Narceus americana

We recently hiked Strickler Knob near Luray, VA.  This hike is similar to Old Rag in the rock scrambling, but a little less strenuous, especially if you use the Scothorn Gap trailhead, and much less crowded.  The 360 degree views at the top are spectacular, but sometimes nature provides intricate beauty on a much smaller scale as witnessed by this North American millipede (Narceus americana).  While I love my work and enjoy Dusty greeting me with exuberance when I arrive home, I also look forward to encountering animal life in more unexpected ways in the middle of the woods, in the back yard, or on the water.  What a gift that we are able to experience  the complexity of nature on so many levels-our senses, intellect, and emotions. And to have the ability to contemplate and share this awareness with others!  One of many reasons for belief in a God who wants us to experience the goodness of His creation! 

Hammy the Hamster

Three days ago this little fellow presented for wobbliness and disorientation.  Neurologic symptoms are often bad news, especially in three year old hamsters, but Hammy seemed to be doing pretty well otherwise and we wanted to give him a chance. Sometimes these symptoms can be due to an ear infection or stroke so we recommended oral antibiotics, frequent hand feeding and watering, and a quiet warm environment. Hammy's family was headed out of town though, so we offered to take care of him for a few days. 

Hammy is a very friendly hamster.  When he is not hanging out in the "sleephouse" he is happy to be held, and over the past 48 hours has made a remarkable recovery.  Fortunately he never lost his appetite so we were encouraged that he might pull through.  He is not out of the woods yet, but we are hopeful!  

(On a side note, vets often get bitten when handling hamsters.  It's not serious but it smarts just enough that we are a bit tentative when doing an exam or administering medication. However,  Hammy showed not the least tendency to bite, and although this is primarily due to his sweet temperament, I also discovered that he lacks upper incisors!)      

Old Rag and a Good Old Dog

Just hiked Old Rag with my family yesterday.

 We are all moving a lot more slowly today! It was a beautiful hike that began with a little insight on the value of canine companionship:

At the parking lot I opened my door and barely tapped the side view mirror of the car next to me. No damage was done, so  I waved an apologetic hello to the driver who then got out to confirm that there was no damage.  Apology #2 was answered with the stern advice to "be more careful next time."  OK-I probably deserved that.  "Sorry" I repeated, followed by another "be more careful"- a little much for a bump I thought to myself!.

Anyway this old Great Pyrenees ambles over to check out our family and is content to have his head rubbed and hang out next to my daughter until we set off on our hike.  Just a good ol' dog that doesn't care about mistakes or power plays and is willing to demonstrate to us a little lesson on friendliness. He set the perfect mood for the rest of the day.  Pets make us better people!

Kitten Feeding

We recently saw three kittens that were rescued from under a barn. Mom wasn't around so they had been struggling to find food, their mouths and bodies covered with dirt. Our client had cleaned them up and brought them in for exams. Two were pretty feisty and started drinking from a bottle right away.  One was disoriented, trembling, and appeared to have a problem with a part of the brain called the cerebellum.  However, his body temperature was low (93 F) so we first put  him on supplemental warm air heat.  That alone corrected most of his symptoms.  He also had some blood in his stool, so we started an antibiotic (directions:  1 drop twice a day!)  We tube fed him and his siblings for a few days, but now they are all taking the bottle and the weak one has surpassed the other two in body weight.   Here is one of the crew enjoying lunch.

Trust

Some of my extended family and friends have recently had a series of intense health issues. My experience in  communicating with the medical teams has given me a renewed appreciation for the trust that you, our clients, have in our care of your pets.

The medical system for humans has an impressive capacity for diagnosis and treatment and some incredibly dedicated and compassionate individuals.   A limitation however, is that care is so specialized that flow of information and therapeutic plans to the family can be a slow and often confusing process.  Further,  the patient/parent/relative who is advocating for proper care can sometimes feel left off of the health care team.

In veterinary medicine, we function more as generalists.  Even at the specialty level, the specialties are fairly broad. This allows us to have an overall view of a patient's health and clients relationship with their companion that allows us to efficiently carry out medical plans.  Further, although predetermined algorithms are very helpful in working through  rule outs for certain symptoms, we often must adapt our plans to the specific circumstances (medical, emotional, and financial) of client and pet.

Even so, it still is an act of faith for our clients to let us take their friend away from them for a surgical procedure or medical treatment in another area of the hospital.  This level of trust is usually unspoken, but next to the satisfaction of healing, is the most satisfying part of our profession.  When a client trusts our recommendations, we know they have confidence in not only our medical knowledge and skills, but in our personal integrity.  We take that trust very seriously and respond through our best efforts on behalf of their pet.  This happens dozens of times each day, but it is never taken for granted.

To all our clients, thank you for trusting us with the care of your companions!

Smokehole Canyon West Virginia

    

This is not really a veterinary post, but Smokehole Canyon is one of the best family canoe trips I've done. My children and I and a couple other families run this river near Petersburg, WV every Memorial Day Weekend. From beautiful scenery to a great canoe-only campsite, challenging hikes, a wonderful swimming hole, a cave, fresh spring and many class 2 rapids, this river has it all and is one of my kids' favorite family trips. Here is yours truly running "Landslide Rapid", the last major rapid before camp (where you don't want to flip and spill all your gear). Fortunately, the canoes have always made it through unscathed.

Batter Up!

The other day I was inspecting our house for wasps, ants, and other pets in anticipation of doing some exterior painting.  I was particularly interested in the wood trim that we had wrapped with aluminum years ago.  As I rounded one corner and looked up, there was a bat snugly nestled between the concrete foundation wall and the base of the trim wrap in a space that could scarcely hold another of its kind.  As I got closer it bared its teeth.  I backed off, but the veterinarian in me was impressed with the lack of tartar and periodontal disease! 

Proverbial Wisdom

A client recently returned a survey card on the appearance of the clinic, courtesy, professionalism, and empathy of the staff, and value of services.  We were pleased to see all outstanding scores, but her note "I appreciated the kindness of the staff and doctors. Proverbs 16:24" made me curious. Here is the reference:

Proverbs16:24 Gracious words are a honeycomb, sweet to the soul and healing to the bones.

Although this quote referred to the words of our staff, her kind sentiments were sweet to my soul and a reminder that graciousness, aside from being good manners, reflects an appreciation and respect for others and the level of composure of one's own soul. 

This is a timely message as we are experiencing frustrating local phone service problems.  In talking to tech support, it is easy to vent about inefficiencies and unresolved issues, but at the other end of the line is someone who is generally trying their best to work within what is an imperfect sytem.  Even someone who comes across as rude deserves a basic level of respect.  Who knows what frustrations they are experiencing?  Perhaps ones that make call forwarding problems seem pretty insignificant.

   

Second Chance

Remember "Chance" from my February 6, 2012 post? She has been making up for lost time (and food!). Here is Chance on presentation:


Then after 6 days of supportive care at Towne:

And now after a month of family life and good cooking:

Senior Blood Work

Often the most successful visits are the least exciting--the surgery that heals well, the diabetic who is easily managed, the limping that turns out to be just a broken nail. Unfortunately the opposite is true as well. It usually doesn't bode well when I have a "very interesting case", although there certainly are exceptions. Many of those exceptions appear in this blog, but today I have a sadder tale.

A 12 year old cat came in for a routine visit several weeks ago to have some lumps checked. These turned out to be mast cell tumors. Although these can be treated more conservatively in cats than in dogs, these tumors were in locations (mouth, eyelid) where they would be difficult to remove if they got larger. Before surgery we ran some senior blood work. This showed a mild elevation in the kidney values and a high red blood cell count. I was suspicious that the high red cells might just be a lab error or some dehydration, but the kidney elevation seemed a little out of place as well.

As most cat families know, chronic kidney insufficiency is common in older cats, but something just didn't seem to fit. The first step in working up this problem is to recheck the values to see if they are consistent. Well, today she came in for a recheck and possible surgery. Unfortunately, her kidney values were even higher and her RBCs remained elevated. I decided the best course was to look at her kidneys with ultrasound to see if there were just age related changes or a more significant problem. Both kidneys looked very abnormal and there was a large (half the diameter of the kidney) tumor in the left one.

Now the pieces fell into place--a kidney tumor that was not only contributing to the kidney dysfunction, but was probably stimulating the high RBCs. You see, the kidneys produce erythropoetin, a hormone that stimulates the bone marrow to produce erythrocytes (RBCs). In fact, some cats with chronic kidney disease are put on epogen (replacement hormone) because their kidneys don't produce enough! For this kitty, the tumor was probably overproducing this hormone.

Needless to say, we cancelled surgery and started supportive care (home fluid therapy) to keep the kidney values in line. Fortunately this condition is not causing any significant discomfort right now, but we suspect that we might see some more complications within the next 3-4 months.

This case is a reminder that some level of preanesthetic screening is a good idea in pets. It saved this kitty from undergoing a procedure that would not have provided the long term benefit that we intended. It also allowed us to intervene earlier in treating the kidney disease. This will certainly lead to a better quality of life, no matter how quickly her condition progresses.

Take a Chance on Me

This is one of those stories that every animal lover hopes for:



A 3.6 pound hypothermic cat with chiggers, neurologic signs, crusty eyes, skin sores, and jaundice was rescued by one of our very compassionate clients from certain death in the outdoors. Finally ill enough to catch, this young stray cat was brought to us with a temperature that didn't even register on our digital thermometer. We were certain that tests would show some sort of major health problem, but blood work and x-rays only showed mild anemia and mild jaundice.

We set to work warming, hydrating and syringe feeding her. At first she seemed to respond well, but her weakness just wouldn't improve. We rechecked her blood work, concerned that the hydration had diluted her blood and found that her potassium was very low. This was treatable, but unfortunately her red cells and protein level were lower. Worse, a recheck 2 days later showed a critically low protein level.

She was eating better with some assistance however, and a vocal personality was starting to emerge, so we sent her home for continued TLC . She started eating without assistance and regained her strength. Still, I was afraid I'd have bad news when we rechecked her blood work today. To my surprise, her red cells and protein were improved and she was noticably stronger and more alert. She still has a long way to go, but seeing her sit contentedly in her new mom's lap was so sweet! And now she has a name: Chance.

I hope to follow up with more pictures documenting her recovery, but 6 days out, here she is:

Plant Awns

Today a Golden Retriever presented with a rapidly growing mass under her jaw. It was not painful or inflamed, but when I took some fluid out of it with a needle, I saw very large numbers of bacteria and white blood cells. I suspected that this abscess could be due to a foreign body or infected salivary gland, so I sedated her and made an incision over the mass. After blotting away the fluid that came out of it, I was relieved to see this plant awn inside.


This 1 cm seed pod can penetrate tissue, and due to its shape, can't back out. Although plant awns are more common out west, we see our fair share of them here. In fact, I once saw 2 dogs, 2 days in a row, with plant awns lodged in the mucus membranes of their left eyes. And they were from the same family!

I believe this awn migrated from the mouth rather than through the skin for three reasons: First, the mucus membranes of the mouth are much thinner. Second, I could actually feel a thin tubular structure leading to the abscess. This was the tract that the awn followed before it was walled off by the body and led to the abscess. Finally, the type of bacteria in the abscess were typical of oral bacteria, and not the skin.

Along for the Journey

Yesterday a man arrived on Towne's front doorstep with 2 dogs, a bike, and what I assume were most of his worldly possessions. He was on his way from New York to Daytona Beach to stay with a friend and was walking the bike and the dogs when he couldn't hitch a ride. The dogs looked healthy but tired, and faithfully stood by their master's side.

Today I was reflecting on his journey and thinking how much more bearable the rough days must be (and how much nicer the good ones) with those companions by his side. Despite our different circumstances, we can all relate to that!

The Upside of All The Rain

After major rainfall, boaters like myself watch the Little Falls guage for the Potomac River. Normally at 2.5-3 feet during the dry summer, the river roars to life at 6 feet and a perfect surfing wave forms where Difficult Run flows into the river. 5-15 boaters wait in line in a narrow eddy to take turns carving up the wave. Even surfboards and stand up paddleboards were seen this past Sunday in perfect 80 degree sunny weather.

Easing your way up the eddy, you power across the eddy line into the current above the wave. A quick ferry across a minor standing wave moves you into position 15 yards above the target. You coast backward into the trough of the wave, then up the back until you are stopped by the breaking foam pile which, at lower levels, can turn into a sticky hole. Now though, it just stops your downstream momentum and you slide back up the wave face.

Now, although stationary relative to the shore, you are carvingback and forth across the water with thousands of cubic feet of river surging under and around you. Periodically the foam pile starts to break on your stern and you plunge deeper in to the oncoming water. Great Blue Herons fly over head. You dodge logs floating through the wave. You surf until the wave spits you out or you've had your fair time on it, then exit off the side and get in line to do it again.

Overall, an amazing way to spend a few hours on a Sunday afternoon!

What, is that Smell?

I love mentoring because I usually learn as much as the mentored. Yesterday I was discussing a case with Dr. Berning, our new associate. My patient, an elderly cat had presented with decreased appetite and lethargy. With a history of hyperthyroidism, multiple missing teeth and several strokes that had resulted in hearing loss, there were many possible causes. In addition, through x-rays and ultrasound, we had discovered a large cyst in front of his heart.

We decided to tap the fluid off the cyst using ultrasound guidance, hoping that, if this was the main problem, we'd see immediate improvement. We also temporarily stopped the thyroid medication since long term use can result in toxicity in some cats. Dr. Berning suggested that another factor might be loss of sense of smell due to the strokes. This made sense since he seemed to prefer fish based foods. With this in mind, we recommended offering these foods, either alone or on top of the regular diet, warming the food, and continued use of an appetite stimulant. Thanks Dr, Berning!

(Interestingly, this patient was exposed to debris from 9-11. Living a mile downwind, he was outside when much of the debris permeated this neighborhood. I don't know that the cyst is related, but cysts are unusual enough that the link must be considered.)

Germs vs Man

Another recent headline: Iodine, Alcohol Prep Pads in Kits Recalled. Guess why.
Bacterial Contamination! Add this to the list of food and pharmaceutical recalls that have taken place over the past several years due to chemical, bacterial, and particulate contamination. In today's mass manufacturing environment, it isn't suprising that these recalls occur, but bacterial contamination of antibacterial materials stands out. Imagine the fallout if a production lot of hand sanitizer became contaminated! This is yet another reason for common sense prevention-hand washing with regular soap and water, sterile technique in hospitals, and judicious use of antimicrobials.

Dog Bite Prevention

A recent headline in one of our trade journals reads: "AVMA, Postal Service Join Effort to Prevent Dog Bites". Although this brings to mind an almost comical image of a mail carrier being nipped at by the family dog, anyone who has been bitten, myself included, knows this is no laughing matter.

Two stats from this article are worth noting. Medical expenses for the 5,669 postal employees that were bitten in 2010 amounted to $1.2 million. And one third of homeowners claims in 2010 were for dog bite related inuries, costing $413 million!

My two most memorable bites were early in my career. Actually the first was at a clinic where I was volunteering as a teenager. I was holding a large shepherd for an injection and he whipped around a grazed my shoulder. It didn't do much damage but seeing how easily my face could have been damaged gave me a healthy appreciation of adequate restraint and the ability to read body language.

The second was with a little terrier that I knew was a biter. She seemed relaxed so I carelessly reached into the cage and she bit me right through my fingernail. That little gift from her stayed with me for a good 3 months!

Biting is one of the most difficult behaviors to correct. Proper socialization and temperament testing can go a long way, so start early with your own pets and educate yourself and your children about approaching other dogs. More in this AVMA brochure.

How Doctors Think

I ran across this book on the Fairfax County Library Audiobook site. Not only has it provided an interesting perspective on how human medical doctors think through cases, but it has provided plenty of material for self-examination. There are many cognitive errors that can compromise a diagnosis, from being satisfied with the first answer we have evidence for (search satisfaction) to letting our relationship with a client unduly affect our recommendations (affective error). Dr Groopman illustrates these with real life examples and follows up with questions that you can ask your doctor when you think something might be being overlooked, such as "What else could be causing these symptoms?" A worth while read for anyone who might have to navigate through the human (or veterinary) medical landscape, and that means most of us.

Mysteries of Life

Recently, my wife and children rescued tadpoles from a tire rut filled with rainwater. This vernal habitat has long since dried up, but 40+ tadpoles are thriving in our home. One of them wasn't looking so well so we removed him(?) from the tank. This prompted us to observe him in a little glass saucer with the 20-4ox power microscope we had gotten for homeschooling years ago.

First we looked at his eyes. I called my wife, the kids, and their friends who were visiting and they all lined up to look through the eyepiece. After many "oohs" and "aahs", I focused on the tail. There, in the transparent part of the tail that surrounds the spinal column, one could see individual blood cells traveling out along arterioles to the tail margin, then back through venules to the main vessels. This poor tadpole obviously wasn't moving much at this point, but his circulatory system was well enough for us to get an excellent view of the wonders of creation.

These same amazingly complex microscopic processes are going on throughout our body 24 hours per day, every day for decades. Unfortunately, we seldom recognize the beauty of biology until something stops working correctly. Mysteries still far outweigh our knowledge when it comes to life, but ever since veterinary school I've felt priveleged to be in a profession that allows me to care for patients within the bounds of that knowledge. (Sometimes that means just not interfering with the body's ability to heal.)

Awww...I want one!

I grew up with a beagle named, don't laugh, "Lassie". The family got her at "Puppy Palace" and on the way home my sister and I were asked to come up with a name. I didn't know any other dog names at that young age, so Lassie it was! She lived a long life and passed away when I was in college--I'm glad I didn't have to face that at the time. Now we have an odd looking but lovable mutt named Dusty, but there will always be a special place in my heart for beagles.