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.

The Excorcism

 And so the story goes..

The seemingly never ending saga of an old dog with a fierce determination to persevere and a mom who can't say goodbye..

Savannah has gotten a new set of high performance all terrain shoes. They significantly help her grip on slippery surfaces. My goal is to keep her ambulatory for as long (or forever) as possible. I only put them on after she is unable to keep her feet underneath her. Any crutch I give her will likely make her more reliant and my hope is that she will only need small short periods of assistance as she retains, or hopefully, re-builds her muscle mass.

When two shoes are enough to keep her moving she gets two. When she needs four, she gets four, but I would rather move her to a place where she doesn't need any and not take any steps backwards while we try to keep moving forward.

We take long walks (at least twice a day) over terrain that is varied and includes uphills, grass, pavement, downhills, and navigating through the twists and turns of the yard. She also benefits greatly from the change in scenery, stimuli of being outside and the regimen of daily exercise to help keep her fit and on a schedule of wake and sleep.

Meanwhile, the rest of the family waits with me..and gets up with me,,,and loves the many multiple home cooked meals that get refused by Savannah.

The winter of 2013-2014 has been a long hard cold white winter. It has been tough on all of us. Keeping her warm and walking in spite of endless sheets of ice, tunnels that need to be re-dug every few days, and wind chills which make me pause and re-think every outside exercise walk. I have pushed her thin weak body to the point of exhaustion and still she wakes up each morning to face another day. The silver lining to these stay at home snow days has been more time with her. I am grateful for each moment of each day.

Each aged ill patient of mine has passed while I have been caring for, treating, and trying to maintain the course with Savannah. We have shared our sad days, our attempts to resolve and ease suffering, and still she has outlived, outlasted, and outshined even my most optimistic hopes.

In an effort to help someone else somewhere else with her condition here is what we are doing now;

1. Melatonin, at bedtime. 3-6 mg (dogs over 30 pounds are at the higher end. But I have been offering more lately). She is about 12 pounds.
2. Tramadol, 1/4 to 1/2 of a 50 mg tablet to get her to rest at night if it looks like she is winding up and not settling down.
3. Amitriptyline, a tricyclic antidepressant that is used to treat anxiety and other behavioral disorders. Possible side effects are dry mouth, raid heart rate, and sedation. (I will hope that I don't see the first two). Long term concerns are for the heart.
4. Long walks twice a day. (Mother Nature could you give me a break for a little while?)
5. Feed! Feed! Feed..I am almost embarrassed to confess her current diet. Yesterday, for example, she ate two slices of cheese pizza (my husband loves being sent to pick up pizza for the dog. He helps himself to wings and a pepperoni pie while is he there), 2 Beggin Strips, and a pack of moist and meaty. Now, mind you, this is after she turned her nose up to; chicken, rice, soup, dry and wet cat food, and canned dog food.. Argh, I'm trying.
6. Free access to fresh water. Although yesterday I found her asleep with her back foot completely submerged in it. And one morning I awoke to some weird whistling noise to find her nose almost submerged while she slept.
7. I keep her bundled up and warm. She has lost quite a bit of muscle mass and chills easily. Her room is kept at 70 degrees and I blanket her at night.
8. She is never alone. She is either at work with me (Thank You!! to my wonderful staff!!), at my mom's house, with my pet sitter, or with me..boy, it puts a strain on traveling.
9. I keep her with me as much as possible. Mostly, because I fear her time is short so I am going to squeeze every last second out of her.

My biggest challenge has been keeping her calm and stable. After a few weeks of doing well she starts to become more and more anxious over littler and littler things. More pacing, getting stuck in seemingly impossible places to get stuck in, circling..etc.. It is grueling to watch, witness, and ignore her pleas at all hours of the night. It is exhausting and excruciating. It has caused me on three occasions to debate putting her to sleep. After two or three nights of this I break. I question her quality of life and what I am doing about it. Twice I have given her acepromazine (a potent sedative to relieve her anxiety and allow her to sleep). Both times I have given her a tiny fraction of the dose, and both times she has had a seizure and the wind knocked out of her. She slept for almost a whole day afterward, and had a very tough time recovering after. I was happy to see her sleep and completely guilt ridden to see it hit her so hard. The third time I sedated her was last Thursday evening at 2 am, after she was up all night for two nights in a row, and getting worse. I gave her a tiny amount of morphine subq. It should have taken her about 15 minutes to relax and get sleepy, but, within a minutes she was vomiting violently and passed out. I lay in bed all night thinking that she was not going to be with me in the morning, and feeling a mixed bag of relief that she was peaceful and grief that she was gone.

Twenty-one hours later she woke up, calm, quiet, relaxed and sluggish.

These three drug induced comas were my last resort. Every time I looked at her at these moments I knew I had to do something to give her some respite from her delusional horrors. Each time two days later she emerged herself again. And I was once again grateful to beat the boogie man back to his sideline.

My hope is that she can die an old lady of old dog exhaustion..not a frantic maniacal schizophrene. Its a dual, a long marathon dual between me, the chemist with a bag full of drugs, and that elusive ghost who lives in her head awaiting the exorcism.

For those of you who question my motives, I say, "I am trying every single option to give Savannah a life that she is happy and content in. If I can keep her ambulatory and happy I will try anything and everything. It is my obligation to her and to my patients."

Magpie, on the hunt,,for anything.

Jekyll watches over the kingdom.

Charlie, always playing second fiddle, and too proud to admit it.

The welcoming committee at the clinic.

A big bonus of the job, I get to spend my days with dogs and cats!
And if they will let me, I get to be their biggest fan for as long as they tolerate me.
(Me exhausted after two nights of no sleep with Savannah)

My favorite Jekyll pose.

The pet sitter arrives to take a shift.

And just for smiles....the ever expressive Jekyll, and his long slow wake up and face the world yawn...

May we all be so relaxed and happy to face each day!

If you have a pet question, experience to share, or want to meet other pet enthusiasts you can find us on Pawbly.com. You can find me at the clinic Jarrettsville Vet, or on Twitter @FreePetAdvice, or catching a cat nap in the corner of my house while Savannah takes one of hers...

Related articles to Savannah's condition can be found at;

The Troubles With Growing Old.

Another Turn Of The Tide

Surviving The Delusions

Savannah's Cognitive Dysfunction

Living And Losing The Last Moments Of Your Terminal Dog