Thursday, August 9, 2018

Bee Med


One of the most fascinating aspects of this profession is the range of creatures veterinarians treat. Personally I have cared for animals from as small as a hummingbird to as large as a bull moose, although I will confess that both were while I was still in vet school. In my own pet practice the range is somewhat more restricted, running from mice to mastiffs. But my colleagues out there will attend to the full spectrum, from bees to whales. Whales, ok, you can probably picture that. Sort of. But bees? Surely I must be exaggerating or joking. I am not.

I am aware of at least three conferences this year that featured sessions on honey bee medicine. The Honey Bee Veterinary Consortium now has 345 American veterinarians listed in its database and there is also a British Bee Veterinary Association with a cool website (britishbeevets.com), as well as a Veterinary Invertebrate Society. The latter appears to be more focused on spiders and lobsters, but it is certainly interested in anything which creepeth or crawleth or buzzeth.

Ok, you can get the obvious jokes out of the way now. You must have a very tiny xray machine! It must be hard to give it a pill without getting stung! How do you take its temperature?! Har har. Nope, nope and nope. Bee medicine is like the medicine of many other food producing animals and is directed towards diagnosis and treatment of large groups at once rather than individuals. Dead bees are tested and then, if appropriate, something is prescribed for the entire swarm.

What has changed recently and made this something more than an obscure reference buried deep in the veterinary literature is a change in the laws governing antibiotics. Since 2017 in the US, and as of the end of this year in Canada, the regulatory authorities will require a veterinary prescription for most antibiotic use in bees. And a veterinary prescription requires a valid "veterinary - client - patient" relationship. Yes, the vet will have to have a relationship with the bee (bees). He or she will have to see them and make a diagnosis before anything is prescribed. This is because in the past bee keepers were able to buy the antibiotics over the counter and misuse, largely due to lack of knowledge and training rather than actual negligence, has led to antibiotic resistance and residues appearing in the honey.

So now vets will have to learn about "varroa mites" and "acarine mites" and "nosema fungus" and "small hive beetles" and "Israeli acute paralysis virus" and "black queen cell virus" and the wonderfully medieval sounding "chalkbrood" and "foulbrood", among many other bee ailments. Foulbrood, a highly infectious bacterial disease killing bee larvae, now affects about 25% of hives in Canada and is the main reason for antibiotic use. With correct diagnosis and careful prescription of appropriate antibiotics at the appropriate doses and times this can be managed better than it has in the past. Veterinarians to the rescue! Other veterinarians though - I'll stick to my mice and my mastiffs, and most of what's in-between. 

Thursday, July 26, 2018

The C Word


Yes, cats and dogs get cancer. And turtles, and goldfish, and budgies, and rats. Actually, especially rats. As a very general rule most diseases exist in some form in most animals. We are all really remarkably similar under the hood. Yet people are sometimes surprised to hear it. And of course they are upset to hear it. It is the most feared diagnosis after all.

But there are some things you should know about cancer. First of all, it is not one disease, but rather it is a large family of diseases. Really whenever cells begin to divide in an uncontrolled fashion it is technically cancer. Everything from that gross little warty thing on the top of Buffy's head, right through to the aggressive volleyball sized thing that caused Duke's liver to fail. When these dividing cells don't destroy important tissues or spread through the system we call it benign cancer. When they do, we call it malignant cancer. Fortunately most cancers are benign. To reduce confusion a lot of us try to avoid calling the benign ones cancer at all and will refer to them as tumours or growths, but you should always ask if you are unclear – is it benign or malignant?

The second thing you should know is that even malignant cancer is not a death sentence. In human medicine many cancers are increasingly viewed as chronic diseases that even if they cannot be cured, can be managed well enough to allow a good quality of life for a reasonable length of time. That is our goal in veterinary medicine too, with a strong overriding emphasis on the quality of life aspect. Ultimately it does not matter what label we put on the disease, what matters is what we can do to provide a good quality of life. The cancer label is not helpful – there are many non-cancer diseases that are worse than many cancers. To be sure, there are too many cancers where we have to move rapidly to a euthanasia conversation, but my point is to not view all cancers the same way as there are some that can be easily managed to provide that good quality of life for some time.

I am sometimes asked, “Aren't we just prolonging his life?” If I'm in the right mood and if I know the client well, my answer to that is, “Everytime you take a breath you are prolonging your life!” It's true. The name of the game for every organism is life prolongation, just so long as it is without suffering. An animal doesn't know how long it's supposed to live. It has no thought for tomorrow and no anxiety when I tell their human companion that we can probably only keep it comfortable for another six weeks. Each happy day for an animal during those six weeks is a happy day. It's that simple. We just want to string together as many of those happy days as we can.

The other stumbling block in treating cancer in pets is the word “chemotherapy”. Some people react quite strongly when I suggest that, as if I've now crossed a line into ridiculous territory. But chemotherapy just means drugs to treat cancer, and much like the cancers themselves, there is a huge amount of diversity in these drugs. The most common treatment for a malignant bladder cancer is the same drug we use for arthritis (a non-steroidal antiinflammatory). Used for cancer it is “chemotherapy” (oooh... aaah...). Used for arthritis it is not. Exact same drug, exact same dose. Even aggressive chemotherapy drugs that can have really unpleasant side effects in humans often have far fewer side effects in dogs (cats are a different story). And we have the huge advantage that if one of our patients does become sick on the chemo, we can just stop. At least we tried. The bottom line here is not to dismiss chemotherapy just because of the scary word. It's not for every pet with cancer, but it is for some.

And finally, I am often asked about cause. People will say, “But we feed her the best food.” Or they will ask about the lawn chemicals or the water or the neighbour's treats. The truth is that none of these have any bearing. Cancer in pets (and in people, a few uniquely human high risk beahviours excepted) is mostly due to three things: genetics, age and bad luck. The genetics is obvious as certain cancers are far more common in certain breeds. This doesn't mean that Fido's parents or siblings had to also have it for it to be genetic, it just means that the risk for an individual in that breed is higher, like playing with loaded dice. The age risk should also be obvious. As time goes on your DNA accumulates damage and errors, like an old car or old house, and some of that damage and some of those errors could lead to cancer. But the biggest factor is simply luck. The body of even the tiniest animal is inconceivably complex. When you begin to look at that complexity it is amazing that diseases and disorders such as cancer aren't actually even more common. Be thankful for what works and don't be afraid of what doesn't. Sometimes it's not as bad as you think. Be like your pet and ignore the labels and words and just work to make each day as good as possible and then enjoy that day.

Thursday, June 28, 2018

It's A Hell New World


When Isabel was little she wrote a short book called "Cat School". The first chapter was entitled, "Kitten Chaos - It's A Hell New World". Yes, she spelled "chaos" correctly, but was hilariously off with her attempt at "whole". Yet, weirdly she was also unintentionally perceptive.

Up until a month ago we had one dog and two cats. The two cats got along with each other well, united in their hatred of the dog, and the dog generally stayed out of their way, so it was a reasonably balanced little domestic ecosystem. Then Lily arrived. It's a hell new world.

Lily is an incredibly beautiful little Siamese cross and she is also the living embodiment of Leo Tolstoy's wise maxim, "It is amazing how complete is the delusion that beauty is goodness." Lily is badness, pure badness. From the very first day these few small ounces of cuddly fluff launched a terror campaign of such energy and ferocity that everyone - the cats, the dog, the kids, Lorraine and me - were caught completely unprepared. She moves so quickly that she appears to teleport. One second I am eating my dinner peacefully, the next second Lily's face is in my plate. Toss her off the table and instantly she is back. Again. And again. And again. One second Gabi is grooming herself peacefully, the next second Lily is on top of her, biting her ears. One second Orbit is munching his breakfast, the next second Lily is in his bowl and he is looking up me, mournfully. One second a picture is on the wall, the next second it is on the floor. One second a vase is... well, you get the idea.

As the internet people say, O... M... G... So, Lorraine and I are both veterinarians and between us we have 56 years of experience. Yesiree. For those combined 56 years we have given all sorts of calm, reasoned, sage advice to pet owners in similar straits. I am here right now to confess that none of this advice works in my own home. At least not yet. Doors are being kept shut to provide refuges to the other cats, toys are being accumulated at a manic pace, kids are being coached to occupy her, but it's still a demented circus around here. Probably the smartest suggestion we got was to get a second kitten to occupy the first. Intellectually I know that this would likely help, but I tell you, psychologically, it feels like we would be pulling the pin on a second grenade after stupidly doing so once already. Not happening.

So to bring this full circle, why did we get a kitten at all? Some of you have heard me advise that two cats is ideal and that three or more is pretty dicey, so what gives? We got her for Isabel. Isabel went from being that happy little girl, singing to herself and writing wacky stories, to being a teenager laid low by crippling anxiety and depression. She has missed so much school that the year is a wash-out. It's the last thing I expected and it's the hardest thing to watch. The sense of helplessness is immense. And then Lily came into Lorraine's clinic from a rescue shelter. Any other time I would have said no. Any other time. But Isabel was at her very lowest and the only spark I had seen in her in weeks was when she saw Lily's picture. And despite all her kitteny badness, Isabel loves her, really really loves her.

This isn't a tidy heart-string pulling story where the kitten saves the girl. If only depression were so simple. Isabel still has many bad days, but you know, there are some good ones now too. Is Lily responsible for any of this possible progress? I have no idea. For the rest of us it's still a hell new world, but for Isabel, hopefully perhaps the first steps to a whole new one.

Monday, June 18, 2018

Dogs Getting High


Ralph was certainly not himself. It was hard to tell how he actually felt, but the old shepherd was barely able to walk, stumbling and swaying each time he tried to take a step. And his eyes had a glassy far-away look.

"His arthritis is so much worse today!" Mrs Sorensen said, clearly upset and worried.
Although he was obviously having trouble getting up and walking, this did not look at all like arthritis symptoms.

"Have you been giving him anything for the arthritis?" I asked, a suspicion beginning to form.

"He gets his glucosamine and fish oil and then recently I started to give him a little CBD oil. Just a little doctor."

Suspicion confirmed - Ralph was stoned.

In theory this shouldn't happen with CBD, also called cannabidiol, because, in theory, it should not contain any THC, the psychoactive component of cannabis. But that's just in theory.

In one year CBD has gone from a "what's that" obscurity to an every day conversation with pet owners. Quite literally every day. I have been in practice long enough to have seen this phenomenon before. Just in recent memory vitamin E, eichinacea, grain-free diets and coconut oil have all had their moment in the sun as potential panaceas. The internet age spreads the word so much faster while amplifying the most improbable stories. In each case these remedies did not end up curing cancer, reversing kidney disease or noticeably "boosting the immune system", but each did end up finding a place in the array of options for some specific conditions in some specific patients. It's just a much smaller place than the enthusiasts had hoped for. If medicine were only so simple!

And so it will be for CBD oil. The range of disorders that people want to try it on their pets for is breathtaking, but the best evidence we have is that it might be useful for three things: epilepsy, nausea and, yes, arthritic pain. There are some problems though.

The first problem is that the research is lacking. There is a lot of work being done right now though, so hopefully we'll have some more clarity soon, but for the time being everything we know is based on anecdote and extrapolation from humans. There are plenty of examples in other areas of medicine where anecdotes and extrapolations have misled us, so some caution is warranted.

The second problem, as illustrated by Ralph's experience, is that quality control and regulation are also lacking. Contamination with THC is not that rare. I haven't seen numbers on that, but I did see another stoned dog with the same story soon after Ralph. Also, some reports indicate that the majority of commercially available CBD oil is contaminated with pesticides and other troubling substances. Google "contaminated CBD" if you're in the mood to be alarmed. Also, when tested, some of the products contain either very little or even no CBD oil at all. Moreover, all of this can vary from batch to batch, so just because Aunt Marge's corgi is like a pup again after three drops of "Doctor Good Earth's All Natural Holistic Small-Batch Artisanal CBD Oil", doesn't mean that your dog will have the same experience.

Patience people. My own dog is epileptic and I'll probably try CBD, but only once the science is in and the quality is truly assured (i.e. not just by the dude at the health food store). If your dog suffers from epilepsy, chronic nausea or arthritic pain and you feel like you can't be patient because nothing else has worked, please check with your vet first before winging it with CBD. New information is coming out regularly.

Ralph was better after about a day. Mrs Sorensen is going to be patient now.

Monday, June 4, 2018

The Shoemaker's Children


A few months ago my wife, who is also a veterinarian, and I began noticing that Gabi, our 11 year old little black and white cat, was becoming even more aggressive about stealing food. I say "even more" because our three cats and one dog are an unruly, barely trained lot who climb on tables and surf counter-tops with impunity. Ok, impunity is an exaggeration because we do shout at them, but this is apparently just a bunch of monkey noise as far as they're concerned. It is, of course, entirely our fault and we have more or less made peace with the situation, but Gabi had become so much worse that it got our attention. She was also yelling more and beginning to look a bit skinny, despite her impressive appetite.

Now those of you with some knowledge of cat diseases are beginning to go, "hmm..." However, Lorraine and I, despite having considerably more than "some" knowledge of cat diseases did not go, "hmm..." We just shrugged and didn't make much of the changes. She seemed fine otherwise.

Fortunately Gabi was due to have some dental work done, so I took her into the clinic for that. I was ordering routine pre-anesthetic bloodwork for her when the penny finally dropped. Seeing her in a clinical setting caused a sudden shift in my perspective. I asked them to run a thyroid level as well. Yup. Our cat was hyperthyroid and had probably been hyperthyroid for several months, displaying textbook symptoms right under our noses.

Most of you have heard the proverb regarding the shoemaker's children. The shoemaker is so focused on making beautiful shoes for his customers that he doesn't notice that his own family is shoe-less. It's not anywhere that extreme for most veterinarians most of the time, but at times the shoemaker's children phenomenon is quite real and it is downright embarrassing.

This is an interesting subject (I hope...) because many clients when faced with a difficult decision will ask us what we would do for our own pets. This is a fair question. In fact, when I first started out in practice I didn't have any pets of my own, but in giving advice I had "if this was my mother's pet" as a mantra to guide me. I can obviously only speak for myself  and I may well be a freakish outlier, but despite that mantra I have to confess that I do sometimes treat my own pets differently than my clients' pets. Often worse, as in Gabi's story, but sometimes better too. Maybe it's instructive to see where I deviate, so I've made a list:

- I never stop vaccinating due to age, because immune function can decline, and I never worry about reactions because they are so very rare, but I am not good at keeping to an exact vaccine schedule. A three year vaccine might sometimes be done in four years when I finally remember. I'm not recommending this slack approach, but it does illustrate that there is some flexibility. Thorough annual exams are important though as pets age five to seven human-equivalent years for every calendar year. If the experience with Gabi has taught me anything it's that I need to do this religiously for my own pets and not rely on those casual assessments that occur because I happen to live with them.

- The moment I finally recognize that something is wrong with one of my animals, I run every test that might conceivably be helpful. With clients we're often concerned about the cost of running lots of tests, but we should give them the option of doing more than the minimum if they can afford it and want the peace of mind.

- When one of my pets is deathly ill I am tempted to try heroics, and have in at least one case done more than was in retrospect sensible to do. I think we do a better job counselling our clients on end of life decisions than we do for ourselves.

- My family feeds more treats and "people food" than I recommend, so I understand what those soft brown eyes and purring leg rubs can do to a person's willpower. This is not an excuse though - you can and should be stronger willed than me (or my family)!

- Ditto for brushing their teeth. We don't do it and I really do know we should and I really do believe in the benefits of it. But it's supposed to be my kids' job. That's my excuse and I'm sticking to it.

Gabi is on medication now for her hyperthyroidism and is doing well, so no harm done. But it was valuable lesson and one that I hope I will actually remember this time!

Thursday, May 24, 2018

Mismatch


Among the more venerable internet memes are the photos of people who look like their pets. Or who allegedly look like their pets. Honestly, in most case it seems to come down to some similarity in hair/fur and being photographed when they happened to have (or, more probably, have been coached to have) comparable facial expressions. Put a little wig on a potato and you could just as easily come up with photos of people who look like their potatoes. That being said, there certainly are a few pudgy flat-faced people with pudgy flat-faced dogs, as there are a few tall elegant people with long noses who have tall elegant dogs with long noses. It is safe to say however that the overwhelming majority of people do not resemble their pets at all. And this, you'll agree, is a good thing.

What strikes me as far more interesting than owners who match their pets are owners who are wild mismatches for their pets, not only in appearance, but in temperament. It goes without saying that veterinarians see all kinds of combinations of animals and people, but the ones that get our attention are the ones that seem the most improbable. I'll share two short stories with you about such mismatches.

The first pair is Tim and Mindy. Tim is the owner and Mindy is the dog. I suppose that's obvious, but you'd be surprised. I can't count the number of times I have accidentally called the owner by their pet's name and vice versa. Consider yourself forewarned if you give your pet a conceivably human name. But I digress. Tim made a vivid first impression with his considerable size, his forceful handshake, his loud expletive laden style of talking and the impressive array of smudgy blue tattoos that looked suspiciously like they had been done in prison. But, as we all know, first impressions can be misleading. Two facts immediately emerged that ran counter to that impression. First of all, Tim turned out to be very friendly and very eager to learn everything he could about looking after his pet. And secondly, his pet was a small quiet female Shih Tzu named Mindy, who sported pink bows in her beautifully groomed fur. There were no pink bows anywhere on Tim. Nor was he especially beautifully groomed. They did not resemble each other in the slightest. In fact, they could be considered opposites.

Tim was a long distance truck driver and Mindy was his companion on the road. "Been with me to 43 states and 8 provinces!" It appeared that Mindy was his only family as well. To see Tim transform instantly from brash and boisterous with me to tender and calm with her was as astonishing as it was heart-warming. Utterly unselfconscious, he would gently and repeatedly kiss Mindy on the top her head while I explained something to him. Almost everybody loves their pets, but Tim's devotion to Mindy was in a category of its own. All of us adults know by now that love is a strange thing that cannot be predicted or judged. This was a prime example of that truth.

I typically saw Mindy once a year in the early spring for a check-up and to make sure that her shots and paperwork were in order for the frequent border crossings. Tim was also one of the few clients who insisted on regular bloodwork to follow baselines on her organ functions. He explained that he wanted the peace of mind and pressed me whether there was anything else we could do to ensure Mindy's health. He gave up smoking when he got Mindy because he was worried about second hand smoke, and he planned his rest stops around where it was best to walk her. I said he was devoted and I meant it.

You might be girding yourself for a heartbreaking ending to this story, but fortunately, to the best of my knowledge, Mindy remains healthy as I write this and I expect to see her again next year. One day there may be an anguished phone-call from Alabama or Arizona, but it hasn't happened yet and, I tell you, I don't even want to think about it.

The second mismatched pair is Mrs Abrams and Max. Max was a German Shepherd. Actually, "Max" is almost always a German Shepherd, unless he is a Boxer or a black cat. I picked this pair for the second story because it is in many ways the inverse of Tim and Mindy. Mrs Abrams was small, quiet, elderly and fragile looking. Max, on the other hand, was large and loud and  rambunctious. He weighed as much as Mrs Abrams, if not even a little more. Her son had given him to her for protection. I suppose this was effective as Max would lunge and bark furiously whenever someone other than Mrs Abrams moved towards him. Actually, he would lunge and bark furiously whenever the wind blew a scrap of plastic towards him as well. Fortunately he was a classic example the bark being worse than the bite and there was no need to be afraid of him, but unfortunately all that lunging made walking him dangerous for Mrs Abrams.

One day she came in sporting a cast on her wrist. Max had pulled her down again. Apparently he had seen a particularly irritating squirrel. Mrs Abrams always excused his behaviour with a chuckle and a 'dogs will be dogs' remark. After I addressed the rash that he had been brought in for I talked to her about safer options for walking him. I had talked to her about this before, about halter types of collars and training methods, but the answer was always the same. In her soft voice she would say, "Oh no, he wouldn't like that." And that was the end of the discussion. What Max liked and did not like was always the decisive factor.

Eventually it came out that Max was also pooping in the house. Here too excuses were made and any type of training that would inconvenience Max in any way was dismissed out of hand. She would smile at Max like all the light in the world emanated from him. Like with Tim and Mindy, this was clearly also love and love that should not be judged, but my God, it was hard not to judge. Max was so manifestly the wrong pet for her. Wrong size, wrong temperament, wrong breed, wrong everything. But she felt safe with him and she loved him with all her heart and these two things obviously made broken wrists and poopy carpets seem like trifling inconveniences to her.

When Max eventually passed away I didn't think I'd see Mrs Abrams again. She seemed incalculably ancient and there sadly comes a time in many people's lives when looking after an animal is just too difficult. I was surprised then to hear that she had booked an appointment with a new pet. Perhaps a cat, I thought, or a little Yorkie? Nope. Another German Shepherd. Also named Max.
  

Monday, May 7, 2018

Incoming!

A number of metaphors have been used to describe veterinary practice, but when it is busy the most enduring one is the battlefield metaphor. I'm sure that people in the human medical field will recognize this as well. I want to be very careful though and point out that this metaphor does have limitations, chief among them is that it should not be taken to imply that the patients and the clients are the enemy. They are not the enemy, but more like civilians caught in the cross-fire with the enemy simply being "circumstances". (Ok, most of the time they are not the enemy...) It's more that the metaphor gives the flavour of what it's like to try to function at a high level of competence in an environment of chaos, noise, confusion and occasional random unpleasantness.

And if the practice can be like a battlefield, it is the receptionists who stand at the front lines. When clients start surging through the doors and all the telephone lines are ringing and the doctors are standing around, getting in the way, and the dogs are competitively peeing on the welcome mat and the couriers are waving documents to sign and the computer system is malevolently generating random errors, then, at those times, to be a receptionist must feel like it feels for soldiers advancing through fire, hearing mortar rounds whistling towards them... "Incoming!"

To be fair, it can be just as stressful and busy at these times for the doctors and the veterinary technicians, but there are important differences. The doctors and techs can withdraw into quieter places to work with patients and clients one-on-one, and, more importantly, the doctors especially benefit enormously from one key thing. That key thing is the client's respect. This makes all the difference. I know that the great majority of clients are decent and sensitive people who do respect the receptionists, but sadly, sometimes it doesn't show. And when it doesn't show, it can really hurt them when they are just trying their best to do their jobs and often don't have the power to change things for the clients. Society is gradually evolving in the right direction, but some old habits persist, and one of these old habits is to automatically, probably unconsciously, assign more respect to the person in the lab coat with the title and a series of initials behind their name than to the person in scrubs sitting behind the reception counter who you call by their first name.

Specifically how does this manifest? The classic scenario is where the receptionist warns the doctor that the client is really angry about something, having just been yelled at by them, and then when the doctor and client are in the exam room together the client is sweet and polite to the doctor. The reverse also occurs wherein the doctor says something upsetting to the client in the exam room, like recommending an expensive procedure, and the client nods and smiles and then leaves the room and, once the doctor is out of earshot, proceeds to freak out at the receptionist about what a rip-off the recommendation is.

I am not suggesting that clients vent anger at the doctors instead, but I am suggesting that they not do so at the receptionists. As in all other areas of life, the best approach when you're angry is to take a few deep breaths, calm down and then politely and respectfully address the concern. But I don't mean to lecture any of you on manners - if you are reading this I expect you are likely not one of the shouters or freaker-outers (to coin a clumsy term). I have seen receptionists in tears after one of these encounters and I have had some threaten to quit. I have had to fire a couple of clients over the years when this sort of behaviour really got out of hand. Yup, I can do that.

Other than basic human decency, why do receptionists deserve respect? They deserve respect because of what they do. Not only is there management of the battlefield as described above when there is so much "incoming", but there is management of the doctor's needs ("Can you print this?" "Can you fill this prescription?" "Can you call so-and-so?" "What's that weird smell in room 2?" etc) and mastery of a remarkable range of skills. Some receptionists have college training in the field, but many do not. Even for those that do, the training is often generic medical reception, and not specific to the veterinary environment. There is a complex (and wacky...) computer system, terminology galore, arcane practice protocols, animal handling and, of course, basic veterinary knowledge. Imagine how daunting it is to have to triage every phone call... Is this person's concern serious enough to warrant an immediate squeeze-in appointment? A later appointment? A return call from the doctor? Or just advice I can give as a receptionist? And imagine the stress of treating something as urgent that isn't and having the doctor complain that it put them behind, and, conversely, the stress of not treating something as urgent enough and having the patient suffer. It is all a bit of a high wire balancing act.

High wire over a battlefield...? Sorry for mixing my metaphors. Whatever it is, we are so very lucky in my clinic to have a group of receptionists who do this so well that they make it look easy. It is not easy. Please respect them for it.

Thank you Barb and Cheryl and Tara and Amber and Cam and Brandi and Lisa! We in the officer's tents and on the sidelines salute you on the front lines!