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 Ear Ache That Just Never Went Away

My friend, (and fellow veterinarian), and I complain that we see endless cases of skin and ears. It is our bread and butter, but goodness it can get frustrating.

Yes, it is frustrating for us, and I know that it is frustrating to my clients., but it is painful, persistent, and a palatial PIA to our pets.

Here is my hope, that if these ailments are so common, and frequent, that I can educate my clients with all of the tricks of the trade to avoid these frequent recurrent problems.

I know that most people don't look for more reasons to visit my office nor do they want their pet to be ill or in pain and not know how to relieve this. So here is my first piece of advice; if your pet has had one ear infection, bout of allergies, or other skin problem, it is very likely to have it again. Talk to your vet about how to identify the problem in its fledgling stages, how to prevent it, and what you can do to minimize any future episodes. 

Today's story is about Tootsie. A cuddle-bug kissing rotund little Yorkie. Her charm is instant and lasting. But, alas, she is a dog with allergies. Tootsie, like many of my patients with allergies, starts to show her first signs of impending irritation via her ears flaring up.

Truth is that in many cases what my clients perceive as an "ear infection" is in some cases just ear 'inflammation." Whether that ear is infected or inflamed the long term consequences of both are the same. 

Chronic irritation creates chronic inflammation. Think of it like a wound that never heals. That wound will become raised and the tissue that makes up that wound will get larger as a scar starts to form. Scar tissue has an irregular raised almost cauliflower look to it. If scar tissue forms around the tunnel of the ear canal then the only place it has to grow is into the tube. The ear canal tube thus gets narrower and narrower. A narrowed ear canal is called stenotic. Unfortunately, over time and repeated inflammation the canal closes off from the outside world. 

Ears benefit from a few key things. 

• Ideally, the ear should be open to air flow. Dogs with erect open ears have fewer ear problems than those dogs with big floppy pendulous ear flaps. Like for instance the difference between shepherd and a spaniel. The erect ears get to breathe because an floppy ear flap shuts out sunlight, keeps in moisture and keeps in dirt and debris. I call this the "fire triangle." Remember when we were in elementary school and we were taught that a fire needs fuel (debris, wax, and dirt), oxygen (darkness), and a source of the heat (inflammation or allergies). With some dogs their ears remind me of the fire triangle.
• The size of the ear canal should be large and open. The brachycephalic dogs have short narrow tortuous tubes..much harder to let air flow through. 
• Excessive ear hair is commonly seen in smaller breed dogs, like poodles. The hair keeps humidity, dirt, debris, and wax in the ear and precludes it from leaving the ear. 
• A dirty, waxy, or parasite filled ear is an invitation to a problem.

One last note. Many pets with allergies have ear problems. You will have a difficult time keeping the ears under control if you cannot keep the allergies under control.

In an effort to keep ears happy and healthy basic ear maintenance and intervention is key. I advice any dog with excessive hair around and in the ears be removed, (remember never use scissors, either pluck or clip), ask your groomer or veterinarian for tips to keep the ears clean and hair-free. Any ear that is red and itchy should be kept impeccably clean with a good veterinary recommended ear cleaner, (read the directions for use, NEVER stick q-tips or swabs in the ear!). Also see your vet about how to distinguish inflammation from infection. If you do have an infection use the appropriate bug specific medication.

Tootsie has had allergies and ear problems for most of her 4 years. She finally has her allergies (mostly) under control. But that right ear, well, it shut its doors to company (medical or otherwise) a long time ago. We have tried every possible concoction to get medicine to the inside of her ear. All with no luck. That right ear was a closed brewing vat of inflammation and infection that was unable to let any kind of medication penetrate into the closed canal of chronic disease.

When Tootsie came to see me I tried once again to treat her proliferative stenotic ear. For weeks we tried to get her infection back under control. With reluctance, and bit of optimism for resolve, we decided it was finally time to surgically open up Tootsies' ear canal. We hoped that this surgery would hopefully provide her the ability to still hear but no longer suffer from infection. For any real chance of keeping a functioning hearing ear we had to re-open her ear canal.

Here are the pictures of Tootsie's ear surgery.  This could only be achieved through surgery.

The first incisions to open the vertical ear canal.
The nerves that innervate the face live here.
Facial paralysis (often only temporary) is not uncommon after this surgery.

Normal post-op swelling.
But a beautiful and finally opened ear canal.

Three days post-op. Still swollen and draining but healing.
These are painful surgeries.
Tootsie has a morphine time-release pain patch and oral opioids to keep her pain free.

Tootsie has had allergies and ear problems for most of her 4 years. She finally has her allergies (mostly) under control. But that right ear, well it shut its doors to company (medical or otherwise) a long time ago. We have tried every possible concoction to get medicine to the inside of her ear. No such luck. That right ear was a closed brewing unable to get to canal of chronic disease.

With reluctance and optimism for resolve we surgically opened up the canal. This surgery will hopefully provide her the ability to still hear but no longer suffer from infection.

If your pet has recurrent chronic ear infections, or an inability to treat any longer please see your veterinarian, a veterinary dermatologist, or a veterinary surgeon to treat this painful debilitating condition.

There is much that you can do, but of paramount importance is keeping your pet disease, pain and discomfort free.

For more information on how to clean ears please see: http://kmdvm.blogspot.com/search/label/Ear%20cleaning

Ears are a common ailment for our pets but in almost all cases being correct with your diagnosis, specific in your treatment plan, and thorough in your ability to prevent any of the predisposing factors that predispose your pet to ear problems.

One week post-op and the ear is healing beautifully!

All healed!! Now back to keeping the chronic skin allergies under control..

Tootsie and her mom.
Every single living creature should have a family that loves them even an ounce as much as Tootsies does!
She is one happy girl!
And her family says she is even happier without her chronic ear problems.
Very best of luck to all of them, and we will always be here to help her with any of her ear, skin, or waistline bumps in the road ahead..