VetInfo Digest

February 2008

Table of Contents:

All about me and January

This month’s note:

Last month (December 27^th), I had a heart attack. I thought that it might be helpful to examine what someone like me, who spends a great deal of time providing medical care and dispensing medical information does when faced with a strong need to obtain medical help and information, instead.

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I have to start by explaining that dogs and cats do not normally have heart attacks because they do not normally form athlerosclerotic plaques. So this is not a syndrome that I am very familiar with from a medical standpoint. I started out about as well informed about my condition as most of the pet owners who come in with pets are informed of conditions affecting their pets.

The first thing about having a heart attack is recognizing it. For this I am grateful that there is so much information available about the symptoms of heart attacks. When I woke up at 4 AM with chest pain and pain down my left arm, I knew that it was important to take the situation seriously.

The second thing that you have to decide when facing a medical crisis is where to go for help. This is much easier for humans than for pet owners, for the most part. Moe drove me immediately to the emergency room of our local hospital. I have to admit that it never even occurred to me to wonder if that was the best choice. I did have a choice between hospitals and they use different cardiac specialty practices, so there was some practical advantage to knowing in advance where I wanted to go. Fortunately, I don’t think there was a major difference in these choices, at least for this particular problem. However, I would recommend not only thinking about where you want to go in an emergency but where that will take you if more in-depth care is necessary, both for you and for your pets. This is most important if you happen to own a breed with known health problems where it may be important to get emergency help and then proceed to the best possible specialist.

So I arrived at the emergency room and said what must be the magic words for emergency rooms, “I have chest pain and my left arm hurts.” They didn’t even ask for my insurance card before rolling a gurney under me and heading for a room where an ECG and blood testing could be performed. I was truly impressed by the speed with which the hospital acted. This is one reason to consider going to an emergency veterinary clinic rather than your usual veterinarian in an emergency situation. They are prepared for emergencies and are often better staffed and equipped to deal with them, at least during the off hours for your usual veterinary clinic. Unfortunately, I know that this is not always the case. At times veterinary emergency clinics get overwhelmed with cases and it can take some time to be able to see the veterinarian. In this situation I wish that I knew magic words that I could impart to you to speed up the process but I don’t. If you know for certain that your pet ingested a specific toxin or if the current crisis is a repeat of a past life-threatening problem it is important to tell the receptionist or veterinary technician what is going on, as calmly as you can – at least the first time.

This is an aside, but I had a frantic phone call from a pet owner who said he was on the way to my office with his toy poodle who had been bitten by a rattlesnake. I have never seen a rattlesnake bite in my practice so I wasn’t overly concerned about the phone call. When the man arrived with the poodle I was doing surgery on another emergency. He began talking to my receptionist who informed him of the situation. He walked back out to his car and returned a moment later with a large Mason jar. Inside was the head of a snake, which he handed to my receptionist with the request that she take it back for me to see. My receptionist, though rather taken aback, did just that. I was able to see immediately that the man was wrong. His dog had been bitten by a copperhead. Since the dog was only 4 pounds I walked out into the reception area , still gloved up, and told him he needed to head to the local hospital to obtain anti-venom from the pharmacy at the hospital. He smiled and said, “I knew you didn’t believe me about the snake. It’s a good thing I brought it with me, isn’t it?” He was partially right, I had been reluctant to believe that a rattlesnake bite had occurred even though I was open to the possibility of a copperhead bite. Still, it did get my attention when I viewed the snake’s head in the jar. As it turned out the little dog did fine.

To get back to the way a person with some medical knowledge feels when confronted with being a patient, I have to start out by admitting that I was not viewing my situation dispassionately as several nurses put intravenous catheters in each arm while other people took radiographs and attached ECG leads. I could follow some of the conversation and it was apparent that the doctor felt I was having a heart attack but was consulting with a specialist over the phone to confirm this and to decide what to do.

I have a pilot’s license, although I no longer fly. So normally I would jump at the opportunity to ride in a helicopter. For some reason, though, when you hear the words “airlift” in reference to yourself while you are in an emergency room, the prospect of a helicopter ride is less enticing. In fact, it really made me wonder just how bad my situation was. On the way to the hospital I had wondered briefly if I was going to make it there. The feeling had only lasted a few minutes and then with the administration of several medications and the general relief of having gotten somewhere where people were trained to help, most of my immediate worries lessened. The whole airlift idea brought the worry back immediately.

When I am trying to work quickly I sometimes forget to inform my clients about what I am doing. In some circumstances there simply isn’t time to keep the client informed and devote enough attention to the pet. Most of the time, though, I try really hard to tell clients what I am thinking and what I am doing. I think it is important for people to understand why we choose to treat a pet one way over another and so I would do this in any case. The major reason I usually remember to do it, though, is the panicked look on a client's face as I work with their pet. In our clinic we rarely keep clients separated from their pets except for surgical procedures. The surgical environment is just difficult to explain to clients while attempting to perform surgery and anesthetic monitoring at the same time. In the past I used to let clients watch surgeries right in the surgery room as I am not particularly bothered by litanies of “why are you doing that?” but my anesthetist is truly annoyed by these types of persistent questions and I want her to be focused on keeping the pet alive.

So I guess that I am saying that it wasn’t too disappointing not to get detailed information about what was going on with testing and planning in the emergency room as I understand that it is a hard place to keep up that sort of effort. It truly helped to have someone else there to ask for clarification of really important issues, though. Moe was able to get information with pretty specific questions and by being willing to repeat those questions when necessary. She didn’t overdo the questioning, which I think was helpful, but she did persist enough to get answers when it seemed really important.

The first question that I asked and that Moe was finally able to get the answer to was whether or not it seemed likely that placing stents would be necessary. I was prepared to argue over this issue as I had a fairly big worry over stents due to the articles about problems with the coated stents from last summer. The answer to the question about stents was pretty much this: “There are going to be stents unless you want to wait for bypass surgery, so get over it.” I truly thought that was a little harsh and it really is a near accurate reporting of the conversation. However, this did prompt the cardiologist to ask why I was worried about stents. This led to a short conversation about the benefits of coated and bare metal stents and the revelation that the hospital didn’t have any coated stents on hand that day so it was a moot point.

All I can really tell you about this type of argument in an emergency is that it is difficult to be prepared to argue for or against the care that will be given with no preparation. I finally just accepted that I was not in a position to make a judgment call right at that moment and that I would have to trust the doctors to do what was best. This was a very difficult decision for me to make. You might have to know me well to realize just how hard it was but there are times when you really do have to simply trust someone to take proper care of you.

After assessing my response to the initial care it was decided that an airlift would not be necessary. I was relieved, even though I really do like to take rides in helicopters. The hospital with cardiac surgery capabilities is about 30 miles away from our local hospital and I was put in an ambulance for the ride there. That seemed like a reasonable choice to me. In fact, I think that I would have just gone home after the initial treatment if that had been an option. I felt much better after administration of nitroglycerine and clot-busting drugs. This is mostly an admission that I can be enormously stupid about my own health.

Within a half-hour of arriving at the regional medical center I was in the cardiac catheterization lab receiving instructions to lay as still as possible during the catheterization procedure. A little sedative and narcotic pain relief makes that fairly easy. It was surreal to look up at the three large screen monitors and to glance over at the two cardiologists manipulating instruments by watching the screen. It was like watching a giant Nintendo game with your own heart as the prize.

I asked again about stents. When you are worried about a medical procedure it is reasonable to get a second opinion even if you have to get it immediately from someone who heard or was aware of the first opinion. You might think that the natural tendency is to back up a colleague but this is clearly not always the case. The cardiologist told me that if it was his heart he’d ask for a coated stent and just take Plavix™ a lot longer. Given that that wasn’t even an option at this time, the advice wasn’t especially reassuring. I was glad, though, that there wasn’t a choice to make because I didn’t want a coated stent even if the cardiologist would have – but it would have made the argument a little harder. Then he reverted to the first answer again, saying basically that if I wanted a good outcome I needed to consent to stent placement. As it turned out, I needed two stents.

Doctors and nurses are people. Listening to them and watching them makes it possible to read between the lines at times. It was apparent that the angiogram was upsetting one of the cardiologists but the other one was reassuring him by pointing out “the great collateral circulation”. It seems I had a complete blockage of the left descending coronary artery but lots of small vessels branching off other vessels into the area. Apparently the result of a partial blockage being present for a long time and a lot of exercise forcing my heart to seek blood from surrounding arteries. It made the 10,000 miles of bicycling over the last two years seem much more important in retrospect. Exercise is a good thing – at least most of the time.

When the cardiologist who was manipulating the stents into place asked me about a problem with his cat not using her litter pan I figured that he wasn’t quite as worried as he sounded previously. I figure that he’d have to be a real heel to ask someone he thought was dying or severely damaged how to get his cat to use her litter pan again. I felt a lot better about my prospect for recovery after that. Then he blew up the little balloon to crush the clot and make room for the stent. I hated him for a few seconds. Several times for a few seconds, actually. I was forgiving each time he deflated the balloon, though. I’m good that way.

I asked lots of questions during the procedure. Unfortunately I was sedated with a combination of Versed ™ and fentanyl. This is a combination that is occasionally blamed (or used) as a way to decrease memory of events. This can be a good thing when there is a great deal of trauma, for instance. I think that it does interfere some with the long term memory of an event because I told Moe some of what happened and then couldn’t remember what I had told her. I guess it is still worth asking questions during procedures you are awake for. Whatever you do remember could be useful.

It was pretty amazing to me that someone could be probing around in my heart at 9 AM in the morning and I could feel pretty normal by noon. This was definitely a good thing, though. In the cardiac intensive care unit there were lots of nurses and lots of down time. One of the things that I am pretty sure of is that you get more information out of the staff at doctor’s or veterinarian’s offices and hospitals than you get from doctors and veterinarians, at least most of the time. You do have to be a little careful about accepting all of the information at face value but if you ask two or three nurses or veterinary technicians the same questions and get the same answers it is pretty likely the information is valid.

Nurses and veterinary technicians are especially good sources of information about basic patient care. Your doctor is happy to tell you about your illness and about any procedures that are anticipated but they aren’t as good about telling you how it will feel when they remove the 6 French catheter (take my word for it – a BIG catheter) out of your femoral artery or to point out that the whole process will take a lot less time if you can manage to lay very still while it is done. When your pet is going home from the vet’s it isn’t a bad idea to ask the veterinary technician what you need to know that the veterinarian might not have talked about.

I need to point out another thing here. People make all sorts of comments without thinking much about them. When the last IV catheter in my arms finally failed and had to be replaced I met the IV nurse for the first time. She looked at my arm and said, “You have great veins.” I told her that a wise person didn’t say that until after they put the catheter in. For some reason this seemed to fluster her. Which resulted in 11 attempts to place a catheter – 5 in my right arm and 6 in the left. My new theory is that a wise person doesn’t say anything that might fluster the IV nurse - or the surgeon , or the anesthetist, or whoever you are relying on to quickly and efficiently finish a procedure!

People really do listen to what you say. If you complain a lot someone has noticed. If you mean to have your complaints noticed, that is great. If you think that you are just being funny or it is just a habit to complain you might want to reconsider. Ask yourself if you would want to hear complaints all day --- and if what you want to complain about isn’t too important consider letting someone off with one less complaint to listen to that day.

I read all the brochures that were handed to me in the hospital. Most of them were written by the companies that made the medications or the stents that had been implanted. While they were helpful I have seen lots of company propaganda over the years. I know that all companies tend to minimize the downside of their products and hype the good effects. This is something that just comes with the territory when you are reading advertisements and instructional materials relating to a company’s products.

One thing that the educational materials medical companies put out can do is help direct the search for additional information. In some cases studies are cited in the literature. I use these references to start to look for information. If there is an article title and author’s name is listed it is possible to find the reference in most cases on the PubMed web site. Once this has been accomplished it is possible to use the site to look for additional information. The “Related Articles” link on the right side of the page is a good way to find additional information. Paying attention to the vocabulary used in the article and using the specific wording to find additional information can also be helpful. While it wasn’t helpful in my searches this month it can be very helpful to know that if you append /ve to a search on the PubMed site it will restrict the search to veterinary articles. It is important to remember that abstracted articles, which is all that PubMed offers, can be misleading. An abstract’s usefulness varies because the value depends on the skill and point of view of the abstractor.

To the right of articles on PubMed there is also a hyperlink for “Links”. Sometimes this is a link to the full text of the abstract. For articles that look good it is best to read the full text of the article whenever possible. An odd feature of PubMed is that there is a second area labeled “Related Links” that is only visible after you have clicked on the link to an abstract. This is actually a link to related articles but you can see the titles and short descriptions of the in the box that is labeled Related Links. This is a very useful feature.

Once I have looked for journal references to a subject I tend to look into sites that provide a comprehensive overview of a problem. This helps me decide if I am on the right track in my thinking about the meaning of the journal references I have found. My favorite medicine site is www.emedicine.com . This site is just organized in a way that is attractive to me and it usually has a brief overview of problems and coverage of the various treatments for it. While it is geared towards emergency situations the information available covers a lot of ground so there is a good chance that something I am interested in will be covered on the site.

It took me two days to get to the point that I thought I could use my laptop at the hospital and another day to get it there and discover that the hospital had a wireless network available. Once I got going I did a lot of research quickly, though. It was nice to find out a little more about troponins. This is an enzyme that is specific to cardiac muscle and so it is tested for quickly when a heart attack is suspected. A rise in troponins indicates that some muscle damage has occurred. I knew that there had been a rise in troponins measured when I was in the ER but I didn’t really know what it meant. Fortunately this is a very sensitive test and even though it measured some muscle damage none was evident on the cardiac ultrasound examination a couple of days later. It was also nice to be able to review the medications used and to know what they were supposed to accomplish.

I have to admit here that I have had a long standing prejudice about the use of ECGs in veterinary medicine. I really don’t know what the usefulness of this test is, other than for arrhythmias, in veterinary medicine. There are other things it can help detect but almost all of them can be discovered using other test procedures and most of the time the other procedures are more useful. It was reassuring to read that isn’t the situation in humans, though. The ECG is apparently a very useful test in determining if a heart attack is occurring and even for evaluating the severity of the heart attack. Perhaps if dogs or cats were more prone to heart attacks I would have a more favorable view of the use of ECGs in veterinary medicine.

One of the things I like to do when I search on PubMed is to get an idea of who the most prolific researchers in a particular field are. It is often possible to determine this by looking at the listed authors. Often one or two of them will stand out as most of the papers listed are authored by them or are collaborations with other researchers in the field of study. It is important to be careful in making assessments about the more prolific authors based solely on the number of papers published but it is still useful to get an idea who is writing about a subject you are interested in and what their point of view is. Sometimes it is readily apparent that there is still a great deal of controversy about some aspect of a subject, such as diagnosis or treatment and to divide the researchers into groups based on which side of a controversy they are on. Over time it is usually possible to pick out a few researchers whose information is usually trustworthy and to use them to gain information about a subject more quickly. It is helpful when searching through lots of search results if you can just scan for the names of researchers or writers you trust.

Another web site that I like a lot for general overviews of various health problems is www.johnhopkinshealthalerts.com . While this site does charge for much of the information available it tends to be well researched information consistent with the image of Johns Hopkins and it usually includes medical information as well as non-medical information that might be helpful, such as dietary changes that might be helpful and exercises or other changes in lifestyle that might also be helpful.

I also like the New England Journal of Medicine web site, www.nejm.org. It is only one journal but often it is possible to read an abstract and then view the full text of the article if desired. If you do this there is usually a large list of references that were used in reviewing the journal reference and these give me a lot of information about who is writing about a topic and how to find them. It is usually possible to find most references by an author by typing their name into the PubMed search box. There isn’t anything there written by me but if there was you would look for it by typing in Richards ME (my initials). If you know the title of the journal reference adding that further narrows the search.

After I was pretty sure that I had a good understanding of what had happened and I had researched the medications to check for side effects I started to look into other options. There were lots of links to articles on dietary changes, nutritional supplements, sites with reports of specific complications involving the medications I was on and alternative approaches to heart health care.

People often claim that conventional doctors ignore alternative approaches using dietary changes, herbal medicines or other non-pharmaceutical approaches to medicine. This didn’t seem to be true in my search for information about heart disease, though. My physicians and their assistants have been willing to discuss alternative care and there were lots of sites on the internet that included both medical therapies and additional measures that might be helpful. Of these, the two most consistently mentioned were fish oil and co-enzyme Q10 . The nurse practitioner at the cardiologist’s office was in favor of using both of these supplements and said that she was glad that I had already started them before my first recheck visit. I’m not actually sure that there is a great deal of proof for the effectiveness of co-enzyme Q10 but since I worry about the side effects of statins such as muscle weakness and possible memory loss, I am taking it.

One of the problems with researching health issues, especially ones that you have a really strong personal interest in, is that it is hard to decide when to worry over adverse effect information. There are several medications that are pretty much standard procedure to dispense when a heart attack has occurred. Of these medications, the statins and beta-blockers are probably the most controversial in terms of side effects.

There are several web sites that list adverse effects for Lipitor that are not emphasized in the prescription insert or patient information literature for the medication, along with several recognized side effects that are covered. As an athlete the side effects of possible debilitating muscle pain have to be accounted for and this is well covered. As a veterinarian an unmentioned side effect of concern that gets some play on the internet is memory loss that occurs after taking statins. While this problem seems rare even with finding several references on the internet it is still such a scary side effect that some research is called for. There is a reference from a refereed journal regarding this problem so it does seem that it exists. On the other hand there are hundreds of thousands of patients on statins and only 60 fairly well documented cases of this problem. This leads me to believe that the benefits of the statins are worth the side effects, at least for now. If there are signs of problems I might change my mind.

Beta-blockers cause dizziness in some people and that seems true for me. Fortunately, the cardiologist is very amenable to altering the dose to try to control that problem. It is difficult to work and deal with dizziness all day. Lowering the initial dose of the medication seemed to help.

I have also been working on maintaining a low fat diet. This clearly seems beneficial based on studies. It is one area I can work on. I have a great love for doughnuts, Twinkies and ice cream. I truly miss them. Other than those types of things my diet wasn’t all that bad. Now it is better. Even though it is a lot easier to control pet’s diets lot of my clients have problems doing it. I have to admit that I am glad that there isn’t a low fat people chow. I do enjoy some variety in my diet. Dogs and cats really don’t seem to mind eating the same foods nearly all the time but it doesn’t seem like a good plan to most people.

I have had my one month recheck and am doing very well. I’m able to work and have been able to ride my bicycle some. I am hoping to be back to longer rides over the next month or so. I took the easy choice and wrote this month’s issue about the heart attack but next month I’ll try to get back to something a little more specific to pets.

I don’t recommend having a heart attack but I do think it is important to use many of your life experiences as learning experiences. I also strongly recommend looking at your pets for guidance when reacting to illness. They take life one day at a time and live it the way that seems best that day. It seems like a very good plan to me.

Thank You For Your Support!

VetInfo Digest

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