A Difficult Call

Dr Bollenbeck found a mass growing inside this dog's eye (the pink circular mass in the center of the picture). This 10 year old is a great companion and belongs to one of our best clients. The location of the mass was a little unusual but the appearance strongly suggested cancer. After an extensive search to make sure that there were no other tumors elsewhere, a decision had to be made about surgery. Should the tumor be removed (which means removing the eye), or should we watch the mass to see if it grows? Fearing that further growth might cause it to spread outside the eye, the decision was made to remove it. Good thing we did, as the biopsy revealed a carcinoma. A difficult decision but the right one for this dog's long term health.

This case highlights a unique aspect of veterinary medicine. Our patients experience little psychological stress from the loss of eyes, ears, limbs, teeth, testicles or ovaries. As dog and cat lovers, we are often affected more by the resulting change than they are. Pets, if they are pain-free and can function socially within the family, live pretty contentedly regardless of their appearance. Just look how happy Pugs are!

OUCH!

Believe it or not, these are just some of the bladder stones from one dog. I've only seen 2 dogs in 20 years of practice with this particular type of stone. Most stones are made of calcium-oxalate, magnesium-ammonium-phosphate or urate. These unique stones are silica and have a "jackstone" appearance. Noone knows why some dogs get them. This patient had several lodged in his urethra and was quite painful. Fortunately, I was able to use a technique called urethrohydropulsion to flush them back into the bladder where they were easily removed. Without this technique, they have to be removed by an incision into the urethra with a resulting painful, complicated recovery. Few men wouild have trouble sympathizing with this dog, but the good news is that he was feeling great within a few days!

FANG-FANG

One of the reasons to wait until 6 months to spay or neuter a dog or cat is shown above. The upper canine tooth (fang) has come in, but the baby fang behind it never fell out. This is an extremely common problem, especially in toy breed dogs, and will be apparent by 6 months of age. This is when most dogs would have had the permanent canine teeth erupt. While pets are under anesthesia, the baby teeth can be extracted, eliminating the crowding of the teeth. This is a delicate procedure since the baby teeth enamel is very thin, but one that pets recover from very quickly. Neutering or spaying can be done as early as 12 weeks of age, but if retained baby teeth have to be removed later, there is the additional cost of a second anesthetic procedure. Worse, pet owners may not notice the retained teeth, and the problem may not be addressed until the next exam. By that time, damage to the teeth and gums may have occurred.

The orange tube delivers oxygen (see the nice pink gums!) and anesthetic and allows us to "breathe" for our patient as need. The rubber bands help to gently hold the tube in place while being easily repositioned during the extraction. A nerve block has been done (hidden by the upper lip) to minimize any discomfort from the extraction.

So that's a lipoma!

Many who have had a dog with a few extra pounds around the waist have seen lipomas develop under the skin. These are benign, slow growing tumors. Ususally we recommend leaving them alone, but occasionally we'll remove lipomas that are in awkward locations like the axilla (armpit). Frequently, these lipomas are encapsulated and come out in one large "glob". This is an example of such a lipoma. It was fist size and probably weighed 2 pounds. It is surprising how little blood supply there is to these tumors. In fact, the major surgical challenge is eliminating all the space that the lipoma took up so that the space doesn't fill up with fluid after surgery. There is no liposuction done in dogs, but this comes close!

Microsurgery

This was a satisfying surgery on a rat with an ear tumor. Fortunately, the mass was attached to the margin of the ear, so I was able to remove part of the ear without having to compromise the canal or any major blood vessels or nerves. The black device is a mask that delivers the anesthetic gas. A little lidocaine cream on the surgery site kept this rat from scratching at the ear when it woke up. Total time: 10 minutes! (The length of anesthesia is critical--small critters cool off and can get dehydrated pretty quickly.)

What's in the box?

Today is one of those days that reminds my staff and me that our role in the end of life issues is just as important as all the preventive care and treatment we do. In addition to our regular appointments, we have 2 euthanasias scheduled and 2 clients who had to bring in pets that had passed away at home after long illnesses. So far they have all elected to have their pets cremated privately and the ashes returned to them.

About half our clients choose this option, as opposed to a group cremation and burial. In less than a week, they will receive a small wooden box. What's in the box?

Stopping by the shelter "just to look".
Having said yes to having this pet in their lives.
The joys and challenges of puppy- and kitten-hood.
An interior re-decorator.
A mood lifter.
Enthusiastic tail wagging or purring.
Encouragement to take a walk.

A "child" who didn't grow up and go off to college.

Years of companionship.
Unconditional love.
A nonjudgmental friend.
A part of themselves.

...and ashes.

A Day in the Life

6am-- Awaken, shower, dress, eat
7am--Leave to drop off boys at their carpool for school
7:15-7:45--Listen to book on tape (currently Red Mars)
7:45--Morning period of meditation in car before going into work
8am-noon--

• Vomiting dog emergency and hospitalization, x-rays, ultrasound
• Call about dental scaler repair
• Two very friendly pit bulls for vaccine visit
• Call Saturday's client about thyroid levels and plan for additional diagnostics
• Second cup of coffee--only 2 sips
• New (extremely cute) Puppy Visit
• Dog Puncture wounds from other dogs attacks

Noon--Enter Quickbooks entries from Saturday.

12:30-2--Lunch meeting with Dr Bollenbeck

2:30--Cat ear injury surgery, Finally get to put on tie and doctors jacket!

3-7pm

• Cat paw injury and x-rays
• Tremoring older dog exam
• Neurologic exam on middle aged dog
• Ear recheck-resolved!
• Dental recheck-resolved!
• Senior exam and Mast Cell Tumor treatment plan
• Fill out scaler loaner paperwork and have techs ship out scaler for repair
• Type up Vaccine policy changes for staff meeting
• Approve amlodipine dispense

8pm-type up blog

8:15-8:45 More book on tape

8:45-Spouse and kid time

I love this life.

Creatures Small

This little hamster presented for a toe injury which the family attributed to a poorly designed exercise wheel. You can see that the tip of the toe is dead and part of it is only hanging on by a thread.

A quick snip and some surgical glue and the wound was closed. Not very high tech, but simple and effective. Satisfying too, as we are often limited in what we can do for these smallest of creatures.

Now to prepare for our 90 pound lab cruciate repair!

Tools of the Trade

A 14 week old boxer puppy presented with 2 weeks of right rear leg pain. He was partial weight bearing, worse after exercise and had mild but definite swelling on the back of his hock (ankle). This area was painful, although I could flex and extend his hock with minimal complaint.

If you look above the text on the radiograph, you can see a slightly irregular outline to the bone as well as a dark area within the bone. Unsure as to whether this was definitely a bone infection, I posted this radiograph on VIN (Veterinary Information Network), an online forum of practitioners and specialists. Within hours, an orthopedic specialist got back to me with a confirmation of infection and recommendations on antibiotic therapy. Within days, this puppy was doing great!

The point of this story is that modern technological tools can augment clinical skills in a way that benefits patient, client and clinician. Without a thorough history and exam, I might have attributed the lameness to strain, sprain or a developmental disorder. Without good quality radiography, I could have easily missed the abnormal bone changes. And without the experienced eyes of a specialist, treatment would have been delayed. In this case the client benefited from an efficient (and less expensive) workup and early diagnosis and our puppy was able to enjoy being a puppy again!

Those who ignore history...

I recently was reminded of the importance of a good history in the diagnostic workup. A hamster presented with a recent eye injury. Now I approach "pocket pets" just like dogs and cats: thorough husbandry, diet, and health history questions, a complete physical, a list of possible diagnoses and the tests necessary to confirm the problem before treatment. True, the nature of pocket pets often limits the amount that we are able to do, but I like to give them at least the benefit of a good history and physical.

Well this little hamster's eye had been proptosed (bulging out of the socket and lids) for at least a day and all my historical questions left the cause uncovered--no change in the cage environment, no previous eye rubbing, no irritants in the house, and no history of known trauma. It wasn't until I asked if there was any interaction with the family dog that I was told that the hamster had been found in the dog's water bowl 2 days earlier!

This answered the trauma question. And fortunately for this hamster, I was able to sedate it, clean and place the eye back in place and, using our smallest suture, suture the eyelids together to keep it in place while the swelling resolved. One week later we took the sutures out and to my pleasant surprise, the eye appeared normal!

That reminds me of another great eye story, but that's a tale for another day.

My First Real Emergency

"The definition of an emergency is when you don't have time to refer to your emergency manual." This piece of wisdom was handed on to me the day before a very distressed Yorkie presented to the Cornell Veterinary Emergency Service. I was the on-duty doctor, and being only two months into my internship, the adrenaline provided unusual focus on "the ABC's of emergency care" (Airway, Breathing, Circulation). Based on the the blue gums and the lack of air movement despite violent gasping, I was able to stop at "A" and quickly came to the realization that I would be performing my first tracheotomy.

Hands shaking, I quickly gave some sedation, incised the roughly clipped skin on the neck, and made the stab incision into the trachea. A rush of air, several breaths, and the gums were turning pink again! 15 minutes later we had a very happy Yorkie and client.

It turns out that this pup had gotten ahold of a snake skin, part of which he had aspirated. During the tracheostomy it was dislodged (and swallowed!) After a night in the ICU for observation, the Yorkie was sent home and a healed beautifully. Several days later I received a thank you card from the client with Snoopy on the front. I forget what the card said, but the owner had drawn a little hole over Snoopy's trachea and written "ahhhhh". I still smile thinking about it. LR

Why I became a Veterinarian

As I was growing up, James Herriott's stories of the life of a British veterinary surgeon provided romantic inspiration for becoming a veterinarian. The mentorship of Robert Brown, a softspoken and wise veterinarian further fanned that flame. My chemistry experience at Va Tech almost diverted my attentions to a laboratory career, but I stayed the course. Research hadn't lost its appeal however, and as I progressed through veterinary school, I became focused on laboratory animal medicine.

Then I went through my internal medicine rotation with Dr. Michael Leib, and everything changed. I was hooked on clinical medicine, companion animals, and clients. Clinical medicine allowed me to combine my academic interests with hands-on skills. I greatly enjoy the physical aspect of procedures such as surgery, endoscopy, and ultrasonography and the intellectual challenges of case management. Being able to do all this while working with dogs, cats, and other animals was particularly satisfying. And getting to know people as clients instead of patients fosters a type of relationship that is personal, and at the same time more objective.

There were some hurdles on the way to this profession: an early allergy to cats and an initial sqeamishness in the presence of blood (I still don't like needles in me!). But since 1988, I've only had two or three days that I didn't look forward to going into work. And all those romantic notions of treating animals from reading All Creatures Great and Small: They're Real!
I hope to share some of them in this blog.

Len Rice, DVM