The Bump That Gets Too Big. (Warning; Surgery Scenes). Why a team approach will always tilt the odds in your favor.

This is Cody's story.

He is an older Springer Spaniel who has been visiting me for the last four years. He came to me seeking a second opinion because his primary veterinarian had given him a very poor prognosis and no plan.

Now, I am a realist. Medicine is about statistics... (by the way, I loathe statistics, numbers; boring, scenarios; boring, population studies; boring, math..well, you get the picture), but as much as it is boring it is a factor in guiding our decisions and our recommendations. Veterinarians look at the physical exam findings, lab work, and then decide which diagnosis fits your pets billet. From there we discuss treatment options and  their corresponding most likely prognosis. To many clients it is a difficult wad of information to chew on and digest, never mind to try to make a decision upon.

My job, as your vet, is to help you all understand your pets ailments, options, and decide where to go with them.

Some vets do this better than others. If your vet, (who I will almost guarantee is one smart cookie), cannot adequately articulate and help you understand which direction to head in, or even worse, if they cannot give you any options, or sign of hope, it's time to rethink the value they add to that relationship.

Soapbox Time: WE HAVE AN OBLIGATION TO HELP YOU NEVER LOSE HOPE, OR AT LEAST PROVIDE YOU WITH AN OPTION TO HELP END SUFFERING! If your vet doesn't give you this find one who will.

Cody's parents did not want to give up on him. At eight years old he was their kid and they felt he had a few years left ahead of him. They came to visit me and we laid out a plan this included a change in diet, a nutritional supplement, carefully planned scheduled monitoring (which includes a plan for Best AND Worst case scenarios), and access to me, or any of the other veterinarians at the clinic to help when the plan changed, as it inevitably will.

Cody has a plan, a clear written list of items for his family to do at home, a schedule to follow and a support network to utilize if anything comes up along the way that his family needs assistance with.

That was over four years ago.

Over those four years Cody has blown two cruciates, had them surgically corrected. He has beaten the odds at every challenge. He has an army fighting for him, and we all know that the odds always shift in your favor when you have a team approach to your problems.

Cody was visiting this time because one of his many bumps had gotten rather large and worrisome.

Like many dogs Cody has gotten a little lumpy as he aged. We have kept track of all of them, monitored them closely and none have changed size, shape, or texture. Well, that was until this one. Cody's previously thought to be a lipoma (benign fatty tumor) had all of the sudden gotten much bigger. It had evolved from golf ball sized to bigger than softball.

Cody's mass is on his lower neck/upper chest area. It is firm, round, and felt as if it was adherent to the underlying tissues (in other words I was not able to get my fingers underneath it and pull it away from the muscle). The skin covering the mass was very red, had visible blood vessels and the hair was beginning to wear off. This is a sign of the mass being either abraded by the surfaces that he is laying on (thereby wearing off of the hair and causing the skin to thin), and/or the skin is being stretched to the point of beginning to tear). Either scenario is a problem.

We discussed Cody's current predicament.

His family had come in because they understood that something had to be done.

Their options were;
1. Do nothing. Not a good one, because unless we thought Cody had only a few weeks left that mass was going to open and we would have a heck of a time (I used the word "impossible") keeping it from bleeding continuously, and/or it could become a source of infection. It is impossible to keep these kinds of masses bandaged, and even keeping as bandage on does not prevent infection. Chronic bleeding will lead to anemia and there is no permanent way to treat this without stopping the source of the bleed. You will end up with your back against a wall deciding whether to euthanize your pet because you cannot manage an open and non-healable mass. Don't wait for this. don't euthanize your pet without trying to heal them.
2. Take it off, cross your fingers that you can close your incision and remove the cancer in total just in case it is a tumor that can spread. to other parts of the body. Plan and hope for excision to be curative.
3. Perform a fine needle aspirate and/or biopsy.  We do these to try to identify what the mass is before deciding which step to take next. Sometimes we classify this as "de-bulking" because we feel that we cannot get the whole mass removed cleanly.

Cody's family opted to take off the mass before it opened up and became a big messy problem.

That same evening in addition to Cody's physical examination we checked a CBC, full chemistry, urinalysis, and three view chest x-rays. 

Thankfully, everything was normal. Cody was scheduled for surgery the following week.

I have to admit that I was pretty nervous. None of us want to admit to being paranoid, but I was afraid that I had pushed my luck too far with Cody already. This was the sixth "older dog not really sure what I am going to find mass removal surgery" in about as many weeks. Could I really be so lucky to not have one of these guys NOT make it through surgery?  And, damn it, I liked these clients a lot,, we had been through too much together already.. weight of the world on my shoulders we went into surgery.

They always look waay more ominous when they are shaved.

The first big sigh of relief. The preliminary exploration of the mass and it all appears to be fat!

Now all I have to do is get my fingers all the way around the big ball of fat, hope that they don't encounter any big angry blood vessels and get this thing off.

The lipoma is off, and I have enough skin (always think about this before you place scalpel to skin) to close the incision. Almost nothing is worse than having a bigger problem after surgery than you did before because there is too much tension, or, it takes months and months to heal because you didn't have a good exit strategy.

A big mass always leaves you a big hole.

Starting to close is more technically challenging than any other part of this surgery..

In the end there is a large incision. It always looks worse after than it does before,prepare your clients for this.

TAH-DAH!

A closed incision must be able to maintain function. Expect some pocketing, some bruising, and monitor very closely for any signs of infection. Some pets need to be hobbled. We bandage the front legs together so they cannot splay open accidentally, or otherwise, and put excessive stress on the incision.

Cody recovered well and seems to have once again proven that if you have a team behind you, and you face the challenges life throws you head on with them, anything is possible!

Related Blogs;

Charlie's Life Saving Lipoma Surgery.

When a Bump Causes You Concern Slay it with a Diagnosis!

If you are a pet person and would like to help others, or, if you are ever in need of help with your pet, please join us at Pawbly.com. Pawbly is a place where pet people can meet other pet people and exchange their questions, experiences, and thoughts. It is free and open to anyone who loves pets. We know that together there is a way to help every pet in every corner of the globe.

If you would like to follow me on Twitter I am @FreePetAdvice. Or find me at the clinic Jarrettsville Vet, in Jarrettsville Maryland.

This is my team.. resting for the challenges life might throw them..later.

The Troubles with Growing Old, Taking Care of Your Geriatric Dog

A big favorite, lasagna.

For many of my clients there is a time when their pet gets either too old or too sick to be coerced to stay on their 'regular' food any longer. 

The discussion of diet and disease state is an important part of every complete treatment plan, but at some place in time that prescribed, or regular diet is not palatable, or interesting enough to keep their pet on it  routinely.

For almost every disease there is a specially formulated highly studied, evolved and exemplary diet. From the most common to the most complicated, or even combinations of diseases, there are dietary options that will lessen the severity, progression, or clinical signs all thanks to your pet being on an appropriate formulated prescription diet. 

Savannah is always fed on a big soft bed.
It is the easiest way for her to keep her feet underneath her and the food in front of her.
Finding ways to assist your pet in eating is key to their ability to
maintain adequate calorie intake and muscle mass.

Over the last few years there has been an explosion of dietary options made available for pets. It is remarkable that so many people are so interested in their pets care that the thought of a $40 small bag of food is deemed to be worthy of their hard earned  dollars. It is easy to understand that pet parents care so much about their family members to want to prove what they believe the best for them. But what is harder for me to imagine is that people are making decisions based on infomercials, store sales clerks, or lay people. Your pet and  their care, I hope, should be based on the recommendations of those who have been trained, educated, and remain unbiased in their quest to provide your pet the best care possible. 

When it comes to diagnosing your pet and assisting them in overcoming their disease or ailment there is no greater authority than your veterinarian. But to prescribe a dietary treatment plan there needs to be some groundwork done, (a physical examination and diagnostics that may include blood work, radiographs, ultrasound, etc.),  and a short  term and long term treatment plan discussed.

When your pet is diagnosed their diet should be an integral part of the treatment plan. You should understand what ingredients are detrimental to your pets condition, which should be avoided, and a few helpful hints to safely and effectively switch your pets over to their ideal food.

When it comes to switching diets I usually suggest a 'slow and sneaky approach'. Ideally we want to switch your pet over to the new food gradually. This will accomplish two things. First, the new diet will not upset the gastrointestinal system, and second, your pet is more likely to transition to a new food if it is done slowly and gradually. Your veterinarian should explain in detail with a time frame as to how this is best accomplished.

In general, I recommend transitioning to a new food over weeks. For dogs with a sensitive stomach, vomiting, diarrhea, or allergies I usually recommend a transition period of a week with the following; 1/4 of the new food with 3/4 of the old food for two days, then 1/2 of the new with 1/2 of the old for two days, then 1/4 old with 3/4 new for another 2 days. For pets transitioning to a kidney friendly diet, especially felines, I recommend a much longer more gradual approach. Kidney friendly diets are pretty boring. They are effective and very beneficial but most cats are hard to convince that they are a delicacy. For this reason I advise switching over weeks. Adding tiny increments over months so that the transition is so gradual your cat doesn't even notice. Should your cat decide that they are not willing to eat a prescribed diet call your vet and inquire about other options. There are multiple prescription diet manufacturers and your cat might prefer one over the other. After all, variety is the spice of life. If your pet still refuses to accept the new food then remember that a little bit, (or as much as possible) of the right food, is better than none.

Yep, asleep with her head in the water bowl.
If I see a pet doing this I am concerned that their thirst is dictating their lifestyle
and I look very closely at reasons that a pet might have an increased thirst.
Regardless of the reason, and regardless of how much urinating is occurring with the increased thirst, PLEASE! Never, ever restrict water. 

At some point along the road of disease, life and age we lose the ability to mandate optimal choice. At some point your pet will tell you that they refuse to submit to your 'ideal diet'.  When this point arrives my advice about what is best turns into advise about how to preserve life. 

When your pet refuses to eat those packaged labeled prescription diets you should know what you can offer with their disease state and dietary consequences in mind. When even those options are being refused the food restrictions are lifted and free choice is prescribed.

Adequate food intake is a careful combination of many factors for the elderly geriatric patient. The food must be highly palatable, smell enticing, and be easy for them to prehend, chew, and swallow. For many clients I advise warming food, mixing in wet food, trying other foods like baby food, cat food, or human food.

For Savannah I usually offer at least three options. If these fail to intice her to partake in them I cook something. This morning's breakfast was shells, tuna, and cheese. All warm and all fresh. It was a hit!

As Savannah ages and loses her peripheral muscle mass (her rear legs are progressively weakening) I have her eat propped up on a bed or even propped up on the bottom step of our stairs. This way she can't slip backwards and away from her meal.

Delicious!

Caring for your older pet requires constant supervision, dedication, and persistence. For every obstacle there is in almost all cases an option to assist them. 

With her front legs planted in her bed, and her back end supported she is able to eat on her own.
Savannah's meal times are always supervised.

Geriatric medicine is very similar to pediatric medicine. Monitoring daily food intake, feeding twice (or more) a day, and also monitoring bathroom behavior is vital to their immune systems and ability to maintain adequate body condition.

Savannah's bedroom area.
Lined with absorbent non-slip blankets and rugs, it has become the cats favorite rumble arena.

Oriole body slams Wren.

Savannah's bed is adjacent to the cats room (the warmest spot and the brightest spot in the house).

At the end of the day there is sleep.

As your pet ages their ability to climb over, or into, things becomes more difficult to impossible.

To address this Savannah's beds have gotten progressively lower to the ground. 

And sometimes we just close enough to think we are in the bed.

It has been a long road of twists, turns, dark days, and long brutal nights. I have tried many treatment options, medical therapies, and been determined to not let a decision be made to let her go without feeling as if I have exhausted all of the options available.

Savannah sleeps through the night, is calm and relaxed, eating well, and happy. I really can't ask for more than that. I am beginning to think that my hope for her will come true. 

That maybe she will get the gift all of us ask for,,, to die of just plain old age.

If you have any pet questions you can find me at the clinic Jarrettsville Vet, or on Pawbly where we help pets with any problem at anytime and always free, or on Twitter @FreePetAdvice.

Related Articles;

Another Turn Of The Tide, Savannah's Story

Surviving The Delusions, Savannah's Story

Savannah's Cognitive Dysfunction

The Tiniest Steps and the Biggest Hurdles. Savannah's End Of Life Story

I have been talking about Savannah for a long time. She is my 18 year old beagle mix who has been struggling with the affects and burdens of aging for the last few years. I have chronicled her slow decline through a few blogs. For those of you who need a summary; She was a very active, stubborn, food driven, obsessive, loyal, and devoted girl since the day I adopted her from a college student who wasn't allowed to (for very good reasons) have a dog, 17 and three-quarters years ago..

I found her tied behind a small apartment on a make shift leash all by herself at 8 weeks old. The moment I saw her I knew she was ours. She was a very fuzzy beagle looking girl who never talked much but always had deep inquisitive thoughts. She loved being in the country, going on walks in the woods, sleeping on the furniture, and came everywhere with us.

About three years ago she had three strokes over about a 48 hour period. When they happened I was thinking the the writing was on the wall and our days with her were numbered. For about a week she couldn't stand or walk in a straight line. She also had a terrible bought of horizontal nystagmus. Nystagmus is when your eyes move in a rhythmic motion. For Savannah her eyes shuttled back and forth from left to right. It is very concerning to see and makes ambulating incredibly difficult.

After about a week all of the side effects of her strokes went away, except for the head tilt. She to this day keeps her head tilted to the left. So when she walks she circles to the left. It is much like steering a horse. If you pull the bridle to the left the horse turns left. Savannah thinks that she thinks she is walking straight ahead but from the birds eye view she spins like a top and always to the left. Because of her inability to walk in a determined direction she is not allowed anywhere near steps.

Over the past months she has gotten more and more tired. In part it is because she is losing muscle mass and in part because her once voracious appetite is waning. For a beagle (or my pig, I know that this implies the writing on the wall is getting bigger).

I keep her on a leash all the time. She has escorted bathroom breaks. When she wakes up its time to go out. If you don't get to her fast enough you will have to clean up. Her world has shrunk to a small contained easy to clean up area lined with pee pads, free from obstacles, areas to get stuck in, and the puppies to bother her. It is also lined with a baseboard heater so her area is the warmest in the house.

She wants to go outside and she tries to wait long enough for you to show up and carry her, but her ability to know its time to go out is about a minute before she has any ability to do anything about it.

I remind my clients that there is a very good reason they make adult diapers. Someday if you are lucky enough to live long enough to see the day you will be perusing the shopping center aisle finding your own diaper size. Savannah at 18 is about 100 for us. I know none of us want to think about it, but aging is the process of adapting to the things your body can't do any more.

Savannah has a hard time walking on almost all interior surfaces. To promote exercise, help her maintain her precious muscle mass and to keep her mentally stimulated I keep her outside as much as possible.

Feeding her has also gotten more difficult. She has to be on her bed, propped up and have her food right infront of her.

I spend every day offering a wide assortment of foods. These days it is about keeping her eating, moving, and stress free. This entails offering her anything, everything and hoping that I can offer something she will pick at. I rotate between hot dogs, hamburger, crackers, cat food, rice and veggies, dried chicken and/or  beef, pizza, and then whatever else I can think of. (I recommend to my clients any and all canned meats, baby food, whatever, and good luck).

The puppies wonder why she gets the good stuff, and they wait like vultures to clean up the food she spills.

When your time to leave this world grows near those little things we all take for granted everyday, like walking, daily activities, and our abilities shrink to a very small scale.

For Savannah the days are spent sleeping. She has beds everywhere. But where they used to be cushioned elevated dog beds they are now large opened sleeping bags. She can no longer get up into any sort of bed. Her shuffle has no ability to step up, or down.

I get up at least twice a night. It has been this way for months. I often have to get up to change her bed linens, run another load if laundry and give her a foot and butt bath. Its an hour long task most often at 2 am. I am tired. Like really really tired. And for as much as I look forward to that night that I can sleep for eight hours, I am bound to taking care of her at the time she needs me the most, and I am grateful for every last second of every last day (and night) that I have left.

Taking care of her at this stage in her life is a series of little tiny steps. Some of them are steps that we have lost. I will never see her run again. And I will never see her outwit me to sneak into the cats room to steal all of their food. As I look at her I am reminded of the girl she used to be, the companion I am slowly losing in tiny pieces and the inevitable turning of the tides.

But for today I am grateful that after the chicken, the rice, and the cat food that she turned away from, she sat and ate two hot dogs.

If you have any pet questions you can ask me, and a whole bunch of other pet lovers at Pawbly.com, or find me on Twitter @FreePetAdvice. 

More stories on Savannah;

Caring For Your Older Dog

Savannah's Story

Almost Hospice Care