Thursday, October 26, 2017

A Duck Tale

    His name was Puddles. His photo still hangs on the wall above my desk. Our relationship began, like so many, with a phone call from a client.
    "Philipp, Mrs. Wickland is on the phone. She wants to know whether you'll see a duck."
    This immediately got my attention. To be honest I sometimes only half tune into what I'm being told as I attempt to catch up on my office work by ineptly multi-tasking. I put down my pen and turned to face the receptionist.
    "Did you say duck?"
    "Yup, a duck."
    I picked up the phone.
    "Hi there, Dr. Philipp Schott speaking. I understand you have a duck now?"
    "Yes! His name is Puddles! I got him from my daughter. The house was so empty after Al and Bandit died."
     Al was her husband and Bandit their dog. Al was an interesting guy and was one of my favorite clients. He was short and round and had a gravelly voice. He was probably in his sixties and you could tell he used to be quite muscular. He told me that he had once been a biker and that if I ever needed help dealing with a difficult client I should ask him because he "still knew some guys" who would straighten things out. I limited my response to a smile and a nod. He also wanted to know whether he could volunteer to walk dogs for us at Christmas. We didn't have any patients stay over that Christmas and then Al died of cancer the next year.

     It turned out that there was nothing wrong with Puddles and that Mrs. Wickland just wanted him to get a checkup. So I read up on ducks as best as I could in advance and then on the appointed day Puddles waddled in the front door, herded gently by Mrs. Wickland. Puddles was a standard white farm duck. Have you ever been up close to one? They are surprisingly large. He was easily ten pounds and when he stood tall he reached halfway up my thigh. Now imagine the scene in the waiting room. A half dozen clients, a couple dogs, a couple cats and in walks a duck. You could pretty much see the pupils of the cats eyes dilate from across the room. The one dog was indifferent while the other, a little Cairn terrier, began barking furiously until the owner settled him down. Puddles was as cool as a proverbial cucumber. He ignored everyone, let out a few soft quacks, strutted (a waddling kind of strut mind you) about the waiting room and generally assumed the air of having claimed the place.

    The examination went well, despite Puddles's clear indignation at aspects of it, and I was able to pronounce him healthy, although I was at pains to make it clear to Mrs. Wickland that I was far from being a duck expert. The years went by and Puddles came in regularly for his check ups and once or twice for relatively minor foot and skin issues. I always looked forward to his visits. I shouldn't play favorites among my patients, but he definitely was a favorite. He was treated like a rock star by the staff and the other clients and his arrival never failed to spark delighted gasps.

    Then one day Mrs. Wickland called to say that Puddles wasn't well. He had been eating less and less and his bowel movements were much wetter than normal. When I looked at him it was obvious that he had lost weight and he wasn't nearly as feisty as he usually was. Also, it became clear that it wasn't watery stool she had seen, but excessive urination mixing with the stool. We ran some tests and determined that his kidneys were failing. He was eight years old at that point, which is elderly for a duck. We struggled along with a few attempts at treatment as Mrs. Wickland wasn't ready to say goodbye yet, but nothing made any difference. With tremendous sadness one blustery March day we let Puddles go.

    Spring is a busy time, so despite his celebrity status I soon stopped thinking about Puddles until six months later when Mrs. Wickland phoned. I hadn't spoken to her since the day of the euthanasia. She had trouble keeping the emotion out of her voice, but she wanted reassurance that she had done everything she possibly could for him. She missed him terribly and she always would. Love is blind. It is blind to gender, colour, age, shape, religion, and it is absolutely blind to species.


Thursday, October 19, 2017

At The Very Heart Of It All

I've been in practice for 27 years. When I'm asked what the biggest change has been over that time I sit back, rub my chin thoughtfully, adopt my best wise old man tone, pause dramatically and then quietly say, "techs". Not all the new drugs - in 1990 we had hardly any pain medications we could send home. Not all the new in-house lab equipment - in 1990 we sent most samples away and waited a day or two for results. Not all the new diagnostic imaging equipment - in 1990 ultrasound was not generally available and xrays were developed in a dark room with dip tanks of stinky chemicals. Not all the new dental equipment - in 1990 I used a hacksaw blade to cut apart large teeth that needed to be pulled. Not all the new knowledge, not all the new techniques, not all the new computerization. None of that. These things are important, crucial even, but the most pervasive change that has touched every aspect of veterinary practice is the role of the veterinary technologist (aka RVT, aka registered veterinary technologist, aka animal health technologist, aka veterinary nurse, aka tech).

To put it simply, since I began in 1990 techs have moved from being overqualified, underutilized animal holders and kennel cleaners, to being at the very heart of almost every small animal practice. In 1990 many veterinarians simply trained people in house to perform whatever simple technical duties the veterinarian didn't want to do himself (and it was usually a himself, not a herself, in those days). The actual college trained vet techs did very little more than these informal techs, which was a demoralizing and frustrating situation that contributed to a high rate of turnover and burnout. Looking back it was a bizarre situation. As the veterinarian I took most of the blood samples, placed most of the IV catheters, took most of the xrays, induced most of the anesthetics and cleaned most of the teeth, even though the college trained techs were perfectly qualified to do all of this. I was basically an expensive (although not that expensive in those days...) tech for about half my job.

Today techs do practically everything except what the law reserves for veterinarians: diagnosing, prescribing and operating. Today, in our practice, techs take every blood sample, place every IV, take every xray, induce every anesthetic and perform every dental prophy and cleaning. Moreover, they command an in-house laboratory that looks like a miniature version of NASA Mission Control, they perform blood transfusions, they hook up ECGs, they monitor and care for critical hospitalized patients and they counsel clients on weight management, behaviour, post-operative care and a host of other subjects. And they do it all well. Very well. Each one is a medical nurse, an ICU nurse, an emergency nurse, a surgical nurse, a laboratory technologist, a nurse anesthetist, a dental hygienist, an xray technologist, a neonatal nurse and a palliative nurse... All of that, and more.

In 1990 I could do absolutely everything in the clinic. I knew what every knob on every piece of equipment did and I knew how to make it do that. I knew exactly how to get blood on every patient (well, almost every patient) and I could wield every instrument and administer every treatment. Today I am more or less useless. Ok, I'm exaggerating for effect. More accurate is that I am useless without my techs. Absolutely useless and helpless.

Most clinics are designed with a large room in the centre called the treatment room. This is where all the action happens. It is the physical heart of the clinic with the laboratory, patient wards, anesthetic prep area, operating room, pharmacy, dental area and xray suite radiating from it. And at the heart of this heart - at the very heart of it all - are the techs. Thank you Jen, Kim, Mela, Brandi, Marnie, Melissa, Jamie and Jasmine. Thank you for making me so much less useless. 

Thursday, October 12, 2017

The Firehose and The Pudding

Most people are looking at this title and are thinking to themselves, "That's weird. Firehose? Pudding? How do these relate to each other, or to pets or veterinarians?"
On the other hand, people who work in vet clinics are groaning lightly and facepalming because they know exactly what I am going to write about. I am going to write about diarrhea. And I'm going to try hard not to be too gross about it. It's tough for me, but I am going to try hard.

Even though it may seem obvious, let's start with a definition. From a medical perspective, diarrhea is stool that has enough liquid in it that it can no longer keep its happy log shape. A single abnormal one could be a fluke, but if it happens more than a couple times in a row, we can properly call it diarrhea. And if you want to get all nerdy technical about it you can refer to the "Bristol Stool Scale" and score the poops from 1 to 7:
(Note that where it says "lacking fibre" for stools scoring 5, this just applies to humans. In animals I would consider 5 to be borderline diarrhea.)
6 is what we sometimes refer to as "pudding" and 7, if it is sprayed out, is "firehose". That's it for the gross bits! All done. You can read on safely now.

Once you know your pet has diarrhea there are really just two important questions we need to consider:
1) How long has it been going on?
2) Does your pet have any other symptoms, or is she otherwise happy and normal?

To the first question, we're only going to talk here about diarrhea that has been going on less than roughly two weeks. This is acute diarrhea. The word acute sometimes confuses people as some believe it means severe, but it doesn't, it just means recent onset. Chronic diarrhea is due to a whole other set of causes, needs different tests and has different treatments. Fortunately it is relatively rare, while acute diarrhea is extremely common.

If the only symptom is diarrhea and there is no vomiting, lack of appetite or lethargy, then you can follow the advice here or just phone or email your veterinarian for their advice. There is no need to rush Billy-Bob down for an urgent examination. If, however, any other symptoms are present, then it's best to get him checked over.

Before we get to what to do, a word about causes. Acute diarrhea in previously healthy pets with no other symptoms is almost always due to either a virus or what we like to call a dietary indiscretion. Even if your pet is not in contact with other animals, viral diarrhea is still possible as these viruses can be found out in the environment and be easily transmitted on their paws (dogs especially) or on your shoes. And dietary indiscretion simply means having eaten something their system doesn't tolerate, like five day road-aged dead squirrel, stuffed pizza crust, nasty random thing in the garbage etc. (dogs especially, again). Keep in mind that what they can tolerate will change over time, so just because Ellie-Mae did well on bacon chips for years, doesn't mean that won't cause diarrhea now.

Treatment for this is usually simple because the body has remarkable healing mechanisms. Often all we need to do is turn off the tap and power down the poop making machine. To do this we need to temporarily replace their regular diet with a low residue diet that produces very little stool and therefore allows the gut to rest and heal. For this you have two options. You can either buy a commercial prescription low residue diet from your veterinarian such as "Gastro" or "I/D", or you can cook for your pet.
For dogs the magic recipe is:

1 part extra lean cooked ground beef (boil or fry and drain until it's just dry meat with no fat), or if your dog can't have beef, use lean chicken breast.
2 parts (by volume, just eyeballing it is fine) boiled white rice, not brown.

That's it! Frequent small meals is best. And no treats or anything else other than water to pass their lips. For cats I usually recommend just a pure lean protein source without the rice, such as canned fish packed in water, or cooked chicken or turkey breast.

Feed this until you've had 48 hours without diarrhea. If it is still persisting after that, please call your veterinarian! There may be no stool at all during this period, but that is not constipation, it is just the result of the low residue diet producing very little waste. Once you're past the two days, mix the low residue diet 50/50 with their regular food for a day or two before switching back completely.

One final wrinkle is that diarrhea that has been going on for a few days, but is not chronic yet, may be persisting due to "dysbiosis", which is both a fun word to say and a useful one to know as it describes an imbalance in the normal gut bacteria. We are learning more and more how helpful the bacteria in our large intestine are. That dead squirrel or sidewalk virus can sometimes lead to a change in that bacterial population that impairs the gut's ability to produce normal stools. Consequently, if a couple days of low residue diet haven't done the trick, your veterinarian may recommend a source of pre-biotic, which is something that feeds healthy bacteria, such as canned pumpkin (weird but true), and/or a pro-biotic, which provide large numbers of the good bacteria. Years ago we used to recommend yoghurt for this, but fortunately there are much better, more dog and cat specific, pro-biotics available now from your veterinarian.

With any luck, ta-da, normal poop! (Ahem, Bristol Stool Scale 3 or 4....)