Thursday, January 18, 2018

In The Dark

This is not a metaphor. I mean it literally. Ok, I'll confess, sometimes it would be an appropriate metaphor, but that's not what I'm writing about today. Today I'm writing about the curious fact that I now spend roughly half my time at work in a dark room.

After ten years in general small animal practice I could begin to see the rough outlines of burnout approaching on the distant horizon, like a cloud of dust way down a gravel road. I didn't know whether that cloud of dust signified a puttering tractor or a careening semi-trailer truck, but I didn't want to wait to find out. It wasn't anything I could put my finger on, just a growing sense that I needed a different challenge. Don't get me wrong, general practice is extremely challenging, but it is made up of thousands of individual challenges, case by case, that keep you running like a proverbial hamster on a treadmill, but for me there was increasingly no sense of progress on something "bigger".

At around that time we were starting to find more and more uses for ultrasound, but no small animal veterinarians in Manitoba were doing it routinely, so we had to get a human ultrasonographer in who moonlighted going from vet clinic to vet clinic with her portable machine. She was great, but the limitations of that set-up were obvious. Moreover, I found the technology fascinating, so whenever I had time I would peer over her shoulder and annoy her by saying, "That's liver, right?" and "What's that grey bit there? Beside the other grey bit?"

I was not a partner yet, so I approached my boss at the time with a proposal to buy an ultrasound machine for the clinic. It was a very big ticket item and even with creative math I could not make a solid financial case for it, but Bob was a remarkably wise man and could both sense the implications to the practice of my restlessness and see beyond what the immediate numbers showed.

So in 2001 we bought an ultrasound machine and I went to Calgary for a course. It was a revelation. Here was a world I could deep dive into that combined a fun technological toy with live anatomy, physiology and pathology, the subjects I loved in school. Blood tests and urine tests and xrays are cool in their own way, but they are static and removed and abstracted from the animal. Ultrasound was more like an extension of the physical exam. It was a live real-time exploration of the interior of my patients. Another exciting thing about ultrasound for me was how it was turning one of our weaker senses as a species, sound, into one of our stronger senses, vision. With ultrasound I was becoming like a dolphin or a bat and was seeing with sound. The hand-eye-brain coordination was going to take time to get consistently right, but the first few times that that grey mess on the screen automatically crystallized into a 3D organ in my mind were exhilarating. Furthermore, because it is done in a dark room, and because I drone on in a monotone, the animals were usually calm and the whole experience felt soothing and peaceful to me. I was hooked.

Over time I took more courses, in California and New York, but it became clear early on that the key to becoming proficient was case load. You just had to practice a lot. It was more like learning to play a musical instrument or a new sport than anything else I had encountered in practice. So I began to set aside time to scan healthy patients who were in for spays and neuters. This also helped me build up a strong sense as to what normal looks like, as well as how much variation there is in normal.

And then the first referral came in. Another practice across town had heard I was doing this and wanted to send a patient over. I was terrified. I agreed on the condition that the pet owner understood that I was still learning. But it went well and I failed to humiliate myself as expected. And then there were a few more referrals from that practice and then some from a second practice and then from a third and....

In the last fifteen years I have done over 12,000 ultrasound studies for close to 40 clinics from southern Saskatchewan through to Northwest Ontario. Now there are many veterinarians as well as an excellent human ultrasonographer doing it, but I am still busy enough with ultrasound that it takes up about half my time. And I still love it and it is still helping keep the burnout at bay.

Wednesday, January 3, 2018

Begins With The Letter "A"

This post carries a mature content warning. Seriously.


Yes gentle readers, today we are going to talk about your pet's anus. Frightened yet? If so, it's not too late to bail out and check if anything new has happened on Facebook in the last fifteen seconds. But if you're still with me, you're in for a special treat, because we are not just going to be talking about the anus generally. Nope, we're going to be specifically talking about anal sacs.

Most people call them anal glands, but technically they are not glands, so veterinarians are taught to refer to them by their correct name: anal sacs. However, most veterinarians soon encounter the situation I did after just a couple years in practice.
"The problem is with Bella's anal sacs," I said.

The client raised her eyebrows and said with a smile, "You have to be very careful how you pronounce that..."

Indeed.  Naively, I hadn't considered this before. I don't often blush, but this was an exception. Not long after that a colleague told me that he had decided to start an explanation of why there was inflammation around a dog's hind-end by first describing the basic anatomy: "So, your dog has anal sacs..."
Outraged, the client interrupted, "He most certainly does not!"

So be very careful how you enunciate that "a". Or just call them anal glands.

And why do they have these bizarre little structures you ask? They have them primarily to use for scent marking. All carnivores have them. Skunks have the most famous anal sacs, having turned a communication device into a weapon. But for our dogs and cats the stinky secretion contains information about them. What specifically we don't know, but we can guess gender and perhaps some individual identification markers. This is why dogs in particular will sniff poop. They are not necessarily interested in the poop itself, but rather in the bit of anal sac material that it is on it.

This then leads to the question of how they normally empty. They empty when the animal has an appropriately sized bowel movement. The pressure of this passing through the anus squeezes the anal sacs. When this does not happen, perhaps because there has been diarrhea or unusually small stools or just at random in some individuals, then the material can gradually build up and lead to problems. Typically a dog or cat with full sacs will lick at the area or begin to "scoot" in an unmistakable fashion whereby they sit down and then drag their bottom across the ground by pulling themselves along with their front legs. Note: scooting is not caused by worms! This old myth is remarkably persistent.

If they are successful in emptying their sacs by scooting or licking you will know - the smell is memorable. Gram for gram anal sac secretion is one of the most potently vile substances on the planet. However, if they are unsuccessful, you should call your veterinarian. One of the more glamorous parts of our job is to put on a latex glove, apply a little lubricant and "manually express" full anal sacs. And here's the cool part - if your dog has frequent issues with full anal sacs we can teach you how to express them at home!* No medical degree required! It's clearly not for everyone though...

If the sacs remain too full for too long the material can thicken and become difficult to express. This thickened material can also become infected, leading to the formation of an anal sac abscess. Some dogs do not give clear warning signs like scooting so unfortunately the first thing you may notice is blood near the anus when the abscess ruptures. Luckily this is usually easily treated with antibiotics, but it can be an alarming mess in the meantime.

Prevention is of course always better than treatment. There is no fool-proof way to prevent anal sacs from filling up, but adding fibre to the diet can help. A source of fibre, such as metamucil, oat bran or canned pumpkin, can increase the bulk of the stools and thus encourage the sacs to empty naturally. Appropriate amounts vary with the source of fibre and the size of your dog, so check with your veterinarian. Incidentally, we generally do not add fibre to a cat's diet but cats fortunately are much less likely to have issues with their anal sacs. One final note is that in some animals food allergies may play a role in anal sac disease, so ask your vet about that possibility.

I got through that without even telling my grossest anal sac story! I'm proud of myself.

 *What a bizarre world we live in. The "For Dummies" series actually has a tutorial on this: