes, here is what I do;

If the coughing worsens, or causes the pet to not be  able to sleep at night we prescribe a sedative, or cough suppressant (if the cough is dry and non-productive). If you cannot sleep you cannot heal.

If the coughing leads to vomiting we discuss i.v. fluids and hospitalization. Again, no rest no heal.

If the lungs sound wet and/or if  the pet becomes quiet, subdued, lethargic, inappetant, or appears sick we take a chest x-ray looking for evidence of pneumonia and prescribe antibiotics and/or hospitalize.

In almost all cases our patients diagnostics (we do a buccal mucosal swab to identify the source of the infection) and treatments are covered by our vaccine manufacturer. It doesn't change the fact that your pet got sick, which we try very very hard to avoid, but it does help our clients with the financial burden of a sick pet.

Call your vet, have your pet seen, know what to look for with respect to any worsening of the illness, and have a plan. Also inquire about the vaccine guarantee.

I hope this helps, and I hope your dog gets better soon,



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If you would like to meet me for a patient evaluation I can be found at the clinic, Jarrettsville Vet, in Jarrettsville Maryland. Or follow me on Twitter @FreePetAdvice