Yes, your dog has neurologic disease

Yesterday I saw an enormous elderly Great Pyrenees named Kevin.

Kevin had been feeling just fine in his old age, until yesterday morning when he was unable or unwilling to stand and walk in his hind end. Kevin's mom took him to her vet, where an abdominal mass was diagnosed. With bloodwork, chest radiographs, and abdominal radiographs in hand, and with the assumption that pain from Kevin's abdominal mass was the cause of him being "down in the hind," Kevin's mom brought him to the VTH for further work up and monitoring.

At presentation, Kevin really was pretty down in the hind. A big guy at over 100 pounds, we had to hoist him out of his owner's van and onto a gurney to take him to the treatment area.

Once we began to evaluate Kevin further, though, it became clear that more was going on than just an abdominal mass. With the support of a belly sling and about 4 people hoisting, we got Kevin to his feet for a neurologic and orthopedic assessment.

What we found was that Kevin was actually willing to try to walk with his right hindlimb, but his left hindlimb appeared to be almost totally useless. A test of conscious proprioception (whether the brain and body can feel where the limbs are in space) revealed zero proprioception in the left hindlimb and minimal proprioception in the right hind. We laid Kevin down on his side for additional assessment. His forelimbs were almost totally normal -- he could walk on them and move them normally, with normal muscle tone and reflexes.

Kevin's hindlimbs, however, were another story. Both limbs were neurologically impaired, with the left more severely affected than the right. Muscle tone was extremely decreased in both limbs, meaning Kevin's muscles offered almost no resistance to manipulation of his limb. His thigh musculature was moderately atrophied on both sides. When we extended either hindlimb and pinched a toe, Kevin could feel the obnoxious sensation but could offer only the weakest of attempts to physically withdraw the limb away from the pinch. Finally, Kevin's patellar reflexes ("knee jerk" reflexes) were very decreased.

All of these findings pointed to neurologic disease within Kevin's lumbosacral spinal cord, with worse disease on the left than the right. Additionally, we could feel a grapefruit-sized mass in Kevin's belly, but he gave us no sign of any pain when we palpated around this mass or elsewhere in his abdomen. In other words, we could find no reason in Kevin's belly for him to be painful enough not to walk.

When we went to discuss these findings with Kevin's owner, however, it became clear that she was convinced that he was orthopedically and neurologically sound. She assured us that his abdomen was painful and that was why he was down.

Fortunately, Kevin's mom seems like a great lady, and she readily agreed to hospitalize him overnight for IV fluids, monitoring, and supportive care, with abdominal ultrasound and thoracic rads in the morning. We also put in a request for a neurology consultation to be done today for Kevin, in the hopes that they can further pinpoint his neurologic disease and determine if it might be related to his abdominal mass. I'm hopeful that with a little more time to process the information, Kevin's owner will come to realize that he has potentially multiple issues.

In other news, poor Wes from Wednesday night was sent on his way to doggie heaven yesterday afternoon. Given that his owners didn't really want to pursue any treatment once they'd gotten the diagnosis of either lymphoma with an acute leukemic crisis, or acute lymphoblastic leukemia, it was probably for the best. It's just nice when you can get them feeling better for a few days before you let them go...

Lymphoma sucks

One of my Urgent Care patients last night was a 4 year old standard poodle named Wes who almost certainly has lymphoma.

Wes had about a 10 day history of some nonspecific clinical signs: lethargy, decreased appetite, and occasional vomiting and diarrhea. Wes's owners felt the need to bring him to their regular vet yesterday afternoon when Wes started sneezing blood (epistaxis).

The rDVM ran some bloodwork that showed a very low platelet count of 23,000. Normal platelet numbers are 200-500,000. This thrombocytopenia could have one of several causes and could certainly be the cause of Wes's epistaxis.

However, the CBC that showed the thrombocytopenia had another concerning finding -- a white blood cell count of almost 70,000 (normal being less than 12,000).

Wes's rDVM was suspicious of lymphoma, so submitted another CBC to an outside laboratory to have a pathologist examine a blood smear and give a definitive "yes or no" on lymphoma by this morning.

But Wes's epistaxis hadn't stopped, and out of concern that he might hemorrhage to death overnight, Wes's owners brought him to the VTH.

On presentation Wes was extremely dull and dumpy. He would wag his tail on occasion, but otherwise had no energy for anything other than lying in a heap on the floor. His gums were pale and dry. His heart rate was very elevated (190 beats per minute, normal in a dog his size being probably 80-100) and he was panting heavily with some obvious difficulty breathing. He was febrile at 103.8 (normal 100-102.5).

Unfortunately, the most pertinent finding was that all of Wes's peripheral lymph nodes were significantly enlarged. Additionally, Wes also had a large mass in his cranial abdomen, which I suspect was an enlarged spleen.

Based on Wes's clinical presentation, we absolutely agreed with his rDVM's top rule-out of lymphoma. We looked at a blood smear, which had a huge population of abnormal cells that I'm 99.9% sure were lymphoblasts (cancerous precursors of a type of white blood cell affected in lymphoma). We offered to do fine needle aspirates of some of Wes's lymph nodes and have them examined by a pathologist at the VTH, so that Wes's owners could have an answer immediately instead of waiting until morning.

However, Wes's owners were hellbent on doing as little as possible until morning when they got their test results -- just enough to keep Wes "comfortable" overnight. Our eventual compromise was to hospitalize Wes on IV fluids and place him in an oxygen cage. His heart rate declined somewhat overnight, though it was still elevated at 150 this morning. Wes still struggled to breathe, even in oxygen. He was still mildly dehydrated this morning. His fever, at least, had come down to 102.9.

After I came in to check on Wes this morning, his owners were still trying to make up their minds what to do with him, having not received their tests results from his rDVM yet. They had pretty much ruled out the recommended aggressive chemotherapy protocol which would probably buy them about a year of quality time with Wes but could cost $4-5000. (And I'm not passing any judgment on that. It's a lot of money for a gamble at getting a few months to a year.) It's just tough to see lymphoma in a dog so young -- Wes will only just turn 4 next month. While it's "nice" that lymphoma is one of the few cancers that responds more readily and reliably to chemotherapy than other cancers, it just plain sucks that it hits dogs so young. Last time I was on Urgent Care last fall, I had another 4 year old poodle freshly diagnosed with lymphoma. I hope that Wes's owners will at least put him on some oral steroids for awhile, to buy him a few weeks or months of feeling good at minimal expense.

Never fails

Last night was my first night of "After Hours Urgent Care." What that means is that I (along with 2 other seniors and an intern) see emergent, urgent, and/or walk-in patients from 4-11 pm on weeknights, and either 7 am-4 pm or 3-11 pm on weekends. What that also means is that a patient that arrives at 10:59 pm is my responsibility, and a patient that arrives at 11:00 pm is dealt with by the overnight students on CCU. So, imagine my surprise (sarcasm) when yesterday I saw not a single patient between orientation at 3 pm and almost the end of my shift at 10:50 pm -- when, of course, a young vomiting Labrador with a history of dietary indiscretion walked in the door. Of course, he needed x-rays of his belly as well as some bloodwork, all of which took a couple hours, then I had to set him up for hospitalization for the rest of the night and finish his paperwork. So after sitting around killing time for 7+ hours, I got to stay 2.5 hours past the end of my shift! And woke up at 11:30 this morning with a killer headache. The only upside is that, for some cases that are admitted in the evening and stay in the hospital until morning, the urgent care student whose case it is has to come back at 7 am to re-evaluate the patient, complete morning paperwork, call the owner with an update, and transfer the case to a specialty service within the hospital. At least I got out of that with this dog. The next 2 weeks could be a lot of "fun"!

I'm ready for some minions

Since returning from my externship at LIAH, I've been unusually annoyed by the many varied intricacies of trying to get simple tasks done at the VTH.

On my current Dentistry & Oral Surgery rotation, I am the only student. There is also only one clinician -- both of which are a little unusual. Generally the DOS service has 2 clinicians and 2 senior students to handle a full caseload (which can consist of up to 8 appointments on consult days and up to 4 procedures on procedure days). We still have that busy schedule, but since I'm the only senior student, I get to do all the busy work.

I think the "busy work" aspect of it is really catching up to me because I greatly enjoyed a full 2 weeks at LIAH with an extremely skilled, competent, and independently functioning technical staff. Don't get me wrong, the technical staff at the VTH are highly educated and extraordinarily capable in their jobs -- but their job description doesn't include a lot of the nitty-gritty things that technicians take care of in private practice.

Let's compare, for instance, how you get a CBC and chemistry panel sent to the lab at the VTH compared to LIAH.

At the VTH: I fetch the patient from the exam room at the south end of the building and bring him to the treatment area at the north end of the building. I gather alcohol, syringes, needles, blood collection tubes, and a Clinical Pathology submission form. If the treatment area is out of syringes, needles, or blood tubes, I walk to Central Supply at the north end of the building to request more supplies. I fill out the Clin Path form, including placing patient ID stickers on both of the carbon copy pages. If I don't have enough stickers, I walk to the east end of the building where I can use the computer program to print more stickers, then to the west end of the building to pick up the stickers from the printer, then I go back to the treatment area at the north end. If the sticker printer is out of paper, I walk over to Medical Records at the east end to request more paper. If the treatment area is out of Clin Path forms, I walk up to the southeast corner of the building and hope there are extra forms in the cabinet. I wait until the dentistry technician is off the phone or the dentistry clinician has finished whatever she is doing, so one of them can restrain the patient for me. I draw the blood myself. I fill out 2 of the smaller patient ID stickers for the 2 blood tubes. I walk the patient back to his owner in an exam room in the south end of the building (or try to convince the technician or clinician to hold the patient for me, or place the patient in a cage, which requires writing up a cage card and getting a blanket for the cage), then go back to the north end to pick up my blood samples and form from the treatment area, then take the samples and form to the Clinical Pathology department (which is about a 4-5 minute walk away, in another building), time stamp the form, and turn in the blood samples, then walk back to the treatment area in time to start the next appointment.

When you've got 4 appointments in 4 hours, and every one of them needs blood submitted, you can see how this gets tedious. It is tedious just to think about it.

Let's compare to how I get my blood submitted at LIAH: I let the owner know that I'm going to collect some blood, and walk about 10 feet from the exam room to the treatment area with the patient. I place the patient in a cage. I write his name on the whiteboard on the wall, along with what tests I want run. In about 5-10 minutes, the team of technicians has drawn the blood, returned the patient to his owner, and gotten everything ready to go to the lab. In that time, I've been doing doctor-type things, like seeing the next appointment, writing up charts, researching a case on VIN, or scrubbing into a surgery.

Now let's see how I submit a urine sample at the VTH: Again, I walk the patient from the exam room (south end) to the treatment area (north end). I wake up my computer, spend a couple minutes logging into the radiology request website, and another 2 minutes filling out an online request for an ultrasound-guided cystocentesis (collecting a sterile urine sample by placing a needle directly into the bladder). I gather a syringe, 2 needles, a sterile tube, a Clin Path form, and 2 large and 2 small patient ID stickers. If any of those supplies aren't in the treatment area, I proceed to Central Supply (north end), the forms cabinet (southeast), and/or the label printer (east and west ends) to gather them. My patient and I walk over to Ultrasound (east end) where we wait for an open ultrasound machine, another person to restrain, and someone to collect the urine sample. Once collected, I walk the patient back to his owner (south end), drop off a tube of urine in the fridge in the Medicine pit (southwest), and again hike to Clin Path in another building to time stamp my form and turn in the urine.

At LIAH: I let the owner know that I'm going to collect some urine, and walk about 10 feet from the exam room to the treatment area with the patient. I place the patient in a cage. I write his name on the whiteboard on the wall, along with what sample I want collected and why. In about 5-10 minutes, the team of technicians has collected the urine, returned the patient to his owner, and gotten everything ready to go to the lab.

I'm sure this post sounds whiny, and it kind of is. And in no way do I mean to speak unkindly of the wonderful technical staff at the VTH, or to imply that me having to do all of the above steps means somehow that the technicians at the VTH aren't doing their jobs. I fully believe that a capable, dedicated, responsible technician is worth his or her weight in gold. Veterinary technical staff are too frequently undervalued, underrecognized, and underpaid for the often unpleasant, exhausting, and behind-the-scenes work that they do. And certainly any veterinarian who is a true team player is happy to do some of the busy work on occasion.

However, since I'll have the letters "DVM" after my name 3 weeks from tomorrow, I'd rather be treated more like a doctor at this point than a technician.

Zombie pets strike again

Remember how much I enjoyed cutting eyeballs out of a soaking wet whole dead cat?

Extracting teeth from a decapitated Beagle has been only marginally more enjoyable on Dentistry & Oral Surgery this weak. Blargh.

How to treat malignant mammary cancer on a $65 budget

I spent the last 2 weeks an hour away from home in a large metro area, externing at what we'll call Low Income Animal Hospital (LIAH). LIAH is run by the state VMA's charity branch. It's a non-profit hospital that employs about 3 full-time veterinarians to provide lower-cost care for low-income clients. All services come with a fee, but those fees are discounted to some degree based on how poor an individual client is.

My 2 weeks at LIAH were a huge learning opportunity. For one thing, I gained (re-gained?) some confidence that I will kind of know what I'm doing when I graduate in a month(!). We senior student externs are given pretty much free rein to see cases and formulate diagnostic and treatment plans.

LIAH is also a great opportunity to be reminded about what type of clientele many vets see out in the "real world" (i.e. not in the "silver tower" of a referral institute). The VTH and LIAH are pretty much polar opposites in terms of the financial ability of their clients. Those who visit the VTH (at least the specialty services) are pretty well self-selected to be willing to pay hundreds or often thousands of dollars for veterinary care. In contrast, the clients at LIAH are basically self-selected as very low-income, with common circumstances such as disability, unemployment, or foreclosure.

It's very sobering to have clients come in who have to choose between a rabies vaccine or a distemper-parvo vaccine for their dog, because they can't afford the $25 for both vaccines in addition to the $35 exam fee.

Or, like one of my patients on Thursday, the pet has a serious medical condition that could possibly be cured, if only it were in the budget. This particular patient was a 10 year old, un-spayed, female kitty named Patty.

Patty presented to LIAH with the complaint of "check lump on belly." The technician went into the appointment initially to record Patty's vitals and get a brief history from her owners, and when she came back to tell me about the case, it was clear we were dealing with badness.

Patty had a very large (about 1.5 inches across) mammary tumor in her caudal mammary chain, which had grown through the skin and was ulcerated and abscessed. Upon further examination, Patty also had about 20 other smaller tumors up and down her mammary tissue. Though these tumors had a characteristic feel to them (often described as feeling like BBs within the breast tissue), Patty's owners had been so distracted by the larger tumor (which, by the way, had been growing for about 4-5 months) that they didn't realize anything else was going on.

Unfortunately, about 90% of mammary tumors in female cats are malignant. Had Patty presented to the VTH's oncology department, we'd have recommended doing some thoracic rads to check for metastasis, sedating Patty for FNA of some of her masses and the lymph nodes that drained them, and, depending on the findings of the previous tests, scheduling a bilateral radical mastectomy.

And I still discussed those steps with Patty's owner. Just because someone doesn't have the money to pursue advanced treatment doesn't mean that you shouldn't give them every option. Is it an awkward conversation to have with clients that you are 99.5% sure cannot afford such a workup? Of course -- but you still have to bring it up. It's considered negligence to not offer the "gold standard" plan, because there are still that 0.5% of clients that will surprise you with what level of treatment they can and will pay for.

However, Patty's owners had scraped together $65 for that day's appointment. It was enough to cover the exam fee (about $35 after their discount), and maybe some meds to go home. My discussion with them moved almost immediately to a chat about palliative or hospice care, rather than delving into curative intent therapy. Patty needed antibiotics to try to treat her infected tumor (though such therapy may or may not be successful in controlling infection), and she needed pain meds because, let's face it, a giant infected tumor on your belly bleeding all over the place can't feel good. Unfortunately, even with the cheapest antibiotic selection and a lower dose of pain meds than I wanted to use, we were still $8 over Patty's owners' budget.

So the technician and I each kicked in $4, and sent Patty on her way for what will hopefully be a more comfortable few days at home before Patty's owners are ready to euthanize her. During our discussion, Patty's female owner also revealed that she herself is in Stage 4 ovarian cancer -- so Patty's owners know all too well what lies in store for Patty, and I think they feel some relief that they will be able to give her a peaceful passing when she is no longer able to be comfortable.

It's a case that will stick with me.