Sunday, May 29, 2011

$200 worth of oops

This Saturday I was “on duty” in the large animal hospital, meaning that I was in the hospital for about 12 hours, theoretically helping with the treatments on all the animals (mostly horses, but we have gotten a few baby alpacas, or crias), along with one of my rotation mates. I say ”theoretically” because in practice, I just worked on my actual patient, a post-colic surgery horse who was extremely time consuming. My rotation mate and the techs handled the other animals, who needed many fewer treatments.

My horse was hooked up to a bunch of bags of IV fluids. In our large animal hospital, we suspend all the fluids from a hanger on the ceiling, and they run along coiled (therefore extendable) lines into a catheter in the horse’s neck. This way the horse can walk around his stall without getting his legs tangled, although the lines will inevitably tangle among themselves if you have multiple of them, which this guy definitely does. And with horses, the amounts of fluids and medications going in are fabulous. He had two five-liter bags of fluids hung at all times, plus a one liter bag of antibiotics, and a one liter bag of painkillers. This is aside from the medications I needed to inject into his catheter periodically, plus the oral meds I had to put down the tube which runs from his nose into his stomach.

The time came to change one of the bags of fluids. One of the techs stood outside the stall and lowered the hanger with all the bags. I removed the empty bag and hung the new one (with much grunting, as it was over my head and heavy). I disconnected the line from the old bag and went to connect it to the new bag — but since the line was also still connected to the second bag of fluids, it immediately started spewing saline all over the stall. I stuck my finger over the open tube to stop the flow just as the tech yelled “It’s sterile, don’t touch it!”

Well, I did know that you shouldn’t be sticking your finger over a sterile tube opening, but I had panicked and done it anyways. I stood there looking sheepish while the techs conferred. Yes, the line would have to be replaced. A new line cost $100. We obviously could not charge the client for this. The hospital would have to eat it. (The hospital is currently not profitable, which made me feel extra guilty.) These things happen when you are learning, but it is still super embarrassing. Also, changing the line was very complicated, and therefore annoying for the tech who did it.

Later in the day I was giving my horse his IV medications, injecting them into the new line. The second medication started turning into a solid powder inside the clear tube. It was precipitating! Just like in chemistry class! Except that that is bad to put into a horse’s bloodstream. I stopped and called a tech. I should have flushed the line with saline between injections. Oops. I flushed the line again and again to get all the precipitate out, but some was just too firmly adhered to the side of the tube. So, you guessed it, we had to change the line a second time, for another $100 eaten by the hospital.

So much to learn! So many embarrassing mistakes to make! I will never make these two mistakes again, though, I am pretty sure.

Tuesday, May 24, 2011

That is what is known as irony

I knew I would leave something behind in the town five hours from home where I did my shelter medicine externship. It was just a question of what. The answer: my wristwatch.

I hate wearing watches, but they are essential in the hospital for taking respiration rates and pulses. My friend is bringing my watch back to me this weekend, so I figured I’d try to tough it out watchless this week on large animal medicine. How many heart rates could I have to take? One a day? I could borrow a watch for that.

This morning I received my second patient, a foal aged 20 hours. His mom (a first time mother) was not letting him nurse. If baby horses don’t get a chance to ingest colostrum while their mom is still making it, before she switches to making normal milk, they miss out on essential antibodies and can die of infection. This is not true for human babies, who get their antibodies through the placenta.

We tested the baby, and indeed his IgG level, which is indicative of the amount of antibody in his blood stream, was almost nil. The solution: give him antibiotics, and give him a plasma transfusion.

I was enthused. I had never seen a plasma transfusion! And now I was going to get to actually do one! The tech said a little dourly, “You may find it a little less exciting once you see how it works.”

This is how you do a plasma transfusion in a neonatal foal: you hook it up to IV plasma and make a vet student watch it drip in for two hours. Every five minutes, the student has to — wait for it — take a pulse and respiration rate, to make sure the baby is not getting fluid overloaded.

It turns out that my cell phone doubles as a stopwatch. Not the most convenient thing to use around large animals, though.

Monday, May 23, 2011

Do not kidnap wild animal babies!

Since spring is upon us, at least in my part of the world, I offer a public service announcement: do not kidnap wild animal babies! If you see unattended baby birds, baby bunnies, etc., please do not pick them up and bring them in to a wildlife clinic. Their parents are very likely to return to take care of them after you leave, and they will do better in the wild than in a clinic. Moving them will probably do more harm than good!

Wild Baby Rescue Center, Inc. has a nice summary of how to know when baby wildlife needs your help.

Wednesday, May 18, 2011

He’s a lover, not a fighter: outreach for the prevention of dog fighting

[This is the presentation I gave at a shelter staff meeting this week, as part of my shelter medicine externship.]

How can we redirect inner city kids away from using their pit bulls for dog fighting, and towards other activities? I looked into two programs that exist to reach out to youth and do exactly that. These programs focus on prevention of dog fighting, on educating kids before they decide that dog fighting is cool, rather than focusing on the punishment of dog fighters.

The first program I looked at is the End Dogfighting campaign from the Humane Society of the United States. The End Dogfighting campaign has several different arms:

  • The Pit Bull Training Team provides alternative activities for youths with pit bulls (or, presumably, other breeds). Set up as a weekly class, the PBTT introduces kids to obedience and agility, and also provides some socialization for the dogs (since fighting dogs, obviously, often have poor social skills with other dogs). For students who do well and stick it out to the end, there is a Canine Good Citizen (CGC) test that they can take. If they pass, they receive a CGC title for their dog from the AKC, certifying that they have a well trained dog. Graduates of the class are encouraged to stick around and mentor new students.
  • The Humane Education arm of the campaign is an 8 week curriculum for middle school students. It’s intended to be a fun set of classes, with mock game shows, videos, and hands on projects. The message of the class is that dog fighting is a crime, it’s violent, and it’s animal cruelty.
  • The First Responder Outreach arm of the campaign is aimed at postal workers, utility works, and public works employees — the people who are out in the neighborhood who might encounter signs of dog fighting rings. The HSUS provides posters with information about what to look for, such as how to recognize the fighting pit where dog fights occur. The HSUS may also provide a presentation if asked.
  • The Law Enforcement Outreach arm of the campaign provides a $5,000 reward for tips leading to the conviction of a dog fighter; law enforcement training classes; a database with the names of known dog fighters; grants for handling seized animals (controversial, as the HSUS recommends that such animals be immediately euthanized); and prosecutor training.
The End Dogfighting Campaign began in 2006 in Chicago. Since then it has expanded to Atlanta and Philadelphia. So far, the campaign is focused on big cities. It seems unlikely that we’re next on their list. However, the HSUS freely provides materials for download to let other groups try to implement individual arms of the campaign.

I also looked into the Lug Nuts program, which is informal weight pulling contests in cities with dog fighting problems — again, providing alternative activities for people to do with their pit bulls. In a Lug Nuts contest, children’s sleds are loaded with food until they are very heavy. Dogs (not always pit bulls, although pits are very muscular and tend to be very strong dogs) are hooked to the sleds with special harnesses. The dog that pulls the farthest wins. The food can also serve as a prize, and the prize can be doubled for animals who are spayed or neutered. As the web page for the program says, there is excitement! Machismo! Thrill! The competitive aspect of Lug Nuts may be an important way to draw people in.

Sue Sternberg started Lug Nuts in New Haven in 2002. It is associated with a Training Wheels program, which brings pet supplies and veterinary services into underserved areas, and takes the opportunity to also bring some education about positive reinforcement training to dog owners.

So who should be going into inner city communities and telling people about these programs to change how they interact with their dogs? I am pretty sure that if I tried, I’d get laughed at. The End Dogfighting campaign solved this problem with the creation of Anti-Dogfighting Advocates (ADAs), graduated students from the program. They encourage people to come in to the weekly classes, and check in on them during the week to keep their interest up. There is definitely a bootstrapping problem here. Who goes out and convinces people to go to the first classes? But the approach of keeping community members involved even after graduation is a nice one.

I like the positive approaches of these two programs. Positive reinforcement works better than punishment! I’d love to see both programs expand to more cities.

Saturday, May 14, 2011

The Purebred Paradox, part four: What can be done?

(Continued from part three.)

Below are my musings on some of the talks at the recent conference, The Purebred Paradox: on the health and welfare of purebred dogs. Specifically, these talks delve deeper into ways some of the speakers thought we could move forward.

Professor Sir Patrick Bateson: “Problems of dog-breeding and what to do about them”

In his keynote address, Professor Bateson called for for “a public awareness and education campaign.” In his talk and in later discussions, the question of whom to educate was raised. Three interest groups were identified: dog owners, dog breeders, and judges of dog conformation competitions. Again and again, speakers at the conference returned with frustration to the question of how to educate dog owners. Once the bulldog has been purchased and the new puppy brought to the veterinarian for its wellness exam, it is too late. How do you educate people about healthy breeds before they bring home and bond with a new dog?

Patricia Haines, DVM: “Canine Genetics, Behavior and the role of the parent club”

Dr. Haines, a veterinarian and breeder of pointers, talked about parent breed clubs. Both the American Kennel Club (the AKC, the largest registering body of American purebred dogs) and the Kennel Club (the KC, the AKC’s British counterpart) are made up not of direct members but of member clubs, or “parent clubs.” These clubs mostly (but not entirely) represent breed specific clubs, such as the Golden Retriever Club of America.

Dr. Haines made the point that work for change would be more effective with the parent breed clubs, rather than with AKC judges. In fact, she said, many breeders joke that the judges don’t really know their breed well. It is the parent clubs which are the guardians of the breed standards, and, perhaps more importantly, the interpreters of them.

Dr. Haines’ insight highlighted, in my opinion, the usefulness of working with members of the dog breeding community. That community is a complex one which can be difficult to fully understand from the outside.
Gail K. Smith, VMD, PhD: “Efficacy of hip dysplasia screening: An animal welfare imperative”

Dr. Smith is the veterinary surgeon who designed the PennHip screening system for hip dysplasia. The more traditional Orthopedic Foundation for Animals screening system involves subjective judgement of a dog’s hips as poor, fair, good, or excellent. PennHip, on the other hand, provides an objectively determined “distraction index,” a numerical measurement of the amount of hip laxity (where more laxity implies worse disease). Dr. Smith explained that his PennHip system is particularly useful for genetic studies of hip dysplasia because it is a better measurement of phenotype, for use in correlation to genotype. In other words, if you want to study what genes produce hip dysplasia, an objective numerical value describing the individual animal’s anatomy is more useful than a subjective value like “fair.”

Of course, the question arises: can other characteristics be measured using numerical scales? How do you measure the flatness of a bulldog’s face? There is work to be done in this area.

Steve Zawistowski, PhD, CAAB: closing remarks
PhD behaviorist Dr. Sawistowski explicitly identified a fissure between those who breed dogs and those who identify themselves as members of animal welfare organizations. He said, “We are going to have to heal that fissure before we can heal the dogs that we all know and love.” This conference did a great job of outlining this goal and the current situation and identifying priorities to be addressed.

Friday, May 13, 2011

The Purebred Paradox, part three: Analyses of the situation

(Continued from part two.)

Below are my musings on some of the talks at last week’s conference, The Purebred Paradox: on the health and welfare of purebred dogs. Specifically, these talks delve deeper into what some of the current health risks are for purebred dogs, and why.

Brenda Bonnett, BSc, DVM, PhD: “Breed risks for disease in purebred dogs”

Dr. Bonnett is an epidemiologist who worked with “12 years of [health] data from over 200,000 dogs yearly,” obtained form Agria Pet Insurance in Sweden. Her talk was fascinating; placed as the very first presentation, it was a great introduction to the conference. She showed a series of graphs comparing the risk of different diseases in different breeds. Using the pet health insurance data, she could identify some risks as part of the risk of “being a dog” (diseases equally likely to occur in any breed) versus the risk of, for example, “being a German shepherd” (hip dysplasia, much more likely to occur in that breed than in most others). These graphs made the case very clearly that many breeds have risks of particular diseases.

The graphs were also an excellent way of demonstrating which diseases should be prioritized in particular breeds. She talked specifically about Cavalier King Charles spaniels, a breed which is prone to a particularly painful brain disorder called syringomyelia. Syringomyelia in CKCS was publicized in Pedigree Dogs Exposed and has been receiving a great deal of attention as a result. But her data suggested that another breed problem, heart disease, is much more prevalent. Syringomyelia, a disease in which your brain is squeezed out of your skull because your head is too small, is certainly very sexy, but if a CKCS is much more likely to die of heart disease, perhaps the issue of the heart disease should be addressed first.

But we already knew that different breeds get different diseases, right? When you are picking the breed of your next puppy, if you’re doing your research, part of your decision is whether you can deal with the risks of that particular breed. Is it more likely to get hip dysplasia? Heart disease? Cancer? Dr. Bonnett made the point that people will accept some types of risk, and some levels of risk, but not others. Life has some risks that you can't avoid; playing with sticks can be risky for a dog (GI obstruction! cracked teeth! splinters migrating into the sinuses!) but people accept those risks because they are part of being a dog. However, owners also accept the risks which are part of being a particular breed. Should they?

Dr. Bonnett concluded her talk by telling the story of a Bernese Mountain Dog (berner) owner who had come up to her after a previous talk. This woman had said that she had known that berners suffered from an increased rate of cancer, but had had no idea quite how bad the situation was until she listened to Dr. Bonnett’s presentation. However, this woman said, she would keep owning berners, because they were her breed. One of the themes of the conference was certainly the deep loyalty people have to “their” breed. (I completely understand it, as I feel that way about golden retrievers.)

Ilana Reisner, DVM, PhD, DACVB: “Unintended consequences of breeding for conformation: Owner-directed aggression in English Springer Spaniels”

Dr. Reisner is a veterinary behaviorist who presented a case study of an owner-agressive English Springer spaniel. This breed is particularly known for what has been called “springer rage,” sudden fits of aggression to the owner. The subject of Dr. Reisner’s presentation, Pluto, had bitten every member of the household, including the 80 year old grandmother. Dr. Reisner joked, “It wasn't too bad, just a few amputations.” She made the point that, while the conference was focused on dog welfare, when people live with dogs who are suffering or who have behavior problems, human welfare is also affected.

Frances O. Smith, DVM, PhD: “The development of dog breeds: Why and how people breed dogs”

Dr. Smith was a veterinarian, Labrador retriever breeder, dog show judge, and theriogenologist. (A theriogenologist is a veterinary specialist who has advanced training and board certification in breeding and reproductive problems.) She was clearly an exemplary breeder. She talked about the best dog she ever bred, who was a conformation champion and a performance champion. Dr. Smith emphasized again the importance of breed specific traits in the hearts of owners and breeders. The breeds must stay unique and recognizable. Any other solution to the problem is going to be very hard for many dog lovers to accept.

Dr. Smith seemed to have been asked to speak as a representative of the breeder side of the debate. I wish that we could have heard from some breeders at the show who were not cherry-picked to be non-controversial, however. The Labrador is a sporting breed, and sporting dogs tend not to suffer from breeding for extreme characteristics, as they are often expected to still be able to do work. (To understand what is meant by “extreme characteristics,” enjoy this post by the producer of Pedigree Dogs Exposed about the Neapolitan mastiff.)

Frank McMillan, DVM, DACVIM: “The impact of puppy mills on the welfare of purebred dogs”

Dr. McMillan is an internal medicine specialist and employee of Best Friends animal shelter in Utah. He talked about the widely publicized problem of puppy mills (high-volume, commercial breeders, who I’d argue are irresponsible by definition). He showed a number of disturbing photos of adult breeding animals taken from filthy and unhealthy circumstances at various mills.

Dr. McMillan’s main point was that the psychological damage done by lack of socialization to adult breeding animals in high volume breeding facilities is severe and should not be overlooked. Even dogs maintained at sparkling clean facilities are not given the socialization time they need as puppies to function properly once they are taken out of the puppy mill as adults. He read accounts and showed photos of these adult rescues, and demonstrated their complete inability to bond with their new owners after months, some even unable to be housebroken as they could not be approached with a leash to be taken outside. He argued convincingly that many of these dogs should be considered victims of post-traumatic stress disorder. No amount of regulation or oversight by the USDA will change this fundamental lack of socialization of dogs kept in situations where they do not get a chance to experience the world outside of their kennel.

(To be continued.)

Tuesday, May 10, 2011

The Purebred Paradox, part two: What’s the problem?

(Continued from part one.)

I recently attended The Purebred Paradox: on the health and welfare of purebred dogs. These are my musings on a few of the talks at the conference, specifically those detailing what exactly the problem is with current methods of dog breeding.

David Sargan, PhD:  “The RSPCA report on purebred dog breeding: Conformational selection and inbreeding in dog breeds”

David Sargan summarized the 2008 RSPCA report on purebred dog breeding. Before the release of the Pedigree Dogs Exposed documentary, the RSPCA had not really focused on issues in purebred dog breeding. This report represents their initial attempt to grapple with how they were going to address these issues.

The report identifies two welfare issues: exaggerated anatomical features that reduce quality of life, and an increased prevalence of inherited disorders. It also discusses current screening practices. Standardized screening is available for eye and hip disorders, among others. These screens are used only by a self-selecting population, however, so are not useful for a description of the true prevalence of a particular disorder in the population. For example, dogs which are not intended to be bred — “pet quality” dogs — are less likely to be screened, though they may well have a genetic disorder. Dogs with unsubtle signs of disease may also not be screened, but simply treated. DNA tests are being developed for many diseases, but many diseases exist for which no DNA test has yet been developed. Of course, many diseases do not lend themselves to DNA tests, as they may be multifactorial in origin, due to many different genes, or to interactions between genetics and environment.

The report outlines possible ways forward. Among its many recommendations are more systematic data collection; an increase in genetic diversity, both by limiting inbreeding and by opening the kennel club stud books (allowing offspring of unregistered dogs to be registered as purebreds); and work to improve the screening tests available.

The report concludes: “the most important element is to ensure that all stakeholder groups buy into the process and fully support the action(s) they need to take. This is the challenge that lies ahead.”

Jemima Harrison: “Pedigree Dogs Exposed: The Aftermath”

The producer of the hugely influential Pedigree Dogs Exposed spoke on the aftermath of the film. Actually, she started by outlining the premath, noting that change has been called for in pedigree dog breeding for over 100 years, and including newspaper stories and other references. She wondered if her film had caused enough change to really get and keep the ball rolling — has the sea change happened? Or is there more work to do?

She wasn’t sure, but she did include a video of Fiona, “the first mongrel to be shown at Crufts.” Fiona is the first low uric acid Dalmation to be shown at the number one UK dog show. The LUA Dalmations are the product of a single outcross to a pointer, and subsequent selective breeding to remove the gene for a genetic predisposition to kidney stones whch is present in every Dalmation except for those with this pointer heritage.

(Continued in part three.)

Sunday, May 8, 2011

The Purebred Paradox, part one: Background

In 2008, the BBC aired Pedigree Dogs Exposed, a documentary about breeding practices in purebred dogs. The documentary suggested that health problems are on the increase in purebred dogs, and that many of them are avoidable. Specifically, some problems are due to limited gene pools and unintentional fixing of traits such as predisposition to cancer; others are due to intentional breeding for extreme characteristics like flat faces or heavily wrinkled skin. This documentary triggered a strong reaction from the public, and the beginnings of some changes in how members of the UK breed clubs approach breeding dogs.

It also triggered a negative reaction from the British Kennel Club, and a great deal of controversy. The two sides of the debate are, in my own words:
  • Dog breeds are part of our heritage and are important to us. Each breed has its defining characteristics (the unique color of the golden retriever’s coat, the size and shape of the Great Dane, the jowly face of the English bulldog). These characteristics are what make each breed unique, and should be celebrated and maintained. I’ll call the people on this side of the debate the dog breeders, at risk of a gross overgeneralization.
  • The health of many purebred dogs is endangered both by consequences of inbreeding (such as overrepresentation of genes for cancer in Bernese Mountain dogs) or by breeding for extreme traits (such as the extremely flat face of the pug). We should start prioritizing the health of our purebred dogs over maintenance of breed purity. I’ll call the people on this side of the debate the advocates for change, although many dog breeders take this viewpoint as well.
Last week, I was privileged to attend a conference in Washington, D.C., called The Purebred Paradox: on the health and welfare of purebred dogs. This conference was intended to move the debate, which had begun in the UK, to this side of the ocean. By my estimates, however, more than a quarter of the speakers and attendees hailed from overseas.

One of the unstated goals of the conference seemed to be to get the two sides, breeders and advocates for change, to start a real discussion. In my opinion, the discussion was hampered from the start by the fact that the conference was not organized by breeders, and was by no means neutral ground. Representatives from the breeder camp were underrepresented, and seemed as well to have been selected to be not too controversial. Everyone was very civil, but I didn't feel like anyone’s mind was really changed.

That didn’t stop me from having two of the most enjoyable days I’ve spent in months or even years. About half of the speakers were veterinarians, and vets were very well represented at the conference overall, which surprised me. It has been my observation in veterinary school that veterinarians are as a general rule not greatly worked up by breeding practices — it’s part of the profession’s usual refusal to judge the husbandry decisions of an animal’s owner in public unless truly abusive. Apparently some vets are coming to see some breeding practices as crossing that line into abuse, and are interested in seeing change.

It shouldn’t need saying, but I will say it, just to be super clear: I have nothing against breeding purebred dogs in theory, and there are quite a few extremely responsible, ethical breeders out there — I met a lot of them at this conference. But there are breeders who do seem to be blind to the discomfort that breeding for extreme characteristics can cause dogs, and there are some breeds that I believe cannot be humanely bred under current practices, though could certainly be humanely bred with some conservative modifications to the breed standard (or to interpretations of it). I am not anti-breeder, but I am very much against certain breeding practices.

(To be continued.)

Wednesday, May 4, 2011

The case of the jaundiced terrier

It was 6:30 am on the last Saturday of my small animal medicine rotation. I had one patient in the hospital to care for that morning, but I was also scheduled to take pick-ups that day — taking on as new patients half of the animals who were transferred to the medicine department that morning from the emergency and critical care department. A rotation mate of mine would take the other half. The transfer list had two animals on it, and since I had gotten to it first, I could pick which I wanted. Feeling relatively bright-eyed and bushy-tailed after a slow week with not many cases, I chose the Boston terrier whose one-word problem (about all the transfer list has room for) was that she was “jaundiced.” Jaundice, or having yellow skin and mucus membranes, suggests a liver problem, as the liver is failing to process your yellow bile acids. I hadn’t had a liver patient yet, and figured it was a good chance to learn something new.

The Boston was in A ward, the ward for sick animals. (Healthy animals who are in for elective surgery and the like end up in B ward. Animals on the other end of the spectrum go into the intensive care unit.) I read her chart. She had come in to the ER the previous morning for lethargy, not eating, and not acting like herself. No blood work had come back from the lab yet. The ER had ultrasounded her abdomen and seen no free fluid in there, which suggested that any liver disease was not far advanced. They had heard a heart murmur, and she had looked yellow to them.

I did my own physical exam. Yellow: hmmm. Maybe I could see that her inner lips looked a little yellow. Maybe not. I chalked this up to my inexperience and wrote “mild jaundice” on the physical exam form. Heart murmur: hmmm. Maybe I could hear it, maybe not. It was a little hard to hear over the sound of her breathing. I thought I could hear some swish to her heart, though. Come to think of it, her breathing was awfully loud. Now, Boston terriers have very flat faces, which makes breathing difficult for them at the best of times. But looking at the depth of her breathing, I thought I saw “increased respiratory effort.” It isn’t something you’d necessarily expect in a liver patient, but I wrote it on the physical exam form with a question mark after it.

The resident on the case, Dr. Crow, took a look at the Boston next. “Did you appreciate jaundice?” he asked. I hemmed and hawed. “Maybe she’s a little jaundiced... I’m not sure,” he said. Oh. Um, good. “Did you actually hear her heart murmur, or just write it down because the ER heard it?” I said I sort of thought I heard it but it was difficult. He nodded. “I’m not really sure I hear it either,” he said. Emboldened, I asked about her respiratory effort. “Yes,” he said matter of factly, “that’s elevated respiratory effort.” I was unsure whether to feel good that I’d noticed, or bad that there had been any question in my mind.

We talked about why a dog with liver disease might have trouble breathing. Dr. Crow walked me through the idea that since the liver is involved in clotting, the dog might have thrown a blood clot into her lungs. We sent her off for x-rays of her lungs. While she was gone, her blood work came back: all of her liver enzymes were significantly elevated. This happens when the liver is so unhappy that it starts to leak enzymes, and when the bile backs up because the liver isn’t processing it properly.

When the Boston came back from radiology, Dr. Crow asked me, “So what do you think about her radiographs?” Her lungs looked terrible. She was having even more trouble breathing, so we put her in an oxygen cage. Dr. Crow called an emergency and clinical care faculty member over to talk through the case. The problems with her lungs were spread too far for him to still suspect one clot. We had submitted a request for clotting tests, but weren’t going to hear back for several hours, as it was a weekend. Dr. Crow and the faculty member decided to do a quick ultrasound of the Boston’s heart. Heart failure can also cause fluid to get into your lungs and make it hard to breathe.

We took the Boston out of her oxygen cage, put her on her side, and put the probe on her chest. And there it was: a big lump on her heart. “Well,” the faculty member said, “I think you just found her problem.” Cancer.

Dr. Crow suspected that the mass was a chemodectoma, a type of cancer to which Boston terriers are particularly prone. However, the cardiology service did a consult on her, and they thought it was more likely to be hemangiosarcoma, because of the speed with which it had appeared and because of its exact location on the heart. Hemangiosarcoma is a very bad diagnosis; animals don’t live very long even if it is excised, and it was going to be impossible to cut it off of this dog’s heart. It is not very responsive to chemotherapy, either.

I asked the cardiology faculty member why he thought the dog’s liver enzymes were elevated. We batted around some ideas, but in the end he shrugged: this was not the dog’s primary problem. And cancer, as the saying goes, can do anything it wants.

The Boston’s owner came in to visit her, and Dr. Crow explained the situation. He said that she was having trouble breathing because fluid (probably blood) from the mass had built up inside her pericardium, the sac around her heart. We could drain that fluid (do a pericardiocentesis) and send her home. If it was actually a chemodectoma, she might do well for a while. If it was hemangiosarcoma, she was likely to have some very serious issues in the next few days.

The owner, after a great deal of soul searching, elected to euthanize the dog. If she had chosen the pericardiocentesis, she would still have had to leave her dog in the hospital for at least 36 hours, to make sure that the pericardium did not fill right back up with blood. If she had then taken the dog home, she would have had to deal with the possibility that the dog would have had little to no time before something else bad happened. Few owners want to deal with the chance of their dog being unable to breathe, and having to rush back in to the hospital with a dog in the car that might go into respiratory arrest. I suspect I would have chosen the same thing.

I learned from this case, as I had from so many others during my medicine rotation, that the one-word summary of an animal’s problem can lead you down the wrong road. And yet every time I am drawn in by the easy answer. I suspect that learning to keep an open mind is part of learning to be a good clinician.

Tuesday, May 3, 2011

Small Animal Medicine rotation

I have just surfaced from the three weeks of my Small Animal Medicine rotation, in which I worked with Internal Medicine specialists. This is widely known as the most stressful of the core (required) rotations. I will sort of miss the reactions that I got when I ran into a classmate in the hallway and they asked conversationally, “So what are you on?” When I told them, I got a respectful “Ohhhh.”

I got up at 4 am. It takes me an hour and a half to get out of the house now that I have the high energy puppy to exercise in the mornings; I had to do this with a flashlight so that I could see the ball when she retrieved it. I arrived on campus around 6 am, just as the sun was coming up. Before 8 am, I had to do physical exams on all my patients, do their morning treatments, review their test results from the previous day, and write up my assessment of their status, my list of their problems from most to least important, and my plan for them for the day. This was a long process, but got faster as time went on. For the first few days, I was completely flummoxed by things like how to unhook a dog from its IV fluids so that I could take it outside to pee.

From 8-9 am we had topic rounds, in which a clinician would talk us through some topic — feline lower urinary tract disease, common vaccinations and parasites, kidney disease, and so on. After that, we rounded on our patients. I had to stand in front of the cage of each of my patients and try to sound intelligent about what was going on with them. Inevitably I ended up feeling like an idiot, but so did all my rotation mates, so I don’t think I did exceptionally badly.

After rounds, we did whatever our patients needed that day. They had x-rays, ultrasounds, cardiology consults, got scoped to see what sorts of things were up their noses or in their intestines, etc. I did not get to do as many procedures as I wanted, but I did get to perform an abdominocentesis: putting a needle in an abdomen to draw out all the fluid that was in there (and should not have been). I pulled out 800mL of fluid from that cat, and there seemed to be quite a bit left when I was done. These tended to be very sick animals, animals that got referred to our specialty hospital when general practice veterinarians didn’t feel comfortable handling the case (for lack of specialty training, or because they did not have 24-hour care facilities).

In the afternoons, we saw appointments. I did the initial physical exam and took the patient’s history, then put together my problem list and treatment plan, and reported to the veterinarian on the case. The vet then went in to see the animal, did their own physical, and told the owner what was actually going to happen (which sometimes had some overlap with my suggestions).

Several of my patients died — the ones that were diagnosed with large tumors. Several did very well — the chronic kidney disease patients who needed rehydration and supportive care. I was lucky not to lose a patient that I had cared for for longer than a day. I saw a surgery student crying in the hallway after her patient, who had been in the hospital for two weeks, arrested in the ICU and could not be brought back after ten minutes of resuscitation attempts.

I was often at the hospital until 6 pm (a 12 hour day). I had several 14 hour days, and one very memorable 8.5 hour day (on which there was much celebration). The hospital was slow during those weeks, so I did not have to experience the usual regular 15 hour days that most students deal with on this rotation. I only had 2-3 patients at a time; many students had to deal with many more than that.  I did work most weekend days, but had one day completely free (I slept for 12 hours) and another day in which I had to go in at 6 am, but discovered there were no patients for me, and got to go back home (and back to bed for 4 hours).

I am still tired today. I am now on a writing week, writing up some of my Master’s research to submit for publication. It is exceptionally pleasant to sit on my couch with the windows open and the spring air blowing in, writing. One of my rotation mates said to me dubiously, “A writing week... Um, you like that stuff, right?”

Yes. I like that stuff.