Getting a second opinion in Vet Med

Getting a Second Opinion

What do you do when faced with a disheartening diagnosis or expensive treatment option in the vet office?  When ‘Fluffy’ is sick and you are told, “there is nothing that can be done”, “the only option is very expensive”, or “I’m not sure what we are dealing with”, what can you do?  What would you do if this was your child, mother, sister or self sitting there in the doctor’s office?

Well, hopefully you ask questions, absorb answers, and then…take a step back. 

Questions you should be asking yourself:  Is this the correct diagnosis?  Are there any other possibilities?  Could it be something else? Do other options exist?  What does the latest research say?  How knowledgeable is this general practitioner or family doctor about this particular disease or problem? 

Doctors and Vets are like everyone else.  No one knows it all.  Everyone is wrong sometimes.  In vet medicine, as in human medicine, there are ‘specialists’.  Doctors, who somewhere along the way in their training decided, “Dang, this is a lot of stuff to know and keep up on”.  And so, decided to focus on one discipline or another, and become proficient in that discipline, so that it is possible to know almost all there is to know about one thing, or at least to know more about that thing than most others.  One discipline is possible to keep up with…all the disciplines?  Not so much.

Should you get another opinion?  How do you get another opinion?  Will you offend your vet by getting another opinion?  Ask yourself this.  If your vet took their child to the doctor and was faced with the same scenario, might they also be considering seeking another opinion?  Of course they would.  And quite frankly, if your vet, or family doctor, has your best interest in mind, which they are paid to do, then they should encourage a second opinion if it is something you feel you need, or they are just not sure they have the best solution or answer.  Of course it is human nature to become ‘defensive’ when our opinions or recommendations are challenged.  A character flaw graciously passed along to us through generations of imperfect parenting…but get over it!  Both of you!  Don’t be afraid to ask for something you are entitled to.  And Dr. Herriot, don’t get defensive when asked.  If you are so certain you are right, you will be rewarded when your client returns to you thanking you for encouraging them to find ‘their truth’…which hopefully happens to also be what you told them to begin with.  I guess if you do absolutely know it all, then and only then do you have some right to be defensive.

I am a specialist, and in my discipline, I know that certain problems have multiple solutions.  Although that is frustrating it comes from the acknowledgement that some problems don’t have a perfect solution; one that works as expected 100% of the time.  When faced with such clinical problems, I try to educate my client as to the nature of the problem, solution options, my recommendations…and if you are not comfortable with that, here is the name of another fella who I think does a good job with this problem.  Ultimately I want my client to be comfortable with the solution offered, because I realize the costs, the risks, and most importantly, that this ‘dog’ or ‘cat’ is a family member to you, and sometimes more.

So here’s what I suggest you do, prioritized in this order:

1.     “Doc, I love you to pieces and respect what you are telling me, and am grateful for it, but this is a big and difficult decision for me, and I need to do my homework educating myself a bit more.  I am sure you understand where I am coming from.  Can you recommend a way for me to learn more about this before I make a decision?”

2.     Ask your Doc if there is a specialist in your region whom you might consult with for a problem like this.  Not necessarily someone you will rush off that moment to see…but someone to consider.  Do they exist in your region?  What are the pros and cons of going for a referral?

3.     The internet.  The number one search topic on the internet is questions of health, and there is an abundance of veterinary health related information out there. Some of the information is really bad, and some of it really good—it is not always easy to find or understand, and may not be applicable to your pet’s situation, but if you are patient and have time, you can educate yourself.  Please consider the source of the information you are reading.  Is the source credible? Is it opinion, or, backed with science?  Are they well organized studies? Are there biases?

4.     Ask a friend or family for referral to another general practice veterinarian in whom they have faith.

Remember:

-Visiting another vet for the same problem will cost money; they are seeing you for the first time. 

-Bring any applicable records with you to the new appointment.  Your vet should not be reluctant (and legally cannot withhold them) to provide you with those records if you have discussed getting another opinion with them in a respectful and courteous manner.

When it's NOT the neck: Other causes of quadriplegia in dogs

When it’s NOT the neck, and why this is important

Generalized Lower Motor Neuron (LMN) disorders are difficult to recognize, particularly in the earlier phases of the disease process. They are commonly mistaken for cervical myelopathies (neck problems).  When we see tetraparetic pets, our first thought tends to be ‘NECK’! But it’s not always the neck and recognizing this is important because the diagnostics, treatments and prognoses are very different.

Lower Motor Neuron:  Functional motor unit comprised of the motor neuron(s) within the CNS, the peripheral motor nerve(s) the motor neurons give rise to, the neuromuscular junction, and the muscle directly innervated by the nerve. We most commonly think of the lower motor neuron with reference to the limbs, but cranial nerves (motor) can also be an example of LMN.

Lower Motor Neuron dysfunction:  Dysfunction arises when ANY component of the motor unit is diseased—that could be the motor neuron itself (as in ALS in people), the peripheral motor nerve (as with Guillain-Barre syndrome and Coonhound paralysis), the neuromuscular junction (myasthenia gravis, Tick paralysis, botulism), or muscle itself (any form of primary acquired or congenital myopathy).  Clinically, this looks like weakness in the limbs, characterized by loss of muscle tone or mass and poor to absent myotactic reflexes—most obviously, poor or absent withdrawal strength (the patella reflex is often normal in early stages of many LMN disorders, disappearing only late in the problem).  The unexpected finding of a normal or even hyper patella reflex in early LMN disorders can be confusing. We’ve all been brainwashed to think that normal or increased patella reflexes always equates to an UPPER MOTOR NEURON problem…Not always! “Pseudohyperreflexia” in the patella reflex occurs when sciatic distribution muscles lack normal opposing tone; the patella reflex therefore appears exaggerated.  Poor or absent withdrawal strength in the limbs is the most common earliest indicator of LMN dysfunction. A cervical myelopathy will never cause poor withdrawal in the pelvic limbs.

Why is it important to differentiate cervical myelopathy from LMN disorders?

A few years ago, there was an article in one of the veterinary news magazines about a miraculous last minute diagnosis that saved a dog scheduled to be euthanized.  The dog was non-ambulatory tetraparetic and was being managed by ER staff in a Specialty/ER hospital.  The working diagnosis was cervical myelopathy, and the owners could not afford MRI and surgery (for suspected cervical IVDD)…they had decided upon euthanasia.  At the dramatic last minute, a tick was discovered on the dog, removed, and within 2 days the dog was up and around. While the doc managing the case was hailed as a hero, the irony is that simple clinical signs were overlooked; signs that should have immediately indicated to the doc that the problem was NOT in the neck.  A careful (even abbreviated) neurological exam would have revealed LMN signs (poor withdrawal x 4 is never a cervical myelopathy).  Additionally, many tick paralysis dogs do lose patella reflexes early…a dead giveaway—no pun intended. This scenario is common. Misdiagnosis can lead to costly unnecessary diagnosis and/or surgery. Misdiagnosis can lead to misguided euthanasia.

LMN disorders can be life threatening in severe cases, but most will have favorable prognosis, and treatment/management doesn’t have the big price tag of MRI and surgery.  Treatment is typically medical, or just nursing care and time.

Pure LMN disorders are relatively uncommon, which is why they are frequently missed. Here are examples of the most common LMN disorders seen in practice:

1.     Polyradiculoneuritis (coonhound paralysis):  Canine.  Immune mediated severe inflammation of the peripheral nerve root/nerve. Similar to Guillain-Barre syndrome in people. Signs typically begin in pelvic limbs and progress as an ‘ascending paralysis’. Pain sensation in limbs normal to hyper. Tail, bladder and rectum are normal. Diminished withdrawal strength in all limbs is the most obvious exam finding supporting this problem. Don’t be fooled by a ‘normal’ patella reflex. High protein in otherwise normal CSF supports diagnosis.  Clinical diagnosis most common, no definitive testing exists.  Severe cases can advance to respiratory paralysis and death. No proven specific treatments. Some academic institutions have experimented with immunoglobulin therapy, which is used in people, but no proven effective results exist in dogs. Good nursing care and PT will aid in functional recovery which can take weeks to months.

2.     Myasthenia Gravis:  More commonly recognized in dogs, but occurs in cats also. Immune mediated block at the level of the neuromuscular junction (Auto anti-acetylcholine antibody blocks Ach receptors).  Prognosis fair to good IF the condition is not associated with thymoma or other paraneoplastic condition. Weakness, dysphagia/regurgitation, megaesophagus, ventroflexion (cats) are the predominant signs. Key exam findings: exercise induced weakness, palpebral reflex that fatigues and may be lost with rapid repetition, megaesophagus in up to 90% of canine cases. Diagnosis supported by clinical response to IV Tensilon. Diagnosis made by detecting high levels of anti-acetylcholine receptor antibody in serum (send out to IDEXX or directly to the Comparative Neuromuscular lab at UC-San Diego). Treatment with pyridostigmine, sometimes alone, more often combined with prednisone and/or other immunomodulating drugs.  Treatment at least 6 months, often longer.

3.     Tick Paralysis: Neurotoxin liberated in saliva of dermacentor variabilis and dermacentor andersoni (among others) interferes with the release of acetylcholine at the neuromuscular junction, causing a flaccid ascending motor paralysis. Clinical signs are present when tick is attached and typically engorged, and begin to resolve within 48 hours of removal. Progression to full non-ambulatory tetraparesis/plegia is rapid, often within 12-72 hours of onset of signs. No specific diagnostic testing is available. I will often treat a suspect dog with ‘tick-o-cide’ even if I can’t find a tick (ie-malamute). Again, poor withdrawal x 4 is the hallmark exam finding—patella reflexes often gone also in tick paralysis dogs in my experience.

4.     Botulism:  Block at the neuromuscular junction from block of ACH release.  Intoxication results most commonly from ingestion of toxin in uncooked spoiled meats, less commonly from liberation of toxin from colonizing C. botulinum in the GI tract or liver. Similar in presentation to Tick and Coonhound paralysis, onset of signs are rapidly progressive.  Unlike Tick or Coonhound paralysis, cranial nerves may be frequently affected.  Autonomic effects may also be seen (pupillary abnormalities, urinary retention, constipation for example). Treatment is supportive.  Antitoxin can be considered in acute cases, but will not ‘unbind’ toxin once it has been bound. Gastrointestinal lavage considered if contaminating contents still present.

5.     Ischemic Neuromyopathy:  Embolism of arterial supply chokes nerves and muscle of its blood/oxygen supply creating LMN paresis/paralysis. More common in cats secondary to cardiac disease. Less common in dogs, this is usually secondary to protein losing nephropathies, advanced Cushing’s, paraneoplastic, idiopathic…generally in that order of likelihood. Flaccid paresis, loss of withdrawal strength and absent patella reflexes are common findings. *this one is just one to remember, as pelvic limbs or single limbs are most often effected, so its not really one that is mistaken for cervical myelopathy.

Stroke in Pets

Stroke:  Cerebrovascular Accident (CVA) in Pets

It was once believed that strokes did not occur in animals. However, the increased availability of advanced diagnostics, like MRI, have shown that pets, like people, experience strokes. Similarly, strokes tend to occur when pets are middle-aged and older. They also tend to strike suddenly and without warning, though symptoms usually don’t last for more than 24 hours before stabilizing or improving.  Strokes, also called cerebrovascular accidents (CVA), come in two varieties; ischemic and hemorrhagic.  Ischemic stroke is obstruction of blood vessel that leads to failure of blood flow to normal brain tissue.  Hemorrhagic stroke is failure of blood flow to normal tissue due to hemorrhage, and is often due to hypertension in pets.

Clinical Signs of Stroke

The signs of a stroke depend on which part of the brain is affected by the stroke. A pet may be having a stroke if you observe a very sudden onset of any of these signs:

• Disorientation • Wobbliness • Pacing or circling • Tremors • Weakness (often unilateral) • Blindness • Seizures • Head tilt • Rapid eye movement

The cerebellum seems particularly prone to stroke in dogs and cats and results in ‘cerebellar’ and/or vestibular signs. These cases are often mistaken as idiopathic or geriatric vestibular syndrome. This is why a complete diagnostic work-up, including an MRI should be considered for all older dogs that have an acute onset of vestibular signs.

Diagnosing Stroke

The only way to determine if your pet had a stroke is with an MRI. An MRI provides detailed images of the brain that x-ray or CT-scan cannot. A spinal tap may also be needed to rule out any type of inflammatory brain disease. Glial cell brain tumors, inflammatory conditions and stroke can sometimes be difficult to differentiate from one another, even with detailed MRI. Once stroke has been determined, additional tests are often recommended to check for diseases that can potentially cause a stroke. Additional tests might include chest and abdominal x-rays, abdominal ultrasound, blood tests (coagulation profile, endocrine testing) echocardiogram.

Causes and Prevention of Stroke

Unlike people, arterial disease like atherosclerosis is uncommon in pets (possible exception being with chronic hypothyroidism). Common predisposing causes include high blood pressure, heart disease (bacterial endocarditis in particular), metabolic disease, Cushing’s disease, clotting abnormalities in the blood, adrenal tumors (pheochromocytoma), cancer, protein-losing kidney disease (common). Early detection and treatment of these diseases may help prevent a stroke. Pets should have routine examinations and general health screenings. Regular blood work, ECG, blood pressure checks and thyroid testing can help identify a number of health issues. In older cats, blood pressure monitoring is especially important due to increased incidence of high blood pressure secondary to conditions like chronic kidney disease and hyperthyroidism.

What to do when stroke is suspected

1.     Check blood pressure (and in cats, check retinas for hemorrhage or detachment)

2.     Check blood pressure

3.     Check blood pressure (not a typo)

4.     Routine CBC, serum chemistry with T4, urinalysis and UPC if indicated.

5.     Send for Neurology consultation and MRI to confirm stroke and rule out brain tumor

6.     Consider Chest rads, echo, and abdominal ultrasound if stroke confirmed or suspected on MRI

Prognosis

In general, the prognosis for dogs and cats is better than for people who have experienced a stroke. This is mainly because dogs and cats can still function despite serious brain injury—no requirement for higher math, fine motor skills, or witty conversation. Still, pets that have had a stroke need time to recover, good nursing care and physical therapy. Additional therapies should be aimed at managing underlying diseases that have been identified. Of course how well a pet responds to treatment depends on the size and location of the stroke—like people. Most dogs and cats that are going to recover show significant improvement within 7 to 10 days.

Recognition of Stroke is important!  Signs of stroke can easily be mistaken for sign of brain tumors.  Stroke carries a much better prognosis than brain tumors!  Don’t mistakenly make a clinical diagnosis of ‘brain tumor’ and miss stroke, which will resolve on its own and be unlikely to recur if the underlying condition is identified and managed.

Some of the content of this article borrowed with permission from Animal Neurology Insights, a publication by The Animal Neurology and MRI Center, Commerce, MI, Dr. Michael Wolf

Medical marijuana products for pets? What are the realities?

Marijuana in Vet Med:  Responding to requests

I am not 100% sure what the right or wrong way to approach this is, but the requests come often.  Maybe to me in particular because of the reports of benefit with epilepsy in people and children. So here is what I’ve researched and here is a quick summary of some legitimate points:

·      It is illegal in the state of Colorado for a veterinarian to prescribe marijuana for animal use. I believe it is illegal in all states still.

·      The active pharmacologic ingredients of marijuana are Δ-9 tetrahydrocannabinol (THC) and Canabidiol (CBD); the pharmacokinetics of these products in animals is incompletely understood.

·      THC has psychoactive effects, CBD does not.

·      In people, cannabis has been used to treat glaucoma, nausea, and vomiting (often chemotherapy related), anxiety, spasticity, peripheral painful neuropathy, and epilepsy. Nabiximols (Sativex®) is derived from plant extract, contains an equal THC:CBD and is approved for use in spasticity associated with multiple sclerosis. Nabilone (Cesamet®) and dronabinol (Marinol®) are synthetic THC compounds approved for use in the US for chemotherapy induced nausea and vomiting.

·      Limited pharmacologic data in dogs suggest low bioavailability of CBD after oral administration due to high first pass effect in the liver.  In one study there was no detectable CBD in the serum of 3/6 dogs administered 180 mg orally

·      CBD is a strong inhibitor of the cytochrome P450s, and may thereby alter the metabolism of other liver metabolized drugs (Phenobarbital, Zonisamide, felbamate, etc). 

·      As of 2015, no scientific studies on the benefit of CBD in spontaneous or induced seizures in dogs was found.

·      Anecdotal claims of benefit from CBD products for seizures in people/children abound

·      There do exist some scientific studies that support the benefit of CBD for people with seizures, and some of the above mentioned applications

·      “A report published Thursday (this past week!) by the National Academies of Sciences, Engineering and Medicine analyzed more than 10,000 studies to see what could conclusively be said about the health effects of all this marijuana. And despite the drug's increasing popularity — a recent survey suggests about 22 million American adults have used the drug in the last month — conclusive evidence about its positive and negative medical effects is hard to come by, the researchers say.”

·      There also exist scientific studies in people and dogs demonstrating that administration of marijuana products (THC in particular) can cause an increase in seizure activity

·      Since increased availability of legal forms of marijuana in Colorado, there has been a 4-fold increase in reported marijuana intoxication in animals

References:

-Michael Podell (ACVIM-Neurology), Abstract from the 2015 ACVIM forum

-CVMA position statement on the topic of marijuana use in animals:

http://colovma.org/wp-content/uploads/sites/8/2017/01/CVMA-Position-Statement-on-Marijuana.pdf

-Petepilepsy.com (website developed and run by ACVIM-Neurologist, also responsible for the content)

The role of genetic testing for specific disease: 2 Case studies

The Emerging role of Genetic testing:  Two recent case studies

Case #1:  Degenerative Myelopathy

A couple of years ago while I was working at the CSU VTH as clinical neurologist, a second opinion case came my way.  This was a 10 yr old Corgi diagnosed here in Grand Junction with a slowly progressive T3-L3 myelopathy (clinical localization) rendering the dog unable to walk—not paralyzed, but a non-ambulatory paraparesis as we say.  The owner told me the dog had spinal MRI and spinal surgery, but was no better, in fact still getting worse…was there anything she still might be able to do for her dog? I reviewed the records and the MRI and was puzzled at the management of the case.  The records clearly stated that the dog had a “T3-L3 myelopathy”, but only had MRI of the lumbar spine, leaving a whole section of spinal cord that could have been affected, unexamined—mistake #1.  The MRI did reveal a mild type II disk bulge at L5-6 and the dog had decompressive surgery at that site.  But signs consistent with T3-L3 myelopathy cannot be caused by a disk at L5-6…not to mention that this disk herniation was not severe enough to cause significant clinical signs.  The L5-L6 disk bulge was not causing the dog’s signs, but had been operated nonetheless—mistake #2. And this was a Corgi!  A breed commonly affected by Degenerative Myelopathy!  And a breed for which the disease has been linked to a genetic mutation that could be tested for; for about $65. This had not been done—mistake #3.

Contrast this case to a very similar case I saw last month.  Princess is an 8.5 yr German Shepherd dog with slowly progressive pelvic ataxia and paraparesis with CP deficits both pelvic limbs.  Her neuro exam suggests a T3-L3 myelopathy.  MRI of her entire thoracolumbar spine identified moderate disk herniations causing spinal cord deviation and mild to moderate and chronic appearing cord compression at T12-13 and T13-L1, and a very large disk herniation at L7-S1.  Although the L-S disk herniation was most severe, it is least likely to be contributing to her pelvic ataxia (T3-L3 signs).  Princess is also a breed commonly affected with Degenerative myelopathy (DM).  Is Princess’ progressive pelvic ataxia due to the disk problems at T12-L1 or does she have degenerative myelopathy?  Will surgery at T12-L1 help Princess or represent unnecessary cost, risk and morbidity?  Without biopsy of the spinal cord (not possible), there is no way to definitively know.  Here is what we did. 

First we submitted a sample for genetic testing to see if Princess carried the gene mutations linked to DM; this would take about 2 weeks.  In that time I put her on a tapering course of prednisone.  Most dogs with compressive myelopathy, regardless of cause (tumor, disk, other), will typically show significant clinical improvement on prednisone.  Of course this evaluation is somewhat flawed as it is highly subjective, but the temporally linked improvement is often obvious.  Princess did not have obvious improvement in her rear limb function.  Her DM genetic test identified her as a homozygous carrier of two copies of the gene mutation; she was likely to be affected or become affected by DM in her lifetime.

So although I cannot say definitively that she has DM, her neuro exam, failure to improve on prednisone and her genetic test results make this conclusion highly probable.  More importantly, spinal surgery at the thoracolumbar sites will probably NOT help her and would subject her to significant risk of getting worse.

To do surgery (or not) at LS is a different question. It may alleviate low back discomfort and may preserve or restore some lower motor neuron mediated strength in her legs, improving her QUALITY of life, but is unlikely to help her pelvic ataxia. 

Genetic testing for DM, although imperfect, has an important role in case management.  It’s affordable and easy to do.

Case #2:  Centronuclear Myopathy of Labradors

Griz, a 6-month M Labrador retriever was also a case I saw last month.  Griz’s complaints included a stiff and stilted bunny-hopping gait, abnormal fatigue with activity, hunching of the lumbar spine and difficulty putting on weight.  His routine lab work was unremarkable including a normal serum CK.  Despite the stiff gait and hunching lumbar spine, Griz’s neuro exam suggested a peripheral neuromuscular problem (diminished generalized muscle mass, diminished patella and withdrawal reflexes, and normal proprioceptive responses).  Griz was acquired from a breeder in Texas (a veterinarian in fact).  There were no such abnormalities in the pedigree and no effected littermates from Griz’s litter.

Neuropathy and Myopathy are generally uncommon, and commonly missed conditions due to relative rarity.  Differentials in a young dog with signs of neuromuscular disease include inherited disease, infectious inflammatory like Toxoplasma and neospora, toxins (rare), CNS storage disease and other conditions mimicking neuromyopathic disease like myasthenia gravis and polyarthritis.  A diagnostic workup for a case like this can be extensive and expensive, including joint fluid analysis, serologic testing, organic acid assays, electrodiagnostics and nerve and muscle biopsy.  All of this was discussed with owner who was committed to finding an answer if possible.  Normal serum CK made a category of inherited myopathies similar to human muscular dystrophy unlikely (they are typically associated with very high serum CK levels).  The referring veterinarian had already ordered and run the genetic test for Exercise induced collapse in Labs and it was negative for the mutation.  Centronuclear myopathy of labs is another inherited myopathy resulting from genetic mutation and a test has been developed to detect the mutation if present.  A simple cheek swab kit for about $65 ordered and performed by the owner confirmed the condition; Griz had two pairs of the mutated gene associated with the condition. 

The test kit allowed us to make a specific diagnosis and spared Griz and the owner a long, invasive and often unfruitful (non specific) series of tests.  Not a good outcome, but easily and inexpensively discovered.  Dogs can live a long life with Centronuclear myopathy although they are handicapped and prone to life-threatening complications like megaesophagus and aspiration pneumonia.  The owners had bought Griz as a hunting dog prospect, so they have re-homed him with a relative who will love him and understands his handicap.  Additionally, Griz’s owners have contacted owners of Griz’s littermates as well as the breeder and informed them that their dogs may be carriers of the mutation and should be tested if breeding is to be considered. Hopefully this will put an end to this disease in this line of dogs.

What to do with the acutely paralyzed dog? The 48 hour rule: Is it a myth?

What to do with the acutely paralyzed dog?

The 48 hour rule:  Is it a myth?

My article summary conclusions and recommendations (in case no time to read the whole article):

·      Published in JAVMA February of this year, Jeffery et. al. have helped to dispel the dogma that ability to regain ambulation in acutely paralyzed deep pain negative dogs is related to time to surgery.  In this prospective cohort study looking at 78 acutely paralyzed deep pain negative dogs, all of which had advanced imaging and surgery for IVDH, time between onset of signs and surgery was NOT linked to prognosis.  “In this group of dogs with IVDH (intervertebral disk herniation), immediacy of surgical treatment had no apparent association with outcome.  The prognosis for recovery may instead be strongly influenced by the precise nature of the initiating injury”.   These dogs are more likely to experience contusion, edema and hemorrhage of the spinal cord as a result of high velocity IVDH, and may or may not have significant cord compression.  Link to article abstract here:   http://avmajournals.avma.org/doi/abs/10.2460/javma.248.4.386

·      The article strongly suggests that acutely paralyzed deep pain negative dogs MAY NOT need to be rushed to surgery as soon as possible to improve prognosis; prognosis for recovery will be in the 50% range in nearly all of these cases.  About 10% of these dogs may be at risk for ascending/descending myelomalacia which is often fatal.

·      Dogs experiencing rapidly progressive (2 weeks or less) paresis>>>paralysis DO have surgical urgency.  These dogs tend to have severe spinal cord compression from IVDH, and their prognosis for full or near full recovery with spinal cord decompression is 90%+.  That prognosis falls off the longer surgery is delayed.

·      Dogs with both moderate and severe neurological deficits need MRI to help define both the reversibility of the condition and the need for surgery or not

·      …for explanations, keep reading.

The study.  Published in JAVMA February of this year, Jeffery et. al. have helped to dispel the dogma that ability to regain ambulation in acutely paralyzed deep pain negative dogs is related to time to surgery.  In this prospective cohort study looking at 78 acutely paralyzed deep pain negative dogs all of whom had advanced imaging and surgery for IVDH, time to surgery (even if delayed beyond 48 hours) did not effect prognosis in a statistically significant way.  “In this group of dogs with IVDH (intervertebral disk herniation), immediacy of surgical treatment had no apparent association with outcome.  The prognosis for recovery may instead be strongly influenced by the precise nature of the initiating injury”.  

For as long as I can remember, the rule was that an acutely paralyzed dog (presumably due to IVDD) needed to have surgery within 48 hours of paralysis…or else!  The world would implode, the sun would begin rotating backwards…this is a real emergency folks and this dog needs surgery NOW!  Such WAS the rule.

Intuitively, the storyline is easy to buy into.  Presumably a disk has herniated.  Presumably, the disk is exerting pressure on the spinal cord.  Presumably removing that pressure from the spinal cord will give the dog the best chance of recovery…the sooner the better. But where did the 48 hour rule come from?  Where is the data to support the rule? In large part from experimental data using laboratory animals.

Early in my career, like everyone else, I bought into the rule.  Over time I realized there was a problem with it.  Many acutely paralyzed dogs recovered with delayed surgery or even without surgery!  Many dogs with timely surgery (often at midnight) never recovered the ability to walk.  Which dogs would walk again and which would not seemed a random event. Senior neurologists I spoke with shared these experiences and sentiments. Something about the rule did not make sense.  But because the rule existed as the ‘gold standard’, we followed along…skeptically. 

Experientially, if a dog became acutely paralyzed without deep pain sensation in its toes, it had only a 50% chance of ever walking again whether it had spinal decompressive surgery in the first 48 hours or not.  The advent and common use ofMRI in vet med began to offer clues.  We could see the damage to the spinal cord from acute IVDH (intervertebral disk herniation). We saw significant spinal cord edema, swelling and hemorrhage, but often very little active compression.  In 2 cases that I have personally seen, and in one published case report, herniated disk fragment actually penetrated the meninges and spinal cord. This speaks to the force and velocity with which nucleus pulposus can herniate.  It also helps to explain the impact component in acute disk rupture.  It’s this impact injury that probably dictates the reversibility of the spinal cord injury in these acute injury cases, and to a lesser extent, the degree of spinal cord compression, although both certainly play a role.  There is no doubt in my mind that relieving even moderate compression sets the stage for optimal cord recovery.  But the impact event is likely to be the more important determinant of injury reversibility.

And then there was another experiential observation.  In acute, higher velocity disk herniations causing acute paralysis, the herniated nucleus pulposus (jelly center of the disk) tends to be more liquid, lower viscosity, and therefore less compressive after it ruptures into the spinal canal.  In contrast, very mineralized high viscosity nucleus(like toothpaste or cream cheese consistency) tends to herniate with lower velocity but be more compressive; causing more slowly progressive signs in the dog.  Semi-liquid low viscosity nucleus>>>high velocity herniation, greater impact>>>acute severe signs.  Mineralized high viscosity nucleus>>>low velocity herniation, less impact but greater compression>>>slowly progressive signs.  To illustrate:  If you apply the same amount of pressure to a tube of toothpaste and a tube filled with water, then pop the top, which material will erupt with greater velocity?  Greater velocity means greater impact and generally, less compression.  Slower velocity means less impact, but generally, greater compression.  The latter is more reversible and carries better prognosis. The spinal cord is compressed, but not traumatically injured, and therefore the reversibility is increased…when compression is relieved.

Ahhhh.  Deep sigh of relief from me, as I’ve been telling people for years, as a point of argument, that of all the subsets of IVDD patients, the acute paralyzed deep pain negative dog MAY be the WORST candidate for spinal surgery…an argument against the widely held belief that spinal surgery should be reserved for that subset of patients alone.  A $3500-7000 (sometimes more) investment with only a 50-60% chance of recovery is not the return on investment owners are after, particularly when most other spinal surgery patient subsets have 90% or greater recovery rates. 

The moral of the story?  The surgical option for IVDD patients should not be reserved for ONLY those most severely affected…the acute paralyzed deep pain negative subset in particular.  Spinal surgery is more effective for other subsets of IVDD dogs; those with chronic signs, those with recurrent signs, those with moderate deficits, and most importantly, those whose signs are progressive (the more rapidly progressive the more urgency for surgery NOW). 

For the acute paralyzed deep pain negative dog, the conversation about surgical success or failure is more important than rushing the dog off to surgery, and understanding why is necessary to intelligently have that conversation.

The 48 hour window….pffff!  NO need to rush off to CSU or elsewhere if I’m not immediately available, and no need to call me in the middle of the night (although that is OK too).

What would I do if it was my dog?

“What would you do Doc?”

Dr. Peter Maguire

DVM, MS, Diplomate ACVIM-Neurology

“What would you do if it was your dog?”  I get that question a lot.  And unless I’m on an airplane, or talking to a relative, it’s not just a question of when to spay, or what vaccines to give, or how to best house break.   Usually they are questions regarding Magnetic Resonance Imaging (MRI), surgery or radiation therapy for the spine or brain. Not just what are they, how much do they cost, but should I pursue these things for my pet or not.  They are issues that involve significant expense, risk, and ultimately the quality of life or death of a pet, a family member and a friend.  The questions of what to do are posed in the face of life threatening illness, and perhaps more importantly, quality of life threatening illness.  You’ll be shocked to realize, there is never a ‘right’ answer, a clearly correct decision or path to follow.  The decisions would be easily made in that case. With just one glaringly obvious path for which the benefits clearly outweighed the risks and the costs, decision-making would be easy.  It’s rarely easy.

The problems in pets for which my services are sought include spinal problems causing paralysis, weakness, wobbliness and/or pain.  Brain issues causing vertigo (vestibular dysfunction), seizures, disorientation, coma.  These are big problems, difficult to definitively diagnose without the help of expensive tests like MRI, CT scan and myelography (precision injection of contrast around the spinal cord enabling its visualization on plain x-rays).  Treatment options for these problems are sometimes medical, but are often surgical (like spinal surgery for “slipped disks”).   For cancerous tumors of the spine or brain, sometimes radiation therapy is the only optimal treatment alternative.  So the combination of serious quality of life threatening or life threatening problems, expensive diagnostics and high risk costly treatment options begs the question....”what would you do?”   A question born in the throes of emotion and indecision.

Tucker was my dog.  A tail thumping, stuffed animal nursing, easy going, lover of all things in general, and food in particular, Chocolate Lab; a sage in a dog’s body.  He was my companion, friend and mirror for almost 14 years.  He went through Vet school, internship and Neurology residency with me.  We spent time living in 5 different states and twice as many homes---one of which was a tent for the entirety of two different summers (Colorado and Alaska).  He went everywhere with me, and knew me better than I knew myself at times.  At the age of 12, he fell over in the yard one day, literally rolling and could not right himself.   The event lasted less than a minute, and then it was over; no ongoing signs.  The problem was clearly (to me) a vestibular event (vertigo), but unusual in that it was so short and seemingly completely self-limiting.  I waited and watched; concerned, but no alarms going off just yet.  A month and 2 more events later I took Tucker for an MRI of his head. 

Why?--”What would you do if it was your dog?”  His signs told me he was having intermittent vertigo.  Vertigo is common in dogs and cats and there are a variety of causes, some serious, some completely self-limiting without intervention.  The intermittent, yet persistent nature of Tucker’s vertigo was atypical.  I chose to do MRI because I needed as much information as possible with which to make subsequent decisions.  I needed to ‘know’, rather than guess. 

I had decided that if he had a brain tumor, I was unlikely to pursue radiation therapy, but I needed to know, and a brain tumor was not the only possible explanation of his signs, no matter what statistics told me. 

The MRI showed a rare primary tumor (cancer) of his skull, not his brain!    It was growing into the back of his brain, not outward where I might have seen or felt it.  The pressure on part of the ‘balance center’ of his brain was causing his signs. The options were to do nothing (just give medications to help him maintain some quality of life living with this growing cancer), put him to sleep, or surgery; at that stage, his balance was so often bad, that his quality of life was not good.  Surgical removal amounted to removing the back of his skull, from which this tumor was growing.  It would be high risk and it would not cure him.  The goal would be to restore his quality of life for as much time as possible. 

When his quality of life deteriorated, I decided on surgery.  It was either that, or put him to sleep.  I contacted the very best at UC-Davis and at Colorado State’s Vet school, but ultimately decided to do the surgery myself.  I wanted Tucker’s fate to be in my own hands.  I decided that I would have regretted it any other way if he did not live through surgery; an accepted and very real risk.  I would be prepared to euthanize him on the surgery table if I did not think he could recover to a good quality of life.  He was at a point where he could no longer function.

I had one more great year with Tucker.  Surgery had gone well, although from that time on he always had a bit of a surprised look on his face---so much tissue removal from the back of his head and my less than optimal plastic surgery skills left him with a bit of a face-lift.  What the heck, the tail was thumping again.  The extra time was invaluable to me.  He was happy, and I had another year to help prepare me for the inevitable goodbye.  It was a good decision.

For me personally, “what would you do if it was your dog” is a fair question to ask your vet.  Many people seem to ask it sheepishly, reluctantly.  As if they are asking for something they are not entitled to.  It is a simple question...what would I do...I welcome the question, and I give an honest answer.  I also make it clear that circumstances are always different (usually there is very little or no cost when treating my dog---big difference). 

There are more variables than you can imagine which influence a person’s course of action for their pet.  This is one of the biggest challenges I face daily in my exam room.  The medicine is not hard.  Although far from perfect, and constantly changing, the medical choices are finite, the algorithm not hard to follow.  The decision making, which path to choose, that is the hard part.  There is so much medicine we still don’t understand, so many questions for which my answer is “I don’t know”--I also know, no one else knows either.  An owner stated it simply for me once...”I always envisioned medicine as a science, but its really much more an art”. What I would do if it was my dog, may not really have relevance, but it is a fair question, and I give an honest answer.  If it helps with your difficult decisions, then its purpose is served.

The Art of Medicine

The Art of Medicine

Dr. Peter Maguire DVM, MS

Board Certified Vet Specialist Neurology/Neurosurgery

When I published my first website introducing my small independent neurology practice, I included a section entitled “Testimonials”; a collection of snippets from cards and messages I have received from pet owners over the years.  Some of these messages were from pet owners whose pets had died or were euthanized while in my care.  When my father first visited the website and read through the testimonials, he emailed me with some advice.  “Maybe you shouldn’t include the notes from people whose pets didn’t make it”…as if death or euthanasia represented some medical failing on my part.  Maybe he was joking.  It wasn’t clear to me if he was kidding, or it was constructive criticism. 

In retrospect, some of my closest and most memorable Veterinarian-Client relationships have developed from, as my father might view it, the ‘failings’.  Even when I’ve done everything by the book, followed all the medical algorithms to a ‘T’, instituted the latest and greatest treatments; sometimes I still fail. Death happens.   It’s as much a part of medicine as diagnosis and treatment.  I had 8 years of formal veterinary training.  I’ve given educational lectures, read countless scientific articles and textbook chapters from both veterinary and human medicine and published my own research.  Early on I believed medicine was a compilation of logic and hard scientific fact, and eventually one could know it all…I just needed to keep reading and cramming it in.  I believe now that medicine is as much, perhaps more, an art, as it is a science.  There is so much more that we don’t know, than we do.  Often, what we believe to be hard truth today, is turned upside down tomorrow; medical ‘fact’ changes.  It advances and withdraws like the tides.  We do our best…I believe that…but we don’t know it all and probably never will.  My “medical expertise” is honed with a combination of knowledge, unbiased research (hopefully), wisdom from experience, and compassion.

Sometimes all the current medical tools and knowledge available to me are still not enough, and as a health care provider I fail to save the patient.  I’ve learned that alone does not define the outcome.  When I am compassionate.  When I demonstrate sincere care.  When I support someone through the loss of their beloved pet.  When I have tried my hardest on their behalf….that is medicine too.  And sometimes for that, I receive the greatest gratitude.

Cervical Spinal Problems in Dogs: A pain in the neck

Dr. Peter Maguire DVM, MS

Board certified Vet specialist Neurology/Neurosurgery

Most experienced veterinarians will agree that when a dog has neck pain from intervertebral disk problems (‘disk disease’ ), one of three scenarios follow:

1.     The medically managed dog will often get better with time, rest, and symptomatic medications (often a combination of anti-inflammatories, pain medications and sometimes muscle relaxants).  In fact, we know that ~40% of dogs who are experiencing neck pain for the first time from a “slipped or bulging disk”, will get better with medical management.  35% of these dogs will have painful recurrent episodes at some point in the future; subsequent episodes are typically worse.  ~20% of medically managed dogs will fail to respond necessitating surgery or euthanasia for intractable pain or neurological deterioration.

2.     Some dogs will have surgery to ‘repair’ the disk problem and will make a speedy complete recovery (99% of the time in one study!).  These dogs will return to normal or near normal, often within a few days of surgery, and only have a 10% or less chance of recurrent signs in the future.

3.     Some dogs will have surgery to ‘repair’ the disk problem, but have a protracted and incomplete recovery.  Sometimes they are worse after surgery, and often the signs recur…the surgery did not seem to really help, or made things worse.

Why these different scenarios for the same problem…‘disk disease’?  And more importantly, how can your predict which scenario will apply to your dog should they suffer from neck pain?

As to why scenarios differ with the same problem (disk disease), the answer is straight- forward…NOT ALL DISK DISEASE IS THE SAME.  We use catchall phrases like ‘bulged, ruptured, prolapsed, herniated disk’, but they are not all the same.  A “bulging” disk is not the same as a “ruptured” disk.  Moreover, the location of the disk problem in the neck can be critically important in determining which of the three scenarios will follow.  In some cases, the most severely effected dogs, those that seem likely to have a poorer prognosis, actually have the best prognosis!  Dogs with milder may have the worst prognosis.

So, there are many nuances of ‘disk disease’ that will influence the signs and outcome in your dog.  Understanding these nuances and being able to recognize which dog has which nuance is key to helping the pet owner decide between medical management and surgery, and accurately predicting the outcome for the course of action chosen.  The more experience the vet has in managing neck pain, the more they are able to recognize the nuances of disk disease.  The more they are able to recognize the nuances, the more success they will have in recommending a course of action.

Here is an example of such a case.

“Koda” is a 6 yr old Labrador Retriever who went from normal one day to limping on a front leg the next,  to being unable to walk on the next day.  Koda could not stand or walk on his own and had neck pain.  The video below is of Koda 3 days after his problem began.  Even with help and encouragement, he was unable to stand and walk.

Based on Koda’s age, his breed, the signs and the history, I was able to deduce that Koda most likely had an acutely ruptured disk in the lower part of his neck (C5-C7).  Some disk problems at this level of the neck in mid to larger sized dogs are very problematic with a good chance of poor outcome with both medical and surgical treatments.  The nuances of Koda’s case helped me to recognize that with surgery, he would have a great chance of recovery, even as severely effected as he was.  Although Koda’s owners loved him dearly as a family member, they did not want to see him suffer and could not manage a dog who could not walk—they were considering euthanasia.  My confidence that Koda could be ‘fixed’ encouraged them to try, and Koda was off for an MRI. 

The MRI showed us what I suspected; that Koda had an intervertebral disk at C6-C7 that had acutely ruptured into his spinal canal.  The ruptured disk fragments were compressing his spinal cord, causing his inability to walk.  That the disk was ruptured and not bulging, that Koda was a Labrador and that this was all an acute event, meant that his prognosis with surgery was favorable—these are the nuances that are important.

So Koda had surgery.

And Koda made a beautiful recovery.  He was up and walking 3 days after surgery and getting stronger every day thereafter.

This is Koda two weeks after his surgery after getting his stitches out………….

Moral of the Story:

We are able to do some pretty neat things in veterinary medicine.  Despite our best efforts, amazing technology and advanced knowledge, sometimes we fail to achieve the desired outcome.  Success or failure can be as simple as recognizing or failing to recognize the nuances in the cases we evaluate.

Get a Grateful Pet

As most veterinarians probably do, I often get asked by friends and family, “what type of dog do you think I should get?”  I often don’t have a specific answer, but here is what I think, based on my own dog ownership experience and the experience of witnessing owners and their dogs for over 15 years now…wow I’m getting old.

My opinion, and its just an opinion, is that the ‘right’ rescued dog will make the best pet.  I also believe that the closest dog-owner bonds I have witnessed as a veterinarian are those that had their beginnings in adoption of a rescue dog; usually and adolescent to adult dog.  I generally believe that dogs are a lot smarter than we give them credit.  It is anthropomorphic of me to say, but I think they experience emotion and memory similar to ours; the tidal wave of facebook videos these days supports this.  They love to be loved and respond to that love.  I am certain, that an intelligent dog differentiates the homeless shelter experience from a loving environment…and they are grateful and appreciative for the love and warmth they receive when they have had a less than optimal past.  So many owners spend so much time training they’re new puppies to come and stay, with so much fear of them running away, not listening, wandering off.  Take a rescue dog with some hardship in its history, show it some basic love and tenderness…it won’t want to leave you, to wander…they know where they want to be, and that is with you.  My first dog was a Labrador puppy.  I had the good fortune of being able to take the dog almost everywhere with me, and when I couldn’t he was with my loving mother.  Our bond and ever presence was most of the training he needed, not much more, but there were times when he wanted to go and would not listen.  My second dog arrived after being hit by a car in the vet hospital where I was volunteering.  He was banged up, but no serious injury.  He was placid and calm and had a great demeanor, about 1-2 years of age.  He went to the local shelter, where unclaimed after 5 days, he was scheduled for euthanasia.  So I adopted him.  I picked him up, put him in the car and stopped for gas at a busy intersection on the way home.  When I stepped out of the driver side door, he scrambled past me out near the street.  I was terrified.  He didn’t even have a name, I didn’t know how to call him.  He ran about 10 yards as I was frantically begging him to come back.  He stopped, turned and looked at me, and then slowly walked back over to me.  13 more years I had him, and a great dog he was.  My third and fourth dogs (my current dogs) are also rescue dogs.  Despite virtually no formal training, they can go with me just about anywhere off leash.  They wait patiently for me outside a restaurant or shop, or in the car.  They appear to the sound of a whistle even if I don’t know exactly where they are when we are out on a hike.

If you want an easy pet, a grateful and appreciative family member, consider adopting your next dog.  And do it this way.  Formulate some idea of what you want in terms of breed or size of dog.  Go to your local shelter(s) or rescue and browse.  When you see one that looks good, spend time with it, on multiple days if possible.  Ideally, if you are allowed to foster it for a few days, do this.  You can quickly ascertain the personality of a dog by just spending some time with it.  See how it responds to you.  Is it relaxed, attentive, responsive to your touch and voice?—you will know.

If you have your heart set on a pure breed, please realize that there are usually local rescue organizations that tend to be breed specific.  Don’t assume that a dog who has been given up for adoption is a misfit; people give up great dogs all the time for personal reasons.  Both of my rescue dogs are pure-bred border collies—they are the best dogs I’ve ever owned.

And remember, when you adopt a dog who might otherwise be put to sleep, you are giving a dog a second chance at life…they will be grateful to you for the rest of their lives.

Six ways to get the most benefit from your Vet visits

Getting the most for your money at the Vet's office:

6 tips to help you and your pet

Not sure where your money goes at the vet office?  Uncertain about what it is you actually paid for?  Do the potential costs of care prevent you from going to the vet when your pet is sick?  This article can help you get the most for your money at the vet’s office.    It is not about how to get your vet bill lower for routine care, but how to get the most value for your dollar at the vet when your pet is sick; which is also when expenses are highest (and come without guarantees).  It is about how to work ‘better’ with your vet to make the diagnostic and therapeutic process more efficient, which in turn makes it less expensive. 

We often try to avoid up front costs on testing due to expense. We opt for a ‘wait and see’ or a “can’t we just try antibiotics first” approach to cut costs.  Sometimes this will work.  Many mild illnesses will get better with nothing more than time.  When it doesn’t work, the cost of multiple vet visits and ineffective trial therapies quickly adds up...and your pet is still sick, or getting sicker. The smaller amounts you spend stretched out over weeks or months quickly become a sum greater than paying up front for testing or expertise that would have gotten the answers you were looking in first place.  More importantly, the chances of successfully treating the underlying disease or condition diminishes over time.  The more advanced any illness gets, the harder and more expensive it is to treat.  Inaccurately diagnosed or managed illness always comes with a worse prognosis for recovery.

That said, I am not a proponent for aggressive blanket testing whenever the problem is not self-evident.  This too can be wasteful for you and stressful for your pet.  Subjecting our pets to medicine in any form, be it testing or treatments, is always stressful.  Stress is not healthy.  Animals don’t like to experience it, I don’t like to administer it.

The goal?  Getting real answers and treatment OPTIONS in the most cost effective and least stressful (for you and your pet) manner.

When your pet is sick, follow these guidelines for a better visit to the vet.

1.  Provide a precise comprehensive HISTORY of the problem in as few words as possible.  I know this is not always easy; signs and symptoms can be vague—THUS THE REASON TO KEEP THINGS SIMPLE…”just the facts m’am”.  While no one knows your pet better than you, and expressing your opinions and observations is essential, resist the temptation to over-interpret the signs in your pet. ‘Interpretation’ is subjective and can be misleading to your vet.  Listen to his/her questions, and provide the best answers in the fewest words.  Vets are trained to listen and we choose our questions carefully.  BEFORE you get to the vet, think carefully about your pet’s problem.  Providing the following information will be extremely helpful; keep it simple and try to stay objective unless otherwise asked.

a.    What is the problem(s)?- list them, and list them simply, using as few words as possible.  ie) frequent urination, seems painful or uncomfortable, difficulty walking, abnormal gait, decreased appetite, vomiting, diarrhea, weight loss,  drinking excessively….

b.    When did the problem(s) start? (approximately as best as you can recollect)

c.    How has the problem(s) progressed…quite simply, is it getting worse, staying the same, or getting better?  This is VERY important, don’t overlook it.

Summary: With this basic information, delivered in concise and simple language, your vet will often be able to make a diagnosis or a good guess, before even examining your pet.  A GOOD HISTORY OF THE PROBLEM IS CRUCIAL TO UNDERSTANDING IT…TAKE THE TIME TO ORGANIZE YOUR THOUGHTS ON THESE POINTS.

2.  The Physical Exam:  Allow, encourage and be patient while your vet does a thorough physical exam. I cannot tell you how many times I have seen obvious examination findings overlooked--be it enlarged lymph nodes, a heart irregularity, or an abdominal tumor (a 7 lb. splenic tumor in one instance...overlooked by another veterinary specialist!).  A thorough physical exam is partner to a thorough history.   Many owners don’t understand the flow of the physical exam or what is being done.  An experienced veterinarian can do a good physical exam very quickly.  To most owners it looks as though nothing has been done.  Ask your vet to walk you through the exam so that the thoroughness of the exam becomes clear to you. The physical exam is structured and generally includes an evaluation of  body weight and temperature, an evaluation of mucous membrane color (typically lips, tongue and gums), evaluation of eyes, ears nose and teeth, lymph nodes, listening to heart and lungs with stethoscope, feeling the abdomen for abnormalities like masses or fluid, and an evaluation of the skin, muscles and bones.  This is often a quick evaluation, scanning for problems that you the owner may be unaware of.  A slower more thorough evaluation occurs in the areas your history brings to light.  For example, if you come to me because your dog has been limping on the right front leg, which started 13 days ago and seems to be getting worse (a thorough objective history in 16 words), I will examine all systems in your dog, and then pay extra attention to the leg.  Be an advocate for your pet, and be an active part of his/her medical care.  Vets are people too.  On any given day I may have a 100 distractions from my personal life and other veterinary patients.  If there is something I have overlooked during my physical exam, I welcome a reminder from you...”Dr. Maguire, how was Fluffy’s temperature (substitute lymph nodes, gum color, abdomen, heart) today?”  “Oh!  Thanks, I almost forgot to check that!”  Helping me stay focused during your pet’s examination is not second-guessing my ability, it is becoming a partner in your pet’s care…and I always appreciate it.  It shows me that you care, and are willing to become an active participant in your pet’s well being. 

Summary:  The physical exam is another critical component of your pet’s evaluation.   Realize that there can be a 1000 distractors which might lead to something important being overlooked...vets are only human.  Becoming part of the process as an advocate for your pet will not only help you to better understand what you are paying for, it will also help prevent important findings from being overlooked.  Be an advocate...but not a pain in ass; its a fine line.

3.  The merit of initial diagnostic testing (blood tests, x-rays, etc):  Generally speaking, vets don’t just recommend basic tests or x-rays for the hell of it.  Extracting precise medical information from a non-speaking patient is difficult, and it depends a lot on the pet owner.  There is often more to distract from the true medical problem than there is to lead to it.  Blood tests offer objective information about the health of the patient.  Basic tests usually include a Complete Blood Count (CBC), a Serum biochemistry, and a urinalysis. 

    a.  The CBC provides information about the state of the red and white blood cells and the platelets.  There may be up to 18 different parameters used to evaluate the number and character of blood cells on a standard CBC, any of which may provide hints as to the cause of a disease process.  Did you know that there are 5 different types of white blood cells, each with unique functions?

    b.  The serum biochemistry is a test that measures various non-cellular parameters in the blood which reflect how the body is working.  Up to 25 different blood values are measured in a routine serum biochemistry panel.  Liver and kidney health, blood sugar levels, electrolyte and mineral levels (sodium, chloride, calcium, potassium, phosphorus), the acid-base balance in the blood as well as other proteins, enzymes, and cholesterol are all evaluated.  The serum biochemistry will tell you about how the body is working, and if it is not, why.

    c.  A urinalysis is an analysis of the urine.  It is not just to check for bladder infections.  Measurable parameters in the urine also reflect kidney and liver health and can be a major aid in identifying diabetes…a urinalysis is necessary to confirm or deny many abnormalities identified in serum biochemistry.  For example, kidney values in the blood can be high for non-kidney reasons--you need to look at the urine to distinguish the causes of high kidney values in the blood.  The urinalysis parameters are essential for interpreting many abnormalities in the serum biochemistry.

Dogs and cats can look perfectly healthy, yet have serious significant underlying disease that will only be detected with objective tests. ALWAYS consider basic tests as part of the minimum workup (diagnostic evaluation) for your sick pet.  If your vet doesn’t suggest these tests, ASK if they should be considered.

Summary:  Basic laboratory tests have value.  They are essential in accurately determining the underlying causes of some illnesses.  Finding out now is almost always more cost effective than finding out later.  Accurate diagnosis now almost always carries a more favorable prognosis than accurate diagnosis later.  Accurate diagnosis often requires these basic tests.

4.  ASK QUESTIONS/GAIN UNDERSTANDING:  Although I cannot verify the reference, I have been told many times that studies in human medicine find that a patient listening to his or her doctor only comprehends or retains about 10% of what is said to them...MISCOMMUNICATION OPPORTUNITY.   Medical explanations are difficult to understand.  When you are stressed about your pet’s illness, these things are even harder to comprehend.  All vets understand this, nevertheless its sometimes hard for us to judge just how much of what we have said is being understood.  You NEED to understand, so that you can make informed decisions!   I will almost always say to a client, “that was a lot of information I just gave you, is there anything you don’t understand or want me to go over again?”  It is important that you ask questions when you need clarification.  Be part of the process.

Bring another set of ears to the exam.    If you are not medically versed, or are very anxious, it is a good idea to bring a friend or partner who can do some listening for you.  They might ask questions you do not think of or they may be able to explain things to you when you get home and realize you had 50 questions you forgot to ask in the office.  Take notes if you need to.  If you are the type who absorbs the written word better than the spoken word, ask your vet if there are any references or reading materials regarding the problem(s) they are discussing.  I have many prepared articles discussing the more common or complex disease processes for just this purpose.  The more informed you are, the more you become involved in the decision making process and the less chance for miscommunication.

Summary:

a.   Don’t be embarrassed about what you don’t understand.  You are not expected to fully understand the ins and outs of medical conditions, testing, etc. in a short appointment.  I expect that you won’t understand everything I have said.  I also expect you to ask for clarification on the points you don’t understand.  I am grateful for the opportunity to clarify important points.  When you ask questions, you are telling me that you care and that you want to be informed and part of the process...this is good!

b. Bring a friend to help you listen and ask questions.

c. Ask for written articles or resources which might help you better understand...or that you can peruse on your own time in the comfort of your own home.

5. RESEARCH:   Do your homework.   Summarize the facts and conclusions discovered or hypothesized by your vet…and then learn more.  The bottom line is this:  the more understanding you have regarding your pet’s disease, signs, or possible disease processes, the better chance for effective management of the problem(s).   Here are some websites that might help you learn more about the initial conclusions about your pet’s illness:

    a.  http://www.ncbi.nlm.nih.gov/pubmed/   This is a medical scientific literature search database.  It will give you access to the very latest published scientific articles, and it provides free abstracts (summaries) of the articles.  It is NOT an informational website where you can read a summary of diabetes in cats.  It is a library of published scientific research articles.  The key to using it is using the correct search words…be patient, there is a wealth of information here.  Remember it searches both human and veterinary sources, so include the species of your pet in the search or you will get endless human articles…not bad to peruse anyway.  For example, if your vet suspects your cat might have inflammatory bowel disease, you can go to this site, search ‘cat inflammatory bowel disease’ and you will be given a list of scientific research articles relevant to your search chronologically listed from most recent to oldest.  You will be able to read a summary of each article in most cases.  You will find the latest research on this site.

    b.  http://www.petmd.com/    This site is more an online pet magazine than a health resource, but they have accumulated a sizeable library of articles about various medical conditions in pets.   I have perused many of their medical articles and I think they have done a good job in keeping a fairly up to date medical resource library.  There are inaccuracies and there are gaps in the info, and there is no substitute for a good vet or a vet specialist, but you will learn and gain some valuable info about specific disease processes.  Just remember, no single source of information is 100% right or wrong...just extract bits and pieces to enhance your understanding.

    c.  http://www.petplace.com/  This site is also a glorified medical resource, albeit an internet pet magazine…but…many of their articles are written by veterinary specialists writing in their field of specialization.  What that means is that you get both up to date and very accurate information, but from a lengthy article that is difficult for the lay person to understand.  So if you have patience and/or medical background, you will find this useful…if not, you will find it frustrating…”I just want an answer to my question!”

    d.  Beware of non-qualifed resources on the internet, they can be more detrimental than helpful.

A good vet will value the research you have done on behalf of your pet, and it will make things easier for him/her to explain if you have educated yourself.  There are a ton of reasons why the information you have researched may not be relevant to your pet’s case (usually miscommunication between you and your vet), so educate yourself, but remain humble; no one likes a know-it-all.

6.  Veterinary Specialists:  If you were not aware, there are veterinary specialists in the fields of neurology, oncology (cancer), cardiology, internal medicine, ophthalmology, dermatology, and surgery.  The scope of medicine in animals has grown so tremendously that it is impossible for any one veterinarian to be proficient in all aspects of medicine…so, as in human medicine, specialization has evolved.  A veterinary specialist typically undergoes 4 years of specialized academic training, an advanced degree, and board certification in his/her field of specialty, in addition to the 4 years of vet school required to be a veterinarian; that is 8 years of academic training in veterinary medicine as compared to the 4 years of training a general veterinarian receives.  Veterinary specialists can be found easily these days, but still not in all regions.  If you think your pet’s medical problem is complex…if you would like second opinions about your pet’s medical conditions, or if the problem remains elusive after initial efforts by your vet…ask your vet if referral to a specialist should be considered…or look for a specialist in your region.

Use these resources to find a regional vet specialist:

http://www.vetcouncil.org.nz/specialistList.php

http://acvim.org/websites/acvim/index.php?p=2  (board certified specialties in internal medicine, oncology, neurology, cardiology)

http://acvs.org/  (board certified veterinary surgeons)

https://www.acvd.org/  (board certified veterinary dermatologists)

http://www.acvo.com/  (board certified veterinary ophthalmologists)

Very often, when working with a veterinary specialist, you will get to the source of the problem sooner, they will be able to offer you the very latest treatment options and be more familiar with prognoses associated with these options.  A veterinary specialist works in concert with your general veterinarian and enhances the overall medical care opportunities for your pet…your family member. 

If your pet is sick and you want to optimize your chances of getting him/her better in the most cost effective manner, these tips will help.  I have 15 years of experience as a referral veterinary specialist…this is the advice I offer my family and friends.