Thursday, October 12, 2017

The Firehose and The Pudding



Most people are looking at this title and are thinking to themselves, "That's weird. Firehose? Pudding? How do these relate to each other, or to pets or veterinarians?"
On the other hand, people who work in vet clinics are groaning lightly and facepalming because they know exactly what I am going to write about. I am going to write about diarrhea. And I'm going to try hard not to be too gross about it. It's tough for me, but I am going to try hard.

Even though it may seem obvious, let's start with a definition. From a medical perspective, diarrhea is stool that has enough liquid in it that it can no longer keep its happy log shape. A single abnormal one could be a fluke, but if it happens more than a couple times in a row, we can properly call it diarrhea. And if you want to get all nerdy technical about it you can refer to the "Bristol Stool Scale" and score the poops from 1 to 7:
https://en.wikipedia.org/wiki/Bristol_stool_scale
(Note that where it says "lacking fibre" for stools scoring 5, this just applies to humans. In animals I would consider 5 to be borderline diarrhea.)
6 is what we sometimes refer to as "pudding" and 7, if it is sprayed out, is "firehose". That's it for the gross bits! All done. You can read on safely now.

Once you know your pet has diarrhea there are really just two important questions we need to consider:
1) How long has it been going on?
2) Does your pet have any other symptoms, or is she otherwise happy and normal?

To the first question, we're only going to talk here about diarrhea that has been going on less than roughly two weeks. This is acute diarrhea. The word acute sometimes confuses people as some believe it means severe, but it doesn't, it just means recent onset. Chronic diarrhea is due to a whole other set of causes, needs different tests and has different treatments. Fortunately it is relatively rare, while acute diarrhea is extremely common.

If the only symptom is diarrhea and there is no vomiting, lack of appetite or lethargy, then you can follow the advice here or just phone or email your veterinarian for their advice. There is no need to rush Billy-Bob down for an urgent examination. If, however, any other symptoms are present, then it's best to get him checked over.

Before we get to what to do, a word about causes. Acute diarrhea in previously healthy pets with no other symptoms is almost always due to either a virus or what we like to call a dietary indiscretion. Even if your pet is not in contact with other animals, viral diarrhea is still possible as these viruses can be found out in the environment and be easily transmitted on their paws (dogs especially) or on your shoes. And dietary indiscretion simply means having eaten something their system doesn't tolerate, like five day road-aged dead squirrel, stuffed pizza crust, nasty random thing in the garbage etc. (dogs especially, again). Keep in mind that what they can tolerate will change over time, so just because Ellie-Mae did well on bacon chips for years, doesn't mean that won't cause diarrhea now.

Treatment for this is usually simple because the body has remarkable healing mechanisms. Often all we need to do is turn off the tap and power down the poop making machine. To do this we need to temporarily replace their regular diet with a low residue diet that produces very little stool and therefore allows the gut to rest and heal. For this you have two options. You can either buy a commercial prescription low residue diet from your veterinarian such as "Gastro" or "I/D", or you can cook for your pet.
For dogs the magic recipe is:

1 part extra lean cooked ground beef (boil or fry and drain until it's just dry meat with no fat), or if your dog can't have beef, use lean chicken breast.
2 parts (by volume, just eyeballing it is fine) boiled white rice, not brown.

That's it! Frequent small meals is best. And no treats or anything else other than water to pass their lips. For cats I usually recommend just a pure lean protein source without the rice, such as canned fish packed in water, or cooked chicken or turkey breast.

Feed this until you've had 48 hours without diarrhea. If it is still persisting after that, please call your veterinarian! There may be no stool at all during this period, but that is not constipation, it is just the result of the low residue diet producing very little waste. Once you're past the two days, mix the low residue diet 50/50 with their regular food for a day or two before switching back completely.

One final wrinkle is that diarrhea that has been going on for a few days, but is not chronic yet, may be persisting due to "dysbiosis", which is both a fun word to say and a useful one to know as it describes an imbalance in the normal gut bacteria. We are learning more and more how helpful the bacteria in our large intestine are. That dead squirrel or sidewalk virus can sometimes lead to a change in that bacterial population that impairs the gut's ability to produce normal stools. Consequently, if a couple days of low residue diet haven't done the trick, your veterinarian may recommend a source of pre-biotic, which is something that feeds healthy bacteria, such as canned pumpkin (weird but true), and/or a pro-biotic, which provide large numbers of the good bacteria. Years ago we used to recommend yoghurt for this, but fortunately there are much better, more dog and cat specific, pro-biotics available now from your veterinarian.

With any luck, ta-da, normal poop! (Ahem, Bristol Stool Scale 3 or 4....)



Thursday, September 28, 2017

Things I Am Terrible At - Part 1


The appointment looked innocent enough, "3:00 - 'Count Basie' Simmons - collect sample". I did wonder briefly what sort of sample, but figured it was probably a needle biopsy of a lump as the techs do all the blood draws.

I entered the room and introduced myself to the owners, an older couple, he sporting a Tilley hat and she clutching a red notebook with "Count Basie" written boldly on the cover. Smiles and solid handshakes all around. There were two dogs in the room, both Rough Collies ("Lassie" dogs, in case you're not sure).

"The Count has a friend along for moral support," I said, chuckling lightly. I crouched down and invited them both to sniff me.
"In a manner of speaking," Mrs Simmons replied, also chuckling lightly. "Ella is his teaser."

Uh oh.

Teaser... My heart dropped. I knew what I was collecting.

Ella and the Count seemed pretty relaxed about the whole thing. Mr and Mrs Simmons smiled at me. Obviously it was my turn to say something.

"So. Um. I am just collecting for analysis then? Or are we... um... using it or freezing it?"
"To analyze please. He's been a bit of a dud I'm afraid. Such good bloodlines, but no luck so far." Mrs Simmons said this in a pleasant, matter-of-fact tone.
"They said you were good!" Mr Simmons added enthusiastically.
I made a mental note to track down the comedian who told them this. It's not that I am in any way embarrassed by the procedure ("I am a doctor."), it's just that I am not good at it. In fact I am terrible at manually ejaculating dogs.
There was that time with the pretty young woman and her toy poodle stud "Robert"...
God.

But I knew what to do. I excused myself to "get what I need", which in fact was mostly just a few deep breaths and a couple minutes to quickly scan the net and the books for tips. It is not, as the saying goes, rocket science. The procedure is essentially what you imagine it to be. Although a cool dog penis fact, if you didn't know this already, is that they have a long bone in their penis, the "os penis". For real. This makes things easier in some ways. I'll leave the obvious jokes to you.

I stepped back into the room. Gloves, lube, collection vials. Everything ready. I looked at Count Basie and he looked at me. Mr and Mrs Simmons smiled encouragingly. I made sure that Count Basie had sniffed Ella, who was apparently just coming into season, and then he and I began.

(Fade out for the sake of decency and decorum.)

It wasn't working.
Mr Simmons offered, "Maybe the white coat is putting him off?"
I took it off, vowing to myself that that was as far as I would go.
It still wasn't working.
I kept trying, varying rhythm and pressure from time to time, reapplying lube, trying to look relaxed and professional, but the Count just stood there, panting, not even glancing at me. My hand was getting tired.
"Oh dear," Mrs Simmons said, and wrote something in her notebook.
I was determined to succeed this time, but my hand was really beginning to cramp.
"I'm sorry, but this just doesn't seem to be the day," I said weakly.
"Don't feel bad, this happened to the last vet too."

I booked them to try again in a week when Ella was more in season. I knew I'd be away then so they'd have to see my colleague.
"He really is the best at this," I assured them, smiling an evil little smile to myself.

This xray shows the os penis (running to the left from the point of the arrow, 
crossing the femur), and shows that it can be a hazard as well as a convenience. 
This poor dog has a bladder stone lodged at the right hand end of his penis bone.



Thursday, September 21, 2017

Cough Cough


There are four exam rooms along the hall leading to my office. The other day when I arrived at work two of the four had signs on their doors stating "No Dogs!!". No, it does not mean that we are transforming into a cat clinic (although there are moments during heartworm season where this starts to sound attractive...). Instead it means that we are going through another outbreak of "kennel cough" and have to sanitize some rooms.

Kennel cough is an unfortunate name as it is misleading. Being a nerd I prefer the far more accurate "infectious tracheobronchitis", but we nerds are an embattled and misunderstood minority. The main problem with the name kennel cough is the kennel part. Dogs can contract this disease any time they are in close contact with disease carriers, especially indoors, but not just in kennels. The easiest way to think of this disease is to think of it like the human common cold. Sure, schools and day-cares (i.e. kennels for kids) are really easy places to pick up colds, but anywhere you are mixing with other people can do the trick. The cough part of the name is occasionally also misleading as some people perceive their dog to be choking or gagging or retching, rather than coughing. This can be even more confusing because a violent coughing fit can lead to hacking up some phlegm or saliva, which can easily look like vomiting to the anxious pet owner.

But all of that notwithstanding, I am not going to change the minds of thousands (ha!) with one blog post, so for the sake of clarity let's keep calling it "kennel cough". Now that I have agreed to that I suppose I should explain what it is. I already tipped my hand above when I compared it to the human common cold. Humans may sneeze more than cough with it because the nasal passages are targeted whereas dogs almost exclusively cough because it hits the windpipe and bronchi, but otherwise the analogy is useful several ways.
Like the human cold, kennel cough:
1) Is very contagious, but not all individuals will be affected the same as some have immunity.
2) Is caused by a large number of different organisms. In humans it's only viruses. In dogs it's mostly viruses plus one bacterium (Bordetella) and something wacky that is neither virus nor bacteria called a mycoplasma.
3) Usually runs a course of one to two weeks and requires no medical intervention.
4) Can occasionally develop secondary complications such as pneumonia or bacterial bronchitis, especially in the weak, the otherwise ill, the very young and the very old.

Consequently, if your dog is just coughing but is still hoovering his food and racing around like the damn fool he is, please give your veterinarian a call before rushing down. We don't want to spread the bugs in the waiting room and can often triage these and give useful advice over the phone (colleagues, please don't send me hate mail for suggesting this). Sometimes we may recommend a cough suppressant if the cough is disrupting sleep or is otherwise distressing. However, we must see the ones that may have secondary complications. These dogs may be depressed, off their food and/or hacking up thick yellowish goo when they cough. In puppies any vomiting, diarrhea or nasal discharge at the same time as the cough is also a reason to come down.

One distinction between kennel cough and human colds is that we have vaccines for kennel cough. These vaccines primarily protect against Bordetella and some also cover a couple of the viruses. Because of the number of potential causative organisms these vaccines only help reduce the risk, they do not guarantee protection the way a rabies or distemper vaccine does. Nonetheless, risk reduction is still useful in high risk scenarios such as, you guessed it, kennels, dog daycares, training classes etc.. Many of these facilities require proof of vaccination as they want to reduce the chance that they'll have twenty dogs coughing simultaneously. The risk in off-leash dog parks is variable and usually quite a bit lower, although it depends on how nose-to-nose your dog gets. Think of it like playgrounds versus day-cares for kids. The daycare is a petri dish sitting in an incubator, but in the playground your child will only get more colds if they lick the slide or wrestle with their friends rather than swinging quietly alone.



Thursday, August 24, 2017

Taboo


It's the biggest taboo of all. Survey after survey indicates that people (North American people at least) are more comfortable revealing details of their sex lives than details of their paycheques. For a variety of cultural and historical reasons it is considered exceptionally rude to ask someone how much they earn. Yet people wonder.

I think most people believe that veterinarians are reasonably well paid, but not nearly as well as human doctors or dentists. And in broad strokes this is correct, so I could just stop there, but for those who are curious I will lift the veil more completely. But first a short story.

We have all said things in the past that make us squirm with embarrassment when we think back on them. I have a veritable catalogue of such statements to draw on, but one in particular is relevant here. When I was a university student I made one of my then very rare visits to the dentist. The dentist was a very pleasant fellow and we had a good chat about summer plans (well, one of those dental chair good chats where the dentist asks questions and I reply, "mm, mm, mhmm"). He really was a nice guy and he did a good job. I don't recall specifically what was done or what the bill was, but I do vividly recall doing the math on how long I was in the chair and then declaring to my friends and anyone that would listen that this guy must make $200 an hour! I was an asshole. And I had done my math wrong, way wrong. Now, thirty years later, I know that "overhead" is the 800 lb gorilla of the balance sheet. It probably ate up 70% of his bill. I feel bad for implying that he was gouging.

Fast forward to the present day when a lot of my day is spent doing ultrasounds, which take around  half an hour (although the client only sees 15 to 20 minutes of that as the rest is report writing) and cost around $300. Most people are not as ignorant as I was at 22, but I'm sure there are a few who walk out thinking, "This guy is making $600 an hour! Must be nice."

One zero too many. I earn $60 an hour.

Some clinics pay a percentage of billings, but we pay a straight salary to the doctors. It's an annual salary rather than a true hourly wage, so there is no overtime or anything like that. As far as I can tell my salary is fairly typical for a small animal veterinarian in general practice with 27 years of experience. It's pretty close to the top end for a non-specialist. New graduates start in the $35 range.

A few of you are probably still thinking, "Sixty bucks an hour - must be nice!" It is nice and I am not going to complain. But allow me to point out two important factors that make it perhaps less nice than it seems on the surface.

First of all, we put in six to eight years of university where rather than working and earning money we are generating debt. Lots and lots of debt. The median debt on graduation has grown dramatically to $65,000 now in Canada. In the US it's $135,000!

And secondly, most of us do not have company or civil service pension plans. A significant amount of our income has to be diverted into retirement savings to make up for this. At least if we are able to and if we are smart enough to...

In the interests of full disclosure, there is another potential income stream. Some of us, myself included, are also practice owners and earn money from any profit the practice might generate (most do generate some, but some don't...). Here, however, there are also two important factors to take into account.

The first is that profit is not free money. Potential owners have to take out massive loans to buy into practices. This money could have been invested elsewhere, like in the stock market or bonds or real estate, but we have chosen to invest it where we work.

 And secondly, I am part of a fortunate minority to have had the opportunity to buy into the practice. Younger veterinarians are having a harder time affording it because of the aforementioned debt load. Also, large corporations are increasingly buying practices which prevents the doctors working there from ever becoming owners.

I know how lucky I am. It's not a life of luxury, but I never aspired to that and it is a very good life. I have the trust of the thousands of pet owners who have come to me to thank for that. So if you are one of those and are reading this, thank you!


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".