Tuesday, May 31, 2011

Industry and laziness

This past Memorial Day weekend I forgot until too late to enter the agility trial I had intended to go to; so for the first time in probably 20 years, I had a three day weekend with nowhere to go, nothing to do, no dog shows, no family obligations, nothing. It was WONDERFUL. I spent most of the weekend working in the yard, cleaning the training room in the basement, lugging my agility tunnels to the car wash to clean, and training the dogs.

Here are a couple of pictures of my project that I finally got done. Last summer I bought a fountain which has been sitting waiting for me to get to it; and even before that I had bought a kit called "poetry stones" which let you pour your own bricks and press words into them. I used them to make a brick for each of my pets who has died, with their names, dates, and titles for the dogs who had earned them. I wanted to make a little memorial garden, or really a memorial flower bed, with the fountain to double as a bird bath and hopefully backdrop for bird photos.

My dad had put the lattice up for me last summer, so I could plant more clematis which seems to love my backyard and will provide a good place for the birds to perch and hide. I had to put down weed blanket, try and level the area with sand, and put paver sand between the bricks, as well as put in a few plants. I planted two clematis which hopefully will take off and grow as well as the ones I put in last year; pickings were slim at the garden stores but I did find one coneflower and put some shasta daisies behind the fountain- hopefully they will grow tall enough to provide a backdrop there.

I put my little curled up kitty garden statue in the corner. I am not very happy with how the bricks turned out- they are not at all level and not very stable, so I may have to figure out a better way to redo them. But at least for now they are in. I need some more plants too, but I think I put it off a bit too long for this year. I did pick up some creeping phlox and a couple dianthus yesterday to add in.

All of my pets are represented, starting with my old dog Winky who I got when I was 3 and was with me until my freshman year of college. I will have to lug the kit out again and make stones for Harley to add in; though he was my parents' dog he deserves a place here as well. I did not include my many many wild critters from my years of wildlife rehab- that would have required a whole patio!

After I was finally finished, I took the pictures (mostly to send to my parents in FL so they could help me come up with what other types of plants to add) and was sitting relaxing in my chair listening to the fountain and watching the birds. I needed to go up and lug my agility tunnels down from the van through the backyard and put them back in the basement, but was struggling to find the motivation. The dogs got hot, so I had put them back inside. A pair of Carolina wrens had been very much in evidence all weekend, flying back and forth between the woods and the deck, and I thought they must have a nest under the deck but hadn't gotten around to looking for it. I see them around occasionally, but they are not usually such a constant presence. As I sat there trying to talk myself into finishing up my last chore, they really started to get annoyed by me and kept landing on the lattice, looking at me and scolding, then making their rounds again from deck to woods and back to deck again. So of course I put the zoom lens on the camera and took a few shots.

This is not the face of a pleased wren! How DARE I occupy his backyard- he obviously had important things to do and had not planned on company!

Suddenly I heard a tiny, higher pitched peep and it became apparent what the adult wrens had been distressed about. Apparently there WAS a nest under the deck, and number one son had decided it was time to strike out on his own. I looked down and there was fluffy, awkward looking baby wren perched on the lattice down near the ground.

By this time Papa and Mama Wren were fit to be tied. I can just see her nattering away at him: "Oh, you HAD to have the nest here. Right by the birdfeeder, you said. Right by the birdbath. Easy access to all the takeout we need. Too close to the house, I said. But noooo... you insisted no one is ever home here and it would be fine. So guess when they decided to be home! Next time you'll listen to me!".

Meanwhile, number one son has hopped over onto the deck steps and is looking at me very curiously, but not at all afraid. He is so close that I actually can't get him in focus with my zoom lens, and I am almost out of space on my CF card! But what are the odds that I would be sitting there with a camera in my hand in the first place?

Even a little out of focus, isn't he just the cutest thing ever? He looks like a little old man with his wild tufts on the top of his head.

I filled up my CF card and had to take a quick break to change it and the lens. NOW I could get sharper shots. Number one son made a brave attempt to fly and landed in the middle of the lily bed, hopping from plant to plant.

I couldn't believe my luck when he flew up and perched right in the middle of a full, bright red lily blossom. I love this shot! Sometimes laziness is rewarded- if I'd lugged my butt up and finished my chores, I would have missed the whole thing.

Here is the little gourd house where the nest was- my aunt painted it for me and I hung it under the deck thinking I would find a better place for it later. Summer before last it hosted a wren family and I never got around to moving it; if anyone used it last year I didn't see them. I had just looked in it a couple of weeks ago and didn't see anything, so didn't think it was in use.

If you look closely, you can see one of the three other babies still in the nest. The other three elected not to make their first flight that evening; but when I came home from work the next day the nest was empty. Good luck, little fledglings! Good thing you didn't come out while the dogs were lying under the deck- you would have landed right in front of their noses and I'm not sure about Cory but I know darn well Robbie would have pounced on you in an instant- he LOVES real feathers and fur. Stay safe from the other critters and I will keep the feeders full for you!

Thursday, May 26, 2011

Veterinary medicine in an information age

This month marks the twenty-first year I have been a veterinarian, and August will be twenty years since I bought my practice and became a solo practitioner. The changes in the profession during that time have been amazing. In my class at Auburn University College of Veterinary Medicine, the class of 1990, we were the first class where the women outnumbered the men-just barely. Now there has been a huge shift towards women in the profession. I remember going to visit colleges during my senior year of high school and the inevitable comment from faculty and advisers when they heard I would be a pre-vet major was "Oh, I hear they're starting to let lots of women in!". At the time I bought my practice, I believe there were two other female practice owners in Northern Ky. Guess that makes me a bit of a dinosaur!

And in more ways than one! When I was a high school student, we went to the NEW high school- Scott High, in Taylor Mill. We were the only group to go on the "five year plan"- we started as eighth graders so the seniors could stay and finish out their time at Dixie. One of the big exciting things about the new school was that it would be the first one to offer computer math. Now, I was definitely on the biology/science track so I didn't take it, but I still remember my friends carrying their cassette tapes that they wrote their programs on around! It was REALLY new technology when 5 inch floppies came along! During vet school, the school had one computer and the only time I remember using it was for some sort of self taught program in our respiratory physiology class. I did sometimes help out over the years at a business my family owned for a while, and spent a little time on one of the old original Apple computers that was in use there.

After graduation I went to work at a practice in Indianapolis and shortly after I arrived they computerized. At that time very few practices had computers, and those that did used them mostly for invoicing, but we went with a system called PSi where all of our medical records were computerized as well. I had NO computer experience, but did have a semester of typing in high school and ten years of piano lessons, so I got to be quite quick on the keyboard and figured my way around the program pretty easily.

When I bought my own practice the following year, I really missed our computer system and in late 1992 I purchased the same system for my own clinic. I had never owned a computer before and was excited when boxes and boxes of equipment came- all with strict instructions NOT to open them until the trainer arrived for three days of staff training. Yeah, right! I opened them up and managed to figure out how to set one up because I just couldn't wait to install a computer game I had bought called "Life and Death". (if you want a good laugh, click on the link for a short video to show you what this game looked like! http://www.youtube.com/watch?v=Y5azQdQR35E). It involved running tests on (human) patients, making a diagnosis, and taking them to surgery. The graphics were EXTREMELY crude-black, white, red and turquoise were the only colors, but it was a fun game. The only problem was, after I loaded it on the computer ALL of the clinic software vanished. Uh Oh. The night before the trainer arrived, I uninstalled the game, put everything back in the box, and feigned ignorance (ok, not a good plan, but it was a plan!). It took him half a day to figure out that somehow I had created a new partition on the hard drive (the game ran on DOS, while the computer system was Xenix based- which all was Greek to me). He did manage to get it fixed and up and running and I must have confessed my transgressions at some point, because he set up a separate DOS partition for me to run the game and a few other programs. At that time, we were using the old monochrome monitors with green type, there was ONE store in Northern KY that sold a little bit of software and computer supplies, but otherwise you had to drive to Comp USA up in Tricounty-45 minutes away, at least. Windows 3 or 3.1 had just hit the market and a lot of programs still used plain old DOS.

Around this time, the news was full of stories about the "information superhighway" and how it was going to revolutionize everything we did; but like most everyone I knew the whole concept made little sense to me and I could not visualize WHAT it would do, much less how it would work. One of the employees at that tiny little N KY computer store told me that you could get FREE internet access through Northern KY University and told me how to get set up, which I promptly did- free dial up access! I wasn't exactly sure WHAT to do once I had it, on my lovely little green and black monitor, but I had it! (and I had to shut the whole system down and restart it to open the DOS partition each time I wanted to use it as well!). Somehow I found out about email lists about obedience training and soon I was staying at the clinic until the wee hours of the morning reading posts from big time and little time trainers all across the country about various training issues. I learned a TON from those early lists. But soon I wanted more...people were starting to talk about "web pages" and my computer just didn't have the capability to look at those, so I ended up buying an ingenious little invention called "Web TV" that hooked up to my TV at home and allowed me to surf the internet on my giant old console TV from the comfort of my couch. Wow.

Before too much longer, I upgraded at work and was able to join Compuserve and make use of a new program started by the AVMA. NOAH, or the Network of Animal Health, was one of two veterinary computer networks that started about the same time. NOAH had various forums including those for canine and feline medicine and general chat, and was mostly populated by general practitioners. I was soon hooked and as a solo practitioner found being able to go to my colleagues, sometimes thousands of miles away, was invaluable. It was the beginning of a new era, and I read each and every post and learned a lot of information, both practical and academic.

Eventually NOAH was outdone by its competitor, VIN, the Veterinary Information Network, which I believe initially was started on AOL if I remember correctly but now is an independent entity. It is a privately owned enterprise started by Paul Pion, a boarded veterinary cardiologist and the man who discovered the link between taurine deficiency and dilated cardiomyopathy in cats- a disease I have never seen in my practice career thanks to his discovery which enabled the pet food industry to begin supplementing all cat food with taurine.

I have been a member of VIN since 1995. VIN is more formally organized than the old NOAH, with a separate "folder" or forum for just about any specialty you can imagine, as well as general chat, veterinary issues, humor, and even politics. Each specialty folder has its own staff of board certified consultants, which read and answer each post, usually within 24-48 hours. It is possible to post radiographs, photos, and videos. For a solo doc, the ability to get input on a case quickly is invaluable. Whether the consultants help to steer you towards a totally different course than what your first impression was ,or just comfort you with the input that they think you have covered all of the bases, it is a great relief at times not to have the feeling of going it alone. However, it's actually not even necessary to post your own case in many instances because you can often find the answer first by simply searching the board archives and the rest of the VIN resources.

In addition to the message boards, there is also a current drug formulary where I do almost all of my checking on drug doses and contraindications; an extensive searchable database that includes not only the board messages but many journals and conference proceedings, and a nifty little program called the Associate. How I wish I had had that when I was a new grad! The Associate allows you to plug in breed, clinical signs, and lab abnormalities and generate a list of possible diagnoses along with what percentage (and exactly which ones individually) of your symptoms fit the diagnosis, and then gives you a brief, thorough summary of that disease, how to diagnose it and treat it. This is a GREAT program to have when you feel like you're missing something, you have an oddball case that doesn't fit the profile, or your clinical signs and labwork are just not adding up. It helps to remind you to think of the less commonly seen diseases or those that you may not see in your area.

Vin has made me feel like I'm no longer flying solo; at times I have gotten input at 3 am on a case going bad from one of the best emergency clinicians in the country logging on during downtime hundreds of miles away. In an age of information explosion, there is no way to stay on top of every development in every field and be able to pull the best option for my patients straight from my head every time. However, with VIN and other technology, even if I don't know the answer, I can find it and find it more quickly, with less effort, and a more thorough result than ever before.

Despite all this technology, though, my BEST tools in practice are still my eyes, ears and hands. The art of a good physical exam and a knowledge of what "normal" is, both generally and for each individual patient, will never be made obsolete by progress. I still try to keep in mind what Dr. Cheryl Harris, one of our local, very skilled veterinary oncologists once told me;
"When I see "WNL" (abbreviation for "within normal limits") on the chart, I know that an awful lot of the time it stands for "We Never Looked". I try to keep that in mind and remember to do a good, thorough and thoughtful physical exam and history on each patient; after all, "garbage in, garbage out"- the technology is only as good as the information we feed it and our observation skills!

Wednesday, May 11, 2011

"Cold Tail"

Meet Jasmine, one of our "frequent flyer" patients (luckily for mostly routine care!). Jazzy came in on Monday with a complaint that her tail seemed painful and was hanging somewhat limp and slightly tucked. The day before she had been on a three hour hike which included wading in some creeks, and when she arrived home she had a bath to get rid of the accumulation of mud (we had 12 INCHES of rain in April with more this past week- FINALLY we have strung together a few sunny days!). When I examined her, she was a little more subdued than usual. Her tail hung straight down for the first 4-5 inches with the remainder tucked slightly between her legs. She was painful when I manipulated the tail, especially at the base, and showed some sensitivity over the root of the tail as well. She has a history of some anal gland issues, so we checked those out and found no problems. She showed no abnormalities in gait and was more than willing to relieve us of a few cookies.

Jasmine was suffering from a malady known as "cold tail", "limber tail", "rudder tail", or "swimmers tail". I was never taught about this in school, but luckily years ago before my first case I read about it on VIN, the Veterinary Information Network- a computer network for veterinarians to discuss cases and get advice from specialists. This is definitely NOT a specialist type case- it's more the type that "Old Doc" can spot in the waiting room but might have the new grad scratching their head! (I guess it is somewhat of a bummer that I am far closer the the "old doc" than "new grad" category these days!). Most hunting dog trainers are quite familiar with this condition as well.

Jazzy's tail had a little more tone than most; in most cases the whole tail will hang limp or the first few inches will be held out straight behind with the rest of the tail hanging limp. The dog still can move it normally and has normal neurologic responses. Many of these dogs are extremely painful. It occurs almost exclusively in short haired sporting breeds, and the most common history is that they had heavy exercise which most likely involved swimming or bathing and/or cold, wet weather. I did find a couple reports (in labs, of course!) where it occurred the day after a prolonged party or family gathering, where the dog's tail never stopped wagging all day! Occasionally prolonged cage rest has been associated as well.

This wasn't the easiest thing to demonstrate in photos but hopefully you can get the idea. Sometimes the hair on the top of the tail will be raised; Jasmine did not demonstrate this symptom.

So what causes it? A study was actually done on several Pointers by Dr. Jan Steiss at Auburn and found that there was damage and inflammation in the coccygeal muscles (which connect the pelvis to the first few tail vertebrae). When swimming, these dogs use their tail as a rudder and in effect pushing against the water is similar to isometric exercises. Any exercise which emphasizes this "rudder" function of the tail has the potential to produce the problem. Most dogs will improve within a few days to a week, and anti-inflammatories can help to make them much more comfortable.

In Jazzy's case, she had had what sounded like a prior episode while vacationing in Florida and swimming in the ocean. Dogs who have one episode have a 50/50 chance of having future episodes. We sent her home on NSAIDs and expect her to make a full recovery in no time. Should she not recover as expected, we will look further for more serious issues but I 'm pretty confident that cold tail is our answer!

Here's a link to an article that gives a little more info if you are interested:


Kohinoor's Baby Boomer

April 21, 1998- May 10, 2011

Harley was my parents' Springer Spaniel; though my sister and I always thought of him as our dog too. When our old family cocker died unexpectedly, my dad lobbied for a bigger dog...when they decided on a Springer, I immediately thought of a dog that Levi and I used to compete with in obedience. Raven had her CH and UDX and was an absolute sweetheart; given that Springers sometimes have temperament issues I decided that if this was what Mom and Dad wanted that I had to convince them we needed a dog from this kennel. We tracked down Raven's breeder, who didn't have puppies at the time, but had bred her stud dog and put us in touch with the owner of the female, who had a large litter of puppies. The three of us drove down to Lexington to pick him out, and a short time later "Grisham" became Harley and came to live with my parents in their new house backing up to a lake- seemed like the perfect place for a sporting dog.

But despite the above picture, Harley was not impressed with the lake and other than a couple of falls into it he was content to stay on the shore. When my parents bought a place in Florida with their own pool, he ventured in a few times but quickly decided he was more of a sunbather instead.

Harley ended up having a sweet, loving temperament just as I had hoped. He was a lot more dog than we had anticipated- he grew to be quite a big boy! But my dad took him through obedience class and he ended up being very nicely trained, including some really snappy cute utility signals and a great "reverse" or run backwards command. I don't think Harley's head was particularly outstanding, but he had a fabulous body and I used to love to watch his beautiful floating trot with such reach and drive even as an old dog.

Harley didn't come to us until he was about three months old; by then he already outweighed both of my shelties, Andy and Levi, and did not particularly respect them after weeks of roughhousing with his littermates. Andy and Levi were not Harley fans until the days they died, though they tolerated him. But when Cory came along, Harley found out about karma and Cory pestered him in much the same way Harley had tormented his predecessors. They ended up being good buddies, though as Harley got older it was harder for him to deal with Cory's exuberance.

When he was less than a year old, Harley had his one and only "bad dog" episode...and it was a doozy. Both of my parents had had the flu and felt terrible. They called me and said Harley was vomiting as well and thought he had the same thing...with viral issues this usually isn't the case and when I took them over some medicine I was worried because he didn't look so good. The next morning he was still no better (though Mom and Dad were) and they brought him in for radiographs. Visible in his stomach were two pieces of metal that ended up being twisty ties; I decided to go in after them and it was lucky I did. In addition to those metal ties which showed up well on the x-rays, he also had eaten cellophane wrappers, plastic bottle caps, the finger of a glove, all kinds of stuff. Wound tight around them wrapping them into one giant hard wad were many individual strands of sissel rope. He had taken one of those stuffed toys with rope arms and legs and strand by strand pulled out and ate pieces of sissel. He survived that episode with no long term effects except that forever after he hated coming to the clinic!

Several years ago Harley started spending his winters and springs in Sanibel with my parents. He was content to visit the beach only occasionally, but he loved his walks with my dad and was constantly on the alert for lizards and iguanas- even more fun than the squirrels and bunnies at home.

Harley was diagnosed with Cushings disease in 2009, but he was the easiest Cushings dog to treat ever, with his lab values quickly normalizing and not even requiring long term medication. His symptoms had very sudden onset- massive increase in drinking and urinating (with accompanying secondary urinary tract infection), changes in his coat, and seeming to age almost overnight. Up until then he looked like a vigorous teenager. He still looked pretty good, but his hard shiny coat got a little softer and fuzzier, his vision was not what it had been, and his legs were not as strong as they once were though he still had that beautiful floating trot.

The picture above was taken at Christmas this year, Robbie's first Christmas and Harley's last.

Last Easter Harley and Cory had a great day playing in Mom and Dad's backyard. Harley still could romp and play and keep up, but boy did he pay with stiffness and soreness afterwards. He was really starting to show his age though he had looked like a teenager until he was 11 or so. The rest of these pictures were all taken that day. Just a couple of weeks later, back in Florida, Harley was not acting right one day and didn't seem to be breathing well. A visit to his Florida vet, Dr. Denise Kalliainen at Gulf Coast Veterinary Clinic in Fort Myers followed by an ultrasound at the specialty referral center showed a mass in his chest which appeared to be wrapped around the big vessels near the heart. An aspirate was unsuccessful in identifying exactly what type of cancer it was; but after talking with his oncologist it was obvious what our choices should be. It was unlikely to be a type of cancer that responded to chemotherapy and the next step would be surgery to attempt to remove as much of the tumor as possible; but it was unlikely given the location that they would be able to get it all. With an older dog with one major health issue already, putting him through such an invasive procedure with our best hope being of only gaining him a few weeks to months would have been counterproductive. We treated him symptomatically and hoped we would have a little more good time with him.

Harley surprised us all and made it out a year after his original diagnosis. His repeat chest films were pretty ugly, but he didn't seem to know it and his quality of life was pretty good all summer and into the fall. As winter came on, he developed some neurologic symptoms and I was pretty sure the cancer had spread. It became harder and harder for him to get up and down and maintain his balance.

So tonight we sat on the screened porch with Harley, overlooking his lake with the birds singing in the background, and let him move on. He had a great life and was well loved and he will be missed by his buddies Cory and Robbie (the obnoxious puppy he loved playing with, who would have guessed the old man would tolerate his behavior?) and his cat Spooky. I know his old buddy Boo the cat was waiting to greet him joyfully; Levi and Andy perhaps not so enthusiastically!

Rest well sweet Harley, you were a good dog and a great friend. I hope you enjoyed the dance.

Monday, May 9, 2011

How to make an emergency muzzle

One important lesson to remember is that ANY dog will bite if he is frightened or fearful enough. Here's a quick, easy way to muzzle a dog in an emergency; you can use any number of items from around the house including a thin leash or rope, pantyhose leg, even a cord from a window blind. Have a pair of scissors on hand so you can cut it away quickly in an emergency. Remember, a dog who is muzzled cannot pant to cool himself so watch for overheating, and never muzzle a dog who is at risk for vomiting as it puts him in danger of aspirating. However, if your dog is injured and you need to transport him to a vet, this video may just give you the information you need to enable you to get everyone there safely. It's also important to remember that if the dog is determined enough, he CAN bite you through the muzzle (especially if you are a novice at placing them), so NEVER trust the muzzle completely and keep your hands out of harm's way. It should give you the advantage in getting out of the way if the dog does decide to try and bite. Don't be afraid to tie the muzzle as tightly as you can- remember, this is generally going to be an emergency, we are worried about safety, not long term comfort, and if you didn't tie it considerably tighter than you probably were comfortable with, odds are the dog can get out of it. It won't be on long, a muzzle that's too loose is more dangerous than no muzzle at all as it gives you a false sense of security.