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VetInfo Digest January 2004

Mistakes Veterinary Clients Make:

Crate and Leashes
Pay attention to puppy and kitten needs
Weight Control Issues
Flea Control Mistakes
Too good to be True
Heartworm Treatment
Don't buy medications you can't give
Injections for all?
Plan for Emergencies
No one there at night
If money is important keep track of it
Don't be distracted
Dangerous Pets
Is a post mortem exam necessary?

This Month's Note:
Your vet is a human being. Humans have a tendency to keep working when they are tired, sick, distracted and in some cases even when impaired by medications, alcohol or illicit drugs. At times it is obvious that something serious is affecting your vet's performance of his or her job. If so, end an office visit as diplomatically as possible and leave. If the situation is an emergency or serious illness you may have to find another veterinarian. Leave anyway. You are the only protection your pet has in this situation and you must be willing to accept this responsibility if necessary. If your vet is generally good but you have just managed to hit a really bad day, reschedule for a better time. I know that I have gone to work some days when I shouldn't have because I was too sick or too tired to do a really good job. When I realize after such a visit that I should have done better, I call and check on the pet and schedule a recheck if necessary but there are probably times when I don't even recognize that I wasn't at my best. Don't hesitate to reschedule a visit if necessary and don't be afraid to say to your vet that he or she seemed distracted or tired on the last visit and that you weren't sure that your concerns were fully dealt with. I know when there is truth in those statements and I suspect that most other vets do, too. I am usually willing to make amends by not charging for the recheck visit or by taking more time on the follow up visit to answer questions. Your vet probably will do this, too.
During my career I have been asked to come in for an emergency only once when I was intoxicated. It was a little embarrassing to tell the client I was too incapacitated to perform surgery. It was almost shocking when the client told me I was lying and wanted me to come out and do a cesarean section on their dog, anyway. Vets really are human. We do sometimes have to admit that --- don't make this harder by refusing to believe it.

Mistakes Pet Owners Make
There are a number of common mistakes that veterinary clients make in caring for their pets. I am hoping that putting a list of these mistakes together will help people avoid them. There are times when it is appropriate to do some of the things that are listed here but in general they should be avoided.
Crates and Leashes
Most cats get nervous on car rides. Most cats aren't really comfortable in new places. Putting your cat in the car and bringing him or her to the vets is a pretty traumatic event for many cats. When cats are frightened they are not likely to cling to you for comfort. They are more likely to take off and try to find a place to hide. Even calm cats can have frightening experience on the way from the car to the veterinary clinic's front door, such as an encounter with a big dog or hearing a car or truck backfire. It is always best to bring your cat to the veterinary office in a pet carrier, with the possible exception of cats who are leash trained and do very well on a leash. It just isn't work taking a chance that your cat will get out of your arms and run into traffic or run off and hide where she can't be found. Buy a good cat carrier and use it to take your cat to the vet.
Dogs should be trained to walk on a leash and should be brought to the vet's on a leash. While dogs are a little more likely to come to their owners when there are frightened than cats are, they still get loose at times and they can still have encounters with other dogs or with overly inquisitive people. When these things happen it is very helpful if your pet is on a leash. If there is an aggressive dog in the waiting room, particularly one with an owner who is not paying attention, it is a good idea to ask the receptionist if you can wait in another spot or if it is possible to put one of the dogs in one of the clinic's cages to defuse the situation until the dogs can be seen by the vet.
I can't speak for all vets but I think that might be helpful to some of you in understanding your vet if I tell you that I almost automatically assume that a dog who wears a harness instead of a collar will bite me if I'm not careful. It might sound judgmental, but it is one of those "rules of thumb" that tends to hold true in our practice.
Pay attention to Puppy and Kitten Health Prevention Measures
Young animals are more susceptible to illnesses than adult animals, at least in general. Vaccinations are important in preventing illness in pets in this age range. Save arguments about whether to vaccinate or not for older pets -- puppies and kittens need vaccinations starting by 6 to 8 weeks of age. At least one vaccination in the kitten and puppy series should be given at 12 weeks of age or older. Rabies vaccination is required by law between 12 and 16 weeks of age in most states.
It is best to adjust the vaccine components to match the expected risks facing a puppy or kitten. It is reasonable to avoid feline leukemia (FeLV) vaccination if a kitten is kept inside continuously and lives alone or with another known FeLV negative cat, for instance. If your veterinarian wants to use every vaccine available and isn't interested in evaluating the relative risk of diseases based on your pet's lifestyle there is reason to be suspicious of the advice and to think about getting a second opinion from a veterinarian who will discuss vaccine recommendations on a case by case basis.
Heartworm prevention medications should be started by the time puppies and kittens are six weeks of age during times of the year when heartworms transmission can occur. It is often acceptable to start medications at a later age when puppies are born in the cooler months. A puppy or kitten born in January in Virginia wouldn't need heartworm prevention medications until May or June, for instance. When we discuss health prevention with new puppy and kitten owners it is surprising how many of them have the idea that heartworm prevention medications should not be started until a puppy or kitten is six months of age. This is the earliest age that it is possible to test for heartworms but not the time when prevention medications should be started.
Weight Control Issues

At some point during most of the discussions we have with pet owners about their overweight pets, there will be this statement, "I can't feed him less, he'd starve." It seems self evident that this statement isn't true. If you are feeding a pet enough that it is overweight, it is getting too much to eat, period. For dogs, there is no lower limit to the amount that you can feed when weight loss is necessary. Dogs appear to be able to sustain long fasts without metabolic damage. While this isn't true for cats, it is true that you can cut down on the amount that you are feeding and help your cat lose weight over time.
It is hard to control weight in multiple cat households when cat food is left down all the time. This is by far the easiest way to manage feeding groups of cats and it is sometimes the only practical way to do it. In this situation it doesn't seem to help much to use weight control diets as the heavy cats just eat more of the foods. To control weight in one cat in a group it may be necessary to go to controlled feeding (two or three meals and no food in between) for all cats, or to isolate the cat who needs to lose weight, if the situation is critical.
The most important thing to remember is that if weight control is important it is possible for you to help your dog or cat lose weight. It is hard in many cases, but it is possible.
Common Mistakes When Treating Fleas
When treating pets for fleas it is necessary to treat all the cats, dogs and other pets that might support fleas in the household. This is especially important if one of the pets in the house is allergic to fleas. You can not control flea allergy signs without completely eliminating fleas and you can't completely eliminate fleas unless you treat all the pets in the household. The new flea products will usually control fleas with treatment of the pet alone, but if your pet has flea allergy it can be very beneficial to treat the house or pet's environment for fleas, too. In truly "flea rich" environments house or yard treatment may be necessary to completely eliminate fleas for any pet, not just the flea allergic ones.
There are only three really good adult flea control products on the market. These are fipronil (Frontline, Frontline Topspot Tm), imidocloprid (Advantage Tm) and selamectin (Revolution Rx). It is necessary to use an adulticidal flea control product when pets have flea allergies. Lufenuron (Program Rx) is a product that will inhibit the flea life cycle. If it is used long enough and in a controlled environment, such as a fenced yard or inside the house and if it is used for all pets in the household, it will eventually work to control fleas, usually taking 4 to 5 months to do this. A slow approach to killing fleas is probably OK for pets who do not have flea allergies. Nitenpyram (Capstar Rx) is also a very efficient adult flea killer. It will kill all the fleas on a pet within a few minutes. However, it has no residual action at all, so any fleas that hop back on the pet in few hours are unaffected by the nitenpyram. A combination of lufenuron and nitenpryam twice weekly for a month and then on an "as needed" basis should be effective for flea control if you don't mind using two products or if you have an aversion to the topical products.
Itching alone is not an indication that flea treatment has failed. If you are using a good flea control product and itchiness continues it is necessary to check for fleas to see if they are present and to consider other causes of itching if they are not. Stopping the flea control products just makes it harder to distinguish between itchiness caused by fleas and itchiness occurring for other reasons.
If it's too good to be true, it probably isn't.
This is one of those truisms that works in a lot of different situations and medicine is one of them. People who don't like to spend money want inexpensive treatments that work for their pet's problems. People with pets who have disorders that require a great deal of time or effort to control want to find hassle free ways to treat their pet's problems. People whose pets have terminal illnesses want to find a miracle.
People who want to make money dream up ways to sell things to people looking for cheap alternatives to real treatments. In some cases these people are clever enough to sell inexpensive, and usually ineffective, remedies that they claim take a long time to work. This has two advantages -- the pet may get better despite ineffective therapy and the remedy is credited -- even better, an inexpensive treatment that you have to give repeatedly can add up to a lot of money over time. It is usually better to make an accurate diagnosis and then to use medications that have been shown to work for the condition diagnosed. Over the long run this is probably the least expensive option for most pets, as well.
If your pet has a chronic illness that is obviously uncomfortable, such as lower urinary tract disorders in cats, the desire to do something to stop the discomfort can overcome reason. At this time, for many of these cats, there is no known effective treatment. Not doing anything will result in resolution of the clinical signs as fast as giving antibiotics, anti-inflammatories and other medications. Avoiding the use of ineffective medications can be tough but is probably better for your pet. Unfortunately, there are a number of conditions for which we simply do not have effective treatments at this time so some discomfort is unavoidable in some cases. This is true for people, too. We live with out chronic problems and pets can do this too, when it is necessary.
Heartworm treatment
It has become evident over time that ivermectin based heartworm prevention medications are capable of causing adult heartworms to die sooner than they would if allowed to live out a natural lifespan. In specific situations this effect is potent enough that ivermectin used continuously on a monthly basis for approximately a year can kill adult heartworms. This is true when the ivermectin is started prior to the time the heartworm is about 8 months of age. It is important to note that heartworm tests currently can not detect heartworm infection until the heartworm is about 6 months of age -- meaning that there is about a two month window when the test can be positive and the use of ivermectin can be very helpful in eliminating the adult heartworms.
This situation does not seem to be well understood among veterinary clients or even veterinarians at this time. If adult heartworms are present they continue to cause harm to the dog, even if they are weakening and dying over the course of a year or so. Accepting this situation is reasonable in the case of a young dog or in a situation in which it is obvious that the heartworm infection is very recent.
When heartworms have been present for a long time ivermectin has very little effect on them. Using ivermectin to try to clear a heartworm infection in this situation is not justified because the damage caused by the heartworms continues to occur. We have treated severe complications from heartworms in patients in which this approach has been tried on several occasions now. There is a heartworm treatment for adult heartworms using melarsomine (Immiticide Rx) that is effective against adult heartworms. This treatment is somewhat expensive and it has some risk of causing severe complications, including death. It would be great if there were a nontoxic, relatively inexpensive treatment for heartworms but there isn't -- this is another situation in which something that sounds too good to be true really is too good to be true, most of the time.
Buying Medications You Can't Give to Your Pet
If you can not give medication to your pets it is necessary to tell your vet. If your vet encourages you to try, anyway, and you have already learned from past experience that you can't give medications to your pet don't give in and take the medications knowing that you aren't going to give them. It may cost more to find an alternative to a medication, such as daily injections or arranging for the medication to be made into a flavored form but it doesn't make sense to pay less to get a medication you can't use at all.
There is a new approach to pill giving in areas in which Waltham products are available (ask your vet). This is a pre formed treat with a cavity made to hide pills in. It is probably a little easier to use than cheese spread or peanut butter and has fewer calories.
For cats who are extremely difficult to give oral medications to it is sometimes possible to use transdermal medications. These are medications mixed by a compounding pharmacy into a gel that is absorbed through the skin. Not all medications will work with these gels but they can be a real help for conditions like hyperthyroidism where daily medication may be necessary for years. These medications will also work for dogs but we don't use them much because dogs tend to be easier to give oral medications to.
Don't forget about the availability of compounding pharmacies. These are pharmacies with the equipment and expertise to make changes to medications in order to make the more palatable or to make dosing easier. This is particularly important when it is necessary to use human medications in small pets where dose size may have to be adjusted dramatically. Some veterinarians have purchased the equipment and compounds to make flavored medications so don't hesitate to ask if it is an option when you know other forms of medication will be hard to give.
Even if you have to accept going back to your vet every day to get an injection of a medication for your pet it is better than not giving a truly necessary medication. If a medication isn't absolutely necessary and is difficult to give, it is reasonable to live with the problem it is meant to correct. If your dog has minor arthritis pain but won't take pills it is reasonable to wait awhile to start pain medications, for instance.
Injections for Everyone?
I have a few clients who seem genuinely miffed at me if I don't give their pet an injection during an office visit. I also know a few vets (fortunately not many) who insist on giving every pet an injection during any visit, either as a method of increasing the cost of some visits or to save questions like "I spent $40 for an office visit and my pet didn't even get an injection?"
Some medications only come as injections. Some medications really do seem to work better by injection even when an oral form is available. If a pet has a condition that may interfere with medication absorption from the digestive tract, such as vomiting, diarrhea or complete inappetance it may make sense to use injectable medications. There are lots of other reasons that injections might be necessary. However, for many medications, the difference between an injection and oral administration of the medication is minimal.
If your vet is putting your pet on antibiotics for a skin condition, an injection of the antibiotic will probably result in it being available to fight infection about 30 minutes faster than if it is given orally. When a medication is going to be used for three or four weeks to gain control of an infection, that half hour hardly seems to make much difference. I think that it is reasonable to ask if injections are necessary and for an explanation of the advantages of injection over just starting with oral medications for the pet's condition.
Plan for Emergencies
If you own a pet there is a chance that you will one day have to deal with an emergency situation. It is much better to have a plan in place for dealing with emergencies than to try to make one up as you go along after finding that your pet has eaten all of your blood pressure pills at 2 AM one morning.
It is important to know who will care for your pet after hours. Many veterinary hospitals now refer to an emergency clinic at night. If you know this in advance it can save the time and effort necessary to call your vet, listen to a recording and to try to get the phone number from the recording. If you have driven to the emergency clinic at least once prior to needing its services you can save unnecessary delay as you try to find the place in the middle of the night in a state of panic.
If your vet will accept night time emergencies but doesn't publish a phone number to call for this service you have to get the phone number before you have an emergency. This isn't an uncommon practice since veterinarians who publish an after-hours phone number often end up doing emergency work for many people who are not regular clients.
Have enough emergency cash or a credit card set aside for emergency use so that you have enough money to pay for emergency services. The emergency veterinary clinics have a relatively high rate of nonpaying customers and many will refuse to see a pet without payment when they finally have to face the fact that being paid is a necessary part of providing services. If you can't save up for emergencies you might be better off having pet health insurance. Like all insurance policies you have to buy pet health insurance before you have an emergency.
Have a crate or pet carrier for your cat. Be prepared to pick up and move your dog if he or she is injured. There are very few pet ambulance services in the U.S., so you must be ready to pick up and move an injured pet. If your dog is very large using a folded blanket as a stretcher works pretty well. Having a muzzle or stretch gauze to make a temporary muzzle with is very helpful in emergencies. Make sure that you can handle moving your pet before you need to. If you can't, then you need to make some kind of arrangement with friends, or possibly with your vet, to make sure someone is available who can help you move your pet in an emergency situation.
Assuming that a veterinary hospital is staffed at night
I think that it is possible that most veterinary clients assume that their veterinarian's hospital is staffed all night. In reality, this isn't the case most of the time. Veterinary hospitals which are staffed at night tend to have signs that say something like "24 Hour Care". If your pet is going to be alone from 6 PM to 8 AM, it is better off at home with you, almost without exception. If care is necessary from day to day, take your pet home at night and bring her back in the morning. If your pet needs around the clock care it may be possible to find a 24 hour care facility near you. It may also be possible to take your pet to an emergency clinic at night and then to bring your pet back to the veterinarian's office during the day. Any of these options is better than leaving your pet overnight when no one is there.
If the Total Fee is Important to You, Keep Track of Charges as you go along
Every now and then we have a client who becomes quite upset over the total cost of a visit or over the total cost of an illness that has taken several visits to resolve. In almost all cases we kept the client informed of the price of testing, services and medications as we went along, although we usually aren't adding the prices up during the visits. If the client wasn't paying attention and adding up the costs as we went along the total may have been surprising even though they were informed.
If you want the best possible care you have to be willing to pay for it. If you are sensitive about costs then you may not be able to provide the best care, but you can make choices that give the best chance of success for the amount of money you are willing to spend. Doing this takes two way communication with your vet. I really think that most vets want to provide the level of care that people can afford and to provide the best possible care for that price range, but they have to able to explain the whole picture to you in order for you to make reasonable decisions about where to spend your funds for best effect. So keep track of what has been spent, let your vet know when you are uncomfortable about expenses and if you are concerned your money will run out before the diagnostic testing is done, tell your vet what the spending limits are. If you can't talk comfortably about costs and about risks and benefits of various diagnostic and treatment plans then you may want to find another vet. If you can't accept increased risk as a tradeoff for lower cost and your vet senses this, expect him or her to be uncomfortable providing services and to possibly even ask you to find another veterinary hospital to deal with. When it is not possible to provide optimum treatment everyone needs to be in on the decision making process so that the best possible choices can be made within the required budget and everyone needs to know how this affects the risk of an adverse outcome. If you aren't willing to participate in this discussion you are not willing to do the most that you can for your pet.
If you really need to know how to care for your pet, bring it yourself and leave distractions at home.
I have three or four clients who always send their spouse with the pet and then call me to find out what happened during the examination because they can't get information from their spouse or they don't trust the information they are receiving. If you don't trust your wife's or husband's handling of your pet's care come to the office with the pet yourself. It is easier on everyone.
I also have clients who come to the office and then must go home to confer with their spouse about what to do with information we give them. This is OK for most situations but doesn't work well at all in emergencies. If you need your spouse's support, or a friend's support to help make decisions about pet health care bring them to the office with the pet.
Try not to send your children alone with your pet, especially children who aren't old enough to make a legal contract with the vet. This is a difficult situation for veterinarians, especially when a pet needs immediate care. Trying to make health care decisions in an emergency when only children are present can have a severe impact on health care in true emergency situations. We have had children as young as 12 bring a pet to our office without a parent present. For some reason the people who provide the rides almost never have input into the decision making. In some instances we simply have to refuse care when an adult is not present.
If you have to have a representative, such as a neighbor or friend, bring your pet to your vet's, make sure that he or she has money to pay for the care or is willing to take financial responsibility for the care. We have had to refuse to provide at least some types of care on several occasions when the neighbor or friend refused to sign an authorization for procedures for which they had to assume financial responsibility.
If your pet is ill and you need to hear the information that your vet is providing about your pet's health care needs it is best not to have very young children with you. There are a lots of times when having children in the examination room is fine and doesn't interfere with the examination of a pet or the flow of information and it is likely that most yearly physical examinations and most simple procedures, such as heartworm examination, are not impacted by a child's presence, even if the child is unruly. When a pet comes to the vet and a serious medical problem is present that requires a lot of input from the pet owner to resolve it is best if children are not present. Having children in the exam room can have a major impact on a client's comprehension of the information we are trying to pass on and even on the ability to accomplish some medical procedures. When it seems important for you to be able to pay complete attention to what your vet is doing and saying it is best to leave children at home.
Is Your Pet Truly Dangerous?
I have a few clients whose pets are truly dangerous and who are absolutely oblivious to the situation or are in complete denial of the obvious. A pet who bites family members viciously and without warning is dangerous and appropriate steps must be taken to control the behavior.
This may sound unreal but I had a client who brought her dog in for examination to find out if a medical problem was causing aggressiveness. The dog had attacked her husband three times, putting him in the hospital twice. She said, "He isn't such a bad dog, he's never gone for my husband's throat, or anything like that." She seemed sincere in the belief that her dog didn't mean to be doing great harm unless it was going for the carotid artery.
If your pet bites someone, even if you think it was reasonable to bite under the circumstances, you have to accept that your pet will injure someone under certain circumstances. When this happens it is important to get good advice for dealing with the aggression from someone who is experienced in dealing with aggression.
Don't pick up the Yellow Pages (tm) and call the dog trainer with the prettiest ad. If possible, find a board certified veterinary behaviorist. If this isn't possible a certified animal behaviorist is a good second choice. A veterinarian with a strong interest in behavior is probably next, although there are some very good dog trainers who really understand aggression. For either of the last two choices it is definitely best to talk to people who have used the services of the vet or trainer and can explain how they work and to think about whether that system will work for you and your pet. No matter what else you do, you have to accept responsibility for preventing future bites. If you can't do this you must either seek help or consider euthanasia. It is unfortunate but a dangerous pet can cause serious harm to people and can also ruin your financial future through lawsuits or even jail time.
Closure -- Is a post mortem exam necessary?
The thought of having a necropsy examination (autopsy, post mortem examination) done when a pet dies is often upsetting to veterinary clients. Veterinarians rarely offer to do an autopsy or to arrange to have one done because the reaction to the suggestion is often bad, especially when death was unexpected. However, a necropsy examination is often the only way to find out exactly why a pet died. When this information is critically important, such as when a pet dies in a veterinarian's care, it is best to have a board certified pathologist perform the necropsy examination. This can be arranged through several national laboratories, most veterinary schools, some state laboratories and in some private pathology facilities. If you prefer not to have your vet make the arrangements it is possible to go to another vet specifically to get a referral for post mortem examination or for the examination itself.

It is important to realize that even a necropsy examination may fail to find a cause of death in some instances. This isn't an especially common outcome but it does happen. More often, it is possible to identify a specific cause of death and sometimes to find contributing factors that make a big difference in how death occurred. Knowing the cause of death when other pets might have been exposed to an illness, when people might have been exposed or when there are serious questions about whether the death was due to negligence or inadequate care can be the difference between years of wondering why and being able to accept a death and move on. Even when the outcome isn't this good it can at least alleviate guilt or make it clear that a good effort was made to prevent death. In worst case scenarios, such as when it is clear that a surgical or medical error was made, at least the cause of death is known and everyone can learn from the situation if that is adequate or you can pursue legal action if you feel it is necessary.
I almost always learn something from necropsy examinations when my clients allow me to do them. This is still true after almost 25 years of practice. If your vet asks if it is acceptable to do a necropsy exam at the vet's cost please consider allowing it. If you have a strong need to know why your pet died, it is worth paying for a necropsy examination. If you feel that you have to know what happened because you would consider legal action, or you just have to know to have peace of mind, consider having a board certified pathologist perform the necropsy examination. This can be somewhat costly but it really might save years of feeling guilty or wondering why a pet died.
This is a decision that is difficult to make right when a pet dies. It is much better to think about how you feel before having to face this decision and to decide way in advance if you are the type of person that has to know what happened. If so, plan on asking for a post mortem exam unless the cause of death is clear to you.

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The opinions expressed in this newsletter are those of Michael Richards, DVM., author.
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This page was last edited 06/15/04
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