Has Your Vet Given Up On Your Pet? Or You? Would You Even Recognize It If They Had?

There are patients who make big indelible marks on my heart. One such pup is Myla. She is a sweet, happy, fluff of curls who is always smiling and always inquisitive about every human she meets.  I had seen Myla every week for the first few months of her life with her adoptive family. Those weekly visits were set up to separate all of her vaccines out into small accountable doses. It may seem odd to most, but in cases of super protective adoring parents, and with our very flexible charging and booking system we do things other veterinary clinics wouldn't consider. That puppy vaccine time frame lasted over four months. During which Myla and I became the very best of buddies. I had spent lots of time reassuring her that I was her friend and that the veterinary clinic was a place for snuggles, treats and affection. As always, I wanted Myla to know that we loved her, and that the vaccines, clinic and staff were not things to be afraid of. In fact, my goal is for them to not even ever realize that they are being vaccinated or examined. Building a bond of love and trust during those puppy visits often determines every other subsequent veterinary exam ahead. Making the vet visits enjoyable helps our patients, our pet parents and our staff. It is vital to our mission in assisting our pets live long, happy, and healthy lives.

Myla and I were back together almost 11 months later for a new health issue. Myla was about 20 pounds larger and almost doubled in size. I was excited to see her again and tell her how much I had missed her, but this time she wasn't as happy or outgoing as I had remembered.

Myla at 4 months old.. her last puppy visit with me.

Is a year too long for her to remember me? NO, she is a dog. Dogs are brilliant. She knew who I was but she had come to hate what I represented. She wasn't happy to be at our clinic and she wasn't happy to see me. Although I didn't yet know why?

Myla had been to our office last week for head shaking and a painful ear. As is often the case at a multi doctor practice open 7 days a week 12 hours a day there are times when other vets will see our once-ago puppy patients. The other vet, like all of our vets, is incredibly capable and intelligent, BUT, she didn't know Myla like I did. She had likely seen a long list of previous vet visits, a complete series of vaccines, preventatives, needed puppy diagnostics. The whole enchilada..but, this would not reflect how her original vet felt about her? Had I failed to note how special she was?

When I saw Myla close up and in person in the exam room a few moments later she slowly and shyly approached to say her "hello." The spirit of this spry girl seemed diminished and distant. As I clutched her face to give a nuzzled kiss I noticed that her third eyelids were elevated. This is not normal... she looked drunk and drifted.

Jekyll, my pup, demonstrates an elevated third eyelid..
he is actually trying to sleep and I am pestering him for a photo for this blog..
aah, the plight of being a vets pup.

"What is that about?" My first real acknowledgment to her mom as I pointed to her obviously abnormal eyes.

"The vet wanted me to sedate her for the exam. Last time one pill wasn't enough. So I gave two for this trip." She replied quickly and openly.

"WHAT? WHY?" I couldn't imagine why this girl needed sedation? She was energetic and happy but never bad. What happened?

Her mom went on to tell me that she knew Myla had "a bad ear". The previous vet had "packed it with a long lasting ear product last week and this week was to see if it needed to be done again."

I listened intently to try to make the puzzle pieces fit. How could my firm conception of Myla as a loving, gentle girl have evolved into this? In usual vet med detective mode I asked mom for more information. Myla is after all only a year old. Myla is too young for ear problems that need a muzzle to manage. She is a poodle mix; curly hair and floppy ears. We knew that she is a breed predisposed to ear issues. (See blog on Excessive Ear Hair, and Veterinary Ear Care Basics).

• What was she doing at home to help the ears not get to this point? 
• Why would sedation be needed. Never mind "doubling the dose?"
• When is "packing the ears" a first time treatment choice?
• What had happened to all of the advice I had given mom at all of those many puppy visits to help keep her predisposition for ear problems at bay?
• How does a not long ago happy quiet sweet pup become so bad so quick?

Here are the answers to every question I posed above:

• Home care was not happening. Hence the ear problem becoming a BIG problem needing a vet to manage, repeatedly.
• If a little drugs don't do the job.. add more drugs. This includes sedation, management at home, and care from the vet. 
• Packing the ears should not be the first treatment option (in my opinion).
• The advice I had given those months ago had to be abandoned when Myla refused to allow them.
• Myla has resorted to being a growling, biting, fighting, squealing,,, now drugged,, dog to avoid her painful ears from being touched. 

Myla has bad ears because her breed predisposed her to them being problematic. The rest was our fault.

Here are the predisposing factors influencing Myla's current ear dilemma;

• Certainly a discussion of removing excess hair, and keeping her groomed is important. 
• We also need to discuss how we can try to keep the ears open to the air when they are heavy floppy ears.
• As with so many ear problems there is often an underlying allergy component. Therefore, keeping Myla on a good parasite (fleas especially) preventative and long term allergy control is all warranted. 
• We need to understand and accept that her ears are ALWAYS simmering. They are ALWAYS waiting for that low boil of inflammation to become full blown infection. Thwarting the simmer before it turns into infection is vital or somewhere down the line she will need a TECA. She will lose her ear canals because they have become too damaged and a source of chronic pain and infection to treat any other way.
• We need to be diligent in monitoring and treating them, even if that is daily. 
• We also have to find a way to let Myla know that we love her and she can trust us.
• Myla needs to believe that we are here to help, NOT HURT. That goes for inside her home and inside our clinic.

Here's what Mylas's mom was doing at home. She had started to clean the ears as we had recommended (see video here), BUT, Myla's ears hurt and therefore Myla wouldn't allow any kind of restraint. Myla associated anything to do with restraint or touching her ears with pain. She was now afraid of the pain that she believed was going to happen. Subsequently Myla's mom started to try to clean and medicate with soaked cotton balls, paper towels, Q-Tips and minimal to no restraint. The problem is that these don't work because her problem is deep within her ears and she needs a thorough washing/flushing. These short cut methods are the consequence left to owners because they cannot restrain. Worse yet, they DON'T allow the ears to be treated and therefore the snowball of ear problems perpetuate and of course, worsen. Pet parents are left feeling disgusted and that they cannot help their pet or assuage the vet. If left unchecked pet parents will often have to choose between what they think is just hurting their pet, or, doing what the vet says. Most pet parents will pick the side of protecting their pet from abuse at their own hands. They will either find another vet, or stop coming back to us. If they do come back to the clinic the vets are then forced to try to manage an unruly scared and desperate patient and left to do things like man-handle, muzzle, and/or drug. Even worse than these scenarios are the pet parents who take our "bad pet management" techniques as gospel and begin to emulate our own treatment of their dog. I have pet parents who return with a more fearful pet because they are FORCING their pet into compliance with more brute force, chains, muzzles, beatings, verbal chastising and utter determination to force submission of the pet into compliance. So now the pet is BOTH painful and bullied. These pets either have their spirit broken OR they fight back. These are the pets who are surrendered or euthanized somewhere down the road.That is the ultimate devastation of BOTH the vets and parents relationship.

Myla at her follow up appointment.
I am delighted to see a smile again.

Your pets ear canals are long tunnels that are "L" shaped. When there is infection or inflammation the tunnels get red, hot, painful and angry. They respond by swelling. This causes narrowing. A narrowed ear canal cannot breathe and it perpetuates and promotes more infection, pain, and irritation. You cannot open up this narrow tube without liquid.. lots of veterinary prescription liquid. Your pet needs medicine in that tiny painful hole that used to be a healthy open ear. The longer you wait and the worse you fail at delivering medicine where it needs to be, AND, the less likely that ear is to ever go back to healthy. Over time the ear closes. Literally swells and closes the infection, the pain and the disease inside. Your pets only options at this point is usually removing the diseased, scarred, non-functional ear canal. I know it sounds awful but these pets are in pain and they will be happier without the smelly infected very painful ear. They already can't hear out of it. You aren't losing function you are simply bidding disease adieu, finally.

It was time to have a sit down talk with Myla's mom. As I talked with Myla's mom and asked for help the technicians all forewarned me that "Myla was terrible last week." Well, of course she was. She is afraid, in pain, and we muzzle her, and then pile people on top of her.

Myla's mom loves her. She, like so many of us, doesn't want to hurt her. In truth all of us have failed her. Failing to address pain and failing to recognize it as the basis for her unruly behavior is inexcusable. Further the sedation we had given was not to provide pain relief, it was just to slow down her responses to it. We can do better.

Admission of a problem. 

1. Myla has bad ears. Her breed predisposed her to this.
2. Myla's ears hurt. Pain is treatable.
3. Myla won't let anyone touch them. She has to learn to trust again.
4. Myla is too young for any of these. Drugs to induce compliance are cheating her and her family of an adequate plan.
5. The staff all knew who she was and all were willing to treat her as if she is Hannibal Lechter. 

Daily Checklist For Myla;

Myla's list of daily care now includes food, water, shelter, love, urinating, defecating, and ears. Every day I want her mom to make sure these are all in good working order. To avoid the narrowed, red, painful ears she has now we need to start treating for the pain AND disease AND then start a long term maintenance that her mom can actually do. For me this usually includes advising the ears to be washed as often as needed. Use your nose, eyes, and ears to assess the ears at home. 

Here is where we are going to refocus our efforts so that at the next vet visit, at the next health care need, and every step in the public everyone is safe and healthy.

1. Pay attention to any condition appearing in such young dogs. These are the patients who need extra time and attention. They are the life long cases. Educate your clients so they can manage their pets optimally through the decades ahead.
2. Mom needs to go back to basic obedience class and learn trust and basic commands. Both mom and dad need to attend. Obedience/Puppy classes are primarily to train parents how to communicate effectively with their pets. Not having both parents present is imperative to Myla getting clear, direct requests spoken (calmly and gently) in one easily understandable language.
3. Mom needs some help from us on how to be able to hold Myla (this is ALWAYS the problem with bad ears long term). Myla was too wiggly and her mom couldn't restrain her. So the daily washing (see video on how to do this here) turned into soaking a cotton ball and trying to get that in the ear.
4. Myla needs a team who is devoted to helping her mind, body, and soul.

Myla's follow up ear appointment with me.
She is her old happy self.
Sedation free and happy to take treats.
She trusts me again.

The point to all of these is that we have all failed her. We turned her in to this "BAD" dog. How did it happen? We forgot to train her to trust. We allowed her to voice an opinion that was detrimental to her health, and we forgot that parenting is the responsibility of the village. 

Myla will come back every week. In some cases it will just to sit in the reception area and make friends. In others we will gradually start to condition  her to accept restraint. In others we will begin to clean her ears. The goal is to condition and desensitize her fearful response to the clinic, restraint, and managing her ears. We are also going to be kind, patient and understanding. Using a drug or muzzle is too often a way to say that we are going to "just get through the exam and get what we can done." It is a terrible way to treat a chronic problem and it will make every subsequent visit that much worse. No vet wants this for their patients.

This is how I want my patients to be; calm, relaxed, smiling, anxiety-free.
If your appointment doesn't look like this ask your vet for help and guidance.
No one wants to be hated or afraid.

If you have a pet who is "required to be drugged," muzzled at the door, or has orange stickers all over their file that reads "CAUTION", please talk to your veterinary team about how to help your pet deal with their own anxiety, and how you can become the welcomed anticipated client not seen or treated like the skull capped grill faced killer craving fava beans.

End of her follow up appointment! Everyone feels better!

Myla returned a week later a different (or should I say the same) dog then she was at the last weeks visit. Her parents are dedicated to keeping her healthy and happy and are making great strides to helping her ears feel and be better. They are working with her anxiety, her fears, and we have almost completely eradicated the pain and infection. I left an open invitation to come back as much as they want to. I am happy to help take baby steps forward so that she is never stressed or not receiving the emotional AND medical care she needs and deserves.

Love you Myla!

Related blogs here;
Everyone Has Ears And No One Treats 'Em Right.

Ear Hematoma Primer

Ear Cleaning Guidelines.

Ears, Everyone has 'em, no one treats 'em right




My Jekyl. His morning ritual. Jumping on the bed to say "Good Morning!"

 

The famous saying in vet school is that "90% of the problems we see as Vets is skin and gut." Problem is that every vet student  bitches about Derm (dermatology) and GI (gastroenterology) class because they are so hard. It's the bread and butter of vet business, the demise of a few vet students, and the frustration of many an owner and their pet.

At the average skin/derm appointment I have to tell my owners to be patient, talk to me alot, and try not to get frustrated. Sometimes the road we get on has many a twist, turn, pit stop, pit fall, and sometimes you just want to drive off a cliff. It can be a life long problem for many dogs and cost their parents a small fortune in the process.

I love Derm and I like GI (well I love GI surgery, does that count?), and I agree it is the bread and butter.

So I thought I would talk about a dermatology topic that I see and live everyday; Ears. You see my adorable floppy eared beagle pup Jekyl has weekly cleaning sessions because those big adorable floppy ears keep the dirt and wax in and the sunshine and air out. Versus my pit bull pup Charlie who has more erect ears.

Anatomically the bigger and floppier your ears are the more likely you are to have ear problems. The Cockers, Bassetts, and Hounds tend to have yeasty ears. The darkness, moisture, and wax (food) make the perfect environment for the yeast (aka bugs) to thrive. The Labs and Shepherds have a predisposition for bad skin, so their ear ailments arise from their skin problem. Then there are the Shar Pei's and Bulldogs who because of their smooshy faces end up having stenotic (narrow) and tortuous ear canals. Ontop of that  many of these guys have ear flaps that are jammed to their head and you get narrow, moist, dark, "I already have bad skin" and being unable to get to their closed ear canals and you have big ear problems!

Here is my ear problem kid, and his brother with out ear problems. See what I mean, genetics dictate!

I want to start with the most basic advice on ears. Keep them clean! Sounds so simple. We all wash our ears, swab them, and maintain our own personal ear hygiene, so why do we wait until our pets are fire red and stink so bad I can diagnose them from the other end of the vet hospital. Or let those ears go to the point of hematoma (the ear flap swells like a pillow). Or progress to deafness? I think it is because many people are scared to clean ears. So for every ear appointment I get I give a demo on how to clean ears.

I gave this demo the other day. I asked what they do? And got the answer that I usually get. "I squirt in some cleaner and then swab out with Q-tips." "OK," I say, "I know that most of us have been taught this way and you see us do it, but I think that there is an easier and more effective way." Then I go onto to explain, "Doctors have their own opinions on how to do everything. I mean they are entitled to them, but they are wrong with ear cleaning." I always say it jokingly, (OK, half-jokingly). I then go get a big bottle of cleaner, (I only sell the big bottles), because if you are here for an ear problem you will very likely have an ear problem again soon, so I want you to be ready before you call me.

My hope is that you won't ever have to call me again. My hope is that when your dogs ears start to bother him, (when he is at the initial inflammation stage), that you at home can clean your way out of the inflammation stage and avoid the (next) infection stage all together. My job is to educate you enough that you can keep your pet healthy and avoid seeing me.

Ok, here is the "primer" on ear cleaning. If all else fails, read the label! The label on our ear cleaner reads. "Fill ear canal until overflowing and then gently massage into ear. Let pet shake out excess." See? very simple. No poking, no swabbing, no fighting, no biting, and no hurting. Now, many pets have ears that hurt, so anytime you touch a painful ear you are hurting your pet. I don't want the ear cleaning to be a torture process that your pet hates because then it won't ever get done. So be gentle, be patient, and don't scare or upset your pet.

For the first few times it is a 2 person job. The first person holds the right hand on the pets collar and left hand firmly on the nose. Keep the nose up and don't let your pet fight out of the position hold. Be firm, be kind, be patient and be gentle, and don't let your pet fight. The second person then takes the ear flap (aka pinna) firmly and gently pulls it straight out away from the face. (Perpendicular to the eye so that you open the "L" shaped ear canal into moee of a straight line). Then fill the ear with the cleaner until it overflows. (No one ever uses enough). You want to "FLOOD" the ear canal, and that's another reason I sell the big bottles only. Remember your pet's ear canal is about 3 inches long. You need to get the cleaner to fill the whole canal. Then fold the ear flap like a burrito (always a reference to food ;-)), and massage into the head. You should be massaging against the skull and you should hear a squishy sound. It is the same concept as the agitator in your washing machine. This should not hurt. Actually, most pets love the ear massage. If it hurts then it means one of two things; 1. The ear is infected and you need a vet appointment, or 2. The ear drum is ruptured and you DEFINATELY need a vet appointment.

I don't want owners to swab the ears because if the ears are red then the swab feels like sandpaper. And a dog with a hurt ear won't want to let you clean them ever again. And the other reason we don't swab is  that we are trying to get rid of the junk in those ears, not shove it back down the ear canal. Let your pet shake out the excess ear cleaner and the junk that is causing the problem.




I also tell people that you cannot over clean, but you absolutely can over medicate. I don't care if you clean the ears daily. Some pets need daily cleaning, some weekly, some yearly. 

Everyday I see a dog in the clinic for "itchy ears." Most often these guys are here for their umpteenth time. There is a huge subset of clients who only come in because their dogs ears are to the point that their dog keeps them up all night, has blood coming out of their ears because they have been itched raw, smell like infection started brewing in them last month, or the ears are so infected and painful that the owner is in fear for their life when they try to put the medication "in that small tube I got last time," in their pets ears.


Oh, the frustration of the phone call that starts as "Hey Doc, I know we haven't been in in awhile, but Sam's ears are bothering him again, and I was hoping I could get more of that medicine he got last time?" Argh, it's a hard call to answer somedays. Firstly, because I would like to see your dog outside of the disasters so that maybe we can find an answer to the problem before it hits catastrophe stage. Secondly, because that little tube you have been using on and off over the last year is a whopper of a steroid with a big gun antibiotic/anti-fungal and I am afraid you are acting like Dr. Frankenstein and inadvertently growing a batch of superbugs in those ears. You see when you have a legitimate infection (most of the time you don't, because most of the time you simply have inflammation.) We are supposed to treat twice a day until the clinical signs (redness, itchy, smell, etc) are gone for at least three days. That way you have killed all of the bugs and not just the weak ones. If you only treat intermittently you are killing the weak bugs and allowing the most powerful bugs to reproduce. Eventually you get what we call "antibiotic resistence." The only treatment after you hit this stage is surgical removal of the entire ear canal. This is called a "salvage procedure."


I have done many ear canal resections to relieve pets of the constant pain of ear infections. It is the only way to stop the pain, and these guys are long deaf by then already.

I met one little Yorkie a few months ago with terrible chronically infected ears. She had just been rescued from a hoarder. Her ears had been so infected (a combination of ear mites and infection) for so long that one of her ear canals had closed already. She had a persistent head tilt and difficulty walking because her balance was off from her ear being so damaged for so long.

The next week I removed her unsavable ear canal. She was 4 pounds and had a tough time with her surgery and recovery. It took a few weeks before she could stand up, walk, and blink normally. Thankfully we were able to save the other ear with very aggressive steroids and antibiotics. She is a very gentle shy girl and her new family gave her the complete opposite life from where she had come from. She receives endless amounts of care, love, time, and she is finally healthy. She will probably never come out of her quiet reserved shell, because was raised being outnumbered and overlooked but she is happy and finally living the life she always deserved.

Post-op, Left TECA, aka Total Ear Canal Ablation

For more information on ears I really like the book "Small Animal Ear Diseases" by Gotthelf.


Here are some of my favorite Big-eared pictures and patients. Oh, I can't resist the ears!

Baby Jekyl, the first week we got him. Note the Sutured butt..



Jekyl, OMG do I love this beagle!