I figure that I will continue the theme from my prior post, and offer my veterinary perspective regarding another topic discussed in the book Better, by Atul Gawande. I would also like to mention that I am trying my hand at Twitter…so feel free to check out my updates at www.twitter.com/williamsburgvet. I am also occasionally posting photos on our facebook page. Anyway, enjoy the post…albeit a month late.
Casualties of War – Pages 51 - 69
The chapter entitled Casualties of War discusses the remarkable success that physicians have recently achieved in reducing the lethality of battle wounds over the past decade. Dr. Gawande notes that this has essentially occurred despite virtually no increase in technology from that which was available during the Persian Gulf War. The primary concept involved with the improved casualty results, centers around the Forward Surgical Team approach (FST’s). These small medical teams consist of just a handful of medical personnel that travel with the troops onto the battlefields. Basically, they carry tents with them that can become a shelter for a temporary hospital, as well as the basic supplies (sterile instruments, anesthesia, handheld lab machines, monitors, oxygen, blood products, etc.). They are without many of the instruments and diagnostics found in just about any hospital in the United States. So, even though these units, using only bare essentials, deal with the “worst of the worst” kinds of trauma, they still save a remarkable percentage of lives. The secret is that they focus on “damage control.” Their limited supplies, diagnostics, and time to deal with such devastating injuries only allows them to focus on avoiding death and minimizing injury, i.e. “damage control” - you stop/minimize hemorrhage, pack/clean open abdominal wounds, obtain an airway, etc. Once death has initially been avoided, and the patient is at least somewhat stable, they are transported to another facility with the equipment and expertise to pursue repair and treatment. This concept of “damage control” in a war zone had me thinking about some analogous situations in veterinary medicine.
Veterinarians do not always have the luxury to go past the “damage control” step. I personally feel it is our duty to do our very best to stabilize and give any critical patient that walks through our door a chance - a philosophy that I am proud to say was learned by watching my dad practice veterinary medicine. However, once we go through the initial steps - physical exam/CPR/injections/IV fluids/oxygen - there does come that point when you have to look reality in the face…and halt treatment. Medications, oxygen, time, etc. all cost quite a bit of money these days. Damage control for the veterinarian can cost hundreds of dollars. However, I feel like I have fulfilled my duty as a veterinarian by at least giving the patient a chance at recovery. The fact of the matter is that I have sent many “damage control” patients home that otherwise would not be alive.
Like humans in a war zone, there are unfortunately pets that deal with their own battlefields. This is sort of our veterinary version of Casualties of War. After reading this chapter, I started thinking about some of my past experiences performing “damage control” for these pets. While we were building Anderson’s Corner Animal Hospital, I worked three day shifts at one of the busiest veterinary emergency hospitals in the country, which allowed for experiencing some of the “worst of the worst” trauma cases. This is when my passion for emergency medicine began. This chapter has its graphic moments, going into detail about the types of trauma our soldier’s deal with on a daily basis, which got me to thinking about similar injuries that I have treated in pets. I will tell you this, nothing good happens when a bullet finds its way into flesh. So here again is the dilemma for the veterinarian. What do you do when presented with a dog with numerous deep lacerations, shot with a nail gun, having a bullet lodged in the chest, knife stuck in their eye, fractured back, etc.? I will tell you - even if this patient is trying to “eat you” (I guess this would be the critical, belligerent drunk in the human field) you say to yourself that this dog, cat, horse, etc. deserves a chance – and you then perform “damage control.” In our field, this may have to involve the difficult decision to euthanize if you feel there is no chance to stabilize the patient. However, if you feel they may have a chance after initial stabilization and treatment, you do what you can to get them through this initial insult/trauma. The body is built for survival, and you would be amazed with how pets can heal with minimal treatment. For the life threatening and/or debilitating injuries, you never know if some of our wonderful rescue groups or a good samaritan will be able to help… and this pet that is staring at you with a look of, “Why did you stop?” will be fortunate enough to get past “damage control.”
Monday, April 5, 2010
Sunday, February 7, 2010
On Fighting
It is a good problem being busy…but I think I can do better than one post per year. My New Year’s resolution is to produce at least one post a month…we will see.
I have been reading the book Better, by Atul Gawande. You would be hard pressed to find a better insight into the world of medicine, and the pursuit to achieve perfection in a profession where perfection is impossible….hence the phrase “practice medicine.” I have come across numerous similarities between the human and veterinary medical fields while reading this book. I will offer my “veterinary” perspective regarding some of the topics discussed in this book. Comments/Questions are always welcome.
On Fighting - Pages 154-165
This chapter goes into detail about an area of medicine that we deal with on a daily basis…albeit more on a subconscious level…that is to always fight for our patients. Although there are many different variables and differences between veterinary and human medicine, the fundamental drive to always fight is the same. Dr. Gawande goes into detail about a spectrum of medical cases, such as patients who have terminal illnesses, patients with unexpected surgical complications, having to deal with minor, but frustrating skin problems, etc. The underlying theme is that a patient deserves a doctor who is willing to fight and not give up. As veterinarians, this should be our approach for every patient, from pets with minor issues that keep returning, to the complicated “you’re the fourth vet I have seen in the past month,” cases. This is the more difficult approach, and may involve calling colleagues for advice, research in the office after you have seen your last patient for the day, looking up journal articles, etc. The easy approach is to say that you did your best, and let the doctor in the other town deal with it, or let the patient live out their “poor/grave prognosis” without giving them another thought. Medicine is not easy, and we owe it to our patients to do the best that we can to practice what at many times feels more like an art than a science.
This “fighting” theme also delves into one of the most complicated/grey areas of medicine…fighting to do more, but when is it too much? When is it time to stop the fight, and just let go? This is not something that is taught in veterinary school, but something that every veterinarian has to figure out on his or her own. In this chapter, Dr. Gawande discusses a situation involving letting a patient’s family know that it was ok to stop life support. The analogous situation in our profession involves euthanasia. I have done a fair amount of emergency work, and every shift seemed to have a pet that needed to be euthanized. Over the years, what I have found is that every situation is unique. What may be right for one family and their pet may not be right for another. In the end, you find that place where you do what is right for both the pet and the family. I am sure that most physicians never become “immune” to letting go of the fight, such as a veterinarian should never become “immune” to euthanizing a pet, no matter how many he or she has done. We are looked to for guidance when this decision is being considered. The right choice may be letting a patient go early in the process, prior to any major ill effects from a terminal disease, or it may involve that late night phone call letting a family know that their 16 year old furry family member has passed away while being hospitalized. I have found that as long as you do what is best for the patient and the family, you can be satisfied that you are practicing good medicine…and that you gave it the “right fight.”
I have been reading the book Better, by Atul Gawande. You would be hard pressed to find a better insight into the world of medicine, and the pursuit to achieve perfection in a profession where perfection is impossible….hence the phrase “practice medicine.” I have come across numerous similarities between the human and veterinary medical fields while reading this book. I will offer my “veterinary” perspective regarding some of the topics discussed in this book. Comments/Questions are always welcome.
On Fighting - Pages 154-165
This chapter goes into detail about an area of medicine that we deal with on a daily basis…albeit more on a subconscious level…that is to always fight for our patients. Although there are many different variables and differences between veterinary and human medicine, the fundamental drive to always fight is the same. Dr. Gawande goes into detail about a spectrum of medical cases, such as patients who have terminal illnesses, patients with unexpected surgical complications, having to deal with minor, but frustrating skin problems, etc. The underlying theme is that a patient deserves a doctor who is willing to fight and not give up. As veterinarians, this should be our approach for every patient, from pets with minor issues that keep returning, to the complicated “you’re the fourth vet I have seen in the past month,” cases. This is the more difficult approach, and may involve calling colleagues for advice, research in the office after you have seen your last patient for the day, looking up journal articles, etc. The easy approach is to say that you did your best, and let the doctor in the other town deal with it, or let the patient live out their “poor/grave prognosis” without giving them another thought. Medicine is not easy, and we owe it to our patients to do the best that we can to practice what at many times feels more like an art than a science.
This “fighting” theme also delves into one of the most complicated/grey areas of medicine…fighting to do more, but when is it too much? When is it time to stop the fight, and just let go? This is not something that is taught in veterinary school, but something that every veterinarian has to figure out on his or her own. In this chapter, Dr. Gawande discusses a situation involving letting a patient’s family know that it was ok to stop life support. The analogous situation in our profession involves euthanasia. I have done a fair amount of emergency work, and every shift seemed to have a pet that needed to be euthanized. Over the years, what I have found is that every situation is unique. What may be right for one family and their pet may not be right for another. In the end, you find that place where you do what is right for both the pet and the family. I am sure that most physicians never become “immune” to letting go of the fight, such as a veterinarian should never become “immune” to euthanizing a pet, no matter how many he or she has done. We are looked to for guidance when this decision is being considered. The right choice may be letting a patient go early in the process, prior to any major ill effects from a terminal disease, or it may involve that late night phone call letting a family know that their 16 year old furry family member has passed away while being hospitalized. I have found that as long as you do what is best for the patient and the family, you can be satisfied that you are practicing good medicine…and that you gave it the “right fight.”
Sunday, February 1, 2009
Antifreeze Toxicity
I gave a talk about antifreeze toxicity at William & Mary a while back. The consequences of any pet consuming this are so devastating that I would like to share some of my notes from this discussion. My focus with the discussion involved the clinical signs that your pet may show in the early stages of this process. The cascade of events that follow stage 1 cannot be reversed.
Ethylene Glycol Toxicity
Possible Sources:
Antifreeze, air conditioning coolants, brake fluid, wintering toilets, Portable goal posts (water is fixed with ethylene glycol), solar heating systems (heat exchange fluid), color processing fluids, brake fluid, etc.
Antifreeze is the most common source – It is a sweet and odorless fluid that is extremely toxic to cats and dogs. A lethal dose in a cat is only about 1.5ml/kg, and in dogs is about 5 ml/kg.
By itself it is not toxic. Only after it is metabolized by the body does it become toxic.
The liver metabolizes it, and ultimately produces metabolites such as aldehyde, glycolic acid, as well as calcium oxalate crystals that eventually lodge in the kidneys and contribute to kidney failure and death.
There are 3 stages…but the best chance for successful treatment is if the pet is seen in stage 1 of this disease. Having worked at an emergency hospital, the majority of these patients present in stages 2 or 3. Once this occurs, the chance of survival is substantially decreased.
Through early treatment, we can reverse this process, and minimize or avoid secondary kidney failure.
In my experience, the patients that end up going home are overwhelming the ones that were seen drinking the antifreeze or present during Stage 1 of the process.
Ethylene Glycol Toxicity
Possible Sources:
Antifreeze, air conditioning coolants, brake fluid, wintering toilets, Portable goal posts (water is fixed with ethylene glycol), solar heating systems (heat exchange fluid), color processing fluids, brake fluid, etc.
Antifreeze is the most common source – It is a sweet and odorless fluid that is extremely toxic to cats and dogs. A lethal dose in a cat is only about 1.5ml/kg, and in dogs is about 5 ml/kg.
By itself it is not toxic. Only after it is metabolized by the body does it become toxic.
The liver metabolizes it, and ultimately produces metabolites such as aldehyde, glycolic acid, as well as calcium oxalate crystals that eventually lodge in the kidneys and contribute to kidney failure and death.
- It is the clinical signs produced earlier in the process prior to kidney failure that are very important to be aware of since treatment can be successful at this stage.
- Stage 1 involves clinical signs primarily associated with the nervous system….very similar to what we would see with alcohol intoxication.
This stage can begin anywhere from 30 minutes to 12 hours after ingestion.
- Signs to look for are depression, wobbly gait, knuckling over, seizures, nausea, excessive drinking, etc. Some cats will present with elevation of their third eyelids.
There are 3 stages…but the best chance for successful treatment is if the pet is seen in stage 1 of this disease. Having worked at an emergency hospital, the majority of these patients present in stages 2 or 3. Once this occurs, the chance of survival is substantially decreased.
Through early treatment, we can reverse this process, and minimize or avoid secondary kidney failure.
In my experience, the patients that end up going home are overwhelming the ones that were seen drinking the antifreeze or present during Stage 1 of the process.
Wednesday, January 28, 2009
Senior Pet Care
When is a dog or cat considered to be a senior? This question has no specific black or white answer….but involves shades of grey…no pun intended. To be more specific, dogs are considered to be senior in the last 25% of their lives. Most toy and small breed dogs can live into their mid-teens, medium to large breeds can average early to mid-teens, and giant breeds tend to average 9-10 years of age. Let us use a beagle for example. The typical life-span of a beagle is 14-15 years. One of my two beagles is named “Jack,” and he will be 14 years old in April, so the points I mention below are from a personal perspective. Since Jack is a senior member of our family, I have thought about that day that I am dreading. I can’t imagine losing my best friend who helped me through undergraduate and veterinary school, strutted into my wedding reception to Elvis Presley’s “You Ain’t Nothin’ but a Hound Dog” and stood guard over my first child this past year. What you may find with some of these following points is that we humans share many similarities and requirements regarding maintaining a high quality of life during these Golden years.
It is a fact that older dogs and cats tend to have more medical problems. This can range from issues such as low or high thyroid levels, arthritis, heart murmurs, cataracts, and so on. Catching medical problems earlier in the disease process always gives us a better chance to treat and potentially cure or minimize the side effects. We therefore recommend evaluating and performing a thorough physical exam and history twice a year. As a general rule of thumb, one year of aging for a pet is like 7 years for us. We may also recommend periodic bloodwork or diagnostics to evaluate organ function or architecture that may not be detectable on the physical exam. Serious problems such as malignant skin tumors may be treatable if detected early. Although not usually a life threatening problem, something like an infected tooth can be dealt with and treated to help improve the pet’s quality of life. We may note some hip arthritis that may only need a joint supplement such as glucosamine that helps decrease pain and ultimately improve their quality of life. There is also a relationship between cost of treating a problem caught early versus one caught later. Expenses involved with catching and treating an ailment earlier rather than later are typically less. As you can see, it is not just the serious tumor or systemic disease that we may uncover, but the more minor problems that may be causing your pet discomfort. Our goal is to help these years be of the highest quality possible for your best friend and companion.
We all know that dogs, cats, humans, etc. experience noticeable changes during the aging process. For example, diminished hearing, eyesight, and activity level are usually fairly evident. Typically we don’t need worry about their nose losing its ability to smell…for good or bad. There really isn’t much you can do about hearing…unless there is an underlying ear infection. If you have two or more pets, a trick I taught my younger beagle was that in order to get back in the house, she needed to go round up Jack, so they could both come in. This helps avoid waking up the neighbors. You may also notice that there is a haziness quality to their eyes, and that your pet is taking longer getting around inside, etc. This is usually one of two things, nuclear sclerosis or cataracts, the former being more prevalent. Nuclear sclerosis is the same reason many humans need to wear bifocals. However, don’t count on doggy bifocals any time soon, so just be patient and realize that things are just not as visually clear for them anymore. Pets and people slow down as they age…there is no other way to say it. However, that does not mean that you or your pet need to become a couch potato. Regular exercise does wonders for your pet…not to mention you. However, I cannot stress enough that you need to go at your pet’s own pace. For example, a dog with severe arthritis may not do very well on an all day hike in the mountains. A 30 minute stroll through York River State Park or around the neighborhood may be more appropriate. Regular exercise helps every system in the body. However, in my opinion, the most important is mental status. Dogs and people alike can have degrees of dementia. Anything to help them stimulate their senses such as a walk through the park can only help. This also helps them maintain muscle mass to help support their joints, improves cardiovascular function, and so on. Grooming should also not be overlooked. This can be more of an issue in cats, causing hair mats, but many dogs also benefit from brushing their coat once every week or so. A good quality senior pet food also helps them get the appropriate nutrition and help maintain a healthy weight. I have found that many folks have a special bond with their pet when they may be dealing with a similar ailment…such as arthritis. Tackling these problems together and helping your pet maintain their health is good for your health too.
There is no secret regarding taking care of your senior pet. Spending time with him or her, putting that extra blanket on their bed, observing for any change in behavior, monitoring their appetite, periodically checking their weight, etc. are all things that help them maintain a high quality of life. Although a cliché, there is truth to not putting off until tomorrow what you "and your pet" can do today. It seems like it was only the other day that I took my 6 week old beagle named Jack home with me during summer break….
It is a fact that older dogs and cats tend to have more medical problems. This can range from issues such as low or high thyroid levels, arthritis, heart murmurs, cataracts, and so on. Catching medical problems earlier in the disease process always gives us a better chance to treat and potentially cure or minimize the side effects. We therefore recommend evaluating and performing a thorough physical exam and history twice a year. As a general rule of thumb, one year of aging for a pet is like 7 years for us. We may also recommend periodic bloodwork or diagnostics to evaluate organ function or architecture that may not be detectable on the physical exam. Serious problems such as malignant skin tumors may be treatable if detected early. Although not usually a life threatening problem, something like an infected tooth can be dealt with and treated to help improve the pet’s quality of life. We may note some hip arthritis that may only need a joint supplement such as glucosamine that helps decrease pain and ultimately improve their quality of life. There is also a relationship between cost of treating a problem caught early versus one caught later. Expenses involved with catching and treating an ailment earlier rather than later are typically less. As you can see, it is not just the serious tumor or systemic disease that we may uncover, but the more minor problems that may be causing your pet discomfort. Our goal is to help these years be of the highest quality possible for your best friend and companion.
We all know that dogs, cats, humans, etc. experience noticeable changes during the aging process. For example, diminished hearing, eyesight, and activity level are usually fairly evident. Typically we don’t need worry about their nose losing its ability to smell…for good or bad. There really isn’t much you can do about hearing…unless there is an underlying ear infection. If you have two or more pets, a trick I taught my younger beagle was that in order to get back in the house, she needed to go round up Jack, so they could both come in. This helps avoid waking up the neighbors. You may also notice that there is a haziness quality to their eyes, and that your pet is taking longer getting around inside, etc. This is usually one of two things, nuclear sclerosis or cataracts, the former being more prevalent. Nuclear sclerosis is the same reason many humans need to wear bifocals. However, don’t count on doggy bifocals any time soon, so just be patient and realize that things are just not as visually clear for them anymore. Pets and people slow down as they age…there is no other way to say it. However, that does not mean that you or your pet need to become a couch potato. Regular exercise does wonders for your pet…not to mention you. However, I cannot stress enough that you need to go at your pet’s own pace. For example, a dog with severe arthritis may not do very well on an all day hike in the mountains. A 30 minute stroll through York River State Park or around the neighborhood may be more appropriate. Regular exercise helps every system in the body. However, in my opinion, the most important is mental status. Dogs and people alike can have degrees of dementia. Anything to help them stimulate their senses such as a walk through the park can only help. This also helps them maintain muscle mass to help support their joints, improves cardiovascular function, and so on. Grooming should also not be overlooked. This can be more of an issue in cats, causing hair mats, but many dogs also benefit from brushing their coat once every week or so. A good quality senior pet food also helps them get the appropriate nutrition and help maintain a healthy weight. I have found that many folks have a special bond with their pet when they may be dealing with a similar ailment…such as arthritis. Tackling these problems together and helping your pet maintain their health is good for your health too.
There is no secret regarding taking care of your senior pet. Spending time with him or her, putting that extra blanket on their bed, observing for any change in behavior, monitoring their appetite, periodically checking their weight, etc. are all things that help them maintain a high quality of life. Although a cliché, there is truth to not putting off until tomorrow what you "and your pet" can do today. It seems like it was only the other day that I took my 6 week old beagle named Jack home with me during summer break….
Saturday, May 10, 2008
Finally...The Fun Part
Hello, and thanks for venturing over to my veterinary weblog. As you may already know, my dad and I are happy to finally see the light at the end of the tunnel regarding our brand new animal hospital. This has been quite an undertaking, but we both know that it is all going to be worth it in the end....which actually leads us both to a new beginning. Having our own animal hospital allows us to incorporate a team of people that share our attitudes and values towards practicing veterinary medicine and animal care. This "team" is Anderson's Corner Animal Hospital, and we cannot wait to begin doing what we do best....taking care of you and your pet....hence the "fun part."
This weblog will incorporate many veterinary related topics that I hope will be of interest to you. I hope it will be enjoyable reading, yet be informative regarding numerous veterinary related topics....and I may even tiptoe outside the realm of veterinary medicine. Most of my posts will involve current animal related issues in the news, share memorable experiences, offer answers to specific animal care questions I have been asked recently, etc. Thanks again for venturing over here, and please post comments at any time.
This weblog will incorporate many veterinary related topics that I hope will be of interest to you. I hope it will be enjoyable reading, yet be informative regarding numerous veterinary related topics....and I may even tiptoe outside the realm of veterinary medicine. Most of my posts will involve current animal related issues in the news, share memorable experiences, offer answers to specific animal care questions I have been asked recently, etc. Thanks again for venturing over here, and please post comments at any time.
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