There Are Worms In My Heart

Ok, not technically right in the heart itself, but more on that later. And not technically my heart, at least probably not, but more on that later too.

It is "Heartworm Season" in Manitoba. Yes, it is. If you work in a veterinary clinic it is unmissable, unmistakable, unforgettable. It's not that our wards are packed full of dogs sick with heartworm disease, rather it's that the testing for and prevention of has to occur in a fairly narrow calendar window. Compounding this, for most people, it's convenient to get all the other annual stuff done at the same time since they've dragged Fido in anyway (incidentally, no actual dogs are named Fido, or Rover, or Rex, or Spot; some cats are though). Consequently, most of us see as many patients in a week in the spring as during a month in the winter.

I don't want to waste time spewing Basic Heartworm Facts. You can get those from, gulp, the internet (try www.veterinarypartner.com) or, better still, from your friendly neighbourhood veterinarian. Some of you even are "your friendly neighbourhood veterinarian", in which case said spewing would be even more time wasting. Instead, I want to touch on a few of the more unusual Cool Heartworm Facts (ok, some of you will consider these Gross Heartworm Facts, but I think they're cool).

Cool Heartworm Fact #1
Heartworm has probably been around forever (or a very long time that may as well be forever) with possible reports in the 1500s. It was first positively identified as such in 1847 in South America and then 1856 in the southeast USA. It has gradually been spreading north and west since, arriving in Manitoba in the 1980s.

Cool Heartworm Fact #2
However, despite that spread, large areas such as Saskatchewan, the Arctic and the West Coast do not have it. Not necessarily because of a lack of mosquitoes, but because of a lack of positive dogs already there. Mosquitoes are just flying syringes moving heartworm from one dog to another. This is why the mosquito paradise of northern Manitoba is heartworm free.

Cool Heartworm Fact #3
Heartworms can be huge, up to 35 cm / 14 inches. And they can be numerous, with infestations of over 100 worms reported.

Cool Heartworm Fact #4
The above-reported size and numbers are very rare, so most of the time "heartworm" is a misnomer. Most of the time the worms are hanging out in the pulmonary arteries leading away from the heart. Only if there are more than about 25 do they actually back up into the heart. But pulmonaryarteryworm is so much more unwieldy. Unless you are German like me, in which case you prefer more accurate but long and unwieldy words.

Cool Heartworm Fact #5
Wildlife can get heartworm. Logically foxes, coyotes, and wolves are most at risk, but it has also been reported in bears, raccoons, leopards, sea lions and, oddly enough, beavers. Cats and ferrets are at some potential risk as well depending on where you live, but that is a big subject best addressed separately.

Cool Heartworm Fact #6
Perhaps the coolest fact. Humans can also get heartworm. Heartworm positive mosquitoes bite us all the time and release microfilaria (baby heartworms) into our bloodstream all the time, but fortunately, we are not good hosts so 99.9%  (and probably a few more 9s after that) of the time they die. However, there have been at least 80 cases reported in humans in the US, mostly in the lungs but occasionally - shield your eyes if you are squeamish - the eyes and the testicles (!). These have mostly been mild infections. The main problem is that on lung x-rays a heartworm lesion looks very much like a tumour, prompting further invasive tests. Radiologists call it a "coin lesion". So if you overhear the interns whispering about this while they shoot sideways glances at you, ask about heartworm...

So You Want To Be A Veterinarian

Veterinarians love animals. This is a fundamental axiomatic truth, much like pilots loving airplanes, chefs loving food and librarians loving books. Given that the love of animals is widespread, the ambition to become a veterinarian is widespread as well. This spawns tremendous competition for the few spots in the veterinary schools, meaning that very high marks are required to get in. Consequently, and quite logically, it is animal lovers with excellent grades who populate the ranks of future veterinarians. But sometimes a third essential ingredient is missing. In fact, this ingredient is rarely even discussed, but it is the one element that more than any other determines whether these keen and idealistic students ultimately become happy veterinarians who maintain some of that keenness and idealism or whether they become disillusioned veterinarians who burn out and succumb to cynicism and regret.

That third essential ingredient is a love of people. The same high marks would easily get any prospective veterinary student into human medical school, but for many this is ruled out not just by the pull of their love for animals but, unfortunately, by the push of their, shall we say, discomfort around people. This is a problem. I tell every prospective veterinary student that comes through our clinic that veterinary medicine is not an animal business that happens to involve people, but a people business that happens to involve animals. I tell them that the sooner they understand this and accept this and embrace this, the sooner they will come to love their profession.

And why is that? The answer should be obvious. Until the dogs and cats and guinea pigs and rabbits and all others come marching in on their own replete with the ability to talk (and pay) we will have to work through their owners and keepers and guardians. You can only help animals by communicating clearly and empathetically with people. Moreover, even when this miraculous Dr. Dolittle day arrives we will still have staff to deal with. And staff are most assuredly people.

I have been chair of our professional disciplinary body for a number of years and can attest without a flicker of hesitation that far far more veterinarians come to grief through an inability to connect with people than through any failings in their surgical skills or medical knowledge.

And once you "get it" you see how fabulously interesting people are in all their freakish variety. And you see that we are a privileged profession as we are permitted to help people who are ironically often at their most human around animals. I remember with startling clarity the specific moment when this dawned on me. I was just about to enter the clinic through the back door. It was a sunny summer morning and as I opened the door I realized for the first time that I was looking forward to seeing the clients who were starting to become my regulars as much as I was looking forward to seeing their pets. It was at this moment that I decided to stay in practice and not go back to school to pursue research, which had been my original plan.

But all that said, the love of animals is still at the heart of things. I often think of a card we got many years ago from a young child who boldly wrote "I want to be a vat!" Yes, I too once aspired to be a large container, but I became an animal doctor instead and I have never regretted that decision.

That Distemperment Shot

You don't have to be in practice very long before you have someone come in with an out of control puppy, expressing relief that the puppy is about to get his "distemperment shot".
"He's getting that distemperment shot today, right doc? I can't wait until he settles down..."
"Um... yeah..."

To be fair it is an odd and confusing name. Its origins reach back to before the advent of modern medicine. Before the mid 19th century the prevailing theory was that good health resulted from a balance between the four "humors", also called "tempers": blood, yellow bile, black bile and phlegm. You can still see it in the language today - melancholy is Greek for black bile and indeed depressed people were thought to suffer from an imbalance of the humors with an excess of black bile. (For the record, actual bile is a greenish yellow, but you probably already knew that.) Dogs stricken with distemper were so profoundly ill and could potentially spew phlegm, bile and blood (in the stool), so they were though to be dis-tempered.

And what is it actually? Distemper is a disease caused by a virus that is related to the human measles virus, although the symptoms are very different. Dogs with distemper often have a constellation of symptoms including fever, heavy nasal discharge, breathing difficulties, vomiting, diarrhea, blindness and eventually nervous system symptoms up to and including seizures in some cases. It is spread through the discharge from a sick dog. The incubation period is up to about five days between exposure and first symptoms. There is no specific treatment, only supportive care which often has to be quite intensive to prevent the patient from succumbing and even so, about half of infected dogs will die.

Confusingly, "feline distemper", more correctly called panleukopenia, is not related to canine distemper. It is in fact a close cousin of canine parvo virus.

Incidentally though, canine distemper can also spread to wildlife. Foxes, coyotes and wolves are definitely susceptible and a mutated form has spread to seals as well where it has devastated some populations. Oddly, some marsupials are also vulnerable and distemper is theorized to have played a role in the extinction of the magnificent Tasmanian Tiger (also called the Thylacine).

That's all the bad news, but the good news is that the vaccines are extremely effective and safe. Consequently distemper is now very rare in areas where vaccination is common, such as here in the city. When we do see cases it is usually in puppies from remote communities. In the Arctic and in isolated First Nations communities it is still rampant.

Actually, I lied. That wasn't all the bad news. There is a worrying trend among some pet owners to refuse vaccination. How often to booster is a subject of some legitimate debate, but not to vaccinate at all is foolhardy (to be polite). It is still a small minority and fortunately their pets are protected by the fact that the majority of their neighbours are more sensible and responsible, so the virus cannot yet gain a foothold, but this could change. On the humans side whooping cough outbreaks are beginning to become more frequent in areas where vaccination rates are dropping. Whooping cough is sometimes fatal in babies.

Distemper is not just sometimes fatal.

And training is the remedy for "distemperment". Now, if we had a shot for that...

The Wild Boreal Chihuahua

By far and away the two most common questions I am asked by new puppy owners are "how big will he get?" and "what breed is he?". These are not subjects we are taught in veterinary school and although with experience our educated guesses improve, they are still just educated guesses. The frustrating part is that some clients judge our overall skill and knowledge as veterinarians based on these guesses and it can take years to live down a bad one. Consequently I've honed the art of being vague while sounding knowledgeable.

The question of breed guessing came to mind the other day when my own DNA test results came in. My wife had given me a "23 And Me" analysis as a gift and one of the findings was that I am 3.2% Neanderthal, which puts me in the 99th percentile of all people tested. I like to think that nobody would have guessed this, but my wife disagrees.

A similar test exists for dogs and I have had numerous clients over the years test their mixed breed dogs, perhaps frustrated by my knowledgeable vagueness.

The most popular of these tests purports to identify a truly astonishing range of breeds, from Affenpinscher to Yorkshire Terrier, including such oddities as Bergamasco, Glen of Imaal Terrier and Xolitzcuintli. I cannot vouch for the accuracy of this apparent extreme specificity and in fact, at the risk of hearing from someone's lawyer, I will confess to a tiny bit of skepticism. In contrast, for the majority of my DNA "23 And Me" is only willing to express confidence that it is generically "European", despite the fact that most of my known ancestors, back 13 generations in some cases, are German. But back to dog breeds I can say that despite the impressive list, the tests are missing one type and that that gap trips people up here, and I suspect throughout western and northern Canada.

For example, Mr. Jackson came in the other day with Bruiser, a 120 lb mound of muscle and fur that eats squirrels for lunch and begs to go outside when it's -40C. Mr. Jackson was perplexed because Bruiser's DNA breed test marked him as having a lot of Chihuahua. Bruiser resembles a Chihuahua the same way Mike Tyson resembles me.

So here's the thing.

The thing is that many of our clients get their dogs from shelters and the shelters here are full of dogs from remote First Nations communities in the north. So, am I saying that the northern Manitoba bush is seething with packs of wild boreal Chihuahuas? No. What I am saying is that when the indigenous people came to North America across the Bering land bridge around 15,000 years ago they brought dogs with them. These dogs are not any particular breed, they are simply, and beautifully I might add, "dogs". The Aztecs began breeding these dogs into a specific line that became what we now know as Chihuahuas. The DNA test then sometimes picks this up as the closest match for Bruiser and his friends. Look carefully at the next Chihuahua you see and take note of the curled tail. The other breeds with curled tales are all northern breeds in the family group sometimes called the Spitz type. Other members of this group are Chows and Akitas, who's DNA  sometimes also cross-reacts with our reserve dogs.

Fortunately for Mr. Jackson's ego Bruiser's test also highlighted husky and lab. Chihuahuas are actually very tough, but they do have an image problem with some people. Especially people who name their dog Bruiser.

I have a lot more to say about purebreds, crossbreds, mixed breeds etc., but I'll save that for another day.

Fish Of Death

Or at least "Fish Of Extreme Pain".
Soon after I graduated I decided to try to develop a sideline in fish medicine as way to  make myself more useful to the practice. Or at least less useless. The sensible among you will immediately see the logical flaws in trying to get people to bring their pet fish into the clinic. There are several such flaws. But my employers, bless them, were indulgent and patient with me. To give myself some credit, I was nothing if not enthusiastic. I made sure I had the best text books and I set to work writing brochures on a variety of fish health subjects. And then I waited for patients... and waited...

Until one day the owner of a nearby pet shop came in carrying a large ice cream pail. I'll call her Carla because that's her name and because even on the very off chance that she'll read this I don't think she'd be at all fazed by an implicit accusation of attempted murder.
"What have you got in the bucket Carla?"
"A fish! Actually two of them."
Imagine my excitement. Just imagine it.
I strode over to Carla and her bucket. Not walked, but strode. I peered into the bucket. Two fish indeed: a large, roughly eggplant sized, colourful fish with bold orange and white stripes and long feather-like things sticking out all over it, and a small, roughly walnut sized, dull brown coloured fish. There were two really interesting things about this scene. The first was that the big fish was a lionfish. (More on why that's really interesting in a moment.) The second was that the little fish was head-first halfway into the lionfish's mouth.

"Carla, that's a lionfish!"
"Yes, it's really expensive and it's choking on that stupid catfish!"
Which fish was more stupid struck me as a debatable point.
"I see..."
"Can you get the catfish out?"
"Um..."

So this is where I should explain what's really interesting about lionfish. Those cool looking feathery things are actually sharp spines (easily sharp enough to slice exam gloves) and are covered in venom. The venom has an entertaining array of potential effects including, and I quote, "extreme pain, nausea, vomiting, fever, breathing difficulties, convulsions, dizziness, redness on the affected area, headache, numbness, paresthesia (pins and needles), heartburn, diarrhea, and sweating. Rarely, such stings can cause temporary paralysis of the limbs, heart failure, and even death". Well, only "rarely" death, so that's ok.

"Well, can you?"
"Um..."
The lionfish actually looked distressed. The catfish was presumably even more distressed, but it was hard to tell.
There was no way to grasp the lionfish without touching the venomous spines and the standard aquarium wrangler's net wouldn't help, so, after a bit of pondering I came up with an idea. I found two long pieces of wood - this was a while ago, so I don't remember exactly, but they might have been leftover molding from a reno - and a large pair of surgical forceps. I wielded the wood pieces with my left hand like giant chopsticks to restrain the lionfish while carefully submerging my right hand with the forceps to firmly grasp the tail of the catfish.
Deep breath.
Then I yanked.
The catfish was free! However, I am sad to report that it did not live to enjoy its freedom. The catfish immediately succumbed to its injuries, or to the shock of the whole unpleasant event.  But the lionfish survived. And I survived. A mortality rate of only 33%. Not bad for a novice fish vet.

But that was pretty much the end of my short-lived fish vet career.

Years later we were in the Cayman Islands and met a local with a boat full of lionfish. It turns out that they are an invasive and aggressive species that is decimating native fish populations. The government there was paying a bounty on them. And they are steadily spreading northwards...

Please Repeat That In English

Every veterinarian gets this from time to time. We have just finished painstakingly explaining a complex medical condition to a client and then, after a brief silence, the client says, "Please repeat that in English!".
We have failed to communicate clearly. We have used jargon or at least we have used words that didn't seem like jargon to us, but clearly seemed that way to the client.

Why does this happen? Three reasons:

1) When we are first starting in practice we sometimes use big words and convoluted explanations to demonstrate our knowledge and win the client's trust in our competence. I looked very young when I graduated in 1990. I got called Doogie Howser a lot (the reference itself tells you how long ago that was...). Consequently I tried to impress with Latin. Look, I really am a doctor! I don't do that anymore. I don't need to. Now I get called "the old guy". I'm undecided which is better...

2) We don't want to insult clients by "dumbing it down". In reality only crazy people are insulted and there is no pleasing them anyway. Most clients who prefer that you use more technical language will politely tell you so, and often be pleased that they have the opportunity to tell you so.

3) We have "The Curse of Knowledge". This is the big one and the hardest one to overcome. A Stanford University researcher conducted an experiment whereby she asked people to tap out the rhythm of a well known song, like Happy Birthday or Mary Had A Little Lamb, and then asked other people to guess what the song was based on the tapping. The tappers predicted that 50% of the time the listeners would guess correctly. In reality only 3% of the listeners did! The tappers had "The Curse of Knowledge". It was impossible for them not to hear the tune in their minds while tapping and it was almost as impossible for them to be able to imagine someone not hearing it. Once you know something it is very difficult to recreate the state of mind that exists when you do not know it.

So, veterinarians can no longer put themselves in the minds of people who don't know the difference between a colon and a duodenum, or between an antibiotic and an anti-inflammatory or, my favorite, between the abdomen and the stomach. We're not alone though. All professionals do this. Actually, all people with specialized knowledge do. Car mechanics and accountants are the worst in my experience.

What can we do about this? If we have certain regular spiels we should try them out on our unsuspecting family members or friends. And we should try to put ourselves in that unknowing frame of mind as often as possible. For my part, I am trying to learn to play the mountain dulcimer (yeah, yeah, whatever) and whenever my musical friends start talking about "the key of..." and "quarter tones" and whatnot they have The Curse of Knowledge and I feel like the drooling guy in the wool cap who delivers the fliers. This make me humble. This gives me empathy, and empathy is a key ingredient in effective communication.

I'll close with an illustrative anecdote. A few years ago an elderly lady came in with a little white fluffy dog. We'll call her Mrs. Winterbottom and the dog Priscilla. Mrs. Winterbottom was a very elegantly dressed woman with a lovely summer dress, matching shoes, matching handbag and even a matching hat. She spoke very properly and politely.
"Mrs. Winterbottom, we're going to need to run a fecal on Priscilla."
Blank look.
"I'd like to do a stool test."
Still blank.
"Um, so, do you think you can collect one of her... um... bowel movements?"
Dawning comprehension and a big smile.
"You mean bring her shit!"
Indeed.
I think I'll stick with "bowel movement".

Getting Tutored

In a straw poll veterinarians stated that their favorite The Far Side cartoon was the one where a dog being driven to the vet brags to his friend, "I'm going to the vets to get tutored!".

This is funny several ways, but the way that is relevant to this post is that it highlights the confusion around the terminology. Even well educated clients will approach the subject cautiously, "I guess it's time to get Fred... is it spayed, or neutered?".

For my lay readers, neuters are for males and spays are for females. At the risk of sounding unprofessional, a handy mnemonic is that the word neuters contains the word "nuts". Which brings me to the next area of confusion: the widespread misunderstanding of what this procedure actually entails. I'll focus on neutering and leaving spaying for another post lest I blather on too long.

So, the technical term neuter is actually orchidectomy. "So doc, you're taking out his... orchids???" Yeah, so that's why we don't use that term at all. A more descriptive term is castration. Large animal veterinarians routinely and happily call it that. The companion animal world is different however. Picture a sweet little old lady with her tiny fluffy white poodle sitting primly on her lap. He has a blue bow at the base of each ear and smells faintly of peaches. Now picture me saying, "Yes, Mrs. Butterworth, it's time to castrate Baby." Moreover, there are people who think that castration means cutting the penis off. Yikes! Yes, there are such people who believe such things. And no, we never do that (except in very special circumstances in cats who have frequent urinary obstructions, but I digress).

What do we do then? We do this: we surgically remove the testicles (remember? neuters contains nuts?). Sometimes I'm asked why we don't just perform a vasectomy instead. This is because reproductive control is only one of the reasons to neuter. In many cases we would also like to remove the ability to produce testosterone in order to eliminate the risk of testicular cancers and chronic prostate infections later in life, as well as to help curb marking behaviour, roaming and male-on-male aggression. You'll note that I wrote "help curb". Too often people use neutering as a substitute for training. It is not. 

Now I'm going to wade into a controversial area. Virtually all cats are neutered. The exceptions involve people who have had their own olfactory nerves removed. However, not all dogs are neutered, at least not at the traditional six months of age, and - here is the controversial bit - this might be ok. There is evidence now that breeds of dogs that are prone to cruciate knee ligament ruptures (typically large breeds) may be at increased risk if they are neutered before their bodies are fully mature. This might mean waiting until 18 or 24 months for some breeds. There may be other risks associated with early neutering in some dogs as well. This is a complex area of ongoing research, so please (please please) speak to your veterinarian first before making any decisions based on what you have read here or elsewhere on the internet. A lot of what we do has evolved from boilerplate "one size fits all" recommendations to a discussion of options tailored to the risk/benefit ratio specific to your pet. And this is a good thing. A confusing thing, but a good thing.

I guess that was more like toe-dipping rather than wading...

Finally, I'm going to leave you with this:

http://www.neuticles.com/

This 100% for real. And endorsed, it seems, by Kim Kardashian. Yes, finally there is help for the owner who wants to neuter their dog, but has an unhealthy attachment to the appearance of his scrotum. Unfortunately it's not the help these people actually need.

Comes with a nifty bumper sticker though!