IVDD A tale of two outcomes

We have these weeks where the storm clouds swirl above you and the seas rise around you and your boat gets rocked hard. It is in the middle of the looming disaster that you test your abilities, and truly get a sense of where your strengths lie and where the weaknesses are cracking your hull. There was a time a few years ago where we literally did 12 splenectomies in a 2 month period. Before that first splenectomy I had been out of vet school for two years and not seen one. In the four years since I haven’t seen 2. So weird, but completely true.

In the last week we have seen two dogs with acute intervertebral disc disease cases. I thought their cases would be a good story to help you understand this disease and how easily an outcome can sway in the balance.

Today is Wednesday the 21^st of September. It is the day that Porter had the disc that was putting pressure on his spinal cord at Lumbar vertebrae 2 and 3 removed. The intervertebral disc in the spine can best be described like a jelly filled donut. Those little jelly filled donuts are the pillows between the vertebrae that protect your lifeline; the spinal cord. The bones that makes up the vertebrae, (your backbone), are like the cars of a train. Once one of those cars gets loose in the track the rest of the cars are more vulnerable. It is an amazing framework of engineering, but one small problem has devastating consequences. If you injure your back to the point that the jelly is extruded from the donut the jelly can only go into your spinal cord space.  Any tiny amount of jelly in this very narrow place is painful and causes pressure and damage to the very sensitive electric wires that are your spinal cord. Too much pressure for too long causes paralysis of these fibers and then the messages your brain is trying to send to the body get slowed down or stop completely. It’s like losing your power to your house because a tree fell on the electric lines between the power plant (your brain) and your house (or say your leg). IVDD (intervertebral disc disease) is common in the dogs with the long backs. The most common dogs we see suffering from this disease are the dachshunds. I also see it a lot in beagles. The obese dogs seem to also have weaker backs.

In some cases we see this disease as a result of dogs playing to hard, or from trauma, like being hit by a car. And in some cases it just creeps in slowly and silently and persistently. Clients will walk in with their pet complaining of not wanting to walk up or down stairs, or not wanting to jump up on the bed, or not able to urinate or defecate. Sometimes it is that they aren’t eating. All of these complaints areyour dog telling you that they are in pain. I have had owners tell me that they think their dog has a belly ache because when they tried to pick them up they screamed. A dog with a “slipped disc” is painful. Sometimes they are painful everywhere, sometimes they are very good at hiding their pain. There have been a few patients that make me have to search hard to get them to elicit where their sore spot is. IVDD can happen in the neck (cervical) or lower back (lumbar). When it happens in the neck I see these dogs reluctant to walk, unwilling to move their head, (think whiplash) and then scream in pain when you try to move their head while holding the rest of them still. Sometimes we also see the four legs not responding normally to basic functions. A dog with lumbar disc disease will not want to jump, or walk up or down stairs, or not wanting to get their butt off the ground. In the end stages of this disease the disc cuts off the spinal cords ability to talk to the limbs ability to ambulate (move), and the body’s ability to urinate or defecate voluntarily.

The tale of Porter and Daymin is about lumbar IVDD.

On Thursday the 15^th of September Daymin was brought to the clinic to be evaluated.  His chart read simply, “Exam, can’t get up, has $ issues.” That was written by the receptionist as was stated by the client to them at check-in.  The technician then wrote the following; “ owner thought he was constipated,  so they gave him an enema. Was fine, normal, all day, sat back, then fell over, urinating on himself.” I was not the vet that Daymin saw that day, but as I read his chart I am once again dumbfounded how many times clients think that their pets are constipated. I know that I shouldn’t make these broad sweeping general statements, but here I go.., “People! Dogs are hardly ever constipated!” As I think back, I have only ever seen one or two constipated dogs. (Now constipation in cats is a real problem, so my statement doesn’t apply to cats!) Perhaps constipation is a big problem in people?, so that’s why they think their dog is constipated? I don’t know? But darn it, don’t give anyone an enema without a Dr’s ok. Enemas can cause big big problems. The veterinarian who saw Daymin stated in her physical examination findings that Daymin was panting, painful, and unable to use his hind legs. Daymin was also very obese. Daymin is a Labrador Retriever and these guys don't typically get this disease, BUT, the fat ones are all susceptible. He had urine and feces on his hind end. The owners had enough money to run blood work and take x-rays. After these were run his preliminary diagnosis was IVDD. Based on the severity of his clinical signs the veterinarian recommended he immediately be sent to a veterinary neurologist specialist. Based on the cost (estimates range from 1700-8000+) the owners declined and sought conservative medical treatment. Based on my experience if deep pain is still present in their back legs (a test your vet will check) and strict cage rest for 8 weeks I would say that 40 to 50% of patients will have a return to function. For dogs without deep pain present this conservative approach has a poorer prognosis, and little chance of return to function. (When I say return to function I mean able to ambulate on four legs.) If the disc material can be taken out quickly the spinal cord can heal and I have seen many dogs go down (paralysis) and be looking normal a few weeks later. Daymin was given a barrage of medicines to try to stop the swelling, protect his stomach from the steroids he was being given, pain relief medications (opioids are the only thing with any chance of relieving this kind of pain) and strict orders to bring him back tomorrow for a re-check.

On the 16^th Daymin was dropped off for the day for us to observe him. his medical record stated; “able to sit up, ate a little, unable to support his weight. No proprioception in the back legs, (this is a test that we do to see if his feet can talk to his brain and then his brain tell his feet that they are in the wrong position to stand). Does have superficial and deep pain present (this means his feet can feel a tickle and a hard pinch, or the nerves in the feet feel a sensation and tell the brain that they can feel something. Deep pain is one of the most primitive functions and the last thing the nerves let go of).  When this is gone there is complete paralysis and without relieving the cause little hope the nerves will talk to the leg again.  At the end of the day his progress report read “eating and drinking normally, leaking urine, but seems more comfortable.” The owners were given directions to keep him in a small confined enclosure, continue the treatment plan provided the day before, re-check on  Monday, or sooner if worsens, owner was told there is a 50% chance of recovery. Owner declined referral to neurologist.”

9/19 entry, “patient here for observation, seems painful.  Unable to support weight on hind legs, no superficial or deep pain. Prognosis poor.” Daymin was not getting better and he needed a neurologist. The owner also gave the Vet a handwritten letter. Dr. E held the letter up to me and gave me her “I don’t know what to do about this, and the guilt is crippling me” look. She summarized that the letter was written to her, because they liked her and trusted her.  “Dear Dr.  Daymin did good over the weekend, he peed and pooped and we kept him clean, like you asked us to. He drug himself around with his front legs. I’m not asking you, I’m literally begging you to please see if you think acupuncture is worth a shot. I just don’t wanna give up yet…please let’s just try a little longer. Please. Thank you..”  I don’t know how the acupuncture thought came into play, but this poor dog was waaay beyond the point of this helping. I am a big supporter of alternative therapies but he needed emergency veterinary care NOW!

Daymin stayed in his cage heavily medicated all day. At the end of the day the owner sent two friends to come pick Daymin up. The owner had made an appointment at the neurologists on Wednesday. He would have to wait until then. When we tried to move Daymin out of his cage he tried to bite the technicians, he also urinated and defected everywhere, despite being medicated, having a morphine patch on, and really no sensation to his whole back half he was in excruciating pain. I went outside to the friends of the owner here to pick him up and explained just how bad Daymin was. Medical management was not working in spite of every effort to provide him relief. His suffering was too great and I knew it wasn’t fair to him to wait and get even worse. The owner elected to euthanize him. it is a hard terrible thing to put down a sweet dog who may have had another outcome if the expense wasn’t so great.  I am in no way trying to pass judgement or assume that his outcome may have been different. It may not have regardless of finances or circumstances. There are many cases whose outcomes are decided by some intangible force no vet, no human, and no amount of money will change. It is the lesson your learn in medicine if you stick around long enough to not grow frustrated or indifferent no matter how hard you pray and want a patient to walk out with a "happily ever after."

Porter and I at Jarrettsville Vets Pets with Santa 2013

That evening my good friend Janet called me to tell me that her 13 year  old mixed Dachsund-ey looking dog was having trouble and reluctant to go up stairs. (Remember how I explained the splenectomy cluster we saw a few years ago? this week was disc disease bonanza).  I told her to bring him in right away. She arrived a short time later. Sure enough Porter was painful in his spine and his radiographs showed some narrowing in the spine at the level of L1 to L3 and L5 to L6, (top and bottom of his lumbar vertebrae). Because it was late in the evening I gave him some pain relief medications, told her to keep him calm and quiet and call me if he worsened overnight. If he wasn’t better by morning she was to bring him back in. at 10:30 pm I received an email saying that he was no longer walking. I told her I would see her first thing the next morning . Before I left for work that next morning I advised her to have a “worst case scenario” talk with her husband. I was pretty sure that Porter had ruptured a disc in his back and based on the fast progression and worsening of his clinical signs he needed to be transferred to a neurologist ASAP. When I saw Porter that next morning he was significantly more painful and would not support his own weight. We started calling to transfer him.

The next day he was examined by a Veterinary Neurologist and then was given an MRI which confirmed everyone’s suspicions. He has ruptured a lumbar disc. He immediately went into surgery. In the 48 hours between him being reluctant to walk up the stairs, he lost deep pain in his back legs. It was the worst case scenario. Luckily for Porter he received all of the care he needed in almost the shortest time possible. He is recovering at the neurologists over the weekend, but so far he is eating, comfortable, and has regained some sensation in his back feet.

I expect, and hope for, Porters full recovery. I will keep you all posted. His final bill will be somewhere in the range of $7000. I jokingly told his mom that they can check off the box that says “Most expensive thing that can happen to your dog”, box now.

Here are some post-op pictures of Porter with his mom giving him his post-op PT.He is doing great! He is a strong, determined, stubborn dog, and I have no doubt he will make a full recovery.

My expert general practitioner advice is to have pet insurance, especially for the predisposed IVDD breeds like dachshunds, Shih Tzus, and beagles. IVDD is uncommon in other breeds as long as they maintain an optimal weight and refrain from dare devil activities. 

For anyone in a financial predicament DO NOT GIVE UP ON YOUR DOG! Follow the vets conservative management guidelines. The most important of which is;

• ABSOLUTE CRATE/CAGE REST FOR 4-8 WEEKS.
• Leash walk only to go to the bathroom.
• Use the pain medications prescribed.
• Don't freak out in the first 3-5 days. They are the worst, but, things will get better.
• Monitor for eating, drinking, urination, defecation. Call the vet with questions. You will need a helping experienced hand. They can help.
• Be strong, be brave, have faith, and try. Your pet is an amazing soul who can beat almost the most impossible of things, IF, you give them a chance and a helping hand of love.

If you would like to learn more about IVDD please see the links below;

The leading source for IVDD help online; Dodgerslist.com

Dr Kelcourse's advice for IVDD patients.

IVDD. Getting a diagnosis. What to do once you have it and associated costs with each option. Encouragement for the first few days (hardest days) after the diagnosis is made. 

Update; Porter did very well with his slight stagger, and somewhat torticollis-sway back stagger for his remaining 4 years! He needed carpet to help him keep his feet from slipping, and he could not climb up stairs, but he never seemed to be in pain or distress and loved his walks with his mom up until his last days at the end of 2015. He lived to be 19. He will always be missed.

In an ideal world resources, financial stability, and access to experts is reality. For the rest  of us lean on your vet, get help where possible, follow directions explicitly, and be patient. There is the other side of this disease, and many pets will shock you at their degree of recovery. I never, ever give up on a disc disease pet. It may be hard to watch, difficult to manage and heart wrenching, but it will pass, and most will dramatically improve IF you can get through the first few days.

If you have a question about your dog with IVDD please find me on Pawbly.com. I am happy to offer assistance and encouragement. Pawbly is free to use and open to all pet lovers across the globe.

If you have a pet that you would like me to see you can find me at Jarrettsville Vet in Harford County Maryland.

I am also on Twitter @FreePetAdvice, and I have a YouTube channel with lots of helpful videos.

Disney's Dilemma

A few years ago a very nice woman came into the clinic with her not very nice dog Disney. Disney was all black, about 40 pounds, and had a long fluffy full coat. She was always overweight even though she always tried to hide it all under a big full jet black coat. I tried many, many, times to convince Mrs. Nicks that Disney was overweight and needed a strict diet, (i.e. no more table scraps), but I knew that she lived with her elderly mother, who she cared for, and between the loneliness of caring for a mom with dementia, and the mom with dementia not ever remembering not to feed Disney table scraps, it was pretty much a lost cause.

The first two years of knowing Ms. Nicks and Disney we had the routine examinations, vaccinations, repetitive pleading of trying to get some weight off Disney, etc. etc. then one day Ms. Nicks called me to tell me that Disney was going outside trying to pee but only a few drops were coming out. And she kept going to the door, and Ms. Nicks kept taking her out, but all Disney could produce were a few drops of urine. I told her to bring Disney in right away. I was expecting to find that Disney had cystitis, (inflammation of the urinary bladder). So all I needed was a few drops of urine, and all Disney needed was an anti-inflammatory and an antibiotic and we were on the mend.

When Disney arrived I gave her an examination. I cannot ever express to the new vets out there how absolutely imperative it is to always give a full complete comprehensive examination.  Instead of finding an empty flaccid small sensitive bladder low in the pelvis, I found a very large full distended painful bladder that took up almost the entire caudal (back half of the) abdomen.  I took a gasp and swallowed the horrified look in my heart. We next went to x-ray. I was hoping to not find anything obstructing her ability to urinate, like a tumor, stones lodged in the neck of the bladder, etc. I was afraid to try to manually express her bladder by pushing too hard on it. You see at this point the bladder has been so distended for so long that often it is a thin weak balloon, and any amount of pressure can cause it to rupture. If the bladder ruptures it will spill the urine into the abdomen and the urine acts like caustic acid to the sensitive peritoneum (the lining of the inside of your abdominal wall). My next plan was to try to sedate Disney to place a urinary catheter. My first priority was to relieve her bladder distension and then try to figure out why this was happening to her. We placed an i.v. catheter collected our blood work and then gave some i.v. sedation. Within minutes there was a flood of dark pungent urine everywhere. I took a deep sigh of relief for Disney. We sutured the catheter in place and started her on the aggressive i.v. fluids I knew she needed to start correcting all of her kidney and electrolyte abnormalities. The next few days Disney seemed to feel more and more like herself. Which in Disneys terms meant she was less and less of a cooperative patient. When she was feeling well enough to not be able to be handled at all I called her mom and sent her home.

During her time in the hospital we ruled out everything except a neurogenic cause to her problem. This meant that the root of her inability to empty her bladder was because she either couldn’t squeeze the muscle of her bladder wall down tight enough to empty, or she couldn’t open the valves that keep the bladder shut. So I started her on all of the medications I could to try to tell her nerves and muscles to work the way they were supposed to. This plan worked for a few months.

Over the next year there were many interrupted evenings of meeting Disney at the clinic to try to repeat the procedures we had tried so successfully the first time. Each time it became harder and harder to get her relief. Until finally one evening I told Ms. Nicks that I would have to open up her abdomen and try to empty her bladder from the inside. I remember crying with her in the surgery room. I knew that Ms. Nicks knew that I was having as much of a difficult time making the decision as I was. I knew that my only hope of getting Disney off of the surgery table alive was with a urinary catheter being placed from inside the balloon instead of my usually threading it through the urogenital opening.  I looked into Ms. Nicks eyes, both of us sobbing, and she said to me, “I know you want to know why she can’t urinate, and I know you want to try to help her again, but I can’t put her through any more”. It was a hard painful decision for all of us. Ms. Nicks had lost her mom a few months ago, and she was losing her last companion. I knew that putting Disney under general anesthesia and exploring her abdomen and bladder might fill in some of the answers I had not been able to get before. But I also knew that we were at the end of her or her mom’s ability to treat her. I lowered my head and told her mom that I was so sorry. I then said goodbye to Disney and injected the pink syrup into her i.v. catheter. I turned off her monitors and I cried over her as she died.

I have talked to Ms. Nicks many times since that day. She still comes to our Christmas parties, and she still drops in to say hello every so often. I have even called her to see if she would be interested in helping us by fostering a dog. But she always tells me that she still isn’t ready for another dog yet. And I understand, and tell her that we miss Disney too. Even though I am pretty sure Disney never liked me back.

If you would like tolearn more about neurogenic anuria and cystitis please see the link below;
http://tinyurl.com/3fwekct

Moe's gentle heart

I am a veterinarian. I usually don’t believe that your job should define you, but sometimes it is the most accurate summary descriptor I can use to characterize myself. I, like most of the rest of my colleges went into veterinary medicine because we like animals better than people. Not really an admirable quality, but honest. Of my many memorable veterinary experiences it is usually the pets that burn a place in my heart and head. This time it was the clients more so than my patient that made this case so memorable.

Any seasoned versed veterinarian will tell you that there are many important qualities to put in your holster on your way to becoming a great practitioner. You have to remember all of that stuff you were taught, tested on, and were supposed to have read, absorbed and understood while in veterinary school, then you graduate and have to learn how to integrate what you learned into what you are seeing, and on top of that, and probably the most challenging, you need to learn how to build a strong trusted relationship with your patients’ owners. Here is where the cavernous juxtaposition lies. We go into veterinary medicine because we like animals then we have to learn how to relate to people so we can help their pets. If a veterinarian can’t master this skill they may be able to practice great medicine but they will never feel as if they made a difference in a life. You see we have the ability to heal but without that human connection you can’t feel the difference you may have made in someone’s life. The longer I practice medicine the more I understand that it is the human’s lives I am impacting through the healthcare of their pets.

Those seasoned vets will also tell you that it is the people you help and touch and the lives on both sides of the file, owner and patient, that in the end leave you feeling as if your career, your talents, and what you give along the way are what makes this job rewarding. You also learn to not judge your clients. Sometimes the softest hearts come in the most unexpected packages. I have learned to treat every client as if they were my mom. You see my mom has a big heart but she is really bad at making healthcare decisions. Whatever her vet tells her to do she does. It isn’t an interactive experience. She cannot understand and decide what to do for her pets.  She wants her vet to decide for her. Unfortunately my dad has to pay the bills. So on many occasions the vet gets stuck in the middle of the healthcare professional and the accountant. I try very hard to present every owner with my professional findings and what treatment plan will be best for their pet. I also give estimates. Sticker shock is an unpleasant thing for all of us. But I cannot decide who gets offered the “great medical plan” and who gets offered the “discount corner cutting medical treatment” plan.

On one Sunday I met the Smitts. They were very kind, soft spoken gentle people. They didn’t dress fancy, and didn’t put on airs of being anything other than very concerned about their kitty Moe. They asked lots of great questions, were very involved in Moe’s care, and wanted nothing but the best care for their beloved kitty. They were clients that we hadn’t seen in a long while.  You see we keep tabs on our paper files that identify when the last time we saw you was. It had been so long that we didn’t have their paper file anymore. We only had a computer print out of the prior transactions they had with us. The last date in the file was the mid 90’s. Today they had brought Moe to see me because he was unable to walk, not eating well, lethargic, and had a large area of excoriation (abrasion) on the side of his head just below the right ear. I began asking for a more elaborate description as to the sequence of events with the wound to his face. They went on to explain that they believed he had ear mites and to treat them they picked up an over the counter ear mite treatment. Upon further inquiry I asked if this cat had been outside. “No, they replied, not in about 10 years or more.” I also asked if he had been vaccinated. “No, not in quite a few years.” I explained to them,( like I do to many clients), that an indoor cat still needs a rabies shot, and still benefits greatly from an annual examination.  It is a very common oversight amongst many cat owners. Veterinary medicine is just starting to get the word out to our clients, that we have been neglecting cats for too long. I understood that they didn’t intend to withhold care, they were just never told that Moe needed it.

My questions to the Smitts didn’t seem to be making my list of Moe’s possible problems shorter, but longer. I tried to politely recommend that in the future the diagnosing and prescribing be left to the vets. I had no doubt that they meant well I was just pretty sure that Moe wasn’t itching because he had ear mites, and that the well intended medication had not made him better. I was fairly certain that his problem lay in his brain, not his ear.

The inner ear lives right next door to the brain. Actually it is not so much as a neighbor but more like the other side of a duplex. There is a thin wall of bone that separates the two chambers but a problem in one side of the home can look a lot like the problem resides in the other. Because Moe was so weak, and unable to walk, I thought that he should be admitted to the hospital for fluids and aggressive treatment. I also explained to them that I had to have rabies on my list of possible diseases. I remind my client’s everyday that even indoor cats can be exposed to rabies and that it is important to have them vaccinated to protect them from this fatal disease. I use the saying “rabies kills everyone it meets” often. I have seen many rabid animals, cats especially, and I hope I don’t ever see anymore ever again. It is especially heart wrenching having to tell a family, including those with young children that they have been exposed. It is hard enough to lose my patients I don’t want to lose a person. They understood my concerns and agreed to have him hospitalized.

After 24 hours of i.v. fluids and antibiotics Moe stopped eating and was unable to get up at all. I called the owners and expressed my concern for him. They were always calm and kind and involved with his care. They came to visit him everyday. They cried over him in his cage. They offered him affection, all sorts of appetizing wet canned food. But nothing got him eating or better. Through every single poke, probe, needle, exam, and medicine he purred and cuddled. He was always so sweet. And his owners never gave up on him. They wanted him to get well despite every bleak prognosis we gave them.

Moe died a few days after he was admitted to the hospital. He purred everytime he was approached by every person in the hospital. He was a sweet, and gentle loving boy until his last breathe.

I hope that the Smitt's adopt another kitty. I can't imagine them not having a cat to share their life with.

I know that Moe was very lucky to have such kind and gentle owners, and I know he was a reflection of them. There is a part of me that truly wishes every kitty was as nice and gentle as Moe, and every client was as concerned and caring as the Smith’s.

If you would like to learn more about rabies please visit the link below;

http://tinyurl.com/3c8nh4a