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.

Ophthalmology

I just finished 2 weeks of ophthalmology. And I tried to blog about it. I really did.

But ophthalmology is such a boring and frustrating subject that living through cases once was enough for me, and I couldn't bring myself to re-hash any of them for you!

I saw a lot of corneal ulcers, cataracts, glaucoma. The usual eye stuff. Watched a bunch of cataract surgeries (which is cool to see the first time, then you never need to see one again because they are all the same).

We had a pig eye lab last Friday, where we sutured corneal lacerations and did conjunctival grafts on eyeballs. It was okay. Yesterday our lab was done on whole dead cats. We sutured eyelid lacerations, did third eyelid flaps, performed temporary tarsorraphies, and finally enucleated one or both eyes. It was disgusting.

I think I still hated necropsy more than ophthalmology, but ophtho was probably my least favorite of all of my clinical rotations involving clients and appointments. I'd even rather repeat orthopedics than spend another 2 weeks on ophtho!

So, adios, ophthalmology. I'm so done with you!

Slow learner

Remember Emmie, my oh-so-naughty rock-eating retriever?

Right, the one who was seen on SAIM for her third offense of rock ingestion requiring medical or surgical intervention?

Well, unfortunately we failed to find any underlying medical condition that would explain Emmie's propensity for gobbling rocks. And we had a stern heart-to-heart with Emmie's mom about how to manage Emmie's bad habit. And it seemed to take.

But today I looked back through the records of all of my SAIM patients, including Emmie. And much to my chagrin, I noticed that Emmie was seen 3 days ago at the VTH. For surgery. For eating rocks.

Sigh. *headdesk*

Apparently Emmie's owners aren't getting it. I think they are the slow learners in this scenario. Poor Emmie!

And the job search continues

I had 4 interviews in Minnesota and Wisconsin this week -- 2 initial interviews at hospitals in the Twin Cities area, and 2 all-day working interviews at hospitals in Wisconsin.

The working interviews are definitely a huge help in getting to know a practice. I'd previously had phone interviews with both of the Wisconsin practices, but that just isn't the same as spending all day with a hospital owner, their associates, office/practice manager, technical staff, and receptionists. It's a nice opportunity to see how everyone functions as a team (and how much yelling there is).

The shorter interviews I had in Minnesota were also helpful because it's nice to talk to people in-person instead of on the phone, even if it's only for half an hour or an hour. In both cases I got to talk to the practice owner along with either several associates or the practice manager, and in one case they showed me around their building too. Though I quite liked one of those two hospitals based on that brief interview, I would certainly want to arrange a working interview before committing to anything.

I could probably type for 3 days about all my interviews this week, but instead I'll summarize some of the "DOs" and "DON'Ts" I encountered this week:

Things I like to see or hear:

* Performing "COHATs" (Comprehensive Oral Health Assessment and Treatment) instead of "dentals" (#2)
* Having digital dental radiographs and actually using them (#2)
* Having ultrasound and using it (#2)
* A well-trained technical staff that is comfortable starting out the appointment, getting a TPR, obtaining a relatively accurate medical history, and doing a ton of client education (#1 > #2)
* A working relationship with the local humane society, within reasonable bounds (#2)
* Requiring or strongly recommending pre-anesthetic bloodwork on all patients (#2 > #1)
* A dedicated CVT assigned to every anesthetic case (whether surgical or dental) solely to monitor anesthesia (#1)
* Multi-parameter monitors including SPO2, EKG, pulse, and blood pressure (#1 > #2)
* Regular use of opioids as pre-emptive and peri-operative analgesia (#1 = #2)
* Hospitalizing patients overnight with no staff present as long as clients give informed consent (#1 = #2)
* Willingness to adjust anesthetic protocols based on an individual patient's needs (#2 > #1)
* Approach to diagnosis and treatment that actually includes seeking a diagnosis before randomly trying a trial treatment (#1)
* Recommending (with decent client compliance) screening bloodwork on healthy patients (#1)
* 3-year vaccine protocols (#1 > #2)
* When I ask why something is done a certain way, the reply includes a reference to a peer-reviewed study or a discussion with a specialist (#1 > #2)
* Ability to run a lot of bloodwork in-house, combined with daily pick-up service from an outside laboratory (#1 = #2)
* A lobby that smells delicious (#1)
* AAHA accreditation (#2)
* Being within a 1 hour drive from the nearest referral 24-hour care facility (#1)
* Having a technician on-call every night to help the DVM on call (#2)

Things I don't like to see or hear:

* Not performing an otoscopic exam on two patients in a row where such an exam was clearly indicated (a dog presenting for scratching the ears, and a cat presented for routine physical but with a lot of otitis found on PE) and instead saying "maybe next time" (#2)
* Giving all SQ injections between the shoulder blades, even in cats (#1)
* Having digital dental radiographs but admitting they are rarely used (#1)
* "The other practices around here don't really like us." (#1)
* Placing an IV catheter but not using IV fluids for "routine" surgeries (#1)
* Watching 3 certified technicians take about 6 total attempts to place a 24g IV catheter on a well-behaved cat (#2)
* Dentals performed by one lone technician in charge of monitoring anesthesia while also performing the dental cleaning and taking all the xrays (#2)
* Ignoring really crappy blood pressure readings on a patient based on the fact that their pulses feel okay; never monitoring blood pressure at all during a cat spay (#2)
* No place in the main treatment area to house hospitalized pets so someone can actually monitor and observe them (#2)
* Not having anywhere in exam rooms for the doctor to sit, resulting in either squatting on the floor or looming over the client (#1 = #2)
* A lobby that smells like eau-du-disinfectant-over-cat-pee (#2)
* Being 2 1/2 hours from the nearest referral 24-hour care facility (#2)
* Having an on-call schedule that includes 2 weeknights every week and every 3rd weekend (#2)
* Having an on-call schedule that includes 1 weeknight every week and every 4th weekend (#1)
* Not having a technician on-call to help with overnight and weekend emergencies (#1)
* The possibility of being expected to work a regular Sunday shift (#2)
* Observing a technician doing the initial check-in on a wellness exam and providing the client with complete misinformation about the hospital's puppy vaccine schedule and when to spay/neuter, and being repeatedly unable to convert between "14 weeks" and "3 1/2 months" (#2)

Both hospital #1 and hospital #2 had a lot of the pros and some of the cons. Overall, though, I liked hospital #1 better. I just feel like more of the "cons" that I found with hospital #1 are things that I could work around or do my own way. If I'm the one giving vaccinations, I can control where on patient's body I give the injection. If the practice has the physical capability for dental radiographs, I can talk to my clients about how important they are and see that they are used when needed (at least on my patients). As long as IV catheter is placed, fluids are available, and blood pressure is monitored, I guess I could live with not actually having fluids running in a young healthy patient with adequate blood pressure during a short procedure.

But with regards to hospital #2, I'm not sure how I feel about a hospital owner who feels it isn't "worth the effort" to do an otoscopic exam on a well-behaved, friendly pet with ear disease. I don't know how much I could do about a team of 3 CVTs who require 30 minutes to place and IV catheter on a health, friendly pet. I think it's incredibly dangerous to have a single technician trying to do a dental and monitor anesthesia at the same time, especially when my own observation shows that the CVT is ignoring (or just not noticing) some potentially alarming things with the anesthesia. Similarly, I think blood pressure is (in many cases) the most important parameter to monitor during anesthesia, particularly in cats, and particularly in the cat I watched who received acepromazine (which induces hypotension) as a pre-med and propofol (which also induces hypotension) as an induction drug and isoflurane (which also induces hypotension) as a maintenance inhalant.

Anyhow, I guess it's all moot unless I get offered both of these jobs at the same time. It sure goes to show the importance of working interviews, though, since I liked both of these practices quite a bit based on brief phone interviews and wouldn't have guessed at some of their differences.

I hate DKA

One of my final patients on internal medicine last week was a sweet little kitty named Jewel.

Jewel's owner brought her to the VTH because for the last 6-8 weeks Jewel had been peeing a lot more than usual. Her owner also suspected Jewel had lost some weight during that same period of time.

Somewhat surprisingly, Jewel had never seen a vet except for when she was spayed. For an 8 year old cat, I wish I could tell you that was unusual -- but it's not. The surprising part is that, instead of taking Jewel to a regular general practice vet, she made a specialty appointment to see internal medicine. This is the type of presenting complaint that can often be handled easily or at least initially worked up by a GP, but hey, we were happy to see Jewel if that's what her owner wanted.

The top 3 differentials for a middle-aged to elderly cat with PU/PD (polyuria [urinating excessively] and polydipsia [drinking excessively]) +/- weight loss are (1) kidney disease, (2) hyperthyroidism, and (3) diabetes mellitus. Fortunately, all of those diseases can be ruled in or out pretty simply by doing a CBC, chemistry, urinalysis, and T4 (thyroid).

Which we did in Jewel's case, and which showed a blood glucose of almost 400 (normal is about 80-120, though upset cats can get up to about 300 just from the stress of being in the hospital) and 4+ glucose in her urine (normal = no glucose). These results, in combination with Jewel's clinical signs, were highly suspicious of diabetes. To confirm, we submitted a fructosamine measurement. This measures a type of protein that gets extra glucose added onto it when the blood sugar is very high for a prolonged period of time. Thus, you can get an assessment of how well a patient's diabetes is controlled during the last 2-3 weeks. Jewel's fructosamine was 790, with a normal cat's being 200-350!

Jewel's owner handled the diagnosis like a champ. The day after we ran the lab tests that diagnosed Jewel's diabetes, her owner returned with her for a lesson in giving insulin injections. At that second appointment, Jewel's owner mentioned that Jewel had seemed very stressed after the previous day's visit and had hid in her carrier all night -- extremely unusual behavior for Jewel. We were not surprised, given that Jewel had basically never been in a carrier, car, or to the vet before.

We sent Jewel home with twice-daily insulin, urine ketone/glucose monitoring strips, and a gradual diet change to a prescription diet for diabetes -- along with extensive client education about diabetes and how it is managed. The next day, however, Jewel's owner called to let us know that Jewel had refused to eat her last 2 meals and had been vomiting overnight. These are never good signs in any cat, and especially in a diabetic, so we of course recommended that she bring Jewel in right away.

Jewel arrived through Urgent Care shortly before we left for the day. She was very lethargic and dehydrated. Repeat bloodwork and urinalysis showed that Jewel was now in diabetic ketoacidosis (DKA). Also known as a "diabetic crisis," DKA occurs in a diabetic when the animal undergoes excessive stress or has another underlying disease process such as cancer or an untreated infection. The body becomes unable to utilize glucose appropriately, so starts breaking down other tissues as a food source. Ketones are produced as a result (the "keto" in diabetic ketoacidosis), and the patient's body because very acidotic (the "acidosis" in diabetic ketoacidosis). Acid-base balance (pH) is extremely crucial to survival. All of the enzymes that control every process in the body only function at a certain pH, so if the body becomes very acidotic, those enzymes can stop working, resulting in organ failure and death.

DKA can be an ugly, labor-intensive, and costly condition to treat. However, if the underlying disease process that kicked off the crisis can be discovered and treated, and if the owner can commit to a multiple-day stay in the hospital and potentially $2-5000, DKA is often treatable. Fortunately, Jewel's owners seem to be in it for the long haul.

Unfortunately, Jewel's case has another complicating factor. Because Jewel refused to eat for several days, she developed a secondary condition called hepatic lipidosis ("fatty liver disease"). Somewhat similar to DKA, hepatic lipidosis occurs when a cat is not eating, so the body utilizes fat stores. If this goes on for long enough, the liver gets overwhelmed by fatty deposits and becomes unable to function appropriately. The treatment for hepatic lipidosis is supportive care (which often means force-feeding, using a nasoesophageal tube, or an esophageal or gastric feeding tube), but even then some of these patients still die and we don't know why.

The good news is that Jewel seems to be improving, after 5-6 days in the hospital. She still doesn't want to eat but has been getting some nutrition from a tube placed through her nostril into her esophagus.

The bad news is that Jewel's primary clinician and I both feel terrible about her developing DKA. We have blood and urine results from Jewel's first visit that prove that Jewel was not in DKA at that time -- her pH balance was normal and there were no ketones in her urine. But when she came back 2 days later, inappetant and vomiting, she was absolutely in DKA as evidenced by huge changes in her labwork.

The frustrating part is that the massive stress alone from Jewel's first visit (where we ran the initial diagnostics that revealed her diabetes) was probably enough to kick her into DKA. Once we diagnosed her DKA, we went on a "hunt" for an underlying cause, including other lab tests, ultrasounds, and x-rays, but found nothing. I feel bad that we didn't have a suspicion of underlying illness on Jewel's second visit to us, when we showed her owner how to give insulin shots and she mentioned that Jewel had hid in her carrier all night. However, I doubt there would have been much we could have done differently at that point anyway, other than potentially catch Jewel's DKA a day earlier -- though that probably wouldn't have changed the outcome.

This case was very educational for me (as was almost every case I saw on internal medicine -- one of the benefits of that service!). It taught me a lot about the initial management of a newly diagnosed diabetic, as well as treatment of DKA. And, especially, it taught me never to underestimate the sensitivity of a diabetic patient to stress and illness, and not to assume that a patient's odd behavior can be attributed solely to a known stressful event the day before.

Internal medicine = busy (again)

Internal medicine is picking up speed as the week progresses. I had a relativly easy start to the week, with 2 hepatitis patient rechecks on Monday and my rock-eating buddy Emmie on Tuesday.

Yesterday, I had a dog with a 10 month (yes *10 month*) history of straining to defecate and fresh blood in his stool. After much rectal examination and poking with many needles, we diagnosed him with a perianal gland tumor, which, in his case, probably has few treatment options. His owners elected to try a diet change, antibiotics, steroids, and stool softeners to see if they can keep him more comfortable for a little while.

My second patient yesterday was a transfer from Urgent Care -- a DKA (diabetic ketoacidosis, "diabetic crisis") dog also with severe pancreatitis and a gallbladder mucocele. The mucocele was a "bonus" find on the ultrasound. Mucoceles generally head to emergency surgery, but this poor kiddo is so sick that we're taking a chance with managing her medically for awhile, and hoping her gallbladder doesn't burst in the meantime. It's a really interesting case, and I hope to have time to blog about it soon! However, as these things go, the more interesting and busy the caseload is, the less time for blogging...

Lesson #895: Don't eat rocks

Yesterday's internal medicine patient was a 9 month old Lab named Emmie.

Emmie presented with the complaint of rocks in her stomach. Upon further discussion with Emmie's mom, I learned that this is Emmie's third offense of rock-eating in the last 4 months, with the first 2 offenses requiring abdominal surgery to remove (count 'em) 7 rocks the first time and 15 the second time.

After Emmie's second offense, her mom completely re-landscaped the yard and thought there were no rocks left for Emmie to access. However, Emmie discovered a hidden cache of rocks and gleefully chowed down.

Two days earlier, Emmie vomited up 5 rocks at home. Her mom brought her to an ER clinic, where vomiting was induced and Emmie produced another 5 rocks. However, abdominal rads showed that Emmie still had 4 rocks in her system.

Emmie spent a day at her rDVM on fluids, hoping the rocks would pass one way or the other. However, repeat radiographs yesterday morning showed 3 rocks in Emmie's stomach and 1 in her colon.

Since Emmie's mom (understandably) didn't want Emmie to have a third abdominal surgery at the tender age of 9 months, she hoped we could get the rocks out endoscopically.

Endoscopy requires general anesthesia, but once a scope is passed through the mouth and esophagus into the stomach, it is often possible to retrieve foreign objects like rocks, coins, hair bands, and tampons using graspers or a wire basket to pull the objects out through the mouth. In most cases, surgery can then be avoided, though in a few disappointing cases, the objects cannot be removed endoscopically and the animal ends up in surgery anyway.

Emmie's first two rocks came out with moderate difficulty. The rocks were very smooth, so kept sliding out of the wire basket. However, within about 30 minutes of starting the procedure, we were 2 down with 1 to go.

The third rock was the smoothest, and was also very long and thin, so it was difficult to get the basket seated around the rock without the rock just slipping out. But after about 2 hours of trying for this rock, with the combined efforts of 3 boarded internists with massive combined experience using the endoscope, the last rock was finally retrieved! In comparison, this type of foreign body removal is usually accomplished in about 45 minutes.

Emmie's mom was thrilled to have her leaving the hospital the same day, with nary an incision, suture, or cone of shame. Now the hard part begins again -- keeping Emmie away from rocks for the rest of her life! It's possible that Emmie may have an underlying disease process like a liver shunt or exocrine pancreatic insufficiency, that may be causing a nutritional deficiency that makes her feel like eating rocks (which is called pica -- a desire to eat non-food objects). But given that Emmie has seemed perfectly healthy her entire life except for eating rocks, it's probable that her rock-eating is simply an annoying habit that will have to be managed. Say hello to the basket muzzle!