One of my most "interesting" clients on Orthopedics last week was a middle-aged woman who brought in her 9-week-old Australian shepherd puppy, Howie, for an exam.
Howie's presenting complaint was "Check legs, littermate had problems." Always ready for a cute puppy with possible deformities, I signed up for Howie's appointment right away.
After the requisite small talk with Howie's mom, we were ready to get down to business -- or so I thought.
"So, tell me about Howie and his littermate," I began.
"Well," said Howie's mom, "there's something wrong with Howie's littermate, but... I don't want to tell you what it is. I want to see if you can figure it out."
"Um, okay?" I offered.
"Because, you know," she continued, "I'm sure that you won't look at the rest of him as thoroughly and do a good orthopedic exam if I just tell you what was wrong with his littermate and what I think is wrong with Howie. And I'm sure you like to have a challenge, so I'd rather just see what you come up with."
(Let me just set the record straight here: A thorough orthopedic exam is performed on every patient that visits the ortho department, even if the abnormality is glaringly obvious. This means that we look at the neck, spine, digits, wrists, elbows, shoulders, hocks, stifles, hips, and tail of each and every patient, whether or not we expect to find anything wrong. Additionally, there are subtle variations in certain joints such that the only way you know whether a finding on orthopedic exam is significant is by placing it in the context of the dog's history and other problems. That is, a slight amount of laxity in a forelimb joint may be significant if the dog has been limping on that forelimb, but insignificant if the limp is in the hind end. Thus, having all the information that owners can offer us actually helps us do a better orthopedic exam with more reliable results.)
Having never encountered a client unwilling to provide information like this, I didn't know what to say, so we discussed Howie's general puppyness (has he had vaccines, when, how many? What are you feeding him?) and I completed my physical exam.
Physical exam showed an apparently normal, healthy, happy (though somewhat bratty) Aussie puppy.
I excused myself to take Howie to the surgery pit to meet with the new first-year surgical resident for Howie's orthopedic exam.
Gait observation (which by the way is rather difficult in a 9-week-old puppy who isn't really leash-trained and nips at your pants the entire time trying to "herd" you) was unremarkable.
Standing exam revealed normal puppy joints, bones, muscles, ligaments, and tendons, as far as we could tell. Nothing significant was found on recumbent exam, either.
By this point, after I had relayed the minimal amount of history that Howie's mom had shared with me, the surgical resident was fairly irritated.
One of the most important factors to a successful veterinarian-client-patient relationship (or physician-patient relationship) is mutual trust. That means that the veterinarian trusts the client to provide truthful information about the pet, lying neither directly or by omission. In return, the client trusts the veterinarian to answer questions honestly and act in the best interest of the client and patient.
Within the first 2 minutes of meeting me, Howie's mom had shown definitively that she did not trust me, the resident who would be Howie's doctor, the orthopedics service, or by extension the VTH. That did not set a great stage for a healthy vet-client-patient relationship, so I could see why the resident was frustrated and even insulted.
On our way up to discuss our findings with Howie's mom, the resident informed me that he was uninterested in telling Howie's mom what he had found on orthopedic exam until she shared with him the very relevant information about what she felt was abnormal with Howie and what his littermate's diagnosis was.
The resident introduced himself to Howie's mom, then said, "Let's play the sharing game. You have information I need and I have information you want. Tell me what was wrong with Howie's littermate."
At this point, Howie's mom fortunately got the drift that the resident wasn't interested in playing games, and readily offered everything she knew about the littermate, and everything she'd noticed in Howie.
In the end, Howie is probably perfectly normal. In any case, it's very difficult to know the accuracy of findings on an ortho exam in a young puppy. Puppies have a normal amount of looseness or "laxity" in their joints, so that you can find things in a normal healthy 9-week-old puppy that, if present in a 5-month-old dog, would be suggestive of orthopedic disease. Conversely, the absence of abnormalities at this age in Howie's case doesn't mean he won't develop orthopedic disease as he matures.
Though Howie appeared normal at 9 weeks and may stay orthopedically normal as he matures (though he'll probably always be a neurotic Aussie), we offered to see Howie back at 6 and 12 months of age to reevaluate him and see if any abnormalities had developed.
And if Howie's mom knows what's good for her and Howie, she'll learn to trust his doctors so they can trust her.
Sunday, July 31, 2011
Saturday, July 30, 2011
Fat Sam and his terrible joints
My orthopedic surgery patient yesterday was a middle-aged golden retriever mix named Sam. Typical of most goldens (and golden mixes), Sam is about the sweetest, gentlest, most angelic dog you'll ever meet. If you stop petting him too soon, he'll ever-so-delicately offer you a raised forepaw and gently brush it on your leg to remind you he's still there.
Sam's mom adopted him from a rescue a year and a half ago. At that time she was told that he had recently been treated for heartworm infection, but was otherwise healthy. Sam's mom got him on regular heartworm prevention, made sure all of his subsequent heartworm tests were negative, and settled into a happy life, just her and Sam with occasional visits from her grown kids.
Sam's mom says that he was in rough shape when she adopted him -- his hair coat was in poor condition, he was "skin and bones," a number of his teeth were broken (possibly from chewing on rocks), and he just seemed neglected.
Several months after his adoption, Sam started limping in his hind end. His mom didn't think much of it until about two months ago, when Sam's limping became severe.
By the time Sam visited his regular vet 3 weeks ago, he was bearing almost no weight on his left hindlimb, with his right hindlimb also obviously painful on his rDVM's exam. Sam's rDVM took radiographs of Sam's hips and knees, and diagnosed him with hip dysplasia, cranial cruciate ligament (CCL, the equivalent of the ACL in people) disease, and luxating patellas. Sam left that visit with prescriptions for 3 different pain meds to help make him more comfortable.
Fast forward to two days ago, when Sam arrived at the VTH for an orthopedics consult. Sam hadn't improved much with the last few weeks of pain meds. He would bear some amount of weight on his left hindlimb but had an obviously limp, was reluctant to bend his left leg, and was more comfortable lying on his right side.
Sam's mom brought his radiographs from his rDVM for us to review. They revealed severe dysplasia of both of his hips, with moderate to severe arthritis. He also had evidence of CCL ruptures in both stifles, already with mild arthritis. Orthopedic exam showed a grade 1/4 medial luxating patella on the right side (insignificant relative to his other issues).
What Sam ideally needed to be ambulatory with minimal pain for the remaining 8-10 years of his life was a CCL repair on his left side, followed by treatment of his hips on both sides (total hip replacements or FHOs), and then probably treatment of his right CCL.
After Sam's orthopedic exam and reviewing his radiographs, we sat down with Sam's mom to discuss his joint diseases and his options. She was shocked to hear our diagnosis of "severe" hip dysplasia after reviewing his radiographs, having been told by her rDVM that he had "some" hip dysplasia but that fixing his knee should basically take care of his pain.
What Sam's mom could afford was a single surgery. So we planned to fix the most obvious source of Sam's current pain, his left knee.
I should mention at this point the other confounding factor: Sam weighs 72 pounds and should weigh 50-55. He is what we call a "body condition score" of 9 out of 9, with 4 to 5 out of 9 being ideal, 1/9 being completely emaciated, and 9/9 being, as the surgery resident put it in Sam's case, "shaped like a coffee table, with buttcheeks on his shoulders."
We proceeded to surgery with Sam yesterday, performing a TTA (tibial tuberosity advancement) which should eliminate Sam's need for a CCL (which was doing nothing it was supposed to in his left knee anyway) and will slow the progression of arthritis in this knee such that it will be almost unnoticeable.
And though Sam went home this morning with adequate pain control, a happy owner, and a bill that was less than her estimate, I can't help but feel that Sam has been failed in many ways in his 5 years of life:
(1) In this case, since Sam is a mutt, at least I can't blame a greedy, conscience-free, bad bad breeder for his joint disease.
(2) With the severity of Sam's joint disease at 1.5 years post-adoption, there is no way that a thorough physical exam performed by a competent veterinarian through the rescue group prior to Sam's adoption would not have identified at least some of Sam's joint issues (most notably his hip dysplasia). This would have allowed the rescue group to do something about it, or at least to better educate Sam's adopter about his likely need for costly medical and surgical care down the road, and the importance of keeping him at a healthy weight and on joint supplements. Whether the rescue group did not consult a vet, did not consult a competent vet, or had the information and chose not to relay it to Sam's mom is unclear.
(3) Sam's rDVM, who took his radiographs earlier this month, either mis-diagnosed the severity of his hip dysplasia, or was not upfront with his owner about how bad it was. Sam's poor mom was taken completely aback when we told her that Sam would ideally have surgery on both of his hips as well. Though there's not much that Sam's rDVM and his mom could have done differently in the last 3 weeks with a honest diagnosis of severe dysplasia, at least she would not have come to the VTH thinking that one surgery would make Sam all better.
(4) Sam's mom, though she loves him dearly, has allowed him to gain weight nearly to the point of literally loving him to death. Sam has pretty long hair, which makes him look like some amount of his bulk is due to fluff and not to fat, but it was a struggle to identify any of his bones underneath his deep fat pads during our orthopedic exams. If I hadn't seen Sam's hip joints on his radiographs, I truly couldn't have told you if he actually had bones there or not, based on palpation. Similarly, his ribs are nowhere to be found, no matter how deeply you dig your fingers into his chest. When we shaved Sam's left hindlimb for surgery, he had wads of fat sagging off his thighs.
It's the obesity that really gets to me in Sam's case.
Yes, there was probably no breeder at fault for Sam's joint disease (other than the owners of his parents who obviously didn't alter their dogs despite probable joint disease in those dogs). So no, Sam's probable inherent genetic tendency toward joint disease is not his current owner's fault.
Yes, the rescue group and Sam's rDVM could have been more thorough or more upfront about Sam's severity of disease.
But despite his "skin and bones" condition at adoption, Sam's mom did not have to allow him to become grotesquely obese, thus putting an enormous amount of unnecessary strain on his already painful hips and knees. This is the one thing that was truly preventible in Sam's case. Would Sam still be painful today and need surgery even if he weighed 50 pounds? I can't say with certainty that he wouldn't, but I'm quite sure he'd be more comfortable, more active, and could have made it longer before requiring the surgical treatment(s) he now needs.
You can give me all the excuses you want about living for months in a rainy climate, Sam not getting enough exercise from the rain, Sam getting "depressed" because he didn't get walked much and you "having to" feed him to make him "happy," and you being depressed from the weather and not caring about Sam's health.
Those excuses mean nothing to me after seeing how much Sam struggles to be a happy dog while combating an extreme amount of pain even while he's on three different pain meds.
Think about a person: Sam is the equivalent of a person having torn ACLs in both knees, and hip arthritis that makes it excruciating to take even a single step. Now take that poor person and make him wear a backpack, 24 hours a day, everywhere he goes (sleeping, getting up from the couch, walking to his car, sitting in a chair, trying to do any kind of exercise or mobile activity), with about 65 pounds of extra weight shoved into the backpack. Think they'd be as cheerful and loving as Sam is?
I find almost no excuses acceptable for an obese dog. You are the human. You can choose the type of dog food. You can choose the exercise plan. You can choose to feed measured amounts as meals rather than filling up the bowl once a day. In 95% of cases, you can make a decision not to have an obese dog.
Anyway, we had a heart-to-heart with Sam's mom about his obesity. I think (and hope) that she has a better understanding now of how important it is for Sam to lose weight. At his consult on Thursday, we recommended putting him on a hard-core weight loss diet (Science Diet prescription r/d), which Sam's mom picked up from her rDVM that same day and switched Sam to on Thursday night. She realizes that treats are now forbidden, and that she'll have to find Sam a new favorite treat from among her options of green beans, carrots, celery, unflavored rice cakes, and ice cubes.
If everything goes as planned at home, Sam won't be back for another 10-14 days, when he'll have his stitches out. At that point I'll be on vacation(!) and another group of ortho students will see Sam for his recheck. I sure hope he's doing well and has lost about 5 pounds!
Sam's mom adopted him from a rescue a year and a half ago. At that time she was told that he had recently been treated for heartworm infection, but was otherwise healthy. Sam's mom got him on regular heartworm prevention, made sure all of his subsequent heartworm tests were negative, and settled into a happy life, just her and Sam with occasional visits from her grown kids.
Sam's mom says that he was in rough shape when she adopted him -- his hair coat was in poor condition, he was "skin and bones," a number of his teeth were broken (possibly from chewing on rocks), and he just seemed neglected.
Several months after his adoption, Sam started limping in his hind end. His mom didn't think much of it until about two months ago, when Sam's limping became severe.
By the time Sam visited his regular vet 3 weeks ago, he was bearing almost no weight on his left hindlimb, with his right hindlimb also obviously painful on his rDVM's exam. Sam's rDVM took radiographs of Sam's hips and knees, and diagnosed him with hip dysplasia, cranial cruciate ligament (CCL, the equivalent of the ACL in people) disease, and luxating patellas. Sam left that visit with prescriptions for 3 different pain meds to help make him more comfortable.
Fast forward to two days ago, when Sam arrived at the VTH for an orthopedics consult. Sam hadn't improved much with the last few weeks of pain meds. He would bear some amount of weight on his left hindlimb but had an obviously limp, was reluctant to bend his left leg, and was more comfortable lying on his right side.
Sam's mom brought his radiographs from his rDVM for us to review. They revealed severe dysplasia of both of his hips, with moderate to severe arthritis. He also had evidence of CCL ruptures in both stifles, already with mild arthritis. Orthopedic exam showed a grade 1/4 medial luxating patella on the right side (insignificant relative to his other issues).
What Sam ideally needed to be ambulatory with minimal pain for the remaining 8-10 years of his life was a CCL repair on his left side, followed by treatment of his hips on both sides (total hip replacements or FHOs), and then probably treatment of his right CCL.
After Sam's orthopedic exam and reviewing his radiographs, we sat down with Sam's mom to discuss his joint diseases and his options. She was shocked to hear our diagnosis of "severe" hip dysplasia after reviewing his radiographs, having been told by her rDVM that he had "some" hip dysplasia but that fixing his knee should basically take care of his pain.
What Sam's mom could afford was a single surgery. So we planned to fix the most obvious source of Sam's current pain, his left knee.
I should mention at this point the other confounding factor: Sam weighs 72 pounds and should weigh 50-55. He is what we call a "body condition score" of 9 out of 9, with 4 to 5 out of 9 being ideal, 1/9 being completely emaciated, and 9/9 being, as the surgery resident put it in Sam's case, "shaped like a coffee table, with buttcheeks on his shoulders."
We proceeded to surgery with Sam yesterday, performing a TTA (tibial tuberosity advancement) which should eliminate Sam's need for a CCL (which was doing nothing it was supposed to in his left knee anyway) and will slow the progression of arthritis in this knee such that it will be almost unnoticeable.
And though Sam went home this morning with adequate pain control, a happy owner, and a bill that was less than her estimate, I can't help but feel that Sam has been failed in many ways in his 5 years of life:
(1) In this case, since Sam is a mutt, at least I can't blame a greedy, conscience-free, bad bad breeder for his joint disease.
(2) With the severity of Sam's joint disease at 1.5 years post-adoption, there is no way that a thorough physical exam performed by a competent veterinarian through the rescue group prior to Sam's adoption would not have identified at least some of Sam's joint issues (most notably his hip dysplasia). This would have allowed the rescue group to do something about it, or at least to better educate Sam's adopter about his likely need for costly medical and surgical care down the road, and the importance of keeping him at a healthy weight and on joint supplements. Whether the rescue group did not consult a vet, did not consult a competent vet, or had the information and chose not to relay it to Sam's mom is unclear.
(3) Sam's rDVM, who took his radiographs earlier this month, either mis-diagnosed the severity of his hip dysplasia, or was not upfront with his owner about how bad it was. Sam's poor mom was taken completely aback when we told her that Sam would ideally have surgery on both of his hips as well. Though there's not much that Sam's rDVM and his mom could have done differently in the last 3 weeks with a honest diagnosis of severe dysplasia, at least she would not have come to the VTH thinking that one surgery would make Sam all better.
(4) Sam's mom, though she loves him dearly, has allowed him to gain weight nearly to the point of literally loving him to death. Sam has pretty long hair, which makes him look like some amount of his bulk is due to fluff and not to fat, but it was a struggle to identify any of his bones underneath his deep fat pads during our orthopedic exams. If I hadn't seen Sam's hip joints on his radiographs, I truly couldn't have told you if he actually had bones there or not, based on palpation. Similarly, his ribs are nowhere to be found, no matter how deeply you dig your fingers into his chest. When we shaved Sam's left hindlimb for surgery, he had wads of fat sagging off his thighs.
It's the obesity that really gets to me in Sam's case.
Yes, there was probably no breeder at fault for Sam's joint disease (other than the owners of his parents who obviously didn't alter their dogs despite probable joint disease in those dogs). So no, Sam's probable inherent genetic tendency toward joint disease is not his current owner's fault.
Yes, the rescue group and Sam's rDVM could have been more thorough or more upfront about Sam's severity of disease.
But despite his "skin and bones" condition at adoption, Sam's mom did not have to allow him to become grotesquely obese, thus putting an enormous amount of unnecessary strain on his already painful hips and knees. This is the one thing that was truly preventible in Sam's case. Would Sam still be painful today and need surgery even if he weighed 50 pounds? I can't say with certainty that he wouldn't, but I'm quite sure he'd be more comfortable, more active, and could have made it longer before requiring the surgical treatment(s) he now needs.
You can give me all the excuses you want about living for months in a rainy climate, Sam not getting enough exercise from the rain, Sam getting "depressed" because he didn't get walked much and you "having to" feed him to make him "happy," and you being depressed from the weather and not caring about Sam's health.
Those excuses mean nothing to me after seeing how much Sam struggles to be a happy dog while combating an extreme amount of pain even while he's on three different pain meds.
Think about a person: Sam is the equivalent of a person having torn ACLs in both knees, and hip arthritis that makes it excruciating to take even a single step. Now take that poor person and make him wear a backpack, 24 hours a day, everywhere he goes (sleeping, getting up from the couch, walking to his car, sitting in a chair, trying to do any kind of exercise or mobile activity), with about 65 pounds of extra weight shoved into the backpack. Think they'd be as cheerful and loving as Sam is?
I find almost no excuses acceptable for an obese dog. You are the human. You can choose the type of dog food. You can choose the exercise plan. You can choose to feed measured amounts as meals rather than filling up the bowl once a day. In 95% of cases, you can make a decision not to have an obese dog.
Anyway, we had a heart-to-heart with Sam's mom about his obesity. I think (and hope) that she has a better understanding now of how important it is for Sam to lose weight. At his consult on Thursday, we recommended putting him on a hard-core weight loss diet (Science Diet prescription r/d), which Sam's mom picked up from her rDVM that same day and switched Sam to on Thursday night. She realizes that treats are now forbidden, and that she'll have to find Sam a new favorite treat from among her options of green beans, carrots, celery, unflavored rice cakes, and ice cubes.
If everything goes as planned at home, Sam won't be back for another 10-14 days, when he'll have his stitches out. At that point I'll be on vacation(!) and another group of ortho students will see Sam for his recheck. I sure hope he's doing well and has lost about 5 pounds!
Monday, July 25, 2011
Money, money, money
I'm one day into my two week orthopedic surgery rotation.
My single appointment today reminded me just how much veterinary care can cost sometimes.
In a vet school/teaching hospital environment, it's often easy to forget that our clientele is not necessarily representative of the pet-owning population as a whole.
Our clients, as I'm sure I've mentioned in a previous post, come self-selected as a group of dedicated owners, most of whom have the time, energy, and especially money to "do whatever it takes" for their beloved pets.
On a rotation such as orthopedics, the vast majority of patients presenting to the service will head to surgery, for everything from limb amputations to fracture repairs to CCL repairs to corrections of congenital abnormalities to total hip replacements. The least inexpensive of the surgeries is, at the very minimum, over a thousand dollars.
So when you see these types of cases day in and day out (and it's not just orthopedics -- it's also the dermatology clients willing to commit $500 for skin testing for allergies, and $600/year for the rest of the animal's life for allergy shots -- and the neurology clients happy to drop $5000 to remove a ruptured disk from their Dachshund's back -- and the medicine clients who don't bat an eye at the $3000 bill for endoscopy and biopsies), it's easy to forget sometimes that in the eyes of a good percentage of the normal human population, spending thousands of dollars on a dog or cat's medical care just isn't something they can afford (or even want) to do.
Nonetheless, even seeing these clients every week who are unfazed by their enormous bills, I still run into the odd patient who makes me step back and re-amazes me with the staggering cost of vet care.
Case in point: Today's patient was a one-year-old exotic breed dog (one of those that you only ever see in the dog shows on TV, and have to struggle to pronounce) named Maggie. Maggie's owners bought her from a breeder as a young puppy.
Not too long after that, it became apparent that Maggie had some musculoskeletal issues. So when Maggie's rDVM spayed her at 5 months of age, he also took hip xrays while she was under anesthesia -- which revealed severe hip dysplasia on one side, already with evidence of arthritis, and moderate hip dysplasia on the other side.
Maggie and her owners made the 4 hour trip to the vet school about a month ago for an orthopedic consult. Given the severity of Maggie's disease (at merely a year old, she can barely walk because her hips are so painful, and has been on pain medication for most of her young life), the recommendation was to perform total hip replacements (THRs) on both of Maggie's hips, 8 weeks apart.
Maggie's owners said go for it.
Let's pause and consider that a single THR, without any significant complications, costs roughly $5500-6500.
Hope you didn't fall out of your chair. I almost did.
Now consider the fact that, in order to undergo a THR, a dog must be proven free of infection anywhere in its body that we can look -- so no fever, no elevated white blood cell count, negative urine culture, etc.
Maggie happens to have a not uncommon conformational abnormality of her vulva (external genitalia), wherein she has extra folds of skin leading to a "hooded" appearance to her vulva, and making her prone to skin infections in that region, which can (and have, in Maggie's case) ascend the urinary tract to cause bladder infections.
So before Maggie can have her first THR, she has to have her urinary tract infection resolved.
In order to keep her UTI from returning, she has to have her perivulvar dermatitis treated.
And her chronic, recurrent perivulvar dermatitis is almost certainly secondary to the abnormal shape of her vulva.
Which means that the news we delivered to Maggie's owners today was that, before we could even think about performing her THR, she'd have to have a vulvoplasty (classily described to the owners as a "facelift for the vulva" by the surgeon).
So we sent Maggie home today, following $400 of diagnostics for her recurrent UTIs, with a 2-week course of antibiotics (at a cost of $100 just for that single drug, due to Maggie's large size), with plans for her to return in a couple weeks for vulvoplasty. Then it'll be a couple weeks of recovery following that procedure, then we'll repeat many of the diagnostics we did today to ensure her infections have resolved, and then she'll be reconsidered for THRs.
As much as I love my pets, and as much as I admire the close relationships between Maggie and her owners, it still just kind of blows my mind that some people don't even bat an eye at the thought of spending what will probably be $12,000-14,000 by the end of it to get their dog in decent shape -- and all this before she's even a year and a half old.
The saving grace? Maggie's already spayed, so there's no chance she'll pass her crappy health genes (though wonderful temperament genes) on to another generation. :-)
My single appointment today reminded me just how much veterinary care can cost sometimes.
In a vet school/teaching hospital environment, it's often easy to forget that our clientele is not necessarily representative of the pet-owning population as a whole.
Our clients, as I'm sure I've mentioned in a previous post, come self-selected as a group of dedicated owners, most of whom have the time, energy, and especially money to "do whatever it takes" for their beloved pets.
On a rotation such as orthopedics, the vast majority of patients presenting to the service will head to surgery, for everything from limb amputations to fracture repairs to CCL repairs to corrections of congenital abnormalities to total hip replacements. The least inexpensive of the surgeries is, at the very minimum, over a thousand dollars.
So when you see these types of cases day in and day out (and it's not just orthopedics -- it's also the dermatology clients willing to commit $500 for skin testing for allergies, and $600/year for the rest of the animal's life for allergy shots -- and the neurology clients happy to drop $5000 to remove a ruptured disk from their Dachshund's back -- and the medicine clients who don't bat an eye at the $3000 bill for endoscopy and biopsies), it's easy to forget sometimes that in the eyes of a good percentage of the normal human population, spending thousands of dollars on a dog or cat's medical care just isn't something they can afford (or even want) to do.
Nonetheless, even seeing these clients every week who are unfazed by their enormous bills, I still run into the odd patient who makes me step back and re-amazes me with the staggering cost of vet care.
Case in point: Today's patient was a one-year-old exotic breed dog (one of those that you only ever see in the dog shows on TV, and have to struggle to pronounce) named Maggie. Maggie's owners bought her from a breeder as a young puppy.
Not too long after that, it became apparent that Maggie had some musculoskeletal issues. So when Maggie's rDVM spayed her at 5 months of age, he also took hip xrays while she was under anesthesia -- which revealed severe hip dysplasia on one side, already with evidence of arthritis, and moderate hip dysplasia on the other side.
Maggie and her owners made the 4 hour trip to the vet school about a month ago for an orthopedic consult. Given the severity of Maggie's disease (at merely a year old, she can barely walk because her hips are so painful, and has been on pain medication for most of her young life), the recommendation was to perform total hip replacements (THRs) on both of Maggie's hips, 8 weeks apart.
Maggie's owners said go for it.
Let's pause and consider that a single THR, without any significant complications, costs roughly $5500-6500.
Hope you didn't fall out of your chair. I almost did.
Now consider the fact that, in order to undergo a THR, a dog must be proven free of infection anywhere in its body that we can look -- so no fever, no elevated white blood cell count, negative urine culture, etc.
Maggie happens to have a not uncommon conformational abnormality of her vulva (external genitalia), wherein she has extra folds of skin leading to a "hooded" appearance to her vulva, and making her prone to skin infections in that region, which can (and have, in Maggie's case) ascend the urinary tract to cause bladder infections.
So before Maggie can have her first THR, she has to have her urinary tract infection resolved.
In order to keep her UTI from returning, she has to have her perivulvar dermatitis treated.
And her chronic, recurrent perivulvar dermatitis is almost certainly secondary to the abnormal shape of her vulva.
Which means that the news we delivered to Maggie's owners today was that, before we could even think about performing her THR, she'd have to have a vulvoplasty (classily described to the owners as a "facelift for the vulva" by the surgeon).
So we sent Maggie home today, following $400 of diagnostics for her recurrent UTIs, with a 2-week course of antibiotics (at a cost of $100 just for that single drug, due to Maggie's large size), with plans for her to return in a couple weeks for vulvoplasty. Then it'll be a couple weeks of recovery following that procedure, then we'll repeat many of the diagnostics we did today to ensure her infections have resolved, and then she'll be reconsidered for THRs.
As much as I love my pets, and as much as I admire the close relationships between Maggie and her owners, it still just kind of blows my mind that some people don't even bat an eye at the thought of spending what will probably be $12,000-14,000 by the end of it to get their dog in decent shape -- and all this before she's even a year and a half old.
The saving grace? Maggie's already spayed, so there's no chance she'll pass her crappy health genes (though wonderful temperament genes) on to another generation. :-)
Monday, July 18, 2011
Guess I should blog someday, eh?
I'm glad to be done with neuro. Although the second week with a different clinician was much, MUCH better than the first, it was still a draining, depressing rotation. It's not much fun to spend 10-12 hours a day seeing dogs that can't walk, dogs with brain tumors, dogs with fatal nerve diseases, dogs with spinal cord cancer, dogs with severe congenital birth defects and owners in denial.
But it's over now! And on to dermatology, which is.... unexciting.
Don't get me wrong, it's nice to have a change of pace for a couple weeks. Knowing that I really won't ever have to be here early in the morning, late at night, or on weekends to care for "dermatology inpatients" (haha, oxymoron) is pretty awesome. Spending last weekend at the Renaissance Festival 2 hours away, a friend's house for dinner, and watching the Harry Potter movie made for some pretty nice relaxation. And you won't hear me complaining about the fact that I've left at or before 5 pm on 4 out of the last 6 weekdays. No, I can see why some people are really drawn to dermatology. (Would I commit another 3-6 years of my life to an internship and residency to become a dermatologist? Um, no.)
However, any enthusiasm I had for seeing dermatology patients in the very first days of my rotation has long since worn off.
The dermatology schedule works like this:
Monday, Tuesday, and Thursday -- 8:30 am topic rounds, then a "never been here" appointment (new patient) at 9:30 am; rechecks every 30-60 minutes from 10:30 am until 2:30 pm.
Wednesday -- reserved for general anesthetic procedures (e.g. biopsies, ear cleanings) and any "emergency" patients that need to be seen sooner than they can be worked into the regular schedule (note: there are not really any true derm "emergencies," but there are dogs and cats that are very itchy, painful, or uncomfortable because their rDVMs have exhausted their resources on how to treat or manage said dogs and cats, so they need to see a specialist). During the rest of the day when we are not helping with appointments or procedures, we work on "unknown" cases that are supposed to make us think about differentials, diagnostics, and treatments when presented with a fictitious patient, history, physical exam, and pictures of lesions
Friday -- grand rounds at 8:30, then rechecks every 45-60 minutes from 9:30 am to 2:30 pm
As you can see, with only 3 new patients in most weeks, that adds up to a LOT of rechecks. And frankly, after going through "How's Maddie been doing since her last appointment? Fine? You feel like her allergies are pretty well under control? She's been doing fine on antihistamines, shampoos, and weekly allergy shots? No new lesions? No new concerns today? OK, let me get the doctor" about 10 times, you're just sort of over it. I feel like, among our recheck appointments last week, a good 75% of them had to be dogs that were undergoing therapy for allergies and pretty much doing just fine.
The dermatology department is having somewhat of a freak-out this week because last week was their last week with multiple dermatologists. Over the last several months, they have made a transition from a four-doctor team to a single dermatologist on staff (albeit with brand new residents due to start sometime later this summer, but likely to need lots of hand-holding and mentorship at first, understandably so). This means they are packing in as many appointments as possible, so that instead of seeing perhaps 4 appointments in one day (the previous "usual" schedule for a single doctor), we're now seeing 7 or 8 appointments. Add to that the fact that there are normally 4-5 senior students on dermatology, and last week and this week it is just me and one other student, and you've got some hectic, paperwork-filled days.
Part of what is also discouraging about dermatology is that so many of the cases require so much time to reach a resolution. Many of the rechecks we see have been coming to see the dermatologists for months or years. Even among the new patients we see, the ones that should have a skin test for allergies, or biopsies of lesions, or anesthetized ear cleanings, can't be fit into the schedule until several weeks down the road, or need to have their medications withdrawn so the tests will be accurate -- which allows for very little continuity with the patients we get to know.
My lone rotation-mate is a poor large animal tracker who is not required to take dermatology. Large animal trackers take 1 small animal "core" rotation of their choosing, selecting from dermatology, ophthalmology, cardiology, or oncology. My rotation-mate got placed in dermatology by accident (it was her last choice of the four), and tried desperately to switch out of derm into another rotation, but since there were only the 2 of us scheduled for derm (and the minimum number of students for derm is usually 4), she couldn't get out of it. The poor thing; she has zero interest in small animals, and we haven't seen a single patient or discussed a single case that wasn't a dog or a cat. Even worse, she greatly dislikes cats and has ended up stuck with both of the cats that we've seen in the last week. I personally think she's doing a remarkable job, given that half of the dermatology lectures I've had took place in a small animal course that she didn't even take. I can't imagine being thrown out into the barn as a small animal tracker thoroughly uninterested in large animals, and being expected to stay cheerful and engaged and do a decent job.
Anyhoo, my first patient tomorrow morning is an itchy (and hopefully cooperative) 6 year old kitty. Here's hoping I don't bring anything contagious home with me!
But it's over now! And on to dermatology, which is.... unexciting.
Don't get me wrong, it's nice to have a change of pace for a couple weeks. Knowing that I really won't ever have to be here early in the morning, late at night, or on weekends to care for "dermatology inpatients" (haha, oxymoron) is pretty awesome. Spending last weekend at the Renaissance Festival 2 hours away, a friend's house for dinner, and watching the Harry Potter movie made for some pretty nice relaxation. And you won't hear me complaining about the fact that I've left at or before 5 pm on 4 out of the last 6 weekdays. No, I can see why some people are really drawn to dermatology. (Would I commit another 3-6 years of my life to an internship and residency to become a dermatologist? Um, no.)
However, any enthusiasm I had for seeing dermatology patients in the very first days of my rotation has long since worn off.
The dermatology schedule works like this:
Monday, Tuesday, and Thursday -- 8:30 am topic rounds, then a "never been here" appointment (new patient) at 9:30 am; rechecks every 30-60 minutes from 10:30 am until 2:30 pm.
Wednesday -- reserved for general anesthetic procedures (e.g. biopsies, ear cleanings) and any "emergency" patients that need to be seen sooner than they can be worked into the regular schedule (note: there are not really any true derm "emergencies," but there are dogs and cats that are very itchy, painful, or uncomfortable because their rDVMs have exhausted their resources on how to treat or manage said dogs and cats, so they need to see a specialist). During the rest of the day when we are not helping with appointments or procedures, we work on "unknown" cases that are supposed to make us think about differentials, diagnostics, and treatments when presented with a fictitious patient, history, physical exam, and pictures of lesions
Friday -- grand rounds at 8:30, then rechecks every 45-60 minutes from 9:30 am to 2:30 pm
As you can see, with only 3 new patients in most weeks, that adds up to a LOT of rechecks. And frankly, after going through "How's Maddie been doing since her last appointment? Fine? You feel like her allergies are pretty well under control? She's been doing fine on antihistamines, shampoos, and weekly allergy shots? No new lesions? No new concerns today? OK, let me get the doctor" about 10 times, you're just sort of over it. I feel like, among our recheck appointments last week, a good 75% of them had to be dogs that were undergoing therapy for allergies and pretty much doing just fine.
The dermatology department is having somewhat of a freak-out this week because last week was their last week with multiple dermatologists. Over the last several months, they have made a transition from a four-doctor team to a single dermatologist on staff (albeit with brand new residents due to start sometime later this summer, but likely to need lots of hand-holding and mentorship at first, understandably so). This means they are packing in as many appointments as possible, so that instead of seeing perhaps 4 appointments in one day (the previous "usual" schedule for a single doctor), we're now seeing 7 or 8 appointments. Add to that the fact that there are normally 4-5 senior students on dermatology, and last week and this week it is just me and one other student, and you've got some hectic, paperwork-filled days.
Part of what is also discouraging about dermatology is that so many of the cases require so much time to reach a resolution. Many of the rechecks we see have been coming to see the dermatologists for months or years. Even among the new patients we see, the ones that should have a skin test for allergies, or biopsies of lesions, or anesthetized ear cleanings, can't be fit into the schedule until several weeks down the road, or need to have their medications withdrawn so the tests will be accurate -- which allows for very little continuity with the patients we get to know.
My lone rotation-mate is a poor large animal tracker who is not required to take dermatology. Large animal trackers take 1 small animal "core" rotation of their choosing, selecting from dermatology, ophthalmology, cardiology, or oncology. My rotation-mate got placed in dermatology by accident (it was her last choice of the four), and tried desperately to switch out of derm into another rotation, but since there were only the 2 of us scheduled for derm (and the minimum number of students for derm is usually 4), she couldn't get out of it. The poor thing; she has zero interest in small animals, and we haven't seen a single patient or discussed a single case that wasn't a dog or a cat. Even worse, she greatly dislikes cats and has ended up stuck with both of the cats that we've seen in the last week. I personally think she's doing a remarkable job, given that half of the dermatology lectures I've had took place in a small animal course that she didn't even take. I can't imagine being thrown out into the barn as a small animal tracker thoroughly uninterested in large animals, and being expected to stay cheerful and engaged and do a decent job.
Anyhoo, my first patient tomorrow morning is an itchy (and hopefully cooperative) 6 year old kitty. Here's hoping I don't bring anything contagious home with me!
Tuesday, July 5, 2011
Neuro cases
In response to a comment on a previous post, here are some of the cases we have seen on neurology over the last week and a half:
* Dachshund with a herniated disk
* Beagle with a herniated disk
* Basset hound with a herniated disk (seeing a theme?)
* Cat with probably peripheral nerve or muscle disease, likely due to a congenital enzyme deficiency resulting in a storage disease
* Border collie with left-sided paralysis caused by a huge brain tumor
* Mixed breed dog with diskospondylitis (infection of the intervertebral disk and surrounding vertebrae, in this case caused by Brucella)
* Shih tzu with only the mildest neurologic dysfunction, probably due to a clot to the spinal cord
* Chesapeake Bay retriever with a left-sided weakness and inability to walk, probably due to a lesion in the cranial cervical spinal cord
* Min Pin/Chihuahua mix puppy with seizures, hypertonicity in all 4 limbs, a severely extended neck, inability to walk, and neck pain -- probably one or more congenital defects
* Maltese with a right-sided weakness and concurrent knee injury
* Australian shepherd with hindlimb paralysis (probably a clot to the spinal cord)
* Shepherd mix with constant tremors in the hindlimbs when standing still
* Bulldog puppy with spinal cord empyema (pus-filled spinal cord)
Pretty exciting, eh?
* Dachshund with a herniated disk
* Beagle with a herniated disk
* Basset hound with a herniated disk (seeing a theme?)
* Cat with probably peripheral nerve or muscle disease, likely due to a congenital enzyme deficiency resulting in a storage disease
* Border collie with left-sided paralysis caused by a huge brain tumor
* Mixed breed dog with diskospondylitis (infection of the intervertebral disk and surrounding vertebrae, in this case caused by Brucella)
* Shih tzu with only the mildest neurologic dysfunction, probably due to a clot to the spinal cord
* Chesapeake Bay retriever with a left-sided weakness and inability to walk, probably due to a lesion in the cranial cervical spinal cord
* Min Pin/Chihuahua mix puppy with seizures, hypertonicity in all 4 limbs, a severely extended neck, inability to walk, and neck pain -- probably one or more congenital defects
* Maltese with a right-sided weakness and concurrent knee injury
* Australian shepherd with hindlimb paralysis (probably a clot to the spinal cord)
* Shepherd mix with constant tremors in the hindlimbs when standing still
* Bulldog puppy with spinal cord empyema (pus-filled spinal cord)
Pretty exciting, eh?
Is neuro over yet?
3 more weekdays of neuro rotation (not that I'm counting), +/- 2 weekend days if I'm unlucky and manage to snare an inpatient for the 4th weekend in a row.
Sigh.
I did get to visit the VTH on each of the 3 mornings of this past holiday weekend (self-pity much?). My inpatient was a 12 year old Beagle who had an acute onset of inability to walk on her hindlimbs on Thursday, which is when she came to the VTH. MRI on Friday showed spinal cord compression, probably due to an acute disk herniation, so off to surgery we went on Friday afternoon. What with 12 year old dogs not healing quite as fast as 3 year old dogs, and all that, the dear Beagle got to spend a "bonus night" in CCU, beyond the usual 2 nights post-op. She went home with her owners yesterday, just in time for me to start my second (and final!!!) week of neuro.
Last week was okay in some ways and annoying/frustrating/irritating in others. The "okay" part was that we got done pretty early in the day (and by "early" I mean that I usually left between 5:30 and 6:30). My weekly hours from Monday through Sunday totaled a mere 54 -- positively relaxing!
I guess that's all I can think of for the "okay" part. On to the irritating parts: The doctors (1 faculty neurologist and 1 neuro resident in her last week of residency) had very little interest in teaching us. They showed up late almost every morning, whether that was late to rounds or late to a morning meeting time we'd agreed upon over the weekend. They would blithely rush through procedures and exams with nary a word of explanation to us students, and often with a great sigh or eye roll if we dared to ask a question about what the heck they were doing.
The faculty neurologist in particular had a horrendous attitude toward just about everybody else in the VTH -- clients, interns, lab personnel, receptionists, other departments, etc. I'm not sure I ever heard him speak to or about somebody else without a tone of arrogance, condescension, and derision. As an example, one of the patients we saw had been referred to the teaching hospital by another board-certified neurologist about an hour's drive away. Upon hearing her name, instead of saying, "She's not one of my favorite people" or "I prefer not to work with her," our faculty neurologist stated, "God, I hate that f***ing woman." Professionalism, where are you??
This attitude continued: About a prospective client trying unsuccessfully to send digital video of her dog's neurologic signs, he commented "Are they stupid or idiots or just trying to make my day even worse?" There was a huge fiasco when the doctors were only able to obtain a small amount of spinal fluid during a spinal tap, and thus had to submit several slides of the fluid to the lab rather than vials of fluid, as is usually preferred. On the lab report, there was a comment about the results being limited because the submitted sample came in the form of slides, not actual fluid to work with. Our faculty neurologist flipped out, raging about how condescending the clinical pathologists were, how it was so out of line for them to imply that he was stupid or incompetent, and how he was sick of people trying to tell him how to do his job. When he received a page from someone saying "If you're not busy or you have a moment, could you please call code #11," he derided the caller, muttering "Oh, like I'm not busy? Like I'm just sitting here twiddling my thumbs just waiting for someone to page me?" One of my favorite occurrences was when the faculty neurologist and the resident walked into the (approximately 10' square) neuro rounds room, loudly discussing how the senior students that come onto neuro rotation are never prepared and can't remember even basic information and how frustrating it is to deal with all of us, when us 3 seniors were already sitting in the rounds room, and the doctors continued their conversation about our incompetence as though we weren't even there. (Never mind that they are the ones that have been teaching us neurology for the last 3 years; never mind that theirs is one of the only specialty departments in the VTH that doesn't provide an orientation handout or list of topics to review before starting the rotation; never mind that, although we are still student doctors with a great deal to learn, we are nonetheless human and don't enjoy being mocked.)
Teaching moments last week were very sporadic; we never had afternoon rounds and only had limited morning rounds due to the doctors' tardiness and disinterest in going through learning topics. After the first couple days, we gave up trying to ask questions and get explanations for things.
Well, fortunately both of those doctors are off clinics this week and we have the other faculty neurologist on with us. He certainly has his own quirks and isn't perfect by any means, but in relative terms, it's a complete 180 from last week. We spent probably 4 hours during the course of today just sitting as a group and discussing cases and topics. He asked us to start a list on the board of things we'd like to discuss in morning rounds. We actually had case rounds this afternoon. We were invited to come along to help with neuro consultations for other departments, rather than being left in the rounds room to wonder where the doctors had disappeared to. Best of all, there was no mocking or deriding anybody all day!
Neuro is still not my favorite rotation, and I'm greatly looking forward to its conclusion. But it's nice to see how a simple change in faculty can make all the difference in a rotation.
Sigh.
I did get to visit the VTH on each of the 3 mornings of this past holiday weekend (self-pity much?). My inpatient was a 12 year old Beagle who had an acute onset of inability to walk on her hindlimbs on Thursday, which is when she came to the VTH. MRI on Friday showed spinal cord compression, probably due to an acute disk herniation, so off to surgery we went on Friday afternoon. What with 12 year old dogs not healing quite as fast as 3 year old dogs, and all that, the dear Beagle got to spend a "bonus night" in CCU, beyond the usual 2 nights post-op. She went home with her owners yesterday, just in time for me to start my second (and final!!!) week of neuro.
Last week was okay in some ways and annoying/frustrating/irritating in others. The "okay" part was that we got done pretty early in the day (and by "early" I mean that I usually left between 5:30 and 6:30). My weekly hours from Monday through Sunday totaled a mere 54 -- positively relaxing!
I guess that's all I can think of for the "okay" part. On to the irritating parts: The doctors (1 faculty neurologist and 1 neuro resident in her last week of residency) had very little interest in teaching us. They showed up late almost every morning, whether that was late to rounds or late to a morning meeting time we'd agreed upon over the weekend. They would blithely rush through procedures and exams with nary a word of explanation to us students, and often with a great sigh or eye roll if we dared to ask a question about what the heck they were doing.
The faculty neurologist in particular had a horrendous attitude toward just about everybody else in the VTH -- clients, interns, lab personnel, receptionists, other departments, etc. I'm not sure I ever heard him speak to or about somebody else without a tone of arrogance, condescension, and derision. As an example, one of the patients we saw had been referred to the teaching hospital by another board-certified neurologist about an hour's drive away. Upon hearing her name, instead of saying, "She's not one of my favorite people" or "I prefer not to work with her," our faculty neurologist stated, "God, I hate that f***ing woman." Professionalism, where are you??
This attitude continued: About a prospective client trying unsuccessfully to send digital video of her dog's neurologic signs, he commented "Are they stupid or idiots or just trying to make my day even worse?" There was a huge fiasco when the doctors were only able to obtain a small amount of spinal fluid during a spinal tap, and thus had to submit several slides of the fluid to the lab rather than vials of fluid, as is usually preferred. On the lab report, there was a comment about the results being limited because the submitted sample came in the form of slides, not actual fluid to work with. Our faculty neurologist flipped out, raging about how condescending the clinical pathologists were, how it was so out of line for them to imply that he was stupid or incompetent, and how he was sick of people trying to tell him how to do his job. When he received a page from someone saying "If you're not busy or you have a moment, could you please call code #11," he derided the caller, muttering "Oh, like I'm not busy? Like I'm just sitting here twiddling my thumbs just waiting for someone to page me?" One of my favorite occurrences was when the faculty neurologist and the resident walked into the (approximately 10' square) neuro rounds room, loudly discussing how the senior students that come onto neuro rotation are never prepared and can't remember even basic information and how frustrating it is to deal with all of us, when us 3 seniors were already sitting in the rounds room, and the doctors continued their conversation about our incompetence as though we weren't even there. (Never mind that they are the ones that have been teaching us neurology for the last 3 years; never mind that theirs is one of the only specialty departments in the VTH that doesn't provide an orientation handout or list of topics to review before starting the rotation; never mind that, although we are still student doctors with a great deal to learn, we are nonetheless human and don't enjoy being mocked.)
Teaching moments last week were very sporadic; we never had afternoon rounds and only had limited morning rounds due to the doctors' tardiness and disinterest in going through learning topics. After the first couple days, we gave up trying to ask questions and get explanations for things.
Well, fortunately both of those doctors are off clinics this week and we have the other faculty neurologist on with us. He certainly has his own quirks and isn't perfect by any means, but in relative terms, it's a complete 180 from last week. We spent probably 4 hours during the course of today just sitting as a group and discussing cases and topics. He asked us to start a list on the board of things we'd like to discuss in morning rounds. We actually had case rounds this afternoon. We were invited to come along to help with neuro consultations for other departments, rather than being left in the rounds room to wonder where the doctors had disappeared to. Best of all, there was no mocking or deriding anybody all day!
Neuro is still not my favorite rotation, and I'm greatly looking forward to its conclusion. But it's nice to see how a simple change in faculty can make all the difference in a rotation.
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