Investing Too Much. When, and Where Do You Draw The Line?

Perhaps I went into this for all of the wrong reason(s)?

Maybe not the wrong reasons, but, perhaps the expectations were unrealistic? Maybe there was too much of me in this endeavor for others? Maybe it's the other way around?

These are the questions I ask myself as I muck through the maze of my daily life as a veterinarian in general practice.

One of the many delightful faces of my vet life day

Yesterday I spent a long time, (to be honest 20-30 minutes), with a sobbing client as she dropped off her dog, Brunswick, for a forelimb amputation. She was, (as every single other amputation pet parent has ever been), reluctant to consent to this surgery. Of all the procedures that we do, and, for all of the many indications this procedure is recommend for, there is no other life-saving, pain alleviating surgery that is met with such pet parent reluctance and resistance. In my clinic over the last 15 years that I have been practicing, I would say that only about 1/4 of the pets who need this procedure, and, I believe would benefit immensely from, actually get it. Most pet parents will sacrifice the pet to spare the removal of a limb. There is this incredibly difficult and deeply rooted mental block on consenting to limb removal as a treatment option. We were at this place; sitting in the front office, debating whether to consent to cutting off the leg of her otherwise perfectly healthy and happy pup.

Brunswick is a timid 7 year old, 50 pound, mixed breed dog. She is a tawny brown with big erect triangular ears, a wide faced and her soft white body is liver spotted from neck to tail. She has a history of a mass removal from this leg that yielded a diagnosis of "lipoma" many years ago. That mass has returned, slowly growing within the armpit of her front leg. It is now pushing the limb out and away from her torso. It has gotten so large that it has exceeded her skins ability to further contain it. The underside of the arm was red, raw and ulcerating. The mass that has been slowly growing for years now is outgrowing her. The cold cruel eventuality of Brunswick's leg was lose the leg or lose her as she would soon have an open wound that would never heal but instead continue to erode her leg, cause her increasing pain, and chew its way up her neck and across her sternum. 

Brunswick walks front legged short stepped, cowboy style. It manifests as a limp. The mass is hidden from obvious view by her bushy hair. The dappled coat hides the magnitude of the mass until you pet her. The diameter of the upper part of her left front leg is easily twice that of her slender athletic right leg. Her demeanor is always stand-offish for a few moments, but, if you are patient, quiet, and gentle in allowing those few moments to pass she will warm up to you to flounder flop on her "good" side for a full belly reveal. It is her not so subtle invitation to focus your affectionate rubs on the tender fleshy part of her belly. She is easy to fall in love with. Her handicap simply reinforces her charm. Her mom adores her. She will tell you that "Brunswick is her first child." 

And, now,,, here we are. Sobbing. Crippled with fear and doubt, and stuck about what to do with it all.

Many conversations get to this point. That critical pivot point where biology, disease and prognosis has met the timetable of limited options. That juncture in a pets life where you have to choose? Are you a proactive parent seeking to gain as much time with your pet as medicine is able to provide? Or, do belong to the crowd that does not believe in surgical procedures for pets? Do you choose to invest multiple thousands of dollars, hours, and caregiving requirements to gain the precious commodity of more time with your companion. Do you value your pet as a member of your family? Are they one of your kids? Can anyone possibly speculate all of the twists and turns that lie ahead if you do, or don't, take action? 

Most pre-op surgical discussions go like this. 

In Brunswick's case we had already done multiple examinations. Two with me, one with the surgeon. At each time we (the "professionals") agreed the best resolution to this tumor was to remove the leg. There were about a dozen emails back and forth to discuss every possible question and concern. And,, yet,, here we were, crying at drop off. 

I sat with her and said; "I know how hard this is. Please do what you think is right. Not what anyone else tells you to do." I firmly believe that this needs to be said to every parent. The road ahead is too full of twists, turns, and potentially even life-threatening landmines. I should add the cost of care, but, for me it is not a part of the equation I will let decide options. If we believe a treatment option is needed we will find a way to make it accessible. (Note: we use multiple payment plan options to help people not let the financial burden be the deciding factor).

I try to ask myself who will benefit from these decisions? Who am I looking after? These are huge weighty decisions with dire consequences. I try to be unbiased, neutral, indifferent. I try to present facts, argue all sides. I soo often feel that I fail miserably at this. I am not ever able to remain indifferent. I am not on anyone's team outside of my patients and their family. It is the dark force that grips my soul surrenders my conscious heart at midnight.

Brunswick post op

Here's where the muck meets the sole. Brunswick needs this operation. She will die within a year from the mass if she doesn't have it. How do I advocate for that? A: I just have to be honest. Then I have to accept the consequences. But, I know Brunswick is loved and I know her mom is making this decision based on that. Seems silly to some, maybe? But that is always enough for me. I am not the vet for indifferent people who don't value pets. That I cannot do. That would kill me.

My pups; Frippie and Storm

These are the elephants I carry on my back all day every day. They remain cumbersome, consuming and catabolic even after I get home at night.

I didn't sleep much after midnight. That mystical witching hour.  My typical work day has me arriving home after 9 pm, a 12 hour day of work without breaks, meals or niceties logged in the record books.  My shear exhaustion leads me to literally passing out on a pillow having foregone the obligatory teeth brushing, face washing, moisturizing and evening medical supplement regimen. They are all tossed out the window for the sake of sparing my legs the 80 paces they would require. There are loads of nights like this. Wrung out dry. I enter home as this zombie-eyed shell. I sleep for 3 hours and the death cipher lets go her grip for the anxiety ridden stressed-out-Suzie to take claim. Its always this exchange of custody each night between the hours of midnight and 2 am. A shared custody battle as the sun sleeps. 

My Frippie always brings me a gift

Why does the day weigh so hard? Brunswick is one example.. this is another. This one happens too often these days. COVID has created a huge demand for puppies. None of them are being socialized appropriately and for some (often breed specific) it is causing potentially disastrous consequences.

The other emotional dilemma of my day was an 11 month old German Shepherd, (let's call her GS), who visited for a pre-spay exam with bloodwork. Her mom had brought her inside the clinic vestibule on a one foot leash to a tight prong collar. Even with moms double fisted grip she could not get GS to remain with four feet on the floor nor have any kind of focus. She had no control of her adolescent puppy, and, she knew it. She told me that she "doubted I would be able to get her blood." She passed my technician the one foot lead and watched us all as we struggled to lead her to the treatment area. All GS needed was a 5 minute physical exam and 30 seconds to pull a blood sample. These appointments are not charged for as they should only take 6 minutes to complete. That didn't happen.

GS was a happy, outgoing 75 pound determined to party firecracker. She was elated to be around people, and in absolute resolve in not sitting for longer than one split second for anything. She knew commands, and she knew how to decide to avoid them. She surged, jumped, boxed, and thrashed. She twisted arms, crashed heads, and started to lunge and bite to have her demands heard.

Our dinnertime excitement

I always stop here...... The three of us; myself, my technician, and GS. We all looked at each other. What to do now? Take a breath? Try a different tactic? All of the above? We took breaks. We tried treats. We tried calm quietness. I tried a large muzzle, just to see if that would settle her. Fifteen minutes into the endeavor and one thing was clear; Nothing worked. We were at the place where one of three things was going to happen;

    1. I lose my patience and I hog tie, muzzle and we pig-pile on her to attempt to bruticaine (brute-force-paralysis vet lingo), and see if she is so shocked by this she gives in.  I just turn into a cold hearted drill sergeant. Bark orders. Intimidate. Force her to be what I want her to be. Force her to hold this command until I feel she has learned who is in charge. Quickly restrain GS and get it done. Get the blood. Skip the exam. Smile and return her to mom. After all what she doesn't know isn't my problem. She can't claim naivete when she already admitted unruliness. Make friends with the owners, even if it  is at the patients expense. A lot of vets have learned this trick. Two faced. Sweet to people, not so much to patients. A bite will likely follow at some point. What the real consequence of this is; To hell with the next guy who has to deal with her.  Might work for some dogs, never works for shepherds. Shepherds are too intelligent, they cement resentment like dolphins. If I do this to her she will never again come happily into our doors.. She will start every future interaction with fear and aggression. A bite will follow at some point soon.

    2. I give up knowing the short game loss is worth the long term gain and we have a family meeting to try to find a way to make her appointments more enjoyable and productive. Her mom had already expected that today wouldn't go well. We come up with a plan for next time. This should include training at home with the family to allow others to handle her. Working with a trainer to help her focus on commands and execution of them with focus and safety. And medications to help bridge the gap as we work on training. 

    3. I just get bitten. No chance to compromise, or convince her that we are not trying to hurt her. She just explodes and bites as fast as she  can. She is done with us and she will remind us she is in charge. 

What happens when a "bite" happens? Paperwork, fear, and almost always the pet parents compounds the tragedy by isolating their dogs in an attempt to avoid future potential bite provocations. Muzzles, prong collars, yelling, over protecting orders and mounting anxiety across all fronts. It's a snowball. Attempt to avoid situations leads to a lowering of estimation of the pets perceived threats. They used to like everyone. They were puppies meeting a world of new sights, sounds and smells. Now they are guardians that bark at the door knocking, or, strangers. You can't take them out in public anymore because now they bark at everyone. Everyone is a perceived threat. They are 100 pounds and you cannot restrain that amount of determined muscle. They become isolated. We reinforce the idea that everyone is a stranger. I used to see them every two to three weeks. We had fun visits. Now I am the stranger. I ask for unreasonable acts of discipline and focus. They don't know me and they certainly can't see a reason to obey me. Hence the bruticaine and indifference. 

Buster

Who's fault is a bite? Well, for the huge majority of clients vets see daily they would say it is our fault. For every time I have handed back a shepherd to say "we need a different plan to make this visit enjoyable." I almost always get, "well, you don't know how to hold her. She is fine with me." Oh, how I long to reply; "Ok then you do the bloodwork and  the spay. I like my fingers and face." Or, "she would never bite me, therefore, you are the problem." 

Here's my advice; it is the advice that every seasoned pet care professional will give you. Train your dog to accept a muzzle. It is NOT a reflection of a persons failure. Nor the pets. It is a tool to provide assistance as we transition out of anxiety based fear laden actions and reactions. Every pet parent should openly and provide permission for a muzzle to be used if deemed necessary. Man-handling, bruticaine, that is not permissible.. ever (unless a pet is endangering another's life). How do we insure this? Trust. If you don't trust your pet care professionals ask to be present for all possible procedures. Ask, demand, insist that pre-anxiety medications be given. Set ground rules for care. Resistance is a flag for scrutiny. Leaving a practice because a person intervenes on your pets behalf is only going to hurt your pet. 

About 30 minutes after I aborted pushing GS any further I sent her home with a training plan and sedatives to try at the next vet visit. I chose to not push her, not exacerbate a bite, and not make it impossible for the next time. Here's what I got for that, a call from the husband saying "they had a bad experience with us and they are going elsewhere." I doubt I will ever see GS again. There is pride before a fall. There are Shepherds relinquished everyday because no one intervened on their behalf at this critical development time. And, worst of fall there are vets who get court orders to put animals down after a "bite" history deems them a danger to the public. Will the next vet push her so hard she bites? Or becomes passive aggressive? Or fears people so much she reacts with defensive aggression to everyone outside of her family? In my opinion she needs help. Will she  get it? It's one of the reasons I awaken at midnight with elephants.

Tex. His first puppy visit. My goal is to have every patients visit look like this.

The truth is that people pine as much as I do, if not more, on what to do for their companions. What is the right/best/safest/compassionate course of action to take? What will consequences for that looks like? Will I hate/berate/beat up/chastise myself for the action, or lack there of, I take? I have been in these shoes. At every moment of my professional life I remind myself that I am still that devoted pet parent who is in turmoil about what to do? Do I trust my own judgement? Do I have enough pertinent information to base my judgements upon? Is there trust here. Maybe GS's parents lack that? They just don't trust my call? The reality is that she is being set up to fail, not flourish, and her "bite" won't be on my account of failing her. 

Brunswick. One week post-op forelimb amputation

What these two cases have in common is that I did my best to make decisions, present options that were in the  best interest of my patients. period. I can fall asleep knowing that. The rest, the worry, the grief, the elephant on my shoulders that I failed them, their parents, or the relationships we have is the midnight hour that clutches my throat and drags me into the abyss of self-doubt of avenues from that first decision to "do no harm."

Magpie helps me motivate for another morning.

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Happy Tail in a Dog. Why Tail Amputation is Sometimes The Answer. Surgery Photos and Cost of Care Included.

Meet Max.

Max is a typical Lab, effervescent, energetic, and incorrigible. He has two speeds; On, as in Full-On, and sleeping. He is so energetic that he is crated during the day. I know lots of clients who think that their dogs have "outgrown" the crate, but, I think that having pets crated when you are not at home supervising them is a great way to insure a pet who rests and has down time. Mind you this takes training and acclimating, ideally starting as a puppy, AND, carting also helps us in the veterinary medical assistance in that we can prescribe cage rest so that pets are forced to relax and rest. It is especially important for the little dogs with bad backs. These pups need to rest, really sleep and rest. No access to anything. Please don't try to convince your vet that your dog will not jump pn and pff the couch when you leave. They are dogs, they are as sweet and innocent and as incapable of a good decision as a toddler is. Crate rest is an important life long training and healing tool. Max is a crated dog. He is also a happily to be crated dog. So he wags in his crate. He also wags out his crate. If Max has his eyes open he wags.

Max also lives inside. Outdoor dogs, wolves, all creatures in the great outdoors don't suffer from happy tail. They don't have walls to inhibit their happiness. And lets also be honest outside wild animals don't wag much. they have busy schedules to keep them busy and focused. Happy, well, happy is an emotion built on luxury.

When Max came to us he also came with a long, many year history of wagging his tail into beaten burger consistency submission,, that still never stopped the wagging.

A dog with a beaten, sore, painful paw (the other extremity) that we talk about on pets will carry that foot and not use it all to walk on. The nerves that feed the toes and foot are abundant and extremely sensitive. The tail, well it is primarily a bone rod with a paltry bit of leather like skin covering it. No fat, no thick skin like the sole of the foot, nope, just a somewhat flexible whip that swings aberrantly on a whim or a wish.

These are surgery photos from Max's tail amputation. We shave the entire tail from about 6 inches above the expected incision site to the end. We also tie it up so I can aseptically (keep the surgical area sterile) wrap it out. 

Draping the tail so that only a small area stays in the surgical field.

First cut is one of the most important. Every surgeon will tell you that they do A LOT of pre-planning and always keep a few back-ups plans in their back pockets. Once you start you have to be able to figure out every single possible scenario to get out with a happy ending, and what the pet parents were expecting.

Max's previous visit was to start antibiotics, attempt to wrap and protect the tail and discuss options for eradication of the condition we could never seem to manage long term. Max's dad, like all of us would be, was pretty frustrated that the tail never seemed to heal for long. A line of blood lashes lined the hallways. The tail would be found bleeding every night they came home from work. Max and the family never got a break.

Here is the conversation that I had with Max's dad when the subject of amputating the tail came up;
1. This might not be the end. A tail will always wag if the happy soul at the other end of it tells it to. Did you know that even pets with complete spinal paralysis can still (sometimes) wag? Yep,, a happy dog will tell you even through paralysis of all of its legs!
2. We have to keep the tail incision site, no matter how short that tail is, protected for weeks. That takes a huge amount of dedication and oversight on Max's family. An e-collar at all times, frequent post op visits, and protecting that tail are hugely important. If he is allowed access to his tail we will have to redo the surgery.
3. If the surgical area gets infected, traumatized (by him chewing, laying, or banging it on anything) I have to remove more tail. The tail is docked by removing segments of the tail bone, which is essentially pieces of vertebrae. You only have so many pieces and then you risk jeopardizing the spinal cord that innervates and commands Max's ability to pee and poop voluntarily.

Max is still under general anesthesia. His surgery is done, but, now we need to bandage the area before he wakes up and starts wagging again.

I've tried lots of splints, covers, and protective options on tails. The problems are always the same;

a. the tail tapers so that a big wag will cause the bandage to just fly off.

b. The tail, the incision and all healing tissue will respond better if it can breathe, so, the plastic cone enclosures I used to use left the tail stump wet, sweaty and delayed in healing,, air,, we all need air!

c. How to protect an incision and end of tail in 360 degrees and also allow air? 

My latest answer has been a spoon splint. It is the blue spoon shaped item to the right if the end of his tail above.

Bandages are the balance of protection, comfort, and durability. It is an art form that takes practice.

 This is Max (note; still smiling!).

He came to visit about 3 days post op so I could check his incision. As much as it is imperative that the incision site, and new end of his tail, stay protected post-operatively, it is also really important to check the incision frequently. Bandaging protects the healing tissue, but, it also hides a problem should there be one. Max also has an e-collar on 24/7 so he can't lick or chew the end of his tail. A dog, or any and every, post op patient will try to lick, bite, or chew at a painful area. So how do we know what is detrimental chewing curiosity, and, what is an indication of a hidden under the bandage problem? well,, we check the incision frequently, and, we pay attention to our patient. Not eating, or not eating well, pain, or signs of reluctance to do normal activities are all signs of a potential problem. Listen to your patients. They will tell you there is an issue, if there is an issue..

The incision is a little red, but holding well, and Max didn't mind us changing, cleaning, or re-bandaging the tail.

I also replaced the bandage in front of his parents (they are EMT's), so they can replace it at home if needed. We send home extra banding supplies,, JIC.

I want pet parents to see the surgical site at every visit. Everyone should know what it looks like at every visit. How else can they also monitor progress and know what normal and abnormal is? I keep parents involved in all aspects of their pets care. It helps them feel empowered, involved and invested. 

Max approves!

Bandage changes happen every 3-7 days. As long as the tail is wagging comfortably, being held at a normal height and angle and showing no signs of wetness, blood, or a bad smell we change it in the clinic with parents present. I expect it will need to be bandaged for about 6 weeks.

For more on Max read his Pawbly.com story here;

The cost of Max's care;

Pre-op exam; $50

Pre-op blood work, full panel $170

antibiotics for infected end of tail $30

surgical cleaner for end of tail $15

Surgery costs;

surgical package; iv catheter, fluids, pump, anesthesia, instrument pack; $250

tail amputation $200

post op pain NSAID $16

splint application $50

additional suture $60

refill antibiotics $30

e-collar $16

Max's story is posted with his families permission. I thank them for allowing me to share his story, photos, and process.

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Rotten Cat Tails. What are your treatment options and the costs?

We all live on a budget even though none of us want to. It is a reality and obstacle we must recognize and accept. When it comes to pet care I will be the first to challenge the notion that there is only one way to do things and that this one way is going to cost you and arm and a leg. The whole idea that vet care isn't accessible or affordable to everyone is the single greatest reason pets are having to do without all of the incredible advances and options modern medicine allows. Technology has provided access, it is time for us to provide affordable options and transparency.

As much as I believe this to be true there are still a few conditions that don't allow many options.

Here is one such case.

This is Haley.

Haley is a stray cat that a very kind client of ours has seen lurking around the neighborhood for awhile. She had been seen chewing and biting at her abnormally shortened tail and she smelled awful. When they investigated her tail they found that it was severed off at the end, bleeding, and terribly damaged.

I strongly believe that people want to take care of the pets that they love. I also believe that too many pets, cats in particular, are left without care because they do not hold a position of importance amongst enough of society. I don't believe in the rest of the paltry arguments about.. "cats are able to care for themselves," or, "I don't like them," (to which I always reply "you don't like them because you don't know them"), or "I cannot afford care." I truly believe that almost every aspect of pet care is affordable if you deem it to be important enough. One of my goals is to help make care transparent, offer affordable options, and provide ways to pay for those options.

When it comes to tail trauma to this degree of tissue destruction there is only one option; Surgery.

There is not another effective treatment option to thwart the constant pain and infection then amputation, or removing the end of the tail.

Haley is under general anesthesia and the tail has been clipped and is soaking in our surgical solution.

The end of the tail after being cleaned and prepped for surgery.

I cut to the closest healthy vertebral body and amputate the tail there. Remember a pets tail is an extension of the spine, so the little pieces of bone that compromise the vertebrae extend to the tip of the tail. They house the spinal cord, nerves, small lengths of muscles, tendons and blood vessels.

Here is what doing nothing might have caused;

• Haley could have either continued to bleed until she became anemic, which would have led to her death as an outside cat.
• Gotten an infection that penetrated her spinal cord. Very bad!
• Kept traumatizing (biting and licking at her very painful tail) until it was a stub and then they keep on chewing until they jeopardize their nervous system and musculoskeletal systems ability to walk, urinate, and defecate. Very, very bad. Absolutely life threatening.

So, as much as I believe that it is imperative to provide multiple options with a range of prices..in these cases I just feel that there is no other option than to amputate.

Now I might not be able to provide good treatment options other than surgery to correct this, BUT, I can offer a few options with respect to how and who does this.

Typically we recommend pre-operative blood work ($40 - $250), FeLV/FIV testing ($50), and all vaccines ($16- $80). For Haley her mom opted for the FeLV/FIV test (I think this is the most important test to do), and her vaccines. She also opted for a microchip ($10) as she is an outside cat and now has a home.

Haley's surgery cost was about $200. She went home with antibiotics ($25), pain medication (Oh, how she loved the pain medication at about $30) and an e-collar ($12).

She is a wonderful affectionate girl and will make a great addition to their family.

This is Haley's tail at her 2 week post-op re-check.

It has healed beautifully. It looks nice, has no open wound, signs of infection and skin and fur cover the blunt end of the spine appropriately. She is also comfortable and not bothering it.

A happy healthy tail gives the "thank-you" salute.

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Could A Neurotoxin Be The New Treatment for Bone Cancer Pain?

There are few diagnoses feared more than cancer. And, few conversations more difficult to discuss with clients than bone cancer. Clients walk in the clinic with what they believe is a simple limping dog and leave with a death sentence and a few months left to enjoy their pet.

By the time we diagnose these tumors they have usually spread. We may not see evidence of those satellite tumors in the chest, but odds are they are there, small, quiet, unorganized, lurking and waiting.

These cases require a patient, calm, repetitive approach. Clients need time to accept, understand, and process the diagnosis. They also need time to come to terms with the treatment options available to them.

I have written about osteosarcoma's and my personal opinions and belief that the one thing we must do for these patients is provide them with some way to manage their pain. Bone tumors are excruciatingly painful. So much so, that pets will refuse to move, eat, or interact on any level just to avoid moving because the pain is so intense. My advice, based on years of practicing and dozens of patients, has always been the same; Get rid of the pain by getting rid of the source. Amputate that useless limb that is killing your pet and killing their ability to live a pain free life for whatever amount of time they have left. They don't use that leg anyway, so get rid of it. I promise they won't miss it and they won't feel bad about looking "disfigured."

But, alas, I am not always able to convince my clients that this is the right decision. And at some point there are no opioids, steroids, NSAID's, or options left to manage their pain. These pets are put down because we cannot keep them comfortable.

It was with great delight and interest that I found the following article on a new treatment option for these patients.

Researchers at the University of Pennsylvania School of Veterinary Medicine injected a single dose of a SP-PAP, a neurotoxin, into the spinal cord, under general anesthesia, and found that the patients receiving the neurotoxin in the study were considerably less painful than those without it. The results were so promising that the drug and study is expected to be used for humans. 

Maybe someday very soon I can offer this instead of euthanasia as a way to keep my patients comfortable?

Please read more about bone tumors and treatment options at Heidi's Story.

Article abstract follows:

Intrathecal substance P-saporin in the dog: efficacy in bone cancer pain.

Anesthesiology. November 2013;119(5):1178-85.

Dorothy Cimino Brown¹; Kimberly Agnello

¹* Professor of Surgery, † Assistant Professor of Surgery, Department of Clinical Studies - Philadelphia, University of Pennsylvania, School of Veterinary Medicine, Philadelphia, Pennsylvania.

Article Abstract

BACKGROUND: Substance P-saporin (SP-SAP), a chemical conjugate of substance P and a recombinant version of the ribosome-inactivating protein, saporin, when administered intrathecally, acts as a targeted neurotoxin producing selective destruction of superficial neurokinin-1 receptor-bearing cells in the spinal dorsal horn. The goal of this study was to provide proof-of-concept data that a single intrathecal injection of SP-SAP could safely provide effective pain relief in spontaneous bone cancer pain in companion (pet) dogs. METHODS: In a single-blind, controlled study, 70 companion dogs with bone cancer pain were randomized to standard-of-care analgesic therapy alone (control, n=35) or intrathecal SP-SAP (20-60 µg) in addition to standard-of-care analgesic therapy (n=35). Activity, pain scores, and videography data were collected at baseline, 2 weeks postrandomization, and then monthly until death. RESULTS: Although the efficacy results at the 2-week postrandomization point were equivocal, the outcomes evaluated beyond 2 weeks revealed a positive effect of SP-SAP on chronic pain management. Significantly, more dogs in the control group (74%) required unblinding and adjustment in analgesic protocol or euthanasia within 6 weeks of randomization than dogs that were treated with SP-SAP (24%; P<0.001); and overall, dogs in the control group required unblinding significantly sooner than dogs that had been treated with SP-SAP (P<0.01). CONCLUSION: Intrathecal administration of SP-SAP in dogs with bone cancer produces a time-dependent antinociceptive effect with no evidence of development of deafferentation pain syndrome which can be seen with neurolytic therapies.

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Jekyll and Charlie, patiently waiting for me to get ready for work.