Elwood Regrets Nothing

Although he looked dejected, and although he would clearly rather be somewhere else, in his heart I am sure that Elwood was defiant. He had done it before and he would do it again. If his people left a Terry's Chocolate Orange lying in reach again, by George, he would snarf it down again before you could say, "Elwood! Drop it!!" No question. Foil and all. It was so worth it for the three seconds the chocolatey goodness was in contact with his taste buds. Furthermore, it was his Christmas tradition and tradition was clearly important to Elwood. Actually, I'm kidding - just access to anything remotely resembling food was important to Elwood. Forget tradition.

I showed the Sykes the chocolate toxicity calculator* which told us that 157 grams of milk chocolate in a 10 kg beagle translated into 35 mg/kg of the active toxic ingredient, which was in the "mildly toxic" range, likely to produce vomiting, diarrhea, shaking and an increased heart rate. Fortunately we had only seen the first symptom, in part because the Sykes knew their Elwood and had rushed him in immediately after the futile "Elwood! Drop it!!" so that we could induce vomiting and get as much out of him as possible. As an aside, I want you to know that although veterinary clinics can be awash in a potpourri of vile smelling substances, chocolate vomit holds a special place near the apex of the devil's perfumerie. I mention this only so that you know that the veterinary staff also suffers when you allow your dog access to chocolate. But I digress.

So chocolate is poisonous to dogs, this much most of you know. But do you know why it is poisonous? The aforementioned active toxic ingredient is theobromine, which is in the same methylxanthine class of stimulants as caffeine. What makes dogs different is that they metabolize it much more slowly than humans. Cats do too, but they are almost never interested in eating enough chocolate for it to matter as they can't appreciate the sweetness. Because it is a stimulant, at a high dose it can cause severe heart rhythm disturbances and potentially fatal seizures. At about 200 mg/kg of theobromine 50% of untreated dogs will die. Theobromine content varies between types of chocolate, with milk chocolate having the least and baker's dark chocolate having the most. As a general rule of thumb, 28 grams (1 oz) of milk chocolate contains approximately 60 milligrams of theobromine, while the same amount of dark chocolate contains about 200 milligrams and baker's 400 mg.

It may be of interest to note that a recent study of 230 vet clinics in England indicated that the risk of chocolate poisoning was four times higher at Christmas than any other time of year except Easter, when it was two times higher. Curiously, there was no increased risk on Valentine's Day or Halloween (although, mind you, the latter is a much smaller chocolate event in the UK than over here and the former usually involves more expensive closely guarded chocolates).

Incidentally, it is theoretically poisonous in humans as well, although we are much less sensitive. A person my size would have to eat about 4.5 kg of baker's dark chocolate, or an impressive 32.5 kg of milk chocolate to be at significant risk of Death By Chocolate. I would imagine that an array of increasingly distressing feelings would precede the fatal overdose and prevent you from getting to that point. But imagine the obituary...


* Here is the play at home version: http://veterinaryclinic.com/chocolate/calc.html
I caution you to please please call your clinic or emergency line regardless though, rather than relying on the online calculator. If you are in a remote location or otherwise unable to reach a clinic you can try to induce induce vomiting by administering 3% hydrogen peroxide at the rate of 1 teaspoon per ten pounds. You will probably need a syringe or a turkey baster to get the poor guy to take it. But he will regret nothing.

The Accidental Veterinarian

I did not plan on becoming a veterinarian. In fact, when I was a child I was only dimly aware of what that was as we did not have any pets other than a gerbil, for whom professional medical care was honestly never a consideration. For many years I wanted to be a geographer or a historian at a university. Yes, I was a strange child. Then in high school my interest in animals and nature, which had always been there at some level, began to grow and I added research zoologist to the list. But veterinarian still wasn't on the radar.

My father was a practical man, and a man who had become cynical about academia. He was a physics professor at the University of Saskatchewan and he believed that academic jobs were becoming both increasingly scarce and increasingly unappealing due to university bureaucracy. Consequently he viewed my interest in pursuing an academic career in zoology, history or geography with growing apprehension. He was fond of the pithy German phrase, "Brotlose Kunst", which translates directly as "breadless art" - in other words a career or job that doesn't put bread on the table. He left the choice up to me, but made it clear that he recommended I pursue a profession instead.

I was a freakishly obedient teenager (mostly), so it came to pass that I spent a sunny Saturday afternoon in March of 1983, the year I graduated from high school, methodically going through the University of Saskatchewan's course calendar. The programs were listed alphabetically. I began eliminating them one by one - Agriculture (boring), Anthropology (Brotlose Kunst), Art (Brotlose Kunst)... and so on. As per the profered advice I paid particular attention to the professional colleges, but I steadily, inexorably, eliminated them all too - Dentistry (ha), Engineering (boring), Medicine (nope - sick people are gross) etc... I was comprehensively alarmed by the time I got to Theology (ha) as I had almost reached the end of alphabet without finding anything that made sense to me. There was only one program left. I turned the page and saw Veterinary Medicine written there.

Huh. Veterinary Medicine...

I couldn't think of a counter argument. In fact, the more I thought about it, the more appealing the idea became. This was essentially applied zoology! Moreover I reasoned that I had always liked dogs and cats, although I had never owned one...

In the impulsive way of 17 year olds I decided right then that, yes, this was Plan A. It also helped that the father of a girl I had a crush on was a professor at the vet college... But I knew absolutely nothing about the profession. I hadn't even read James Herriot. When I did find out more about it I began to waver (Herriot had the opposite effect on me than he did on most people) and completed a Biology degree first, but my faculty adviser echoed my father's advice - get a profession, go into veterinary medicine like you had planned. And so I did.

The great majority of my colleagues wanted to be veterinarians for as long as they could remember. In most cases they had to move a considerable distance to Saskatoon or Guelph to attend veterinary school. Their plan was clear and their commitment was strong. In contrast I still marvel at the accidental nature of my entry into the profession, a profession that has not only given me a wonderful career, but through which I met my wife and through which I moved to Winnipeg. What would have happened if the U of S hadn't offered Veterinary Medicine and the last entry in that course catalogue had been Theology...?

Some accidents are happy. This is one of them.

The Anatomy Of A Vet Bill

Mr. Malloy was the type of jovial older guy who wore a camouflage coloured cap and red suspenders over an expansive gut. And the type of guy who loved cracking lame jokes. You know the type. Kind of annoying, yet also kind of lovable.
One day he was at the counter paying his bill when he said, "Holy Dinah! A hundred bucks? You gotta be kidding me? I must own a wing of this hospital by now!"
At the other end of the counter Mrs Chu was paying her $1500 bill and quietly exchanging knowing smiles with the receptionist.

If we had a hospital wing for every client who felt they had paid for one, we would be the size of the Pentagon by now. (Besides, veterinary hospitals generally don't have "wings"...)

But I get it. For a lot of people veterinary medicine is expensive.

Some in my profession push back against that statement and say that we just need to look at dentists and plumbers bills to see that we are not that expensive. No, dentists and plumbers are also expensive, just like us. A lot of modern life is expensive. For many people living paycheque to paycheque (47% of Canadians in 2017) a surprise $500 veterinary bill (or dental, or plumbing, or whatever) is difficult to manage, and a surprise $2000 bill is a potential financial catastrophe.

So now that we have established that veterinary medicine "is expensive", why is it expensive? The number one reason is that we have rapidly evolved to a point where our standards of care compare favourably to those for humans. The arguments about the rightness or wrongness and the whys and wherefores of this evolution are best left for another post, but the fact remains that we now practice close to "human level" medicine and consequently have some "human level" expenses. There are no special veterinary grade sutures, catheters, pills, computers, rent or education for that matter. In fact, for many of our supplies we pay more as we don't have access to the volume discounts the human hospitals do. It is interesting  to note that Americans complain about veterinary bills less often than Canadians because they know what human health care costs.

There are many scary expressions in a practice owner's lexicon - "audit", "lawsuit", "burst pipe", "crashed server" - but one of the scariest is "overhead". The others are avoidable, but overhead is unavoidable and in some practices it can gobble up almost all of the revenue. In my clinic I have calculated that it costs us $400 an hour to keep the lights on, the doors open, the supplies stocked and the non-veterinary staff in place. This is before any veterinarian gets paid. During the busy season this is easy to cover, but in the doldrums of January when you can hear the proverbial crickets in the waiting room you may see me obsessively watching the bank balance and line of credit. I might even be chewing my fingernails...

So, where does your money go? In our practice on a very broad average, for every dollar you spend about 25 cents covers veterinary salaries and benefits, 21 cents to staff salaries and benefits, 27 cents for variable costs like drugs, supplies, lab charges etc., and 15 cents for fixed costs like rent, computers, utilities, accounting, maintenance etc.. This obviously varies enormously from service to service, and it also varies a bit from year to year. Our veterinarians are on salary, so the 25 cents doesn't go straight to them, but in some practices vets are paid a percentage of their billings.

The mathematically astute among you will notice 12 cents missing. That is the theoretical "profit" or, more accurately, "return on investment", that is divided among the owners (there are seven in our practice) when we have kept a good eye on our overhead. I discussed this in a previous post, but in brief, those of us who own practices have to take out substantial loans to buy them, or, in the case of a new clinic, build them, so this money helps slowly pay those loans off. I suppose a theoretical non-profit clinic would be able to lower it's prices by that 12% and would have to somehow fundraise to build, expand etc.. It still would be expensive. Veterinary medicine is expensive. But - and forgive the self-serving nature of this comment - it is so worth it. What price can you put on health and love? Especially in a world where people are apparently buying thousand dollar smartphones...

Mook

Mook was my first "real pet". This statement may prompt hate mail from the gerbil lobby as I did have a gerbil named Bobo (http://vetography.blogspot.ca/2015/12/bobo-christmas-gerbil.html) when I was twelve years old and I suppose I loved him, but to be honest, only in the way I loved my favorite toys. I really wanted a dog, but there was simply no way that was going to happen. My parents didn't have pets growing up (it was worn-torn Germany after all - there were many other priorities, like survival) and none of the people they knew once they emigrated to Saskatoon had pets. It simply wasn't part of their world. They didn't view it as a bad thing necessarily, but it was something "other people" did, like line-dancing or cross-dressing.

Then while I was starting second year biology at the University of Saskatchewan, we moved to an acreage about 20 km southwest of the city. It had always been my father's dream to own land and live in the country. Experimental plasma physicist by day, gentleman farmer by night (and weekends and holidays). He began to collect tractors and outbuildings to house these tractors.

One late autumn day a black-and-white kitten appeared in the tall grass around one of these outbuildings. It was good mousing terrain I suppose. It was a boy and it was probably about 10 weeks old. My parents had no idea what to do. I was preoccupied with school and with being a young adult with a car and a social life (such as it was...), so I didn't pay too much attention at first. The kitten was extremely friendly. It would run up to you and immediately begin rubbing on your pant leg, purring at an improbable volume for such a small creature. And in the way of cats who hone in on the least cat friendly person in any given crowd, he took a special liking to my father.

Winter can hit quickly in Saskatchewan and it can hit hard. After gentle badgering from the rest of us my father allowed the kitten to come into the detached garage and began to feed him there. He did this himself, saying he was in there all the time anyway. Sure, it was a nuisance, but not much of one. But the kitten was only to be allowed into the garage, nowhere else. Certainly not the house.

Somewhere around this time the kitten acquired a name. We called him "Mook" because my mother said that that was the chirping sound he made when he head-butted your hand, "mook, mook".

I imagine that many of you have already worked out for yourselves where this story is going. You are absolutely right. As winter set in the garage became quite cold as well. My father said, "Ok, the cat can come into the house, but only the basement. Nowhere else." Our basement stairs had a door at the top, so in theory it was relatively simple to keep him down there. Mook would however cry pitifully from behind the door. So soon my father said, "Well, during the day Mook can come up on the main floor, but at night he goes down. And he does not go into the bedrooms or my study."

A few weeks later I came home early from a Saturday running errands in town. My mother and brother were still out. When I came in the front door I heard an odd sound coming from upstairs. It was a shuffling and scraping noise and the sound of my father chuckling, although he was home alone. I went upstairs and saw that the door to my father's study was open. I peeked inside and saw him on his hands and knees, playing with Mook, both of them delighted.

I started veterinary school two years after Mook came into our lives and he was my constant study companion. He knew exactly where to lay on my desk where I wouldn't shoo him off. He made some of the abstractions that were being taught seem more real and he was a source of comfort when I was stressed.

In 1990 I graduated and moved to Winnipeg. Although I called him "my cat", Mook was really more my parents cat, so there was no question that he would stay. He continued to have adventures on the acreage including being quite seriously injured when he was either hit by a car or fell out of a tree, we're not sure which. My mother was visiting family in Germany when this happened, so my father nursed him back to health, giving pills, changing bandages and phoning me frequently for updates and advice. My father had never phoned me any other time for any other reason. Something shifted between us when he did this. Two adults talking together, needing each other. He passed away in 1994 from a brain tumour.

Then in 2002 my daughter Isabel was born. Mook was quite old by that point - I suppose 18 when I do the math. During one of the first visits with the baby to Saskatoon Mook padded into our room and clambered up onto the bed, where I was holding Isabel, trying to settle her to sleep. Mook curled up beside her, purring. I remember so very clearly how grateful I was to him and how strongly I felt the connection from Isabel to my father through this cat. A living link. I couldn't stop myself from crying.

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.

    

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, which is just 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, Melissa, Jasmine and Mark. Thank you for making me so much less useless. 

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:
https://en.wikipedia.org/wiki/Bristol_stool_scale
(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....)

Things I Am Terrible At - Part 1

The appointment looked innocent enough, "3:00 - 'Count Basie' Simmons - collect sample". I did wonder briefly what sort of sample, but figured it was probably a needle biopsy of a lump as the techs do all the blood draws.

I entered the room and introduced myself to the owners, an older couple, he sporting a Tilley hat and she clutching a red notebook with "Count Basie" written boldly on the cover. Smiles and solid handshakes all around. There were two dogs in the room, both rough collies ("Lassie" dogs, in case you're not sure).

"The Count has a friend along for moral support," I said, chuckling lightly. I crouched down and invited them both to sniff me.
"In a manner of speaking," Mrs Simmons replied, also chuckling lightly. "Ella is his teaser."

Uh oh.

'Teaser'... My heart dropped. I knew what I was collecting.

Ella and the Count seemed relaxed about the whole thing. Mr and Mrs Simmons smiled at me. Obviously it was my turn to say something.

"So. Um. I am just collecting for analysis then? Or are we... um... using it?"
"To analyze please. He's been a bit of a dud I'm afraid. Such good bloodlines, but no luck so far." Mrs Simmons said this in a pleasant, matter-of-fact tone.
"They said you were good!" Mr Simmons added enthusiastically.
I made a mental note to track down the comedian who told them this. It's not that I am in any way embarrassed by the procedure ("I am a doctor."), it's just that I am not good at it. In fact I am terrible at manually ejaculating dogs.
For example, there was that time with the pretty young woman and her toy poodle stud "Robert"...
God.

But I knew what to do. I excused myself to "get what I need", which in fact was mostly just a few deep breaths and a couple minutes to quickly scan the net and the books for tips. It is not, as the saying goes, rocket science. The procedure is essentially what you imagine it to be. Although a cool dog penis fact, if you didn't know this already, is that they have a long bone in their penis, the "os penis". For real. This makes things easier in some ways. I'll leave the obvious jokes to you.

I stepped back into the room. Gloves, lube, collection vials. Everything ready. I looked at Count Basie and he looked at me. Mr and Mrs Simmons smiled encouragingly. I made sure that Count Basie had sniffed Ella, who was apparently just coming into season, and then he and I began.

(Fade out for the sake of decency and decorum.)

It wasn't working.
Mr Simmons offered, "Maybe the white coat is putting him off?"
I took it off, vowing to myself that that was as far as I would go.
It still wasn't working.
I kept trying, varying rhythm and pressure from time to time, reapplying lube, trying to look relaxed and professional, but the Count just stood there, panting, not even glancing at me. My hand was getting tired.
"Oh dear," Mrs Simmons said, and wrote something in her notebook.
I was determined to succeed this time, but my hand was really beginning to cramp and Count Basie remained as unmoved as a deaf man at a symphony.
"I'm sorry, but this just doesn't seem to be the day," I said weakly.
"Don't feel bad, this happened to the last vet too."

I booked them to try again in a week when Ella was more in season. I knew I'd be away then so they'd have to see my colleague.
"He really is the best at this," I assured them, smiling a wicked little smile to myself.

This xray shows the os penis (running to the left from the point of the arrow, 

crossing the femur), and shows that it can be a hazard as well as a convenience. 

This poor dog has a bladder stone lodged at the right hand end of his penis bone.

Cough Cough

There are four exam rooms along the hall leading to my office. The other day when I arrived at work two of the four had signs on their doors stating "No Dogs!!". No, it does not mean that we are transforming into a cat clinic (although there are moments during heartworm season where this starts to sound attractive...). Instead it means that we are going through another outbreak of "kennel cough" and have to sanitize some rooms.

Kennel cough is an unfortunate name as it is misleading. Being a nerd I prefer the far more accurate "infectious tracheobronchitis", but we nerds are an embattled and misunderstood minority. The main problem with the name kennel cough is the kennel part. Dogs can contract this disease any time they are in close contact with disease carriers, especially indoors, but not just in kennels. The easiest way to think of this disease is to think of it like the human common cold. Sure, schools and day-cares (i.e. kennels for kids) are really easy places to pick up colds, but anywhere you are mixing with other people can do the trick. The cough part of the name is occasionally also misleading as some people perceive their dog to be choking or gagging or retching, rather than coughing. This can be even more confusing because a violent coughing fit can lead to hacking up some phlegm or saliva, which can easily look like vomiting to the anxious pet owner.

But all of that notwithstanding, I am not going to change the minds of thousands (ha!) with one blog post, so for the sake of clarity let's keep calling it "kennel cough". Now that I have agreed to that I suppose I should explain what it is. I already tipped my hand above when I compared it to the human common cold. Humans may sneeze more than cough with it because the nasal passages are targeted whereas dogs almost exclusively cough because it hits the windpipe and bronchi, but otherwise the analogy is useful several ways.
Like the human cold, kennel cough:
1) Is very contagious, but not all individuals will be affected the same as some have immunity.
2) Is caused by a large number of different organisms. In humans it's only viruses. In dogs it's mostly viruses plus one bacterium (Bordetella) and something wacky that is neither virus nor bacteria called a mycoplasma.
3) Usually runs a course of one to two weeks and requires no medical intervention.
4) Can occasionally develop secondary complications such as pneumonia or bacterial bronchitis, especially in the weak, the otherwise ill, the very young and the very old.

Consequently, if your dog is just coughing but is still hoovering his food and racing around like the damn fool he is, please give your veterinarian a call before rushing down. We don't want to spread the bugs in the waiting room and can often triage these and give useful advice over the phone (colleagues, please don't send me hate mail for suggesting this). Sometimes we may recommend a cough suppressant if the cough is disrupting sleep or is otherwise distressing. However, we must see the ones that may have secondary complications. These dogs may be depressed, off their food and/or hacking up thick yellowish goo when they cough. In puppies any vomiting, diarrhea or nasal discharge at the same time as the cough is also a reason to come down.

One distinction between kennel cough and human colds is that we have vaccines for kennel cough. These vaccines primarily protect against Bordetella and some also cover a couple of the viruses. Because of the number of potential causative organisms these vaccines only help reduce the risk, they do not guarantee protection the way a rabies or distemper vaccine does. Nonetheless, risk reduction is still useful in high risk scenarios such as, you guessed it, kennels, dog daycares, training classes etc.. Many of these facilities require proof of vaccination as they want to reduce the chance that they'll have twenty dogs coughing simultaneously. The risk in off-leash dog parks is variable and usually quite a bit lower, although it depends on how nose-to-nose your dog gets. Think of it like playgrounds versus day-cares for kids. The daycare is a petri dish sitting in an incubator, but in the playground your child will only get more colds if they lick the slide or wrestle with their friends rather than swinging quietly alone.

Taboo

It's the biggest taboo of all. Survey after survey indicates that people (North American people at least) are more comfortable revealing details of their sex lives than details of their paycheques. For a variety of cultural and historical reasons it is considered exceptionally rude to ask someone how much they earn. Yet people wonder.

I think most people believe that veterinarians are reasonably well paid, but not nearly as well as human doctors or dentists. And in broad strokes this is correct, so I could just stop there, but for those who are curious I will lift the veil more completely. But first a short story.

We have all said things in the past that make us squirm with embarrassment when we think back on them. I have a veritable catalogue of such statements to draw on, but one in particular is relevant here. When I was a university student I made one of my then very rare visits to the dentist. The dentist was a very pleasant fellow and we had a good chat about summer plans (well, one of those dental chair good chats where the dentist asks questions and I reply, "mm, mm, mhmm"). He really was a nice guy and he did a good job. I don't recall specifically what was done or what the bill was, but I do vividly recall doing the math on how long I was in the chair and then declaring to my friends and anyone that would listen that this guy must make $200 an hour! I was an asshole. And I had done my math wrong, way wrong. Now, thirty years later, I know that "overhead" is the 800 lb gorilla of the balance sheet. It probably ate up 70% of his bill. I feel bad for implying that he was gouging.

Fast forward to the present day when a lot of my day is spent doing ultrasounds, which take around  half an hour (although the client only sees 15 to 20 minutes of that as the rest is report writing) and cost around $300. Most people are not as ignorant as I was at 22, but I'm sure there are a few who walk out thinking, "This guy is making $600 an hour! Must be nice."

One zero too many. I earn $60 an hour.

Some clinics pay a percentage of billings, but we pay a straight salary to the doctors. It's an annual salary rather than a true hourly wage, so there is no overtime or anything like that. As far as I can tell my salary is fairly typical for a small animal veterinarian in general practice with 27 years of experience. It's pretty close to the top end for a non-specialist. New graduates start in the $35 range.

A few of you are probably still thinking, "Sixty bucks an hour - must be nice!" It is nice and I am not going to complain. But allow me to point out two important factors that make it perhaps less nice than it seems on the surface.

First of all, we put in six to eight years of university where rather than working and earning money we are generating debt. Lots and lots of debt. The median debt on graduation has grown dramatically to $65,000 now in Canada. In the US it's $135,000!

And secondly, most of us do not have company or civil service pension plans. A significant amount of our income has to be diverted into retirement savings to make up for this. At least if we are able to and if we are smart enough to...

In the interests of full disclosure, there is another potential income stream. Some of us, myself included, are also practice owners and earn money from any profit the practice might generate (most do generate some, but some don't...). Here, however, there are also two important factors to take into account.

The first is that profit is not free money. Potential owners have to take out massive loans to buy into practices. This money could have been invested elsewhere, like in the stock market or bonds or real estate, but we have chosen to invest it where we work.

 And secondly, I am part of a fortunate minority to have had the opportunity to buy into the practice. Younger veterinarians are having a harder time affording it because of the aforementioned debt load. Also, large corporations are increasingly buying practices which prevents the doctors working there from ever becoming owners.

I know how lucky I am. It's not a life of luxury, but I never aspired to that and it is a very good life. I have the trust of the thousands of pet owners who have come to me to thank for that. So if you are one of those and are reading this, thank you!

Haiku For My Dog

Barker at the dawn;
Thief of snacks and foul tissues;
Soft brown eyes meet mine.

His name is Orbit, and he is five years old today. I didn't think we were ready for a dog. We were busy people with two young children and two dog-averse cats. We both worked and we traveled a lot. But my daughter talked us into it. "When will I ever get a dog?" she sobbed. And in my heart I wondered what sort of a veterinarian did not have a dog.

As intended, Orbit was my daughter's dog. She loved him so much. She brushed him and fed him and helped train him and walked him at least some of the time. But then in almost imperceptible increments this changed. Did the novelty slowly wear off for her, as everyone said it would? Did he grow on me in soft stealthy steps, as everyone said he would? Yes, both I think. My daughter still loves him, of course, but I love now too, fiercely even. I brush him and feed him and walk him and spend a ridiculous portion of the commute home looking forward to his greeting. And the hilarious thing is that he isn't even objectively "a good dog". He's actually a bit of an idiot. But he is a lovable idiot and, naive as I know it is, I manage to believe that his heart is pure. And this is really all that matters.

So when I enter an exam room and see a dog sitting beside their human companion I now have a more personal and immediate sense of what can pass between them.

Thank you for this Orbit. And for those greetings and dawn walks and everything else. Happy birthday.

The Other Side Of The Mountain

(This is not a lame Toblerone sketch. It is a real graph generated from our numbers.)

If you are the type of pet owner who we affectionately refer to as a "frequent flier" and are in the clinic monthly (or more...), then you might have noticed that the staff and the doctors look more relaxed, more cheerful, less tired and less frazzled than they did a couple months ago. You were probably offered a range of appointment times and when you got there the waiting room no longer looked like a scene from "Pets Gone Wild 2". August is the other side of the mountain.*

Small animal practice has become highly seasonal. You can see from the graph that the seven months from August through February are pretty steady and then sometime in March we begin climbing, at first gradually and then sharply, reaching the peak around mid to late May. We are almost twice as busy then as in the slowest time of year.

Why is this? In a word, heartworm (and to a lesser extent ticks; I guess that's two words...). The start of prevention of heartworm disease has to happen in a fairly narrow window, pretty much exactly defining the mountain. This by itself only accounts for a portion of the traffic though. What has happened is that many dog owners would rather only come in once a year, so we've seen the annual physicals and vaccinations drift into this time-frame too. And then, when they're in for their physicals, we sometimes end up finding medical issues that need further attention, so more and more work gets piled into the peak months.

This makes staffing appropriately an enormous challenge. With a few exceptions the labour market for veterinarians and veterinary staff does not permit hiring people seasonally, so you end up staffing for a moderately busy scenario and then being short-staffed when it is really busy and over-staffed when it is quiet. A few tweaks can be made, such as discouraging vacation time during the peak season, but generally you just expect to be exhausted come the end of June, accompanied by the nagging feeling that you haven't given some of your patients the full time and attention they deserve because you were being pulled in too many directions at once (see: http://vetography.blogspot.ca/2017/06/supersonic-octopus.html).

Is there anything you the pet owner can do to help? I'm glad you asked! To begin with, cat owners should be aware that the mountain is mostly made up of dogs. Consequently, unless your cat really delights in the sights, sounds and smells of dozens of hyperactive and stressed out dogs, you should give some thought to booking his annual physical and vaccinations some other time of year. And then for dog owners I have one suggestion. If your dog's annual visit is during the spring and if she has a significant chronic medical condition you'd like to discuss, there are are some advantages to making a separate appointment for that during the fall or winter. The veterinarian will likely have a clearer head and more time for you. The spring visit can then be used as a quick recheck. Paying for two visits this way might seem extravagant, but I think in many cases this strategy will actually save money in the long run by resulting in more carefully thought out treatment strategies.

But if you have to come in May with your list of fifteen problems, don't worry. We still try our hardest and most of the time everything works out fine. Just don't ask about the bags under my eyes...


*Although sometimes we don't notice it until September because if our colleagues are on summer vacation in August the same amount of work gets dumped on fewer laps...

Yellow

After the success of my "Rainbow of Poo" post (http://vetography.blogspot.ca/2017/01/rainbow-of-poo.html) it was only a matter of time before I turned my attention to the colour of pee. It should be obvious that I will not be talking about rainbows here.

Pee is yellow. This much you know. But why is it yellow? Do you know? Do you even care? Quickly then a bit of science (cue the echoing "science, science, science" like from an 80's educational show). Urine is yellow because of the presence of urobilin. Urobilin is a breakdown product of bilirubin, which also gives bile its yellowish colour. And bilirubin in turn is a breakdown product of hemoglobin. As red blood cells are constantly being turned over (in the average human 100 million red cells die each day, but fortunately 100 million are born each day as well), there is a constant stream of urobilin waste the body needs to get rid of. 

Urine is full of all sorts of other waste products as well, most notably urea, which is a byproduct of protein metabolism. These other waste products are colourless though and the urobilin is excreted at a more or less constant rate, so the only variable in how yellow the pee is is how much water is being excreted. More water means more dilute urobilin and less yellow and less water means more concentrated urobilin and more yellow. Logical, yes?

So now that you know this, what can you do with this information? The first thing to understand is that urine concentration will vary from day to day, so one really clear pee or one really dark yellow pee doesn't mean much. If however your dog (I'll get to cats later) is producing very clear pee day after day, there may be something wrong. There may be. It may also be that he just loves to drink water and his body is getting rid of the excess. But definitely get it checked out to rule out diabetes, kidney disease, adrenal gland disease etc.. If your dog is producing very dark yellow pee day after day he may be dehydrated. This is a decent discussion of how to tell:

http://www.wikihow.com/Determine-if-a-Dog-Is-Dehydrated

That's all well and good for dogs, but what about cats? You'll only see the colour of your cat's pee if you are invading their privacy much too closely or if you are unlucky enough to have the pee appear on a white towel or bed-sheet. However, if you use clumping litter you can use the size of the clumps as a way to guess at concentration, because as volume goes up, concentration tends to go down, and vice versa. If the clumps start getting much larger, the urine is possibly becoming more dilute and you should contact your veterinarian. By the same token, if the clumps are getting smaller make sure dehydration is not an issue.

What about other colours? Red is the only one worth talking about. Any redness or pinkness in the urine could indicate a problem such as an infection or inflammation or stones and needs to be brought to your veterinarian's attention. Also, if it is April 1, collect a normal sample, put some blue food colouring in it and drop it off at your clinic...

Finally, a few random facts about pee:

- Many people assume that a pet in kidney failure will stop producing urine. The opposite is in fact true. Up until very close to the end kidney failure patients produce a lot of dilute urine. The kidneys are failing to concentrate the urine, not failing to make it.

- Urine kills grass because the urea being excreted is high in nitrogen. It's like dumping a bunch of nitrogen fertilizer in one spot.

- Stinkier dog pee usually just means more concentrated pee (unless you've fed your dog asparagus or something strange). I actually get that question a lot. Infection is a possible cause too, but generally there are other symptoms such as accidents, urgency or straining. 

- Dogs and cats can tell large numbers of other specific dogs and cats apart by their urine scent, so all that sniffing on the walk is about figuring out who was there and do they know them. A longer deeper sniff usually means that it was an unfamiliar animal. It's a pretty exciting day for Orbit, my dog, when I come home from work after being peed on...

Helpful sign posted above a urinal in Bali. Hard to imagine you'd still be standing if you scored a "7".

Take The Parka Challenge

Ok, now that summer is well and truly here I would like to issue a challenge to dog owners. Those of you whose dogs have long fur or an undercoat, please put a parka on. Those of you with short-furred, single-coated dogs, a spring or fall jacket will do. And if your dog has hairy or floppy ears, pull up the hood or put on a toque. Got it? Now here's the fun part: leave it on 24 hours a day... forever. Anyone up for this?? Waiting... Waiting... Come on you guys!

To be fair, and to make this challenge realistic, you are permitted to grow a Gene Simmons tongue and to leave it hanging out constantly for cooling.

I think we sometimes forget that our ancestors evolved in the tropics. As a result we have an amazing cooling system with our ability to both dilate capillaries and sweat just about anywhere on our (mostly) hairless body. Our dogs' ancestors evolved in the subarctic, which has consequently only equipped them for cooling with a big tongue that drools and a little nose that sweats (and sweaty paw pads, but that's useless). We've created a few more heat tolerant breeds such as Chihuahuas that have much thinner shorter coats and have big erect ears for some of that capillary dilation action, and there is the occasional goofball black Lab who likes to sprawl in the sun, but the majority of our dogs dislike the heat.

How do you know that your dog is hot? Simple: panting. I get a lot of questions about panting dogs as people sometimes worry that it is a sign of something serious. Very rarely it can be an indication of a fever or of heart disease or respiratory disease, but if there aren't any other symptoms of those problems your dog is almost certainly panting for one of three reasons:
1. Hot
2. Stressed, anxious or excited
3. Painful
You should rule out stress, anxiety, excitement and pain first, but chances are your dog is simply trying to cool off. This does not necessarily mean that he is suffering, no more than a person who is sweating is suffering, but it does mean that you should be aware he is hot and might actually be too hot.

The solutions are hopefully too obvious to bother mentioning, but I'll do it anyway (in a handy numbered list again!):
1. Professional grooming.
2. Early morning and late evening walks.
3. Access to cool resting areas in the house.
4. Move to the Arctic.

All The Crazy People

Summer is the time for light things. Light food. Light clothing. Light conversation. Light work schedules (hopefully). And light reading. My most popular posts by far have been the heaviest and darkest ones. I'm not sure what to make of that. Regardless though, it is summer now and you are hopefully on your deck with a gin and tonic and, damn it, you should read something light.

As I've mentioned before, veterinary medicine may be fundamentally about animals, but it is also far more about people than you might expect. The world is full of all manner of interesting people, but it seems that the "most interesting" ones all own animals. This is why veterinarians make great dinner party guests. If you can prevent them from telling gross-out stories (oh, but the urge is so strong...), they often have some fantastic crazy people stories. Before I tell a few of mine (in point form to keep it light!) I should make a couple disclaimers.

First Disclaimer:
Don't be alarmed. If you are reading this you are almost certainly not featured in the stories below. None involve regular clients. If you think you are crazy you are probably not. The truly crazy generally don't realize it.

Second Disclaimer:
The use of the word "crazy" is a shameless and amateurish attempt at click-bait. Most of these people have something else going on like intense grief, or intense anger, or intense stupidity. But some are definitely full-on bat poo.

So, in no particular order, here are the inductees to my Crazy People Hall of Fame:

- The young man who had his beloved dead ferret freeze-dried and mounted on the mantlepiece in what he described as a "heroic pose".

- The elderly woman who kept an astonishingly detailed diary of her perfectly healthy cat's eliminations on reams of loose leaf and then would proceed to try to read two months worth aloud to me. "On March 13 he had one regular sized bowel movement at 6:03 in the morning and then..."

- The man who threatened to punch my partner when he remarked that the man's dog was overweight. The man was seriously going to assault Bob. The dog was seriously obese. Bob calmed him down. The man never came back.

- The man who missed his appointment because the bus driver wouldn't let him on. He had had his sick four foot long ball python draped around his shoulders.

- The woman who came to visit her dead dog the day after the euthanasia in order to groom him before the crematorium picked him up. He was a very large dog. She bathed him, shampooed him, blow-dried him and brushed him out, humming all along. It was heartbreaking.

- The young woman who began to un-button her pants, saying she wanted me to tell her whether the bites she had were from fleas. I declined saying that all bug bites look the same.

- The woman who brought her budgie in wanting to know why it wouldn't sing or eat. It was dead. Cue the Monty Python sketch...

- The couple who were astonished to find out that their young cat was pregnant. "How could that happen? She doesn't go outside and the only male around her is her brother!" (I'm sure every vet has run into this at least once.)

-  The woman who phoned and in a very high squeaky voice said, "I have always had the ability to smell cancer. All my friends say I can smell cancer. And I smell it on Billy. I want to bring him in so you can find it and get rid of it."

The last one and one that you may not want to read aloud to the kids:
- The woman who, with an entirely straight face, asked whether venereal diseases are transmissible between humans and dogs.

I have left the very best one off this list because it deserves an entire post of its own, and I'm still wresting with whether to let it out into the public domain yet or not. Let's just say that it involves a teddy bear. Don't even try to guess - you'll be wrong. I apologize for the cruel teaser.

Now you can return to your gin and tonic and the next piece of click-bate.

Supersonic Octopus

June 1.
First receptionist, "Philipp, Mrs Patterson is late, can I set up Mr. Cho instead?"
"Uh, sure." I'm trotting down the hall, hoping to get to my computer to catch up on files.
Then it occurs to me, "Mr. Cho? I don't remember seeing him in the schedule."
"No, he's a squeeze in. Killer collapsed and he says 'stuff is coming out of him'!"
"Oh, ok."
I turn around and head to the exam room.
Second receptionist, "Mrs. Patterson just showed up. She apologizes, it was the traffic, but she has to see you today. And your next appointment is here too. They're a bit early."
"Ok, well I'll look in quickly on Killer and then I'll see Mrs. Patterson's dog."
First technologist, "Philipp, can you come into the back, I think Dodo is having a seizure."
Third receptionist, "Can you pick up the phone first please, Mrs. Wilson says she has left three messages and needs to talk to you right now before they leave for the cottage."
"Um."
First receptionist back again, "Before you see Cho and Patterson, Samsons are here to pick up those prescriptions you told them you'd have ready..."
First colleague, "Philipp, can you squeeze in an ultrasound soon? I think Buzz Firth is bleeding internally..."
Second technologist, "Buzz's owners are here now visiting him and want to know what's going on. Did you do that ultrasound yet?"
Second receptionist again, "I set up Mrs. Patterson, she brought her other dog too, hoping that after you see Marvin for his chronic diarrhea you'd have time to discuss Melvin's chronic skin condition which has gotten a lot worse."
(Yes, a pair of cockers named Marvin and Melvin.)
Third receptionist again, "Before you talk to Mrs. Wilson, can you quickly answer a question from your last appointment? Mr Schmidt's at the counter still and has his wife on the phone who reminded him what he was supposed to ask."

I haven't checked phone messages in two hours.
I haven't written on files in three hours.
I haven't been to the bathroom since I got to work...

Then my brain began to liquefy and I slumped into a gibbering vibrating heap on the floor.

Ok, that last bit isn't precisely true. And the very first line is misleading too - June 1 is truly the epicenter of our ultra-busy heartworm season, but I'm not at the clinic today. Today is my day off. Today I am mowing the lawn, drinking beer and writing this.

When the kids were small and they would pepper me with a series of complex overlapping requests I would joke with them that I was not a "supersonic octopus". This expression comes back to me frequently this time of year...

A Public Service Announcement Postscript:
It is critical that you give your dog heartworm preventative medication.
It is not critical that you give the first dose right on June 1. Please do not phone your clinic in a panic today or tomorrow. As long as the first dose is given within a month or so of the first mosquito bite it will still work well. The medications kill the first larval stages of heartworm in the bloodstream before they can do any harm.

The Cats Who Might Be Canaries

Everyone has heard the expression "canary in the coal mine". Before the advent of modern toxic gas detectors coal miners did actually bring canaries down into the mines. The birds were far more sensitive to the build-up of carbon monoxide than humans, so when they began showing signs of poisoning it was an early warning for the miners to get out out of there.

In 1979 reports began to emerge of a new disease in cats. Older cats were losing weight rapidly despite a good appetite. A veterinarian in New York figured out that these cats had developed benign tumours in their thyroid glands that caused the gland to produce excess thyroid hormone - a condition called hyperthyroidism. Soon hyperthyroid cats were being diagnosed all around the world. By the late 1980s, when I was going to veterinary school, it was estimated that 1 in 10 cats would develop it. Where did this disease come from? New diseases did occasionally arise, but they were always infectious diseases with clear origins, such as canine parvovirus, which was the mutation of the cat distemper virus, and heartworm, which was the northward migration of a tropical disease.

Some speculated that it was just that cats were living so much longer that we were now seeing more geriatric diseases, but this made no sense as the gains in life expectancy were gradual and the apparent emergence of hyperthyroidism was relatively sudden. Veterinarians, being neurotic as a group, also blamed themselves, assuming they had just missed it before. This also made no sense as the disease is dramatic and obvious in its advanced form. One researcher looked through 7000 old autopsy reports and found no evidence of hyperthyroidism. It really was a new disease.

So various other more reasonable, but still flawed, hypotheses were put forward through the 1990s and 2000s, but to speed the story along I'll take you straight to what appears to be the answer. In four letters it is PBDE. This is the acronym for polybrominated diphenyl ether, a common fire retardant found especially in furniture foam, carpet underlay, some clothing and bedding, and in the plastic housing for some electronics. PBDEs gradually, microscopically, shed into the home environment and become part of the dust. Cats, being close to the ground, are exposed to dust even in relatively clean houses. And crucially, PBDEs have been shown to be endocrine disruptors, meaning that they can interfere with hormonal functions. Thyroid is a hormone. Tellingly, for this story, PBDEs first became wide-spread during the 1970s. This is all circumstantial evidence, but the research evidence is mounting as well with a steady stream of ever more persuasive studies, the most recent just in 2016.

PBDEs were declared "toxic" by the Canadian government in 2004 and their manufacture and import was restricted. Unfortunately though they are still pervasive in the environment and industry has side-stepped the regulations by devising new fire retardant chemicals which may or may not have the same effects. Nobody knows yet. Government regulations are slow to play catch-up. Nonetheless, I think I am seeing  fewer cases of hyperthyroidism than I did back in the 90s. What I am seeing far more of is pancreatitis. Canine pancreatitis is more or less unchanged, but feline pancreatitis is sky-rocketing from a very rare diagnosis twenty years ago, to a weekly one now. Did we just miss it before? The discussion is starting to sound familiar...

So back to the canary metaphor. The incidence  of human thyroid cancer has increased more rapidly than most other cancers since the late 1970s. This is far from conclusive and studies are ongoing, but maybe our cats are telling us something. Maybe we should listen more carefully.

The Ugly

The Good:
Fluffy kittens, puppies who wag their whole hind-ends, difficult cases solved, lives saved, tricky procedures mastered, grateful clients, happy staff, appointments all running on time and so much more. Did I mention fluffy kittens?

The Bad:
Screaming cats, biting dogs, cases gone sideways, lives lost, procedures failed, angry clients, grumpy staff, running three appointments behind and so much more.

The Ugly:
This is what I want to talk about today. Briefly. Briefly because it aggravates me too much. "The Bad" is part of what we signed up for and honestly, it is swamped by "The Good", so most of us shake off "The Bad" pretty easily. But we didn't sign up for "The Ugly". "The Ugly" is clients who are not only angry, but who are unreasonable, disruptive and abusive.

In the past I might have slotted them under "The Bad" as generally these stressful encounters were face to face, more or less private and blew over quickly. Now these abusive clients take to social media and vet ratings sites to become trolls and give their venom a sustained public life online. This is thankfully extremely rare, but even one can have a dramatic impact on a veterinarian's peace of mind. These people generally have mental health issues which most readers of their rants will spot, but nonetheless even the most ridiculous slander, once out there, will have some impact. I've been lucky, but a couple of my colleagues have been attacked this way recently.

Maybe eventually social media and ratings sites will find a way to weed this out, but in the meantime, if you like your veterinarian the very kindest thing you can do is to go on Google, Facebook and "vetratingz" and write positive reviews. And bring in a fluffy kitten. Or two.

Feeling Ticklish?

I apologize for the egregious use of a lame pun as a post title. I am defenseless against the ease with which one can make puns with the word "tick". Even the national veterinary association has launched a "Tick Talk" (I can hear your groans from here) awareness campaign, complete with an entirely over-the-top horror themed ad:
https://www.youtube.com/watch?v=177IXkA7iEM&feature=youtu.be

I imagine that you have already heard a fair bit about ticks and about the diseases they transmit, so I'm not going to repackage that information for you here. The "Veterinary Partner" website (https://www.veterinarypartner.com) is a trustworthy resource if you have specific questions. Instead I'm going to highlight a less often discussed aspect that is alluded to in the title: ticks going on people. More specifically, ticks going from your dog onto you.

Ticks are potential vectors for disease. The word vector just means transporter, a kind of living vessel that carries a disease causing organism from one animal to another. Most famously the deer, or black-legged, tick is a vector for the Borrelia organism that causes Lyme disease. But what we don't often consider is that your dog (and potentially, although quite rarely, your cat) could be a "vector for the vector", a kind of meta-vector, to coin a term. Most people with tick-magnet dogs - you know, the dogs that disappear into the tall grass and come back with twenty ticks on them - are already familiar with the phenomenon of later finding ticks in the house, presumably having fallen off the dog. This could theoretically happen with any dog, particularly if they have darker or longer fur, as ticks can be very difficult to spot unless you are making a point of checking carefully. While I could find no studies that looked at the actual incidence of this, it is reasonable to assume that any dog could accidentally bring a deer tick home that could then infect you with Lyme disease. 80% of humans who contract Lyme become ill, sometimes quite severely, whereas only ~10% of dogs do.

And if this isn't enough to make your skin begin to crawl*, the less harmful but equally creepy "brown dog tick" can actually reproduce and complete it's entire life cycle inside your house, causing a serious infestation. They like to crawl up walls and hang upside down. The good news for local readers here in Manitoba is that that tick is not, to the best of my knowledge, reported here ("wood ticks" are the other ones we see besides deer ticks), but we should remain alert as the American CDC considers it endemic in North Dakota and Minnesota, and it is common in Ontario.

Now I have totally freaked you out.

So let me conclude by trying to unfreak you. Fortunately this comes at a time when we finally have good tick medication. For years when people were concerned about ticks we would more or less shrug and say something along the lines of, "well, you could try this, it helps a bit". In the last two or three years new products have come along that are easy to administer, very safe and far more effective than the previous generation. I'll leave the specific recommendations regarding which product is best for your dog to your veterinarian. None are 100% perfect though, so I still recommend checking your dog over carefully after a walk on anything other than just the sidewalk, but at least now you have far less reason to feel... ticklish.


*Actually that crawling sensation you are feeling on your leg right now, or possibly in your scalp, is almost certainly not a tick as people generally can't feel them moving about. Sorry, I think I might have freaked you out again...;-)

The Lonesome Zebra

Eddie pants nervously as I part his fur and examine the lump that Mr. Williamson is concerned about.
I'm about to comment on it when Mr. Williamson asks the inevitable question, "Have you seen something like this before?"
To which I reply, "Yes, I have. Many times. Daily in fact. But that doesn't mean much." And then I explain myself briefly. But as you and I have a lot more time right now, and as you are presumably more interested in these things than the average person, I will explain myself at much greater length here.

It begins with the fact that humans are excellent at pattern recognition. This is largely a good thing and it is one of reasons our distant ancestors were able to avoid being eaten on the savannas of Africa. Our brains are strongly wired to match everything new we encounter with past experience, whether consciously or unconsciously. That particular type of rustle in the tall grass? Could be a lion. Better keep quiet and slowly retreat.

However, in medical diagnosis pattern recognition is a problem. Some symptoms are what we call "pathognomic", meaning that they are specific to one particular disease, but the great majority are not. A red eye can be due to dozens of conditions. Coughing has scores of causes. And poor appetite can quite literally have hundreds of explanations. In veterinary school they try to beat pattern recognition out of us and replace it with a "problem oriented" diagnostic process. I won't explain what that is. Trust me that it is as boring as it is important.

Eddie's lump is small, loose under the skin, smooth in contour and slightly rubbery in firmness. Pattern recognition dictates that this is almost certainly a lipoma, which is a benign fatty growth. But only "almost certainly". Eddie has never had one before - most dogs with lipomas have several - so I am wary of falling into that trap as a type of cancer called a mast cell tumour can feel very similar. I suggest collecting a few cells with a needle. Eddie is good for this as he is far more worried that I might be planning to trim his nails, which he hates more than anything in life. The needle aspirate just produces fat cells, so thankfully it is just a lipoma.

So what about the zebra advertised in the post title? I apologize if you read this hoping for another wacky patient story,  but no, nobody has consulted me about their zebra problems. Which is a good thing (see my previous post: "A Mile Wide"). Instead I am referring to an old aphorism taught to every medical and veterinary student which highlights the flip-side of this issue: "When you hear hoof-beats, don't think of zebras." In other words, although a set of symptoms could be the result of a bizarre rare disease, the common diseases are far more... common. Consequently veterinarians have to exercise some balance and judgment and avoid freaking pet owners out with a laundry list of horrible possibilities, accompanied by a wildly expensive diagnostic program.

Balance. Judgment. Tricky things. Don't obsess about the zebras, but don't ignore them either.

Spunky Swings Low

Pity poor Spunky, the captive sugar glider. Pity his adorable big black eyes. Pity his cuddly soft grey fur. Pity his delightful cupped-handful size. Pity him because these features make him irresistible as a pet - a little plush toy come to vigorous life - and pity him because he does not want to be a pet. Ok, "want" is a tricky concept in a creature with the brain the size of a chickpea. He is unlikely to be conscious of the fact that his kind lives in the forests of Australia, not the apartments of Canada, and he is unlikely to be conscious of the fact that his kind lives in large family groups of other sugar gliders, not in a household of enormous loud and smelly primates and possibly one or two four-legged predators. He is also unlikely to give much real thought to the problems inherent in wanting to be busy and noisy at night when the primates are sleeping, and then trying to sleep in the day when the primates are themselves busy and noisy. Even though he does not think about these things, there is no doubt that he would be far happier if he were ugly and were left alone to glide from eucalyptus tree to eucalyptus tree, with his family, at night.  

Further pity poor Spunky, for I have been asked to castrate him. As with many cute and fluffy creatures, Spunky does not know that "cute and fluffy" also means "passive and gentle" to his primate captors. In his mind he is fierce and he is tough and he has had it with you and all your b.s.. Tiny cuddly creatures with big baby eyes can still bite hard. And these ones in particular can swoop down on you from above. His owners were members of the online sugar glider community and had tried all the recommended behavioural and environmental modifications, but at the end of the day Spunky was still too... "spunky".

The medical care of captive non-domesticated species can present the veterinarian with an ethical and moral quandary. My approach is to strongly discourage ownership of such animals but also to recognize that an animal like Spunky is now stuck with this situation as he cannot be released into the wild, so I have an obligation to do what I can to help make his life as pleasant as possible, under the circumstances. And on balance, in this case, it meant trying surgery.

So Spunky was presented on the appointed day and the nurses handled him gently, gave him pain medication and then carefully induced general anesthesia, at which point I was called into the o.r. for the procedure. While I had given the ethical  and moral dimensions of this some considerable thought, I hadn't really done the same for the technical aspects. Neuters are, after all, really pretty similar from species to species.

Pretty similar, except in sugar gliders as it happens. They are marsupials and marsupials are strange. And before I get hate mail from Australia, I don't mean strange in the pejorative sense. I mean it in the strict traditional sense of the word - "unusual or surprising" - as seen from the perspective of someone whose practice includes no marsupials at all. Except Spunky.

So what was strange? His scrotum. Spunky's scrotum was strange. It dangled down between his hind legs on a long thread-like stalk like a teensy weensy little tetherball.

Now consider this carefully for a moment. Here is a creature that glides from tree to tree in the dark, presumably dodging twigs and branches, his scrotum dangling free beneath him all the while. Doesn't it strike you as problematic from an evolutionary perspective? Men reading this are feeling a little queasy now as they picture what must be a common mishap...

In any case, there he was, deep asleep, and there I was, scalpel in hand. I glanced at my nurse. She shrugged. I looked back at Spunky's scrotum and it's breathtakingly long and narrow attachment. I will spare you the technical details, but ultimately I had to abandon the normal approach which involves a lot of careful dissection, transection and ligation and instead... just lopped it off. I snipped the stalk, sewed it up and that was that. Ten minutes of pondering and ten seconds of actual surgery.

Somehow simultaneously both the easiest and the hardest neuter I have ever performed.