Friday, August 11, 2017

Haiku For My Dog


Barker at the dawn;
Thief of snacks and foul tissues;
Soft brown eyes meet mine.

His name is Orbit, and he is five years old today. I didn't think we were ready for a dog. We were busy people with two young children and two dog-averse cats. We both worked and we traveled a lot. But my daughter talked us into it. "When will I ever get a dog?" she sobbed. And in my heart I wondered what sort of a veterinarian did not have a dog.

As intended, Orbit was my daughter's dog. She loved him so much. She brushed him and fed him and helped train him and walked him at least some of the time. But then in almost imperceptible increments this changed. Did the novelty slowly wear off for her, as everyone said it would? Did he grow on me in soft stealthy steps, as everyone said he would? Yes, both I think. My daughter still loves him, of course, but I love now too, fiercely even. I brush him and feed him and walk him and spend a ridiculous portion of the commute home looking forward to his greeting. And the hilarious thing is that he isn't even objectively "a good dog". He's actually a bit of an idiot. But he is a lovable idiot and, naive as I know it is, I manage to believe that his heart is pure. And this is really all that matters.

So when I enter an exam room and see a dog sitting beside their human companion I now have a more personal and immediate sense of what can pass between them.

Thank you for this Orbit. And for those greetings and dawn walks and everything else. Happy birthday.






Thursday, August 10, 2017

The Other Side Of The Mountain

(This is not a lame Toblerone sketch. It is a real graph generated from our numbers.)

If you are the type of pet owner who we affectionately refer to as a "frequent flier" and are in the clinic monthly (or more...), then you might have noticed that the staff and the doctors look more relaxed, more cheerful, less tired and less frazzled than they did a couple months ago. You were probably offered a range of appointment times and when you got there the waiting room no longer looked like a scene from "Pets Gone Wild 2". August is the other side of the mountain.*

Small animal practice has become highly seasonal. You can see from the graph that the seven months from August through February are pretty steady and then sometime in March we begin climbing, at first gradually and then sharply, reaching the peak around mid to late May. We are almost twice as busy then as in the slowest time of year.

Why is this? In a word, heartworm (and to a lesser extent ticks; I guess that's two words...). The start of prevention of heartworm disease has to happen in a fairly narrow window, pretty much exactly defining the mountain. This by itself only accounts for a portion of the traffic though. What has happened is that many dog owners would rather only come in once a year, so we've seen the annual physicals and vaccinations drift into this time-frame too. And then, when they're in for their physicals, we sometimes end up finding medical issues that need further attention, so more and more work gets piled into the peak months.

This makes staffing appropriately an enormous challenge. With a few exceptions the labour market for veterinarians and veterinary staff does not permit hiring people seasonally, so you end up staffing for a moderately busy scenario and then being short-staffed when it is really busy and over-staffed when it is quiet. A few tweaks can be made, such as discouraging vacation time during the peak season, but generally you just expect to be exhausted come the end of June, accompanied by the nagging feeling that you haven't given some of your patients the full time and attention they deserve because you were being pulled in too many directions at once (see: http://vetography.blogspot.ca/2017/06/supersonic-octopus.html).

Is there anything you the pet owner can do to help? I'm glad you asked! To begin with, cat owners should be aware that the mountain is mostly made up of dogs. Consequently, unless your cat really delights in the sights, sounds and smells of dozens of hyperactive and stressed out dogs, you should give some thought to booking his annual physical and vaccinations some other time of year. And then for dog owners I have one suggestion. If your dog's annual visit is during the spring and if she has a significant chronic medical condition you'd like to discuss, there are are some advantages to making a separate appointment for that during the fall or winter. The veterinarian will likely have a clearer head and more time for you. The spring visit can then be used as a quick recheck. Paying for two visits this way might seem extravagant, but I think in many cases this strategy will actually save money in the long run by resulting in more carefully thought out treatment strategies.

But if you have to come in May with your list of fifteen problems, don't worry. We still try our hardest and most of the time everything works out fine. Just don't ask about the bags under my eyes...


*Although sometimes we don't notice it until September because if our colleagues are on summer vacation in August the same amount of work gets dumped on fewer laps...

Wednesday, July 26, 2017

Yellow


After the success of my "Rainbow of Poo" post (http://vetography.blogspot.ca/2017/01/rainbow-of-poo.html) it was only a matter of time before I turned my attention to the colour of pee. It should be obvious that I will not be talking about rainbows here.

Pee is yellow. This much you know. But why is it yellow? Do you know? Do you even care? Quickly then a bit of science (cue the echoing "science, science, science" like from an 80's educational show). Urine is yellow because of the presence of urobilin. Urobilin is a breakdown product of bilirubin, which also gives bile its yellowish colour. And bilirubin in turn is a breakdown product of hemoglobin. As red blood cells are constantly being turned over (in the average human 100 million red cells die each day, but fortunately 100 million are born each day as well), there is a constant stream of urobilin waste the body needs to get rid of. 

Urine is full of all sorts of other waste products as well, most notably urea, which is a byproduct of protein metabolism. These other waste products are colourless though and the urobilin is excreted at a more or less constant rate, so the only variable in how yellow the pee is is how much water is being excreted. More water means more dilute urobilin and less yellow and less water means more concentrated urobilin and more yellow. Logical, yes?

So now that you know this, what can you do with this information? The first thing to understand is that urine concentration will vary from day to day, so one really clear pee or one really dark yellow pee doesn't mean much. If however your dog (I'll get to cats later) is producing very clear pee day after day, there may be something wrong. There may be. It may also be that he just loves to drink water and his body is getting rid of the excess. But definitely get it checked out to rule out diabetes, kidney disease, adrenal gland disease etc.. If your dog is producing very dark yellow pee day after day he may be dehydrated. This is a decent discussion of how to tell:

That's all well and good for dogs, but what about cats? You'll only see the colour of your cat's pee if you are invading their privacy much too closely or if you are unlucky enough to have the pee appear on a white towel or bed-sheet. However, if you use clumping litter you can use the size of the clumps as a way to guess at concentration, because as volume goes up, concentration tends to go down, and vice versa. If the clumps start getting much larger, the urine is possibly becoming more dilute and you should contact your veterinarian. By the same token, if the clumps are getting smaller make sure dehydration is not an issue.

What about other colours? Red is the only one worth talking about. Any redness or pinkness in the urine could indicate a problem such as an infection or inflammation or stones and needs to be brought to your veterinarian's attention. Also, if it is April 1, collect a normal sample, put some blue food colouring in it and drop it off at your clinic...

Finally, a few random facts about pee:
- Many people assume that a pet in kidney failure will stop producing urine. The opposite is in fact true. Up until very close to the end kidney failure patients produce a lot of dilute urine. The kidneys are failing to concentrate the urine, not failing to make it.
- Urine kills grass because the urea being excreted is high in nitrogen. It's like dumping a bunch of nitrogen fertilizer in one spot.
- Stinkier dog pee usually just means more concentrated pee (unless you've fed your dog asparagus or something strange). I actually get that question a lot. Infection is a possible cause too, but generally there are other symptoms such as accidents, urgency or straining. 
- Dogs and cats can tell large numbers of other specific dogs and cats apart by their urine scent, so all that sniffing on the walk is about figuring out who was there and do they know them. A longer deeper sniff usually means that it was an unfamiliar animal. It's a pretty exciting day for Orbit, my dog, when I come home from work after being peed on...


Helpful sign posted above a urinal in Bali. Hard to imagine you'd still be standing if you scored a "7".

Thursday, July 13, 2017

Take The Parka Challenge



Ok, now that summer is well and truly here I would like to issue a challenge to dog owners. Those of you whose dogs have long fur or an undercoat, please put a parka on. Those of you with short-furred, single-coated dogs, a spring or fall jacket will do. And if your dog has hairy or floppy ears, pull up the hood or put on a toque. Got it? Now here's the fun part: leave it on 24 hours a day... forever. Anyone up for this?? Waiting... Waiting... Come on you guys!

To be fair, and to make this challenge realistic, you are permitted to grow a Gene Simmons tongue and to leave it hanging out constantly for cooling.

I think we sometimes forget that our ancestors evolved in the tropics. As a result we have an amazing cooling system with our ability to both dilate capillaries and sweat just about anywhere on our (mostly) hairless body. Our dogs' ancestors evolved in the subarctic, which has consequently only equipped them for cooling with a big tongue that drools and a little nose that sweats (and sweaty paw pads, but that's useless). We've created a few more heat tolerant breeds such as Chihuahuas that have much thinner shorter coats and have big erect ears for some of that capillary dilation action, and there is the occasional goofball black Lab who likes to sprawl in the sun, but the majority of our dogs dislike the heat.

How do you know that your dog is hot? Simple: panting. I get a lot of questions about panting dogs as people sometimes worry that it is a sign of something serious. Very rarely it can be an indication of a fever or of heart disease or respiratory disease, but if there aren't any other symptoms of those problems your dog is almost certainly panting for one of three reasons:
1. Hot
2. Stressed, anxious or excited
3. Painful
You should rule out stress, anxiety, excitement and pain first, but chances are your dog is simply trying to cool off. This does not necessarily mean that he is suffering, no more than a person who is sweating is suffering, but it does mean that you should be aware he is hot and might actually be too hot.

The solutions are hopefully too obvious to bother mentioning, but I'll do it anyway (in a handy numbered list again!):
1. Professional grooming.
2. Early morning and late evening walks.
3. Access to cool resting areas in the house.
4. Move to the Arctic.

Thursday, June 8, 2017

All The Crazy People


Summer is the time for light things. Light food. Light clothing. Light conversation. Light work schedules (hopefully). And light reading. My most popular posts by far have been the heaviest and darkest ones. I'm not sure what to make of that. Regardless though, it is summer now and you are hopefully on your deck with a gin and tonic and, damn it, you should read something light.

As I've mentioned before, veterinary medicine may be fundamentally about animals, but it is also far more about people than you might expect. The world is full of all manner of interesting people, but it seems that the "most interesting" ones all own animals. This is why veterinarians make great dinner party guests. If you can prevent them from telling gross-out stories (oh, but the urge is so strong...), they often have some fantastic crazy people stories. Before I tell a few of mine (in point form to keep it light!) I should make a couple disclaimers.

First Disclaimer:
Don't be alarmed. If you are reading this you are almost certainly not featured in the stories below. None involve regular clients. If you think you are crazy you are probably not. The truly crazy generally don't realize it.

Second Disclaimer:
The use of the word "crazy" is a shameless and amateurish attempt at click-bait. Most of these people have something else going on like intense grief, or intense anger, or intense stupidity. But some are definitely full-on bat poo.

So, in no particular order, here are the inductees to my Crazy People Hall of Fame:

- The young man who had his beloved dead ferret freeze-dried and mounted on the mantlepiece in what he described as a "heroic pose".

- The elderly woman who kept an astonishingly detailed diary of her perfectly healthy cat's eliminations on reams of loose leaf and then would proceed to try to read two months worth aloud to me. "On March 13 he had one regular sized bowel movement at 6:03 in the morning and then..."

- The man who threatened to punch my partner when he remarked that the man's dog was overweight. The man was seriously going to assault Bob. The dog was seriously obese. Bob calmed him down. The man never came back.

- The man who missed his appointment because the bus driver wouldn't let him on. He had had his sick four foot long ball python draped around his shoulders.

- The woman who came to visit her dead dog the day after the euthanasia in order to groom him before the crematorium picked him up. He was a very large dog. She bathed him, shampooed him, blow-dried him and brushed him out, humming all along. It was heartbreaking.

- The young woman who began to un-button her pants, saying she wanted me to tell her whether the bites she had were from fleas. I declined saying that all bug bites look the same.

- The woman who brought her budgie in wanting to know why it wouldn't sing or eat. It was dead. Cue the Monty Python sketch...

- The couple who were astonished to find out that their young cat was pregnant. "How could that happen? She doesn't go outside and the only male around her is her brother!" (I'm sure every vet has run into this at least once.)

-  The woman who phoned and in a very high squeaky voice said, "I have always had the ability to smell cancer. All my friends say I can smell cancer. And I smell it on Billy. I want to bring him in so you can find it and get rid of it."

The last one and one that you may not want to read aloud to the kids:
- The woman who, with an entirely straight face, asked whether venereal diseases are transmissible between humans and dogs.

I have left the very best one off this list because it deserves an entire post of its own, and I'm still wresting with whether to let it out into the public domain yet or not. Let's just say that it involves a teddy bear. Don't even try to guess - you'll be wrong. I apologize for the cruel teaser.

Now you can return to your gin and tonic and the next piece of click-bate.

Thursday, June 1, 2017

Supersonic Octopus


June 1.
First receptionist, "Philipp, Mrs Patterson is late, can I set up Mr. Cho instead?"
"Uh, sure." I'm trotting down the hall, hoping to get to my computer to catch up on files.
Then it occurs to me, "Mr. Cho? I don't remember seeing him in the schedule."
"No, he's a squeeze in. Killer collapsed and he says 'stuff is coming out of him'!"
"Oh, ok."
I turn around and head to the exam room.
Second receptionist, "Mrs. Patterson just showed up. She apologizes, it was the traffic, but she has to see you today. And your next appointment is here too. They're a bit early."
"Ok, well I'll look in quickly on Killer and then I'll see Mrs. Patterson's dog."
First technologist, "Philipp, can you come into the back, I think Dodo is having a seizure."
Third receptionist, "Can you pick up the phone first please, Mrs. Wilson says she has left three messages and needs to talk to you right now before they leave for the cottage."
"Um."
First receptionist back again, "Before you see Cho and Patterson, Samsons are here to pick up those prescriptions you told them you'd have ready..."
First colleague, "Philipp, can you squeeze in an ultrasound soon? I think Buzz Firth is bleeding internally..."
Second technologist, "Buzz's owners are here now visiting him and want to know what's going on. Did you do that ultrasound yet?"
Second receptionist again, "I set up Mrs. Patterson, she brought her other dog too, hoping that after you see Marvin for his chronic diarrhea you'd have time to discuss Melvin's chronic skin condition which has gotten a lot worse."
(Yes, a pair of cockers named Marvin and Melvin.)
Third receptionist again, "Before you talk to Mrs. Wilson, can you quickly answer a question from your last appointment? Mr Schmidt's at the counter still and has his wife on the phone who reminded him what he was supposed to ask."

I haven't checked phone messages in two hours.
I haven't written on files in three hours.
I haven't been to the bathroom since I got to work...

Then my brain began to liquefy and I slumped into a gibbering vibrating heap on the floor.

Ok, that last bit isn't precisely true. And the very first line is misleading too - June 1 is truly the epicenter of our ultra-busy heartworm season, but I'm not at the clinic today. Today is my day off. Today I am mowing the lawn, drinking beer and writing this.

When the kids were small and they would pepper me with a series of complex overlapping requests I would joke with them that I was not a "supersonic octopus". This expression comes back to me frequently this time of year...

A Public Service Announcement Postscript:
It is critical that you give your dog heartworm preventative medication.
It is not critical that you give the first dose right on June 1. Please do not phone your clinic in a panic today or tomorrow. As long as the first dose is given within a month or so of the first mosquito bite it will still work well. The medications kill the first larval stages of heartworm in the bloodstream before they can do any harm.

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.