Thursday, May 18, 2017

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.

Wednesday, April 26, 2017

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.


Thursday, April 20, 2017

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...;-)

Thursday, April 6, 2017

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.

Thursday, March 16, 2017

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.

Thursday, March 2, 2017

Black Coat


Some days I feel like I should be wearing a black coat instead of a white one. Some days I feel like I am ending more lives than I am saving. Some days I really understand the people who tell me that they wanted to be a veterinarian until they learned that you have to euthanize pets.

After 26 years in practice, euthanasia is still the hardest thing I routinely do. I've gotten used to all manner of grim fluids and funky smells and chaotic days and wacky clients and freaked-out pets and hopeless cases, but I have not fully gotten used to euthanasia. Watching the light go out of an animal's eyes as their human companions dissolve into grief is not something that anyone should ever get used to, so it being hard will be a necessary and integral aspect of my job until I retire.

And it is a frequent part of my job as well. I think most of us average maybe two or three euthanasias a week. They tend to cluster so sometimes I can end up performing three or four on a single day. Those are the black coat days. Most pets, probably 80 - 90%, die of euthanasia rather than of "natural causes" at home. If you think about it it makes sense. How many people get to die in their beds at home? The majority of us will die in hospital or by slow degrees in palliative or chronic care facilities. There is no such place for a dog or cat to go once their quality of life is poor at home, and there is no longer any hope of it improving. There is no ward for demented pets to live out their last days, wearing a diaper, unable to walk, unable to feed themselves. There is only a reasonably good life at home, or death.

Seen this way euthanasia is of course, perhaps ironically, one of the best things we do as veterinarians. It allows us to fully focus on quality of life. No animal needs to suffer pointlessly the way some people do. It gives us a powerful tool many on the human side wish they had, if only they could find a clear path through the ethical minefield. We are still far more comfortable wielding the power of life and death over animals, but with that power comes responsibility, and with responsibility inevitably comes stress. It's just the way it is, and the way it must be.

It is interesting to note that I get far more thank you cards after a euthanasia than after any other procedure. Far far more. Some of this is thanks for service over the life of the pet, but some of it is also gratitude for the way the end of the pet's life was handled. It's funny, but veterinarians themselves are always most impressed by their colleague's diagnostic and surgical skills, by the cool cases they figured out and by the new treatments they mastered. Clients never are. They just assume we know how to do all that stuff. What they are most impressed by is our compassion and caring, especially in those terrible emotionally fraught moments at the end of the pet's life.

But all that said, my heart still sinks every time I see a euthanasia booked for me.

Thursday, February 16, 2017

A Mile Wide


When people say that it must be harder to be a veterinarian than an MD they often make two observations. The first is that our patients don't talk. (As an aside, this is actually not always a bad thing. It's difficult enough to sort through contradictory information between the husband and the wife without the cat talking too...) The second observation is that we have to deal with so many different species. This is correct for the profession as a whole but in truth there aren't very many James Herriot "All Creatures Great And Small"* types around any more. More and more of us restrict our practices to a handful of species. Which is of course still more than one.

However, what people often don't consider, and what is truly difficult (but fun), is the range of what we can do. Physicians are usually limited to family practice or a specific specialty, whereas as a veterinarian in general practice I am a "family doctor", an internist, a general surgeon, a dentist, an anesthesiologist, a radiologist, a behaviorist, a nutritionist, an oncologist, a cardiologist, an ophthalmologist, a dermatologist, a pharmacist, an obstetrician, a pediatrician, a gerontologist and a bereavement counselor.

I am a mile wide.

And, as the aphorism goes, unfortunately sometimes (often?) just an inch deep. To be fair, the depth does vary. Most of us are deepest in the general medicine / family doctor, internal medicine and general surgery categories and then have a handful of other areas of interest where our depth exceeds the proverbial inch. Three things save us from malpractice in the shallow zones.:

1) Colleagues. Veterinarians, as a rule, get along well together and veterinarians, as a rule, know their own limits. Strengths and weaknesses tend to balance each other out within a group of veterinarians working together so cases are discussed and shared. And when this is not enough, or for those in solo practice, referral to specialists or to colleagues in other practices with particular training, experience or equipment, is common.

2) Continuing Education. In order to maintain our license we have to attend conferences where new information is presented and where refresher courses are offered. I was just at a conference in Florida last week for exactly that reason. Sure Philipp, a "conference" in Florida... in February... how convenient... Ok, we did tack on a holiday after, but honestly, during the conference time the warmth and sunshine outside were an abstraction when considered from the artificially lit, aggressively air conditioned interior of massive lecture halls. But it was fun! For those of you youngsters out there, here's a fact that may surprise you - learning is big fun when there are no exams or assignments or pressures of any sort.

3) The Internet. There, I said it in a public forum. Vets look stuff up on the internet. However, I don't mean the wide open internet, but specifically the Veterinary Information Network, or as we all call it, "vin". Vin is a life saver - literally for some of my patients - and it is something other professions are jealous of. It's an online subscription service that allows us access to scores of specialists to whom we can post questions on open forums**. It also has an impressive array of tools and resource materials and, as it has been running for about 15 years, it now has such a massive searchable database of past questions that I am often hard pressed to think of anything new to ask. Here's a secret: when your pet has something odd and your veterinarian pops out of the room for any reason or excuse, chances are they are also quickly logging into vin...

Being wide keeps things interesting. Being shallow keeps things scary. As with most things in life the key is in getting the balance right. And in leaving the hippos to the specialists.

*Widely referred to among veterinarians as "All Creatures Grunt And Smell".

**The free public access sister site is https://www.veterinarypartner.com/ , which is a reliable and highly recommended source of information when you are tempted to check in with Dr. Google.