VetInfo Digest         March 2001

This Month:

What Do YOU Do Doc? Part II

Trauma

Kidney Failure and Cats

Inflammatory Bowel Disease

Anesthetic Monitoring

Chronic Bronchitis/ Asthma

Dental Care

About a hundred yards into the woods behind our practice there is a swamp. There is standing water most of the year, punctuated with little islands of grass or moss covered tree stumps. For some reason, every cat that gets loose at our clinic heads for the swamp. It is hard to find cats after they settle into a good hiding place, so we try hard to keep up with them and to keep track of where they are until they decide to give up and let us catch them. This often involves running through the water as the cat jumps from island to tree stump to island again -- until it finally has to choose to sit still or to go swimming.

This week, I chased one cat into the swamp and kept up with him as he moved quickly through it. When he climpbed onto a fallen tree and ran the length of it to the next jumping point, so did I. When he jumped, I waded through the water to the tree stump he now occupied. He jumped again, this time to a very moss covered remnant of a stump that just barely held his weight. Sensing imminent danger of falling into the water, he wisely let me pick him up and take him back to the clinic. We lent the owners a carrier to get him home. I can remember two cats who got loose in our parking lot who were never found, though. I'm sure there are worse hazards than a swamp near many veterinary practices.

Be safe -- bring your dog to the vet on a leash and your cat in a carrier!

What Would YOU Do, Doc? Part II

Trauma at the Veterinarians

When a patient arrives at a veterinary hospital with a traumatic injury requiring extensive and immediate care, the business of veterinary medicine, the realities of the limitations of veterinary medical care and the desires of the client and veterinarian to pursue a good outcome with the best possible medical care really clash. Clients are often emotionally charged and this can interfere with effective communications. The need to drop everything else going on in the clinic and to involve most of the staff in an emergency situation is stressful for the veterinary staff and the veterinarian in charge of the case. The patient is often in severe pain and may exhibit extreme fear aggression, biting anyone who poses a threat for increasing that pain. In the midst of this situation, life or death decisions must be made very quickly and often these decisions hinge on the amount of money a client is willing to spend, or capable of spending, on the gamble that a pet can be comforted and recover from the injuries that are present.

To give you some idea of the economics of trauma, it is not unusual for a dog or cat who has been hit by a car to require $400 to $600 in care within the first half hour in our veterinary clinic, just to reach a point where we have controlled the pain, placed an intravenous catheter, corrected immediate life threatening problems such as hemorrhage, respiratory difficulties and shock, taken X-rays to assess the injuries and reached a point where we can provide an assessment of the patient's injuries. Treating the injuries may then cost as much, or more, over the next few days.

There is a saying in emergency veterinary medicine that explains this situation bluntly and clearly. A veterinarian must figure out a way to let the client know that they are making this decision:

"Do you want "A" dog, or "THIS" dog?

Wanting "a" dog allows for the possibility of ending the trauma with a decision to euthanize, for medical or economic reasons. Wanting "this" dog entails making a commitment to spending whatever it takes to try to save the patient and also an acceptance of the fact that there is not a guarantee, at any expense, of a successful outcome in trauma cases. It can be very difficult to think clearly about this situation when dealing with the emotions of the moment. This is something that pet owners should think about in advance. It is hard to be put in the situation where you must make life and death decisions based partially on money, but when it happens, you will be better able to deal with it if you have thought it over in advance.

The other side of this is the veterinary hospital's need to decide how far they are going to go in providing services when it is obvious that payment is questionable. It is extremely tense in our clinic when a patient arrives with severe traumatic injuries and an owner who has a poor past credit history or no history at all with our practice. My staff members usually try to tell me that I have to deal with the economic issues right away, hoping to avoid having to collect the money and deal with the owner for weeks to months after the initial visit while doing this. Our choice is just as hard as the client's in this situation. Do we risk losing hundreds of dollars or do we refuse care? If we do choose to risk the loss, how many times can we do that before it impacts on the care of all the other patients in our practice? At the present time, most veterinary hospitals net between 20 and 25% of the gross income. So if a practice loses $200, it must make $800 to $1000 before it has recovered the loss. There is almost no government support for pet health care and even though there are a few charities that might help people, for the most part each pet owner must be responsible for their pet's medical bills. In our practice, we refuse care, except euthanasia, if a client has not paid us on two or more previous occasions, unless we are able to make arrangements with a charitable organization or we have money in our own charitable fund (our practice and a small number of our clients contribute to a fund for people who really can't afford care). However, these funds are limited and can't be counted on for all patients. It is best if veterinary clients are prepared for an emergency, both mentally and financially.

The other difficult situation in trauma cases is when we know that a pet can not live with the injuries that have been sustained, or that the patient can live but will require continuous care to continue to survive. It is usually not possible to maintain a patient requiring continous professional care in veterinary medicine, but the client may not have accepted this situation. Most clients have no way to provide for intense rehabilitative care for severe head injuries, to provide for patients requiring continuous assisted respiration or to provide around the clock nursing care for the lifetime of a pet. When we know that such care will be necessary but a client is in denial, it can be extremely difficult for all involved. Sometimes, veterinary clients just don't understand the differences between the level of care that is available for humans and the level of care that is available at a general veterinary practice.

One of the most memorable cases in our veterinary clinic revolved around the traumatic amputation of a German shepherd's leg. The leg was cleanly removed by a weed whacker with a saw blade made to cut brush. The owners brought the dog and the leg, chilled on ice. They wanted us to reattach the limb. I tried valiently to explain to them that limb reattachment required equipment for microscopic surgery and that it was usually done by teams of physicians, with as many as ten to fourteen doctors and attending support staff. One vet, without an operating microscope and specialized suture material and equipment, can not reattach a limb. A difficult discussion followed, in which the owners claimed I was just too busy that day to care about their dog. I finally had to point out that I thought their dog was in imminent danger of dying if they did not let me go and salvage what I could of the situation before they gave up on the idea of limb reattachment. I know that they called a number of other veterinary hospitals over the next few days, trying to find one that would claim to have the ability to reattach a limb, absolutely convinced that I was just not a good enough surgeon for the task.

Twice during my career I have had to stop treating a critically ill patient and tell the owner (or family members) they had to go away if they wanted their pet to live. In one case, the fifteen year old daughter of the owner was actually hitting me with a twitch handle (same as a pick-ax handle) and screaming "Stop! You're hurting him!" as I tried to suture a wound on her horse's lower leg, from which he had already lost approximately 1 gallon of blood --- and I know this because his foot was in a three gallon bucket while he was bleeding. I guess in that case, I actually told the owner that she had to leave her own barn or I was going away.

In the other instance, I was trying to get a St. Bernard through a case of anaphylactic shock from a bee sting that had brought on respiratory arrest, fortunately just about the time the dog arrived at the clinic. We were trying to provide assisted respiration and emergency medications while the owner kept saying "Don't do anything to him until you explain to me what you're doing. Don't give him any steroids. Don't give him any drugs without talking to me first....." Under most circumstances, I think it is good when clients want to be sure about medication information and patient care. In an emergency, there just isn't time for this. You have to let your vet work. I asked her to let me just treat her pet several times. I finally had to sit back on my heels and say, "OK, we'll let him die while we explain what we are doing and not using the best medications for his condition, or you can leave right now and he might live." She was smart enough to leave. She came back in an hour, collected her dog, who was now doing well --- and we never saw her again.

The last thing to remember about trauma is that you must be able to move your dog or cat to a veterinary hospital when it is injured. It can really pay off to have a good muzzle or to know how to fashion a temporary muzzle from soft gauze for dogs. Your vet can show you how to do this. A crate or other restraint device is really important for cats. If it seems best to move your pet as little as possible, sliding a board under them, then just moving the board and pet together, can prevent further injury to fractured limbs or a fractured pelvis. Until your pet reaches the veterinary hospital, it can not be treated for its injuries, so don't delay a move for too long.

This is how we handle trauma, most of the time:

All dogs and cats are first assessed for bleeding and respiratory distress. If either is present, we deal with those problems first. If the client is calm we let them stay with the pet. If not, we try to move the pet to a different part of the clinic. We almost always place an IV catheter to give fluids to maintain blood pressure and to ensure that we can find a vein if there is a sudden onset of shock. We try hard to obtain a diagnosis but we also try to remember not to put a patient at risk of further injury or deepening shock while we try to obtain that diagnosis. This is especially true for cats in acute respiratory distress. It is often better just to put the cat in an oxygen rich environment (we use "blow by" oxygen, not an oxygen cage) and wait until it has adjusted to the hospital. If that is too much of a hassle for the patient, we just leave them alone entirely. Sometimes we take this same approach with dogs who have been hit by cars. Often, taking a few minutes to let the pet adjust to the clinic, while we control pain, lack of oxygen and other factors that we can control, without stressing the pet, will allow it to live through a situation it would not have made it through. If we had the option of very advanced care, with total life support capabilities, we might take a more aggressive approach, but that is not the way it is at our practice, nor at many veterinary practices. We do not routinely use corticosteroids for shock but we do use them for some situations. We have an in-house blood analyzer and can provide some blood chemistry values quickly in emergencies. It is important to have X-rays of the chest in any case in which a pet has been hit by a car and has respiratory distress, even if it is slight. It is reassuring to have chest and abdominal X-rays in almost any case in which a dog or cat is hit by a car, even when there are no obvious respiratory problems. We have to look for bullet wounds frequently in our rural location. We consider this possibility any time we have any sort of puncture wound and the owner didn't see a dog or cat fight. We find that it is helpful to have a staff member talk to the pet owner after their pet is doing well enough that they have calmed down some and to go over the entire history of the case again. Sometimes people remember important details once the stress is over. We transfer pets who need constant observation to the emergency veterinary clinic at night. This doesn't happen very often, but when we suggest it to a client, we really think it is necessary.

Call your vet before you arrive at the clinic in a panic. A veterinary clinic prepared for your arrival will be much more likely to be able to provide the care you need -- and you might find that you have forgotten about clinic hours or that your vet is out of town for vacation or continuing education and that you can save a lot of time by driving directly to another clinic.

Kidney Failure In Cats

Older cats frequently have kidney failure, which is really more like "kidney insufficiency". In these cats, the kidneys are usually slowly losing function and with support can continue to do their job for a long time, sometimes for years. There are a number of medications that might be helpful for a patient with kidney failure. These include subcutaneous or intravenous fluid therapy, calcitriol, potassium, phophorous binding agents, blood pressure medications, gastro-intestinal protectants, appetite stimulants, and erythropoietin. Low phosphorous diets with moderate to low protein can be used to help protect the kidneys from damage due to excessive protein and high phosphorous levels. It is not necessary to use every treatment in every patient. Deciding which treatments are appropriate for which patients can be very difficult and makes careful communication between clients and veterinarians essential to provide the best care for each individual patient.

At the present time, the consensus of opinion among experts on kidney failure in cats appears to be that it is best not to switch to the controlled protein diets, such as Hill's k/d (tm) and Purina's NF (tm) until the BUN is over 80 and/or the creatinine over 3.5 (some vets use 4.0). I think that most general practice veterinarians tend to start these diets earlier but it may be time to rethink that practice. As more evidence is collected regarding the effect of diet on the progression of kidney disease it appears that early damage may actually progress more quickly if protein is restricted. Once there is sufficient damage to make it difficult for the kidneys to handle protein, it does make sense to try to use the minimum amount of high quality protein necessary for nutritional needs.

In our practice, we try to start fluid therapy, at least on an intermittent basis when the creatinine level rises above 2.0 or the BUN exceeds 75. We believe that fluid therapy is the most important part of therapy for kidney failure for most patients. It is possible for most cat owners to learn to administer fluid therapy at home, which has many advantages, including less stress for the cat, lower cost for the client and a better opportunity for daily fluid administration when necessary. We encourage almost all of our cat owners who have feline companions with kidney insufficiency to learn to administer fluids. Not all cats are good about this but most will tolerate it.

Early in kidney failure we try to encourage potassium supplementation and to offer calcitriol administration as an option. Potassium is low in many cats with kidney failure and potassium supplementation may help to maintain appetite and slow the progression of kidney damage. Calcitriol, which is an active form of Vitamin D, is reported to make many cats feel better and to limit the possibility of secondary hyperparathyroidism by helping to control the calcium and phosphorous levels, which can become deranged due to kidney failure.

Blood pressure medications can be very helpful in cats with kidney failure. Kidneys produce the hormones that regulate blood pressure. They do this because kidney function is very dependent on proper blood flow -- so important that they get to regulate the pressure. This is a good system until kidney failure occurs. When the kidneys are not able to do their job, they suspect blood flow is the problem and begin to produce hormones to raise blood pressure. This goes on until hypertension results. The most recognizable symptom of hypertension in cats is sudden blindness. Any older cat with a sudden onset of blindness should be suspected of having hypertension. Quick treatment at this stage can allow a restoration of sight, so knowing that this can happen can be very important. High blood pressure can also lead to loss of appetite, weakness and night time restlessness or vocalization. There are some veterinarians who think that all cats with symptoms of renal failure should be placed on anti-hypertensive medications. It certainly is a reasonable choice for many patients. We have the best luck with amlodipine (Norvasc, Rx), but some vets prefer enalapril (Enacard Rx) because it helps to control blood pressure and may also help the kidneys preserve protein. We have used both medications but I still prefer amlodipine at this time.

It is not possible to use all of the medications available for kidney failure in every patient. Many cats have a limit to the number of times a day they will allow themselves to be poked, prodded and pilled. Cats often refuse to eat the diets that we think they should. Clients have schedules that they must adhere to, in order to be able to provide for their families and their cats. Some clients are squeamish about needles and others just can't give oral medications. Oddly, most people seem to be able to one or the other, though. What this all adds up to is a situation in which we are often forced to pick the best of the therapies for a particular patient and leave other things out. What is best for one cat, or one client, is often not the best for another.

A rough progression through the treatments we think are most important at various stages of kidney failure starts with the cat whose lab values are suggestive of a problem but who is showing few if any clinical signs. These patients we usually try to help with calcitriol or phosphate binding agents (not both) and/or potassium supplementation. We begin to talk about subcutaneous fluid therapy and administer it during office visits so that the client and cat become familiar with the process. This is the point where we try to ask if a client would seriously consider a kidney transplant, since they work best once kidney failure has been clearly identified but before it progresses too far. We think clients should know this is an option, even though we know most will not want to go this far with care. The next stage is the cat who has persistently high BUN or creatinine or an inability to concentrate urine, along with weight loss or chronic slight dehydration. We try to continue the original treatments but now we want the client to administer subcutaneous fluids at home and we begin to think hard about blood pressure medications. As the BUN and creatinine rise, especially after the BUN reaches 75 to 80 and the creatinine 3.5 to 4.0, we really would like to use the reduced protein, low phosphorous diets such as Hill's k/d (tm) or Purina NF (tm). Now we think that cats really need to be on blood pressure medications and we think about famotidine (Pepcid AC tm) to protect the gastrointestinal tract from irritation due to the toxins the kidney can't remove from the blood stream.

If appetite has become a problem, appetite stimulants such as cyproheptadine (Periactin Rx) or diazepam (Valium Rx) may be necessary. We do not use erythropoietin, a hormone that stimulates blood production, until the patient exhibits pretty severe anemia, usually waiting until the hematocrit (the percentage of blood that is composed of red blood cells) is less than 15%. If an feline origin erythropoietin becomes available, which is rumored to be in the works, we will use this medication sooner. The present medication is human erythropoietin and cats may become sensitized to it, leading to an even more complicated problem with anemia. If you add all that up, a cat might be on daily subcutanous fluids, phosphate binders or calcitriol, blood pressure medications, potassium, GI protectants, appetite stimulants and a special diet -- or whichever parts of this therapy can reasonably be administered and appear to necessary.

Inflammatory Bowel Disease

Right at the start of this discussion, I need to make one thing clear. I always prefer to be working from a confirmed diagnosis rather than guessing. The best way to make a diagnosis in cases of inflammatory bowel disease is to have biopsy samples of the gastrointestinal tract. These can be obtained through endoscopy or through exploratory surgery and full thickness surgical biopsy. the full thickness biopsy is better from a diagnostic standpoint but a lot harder on the patient, so we refer our patients, whenever possible, for endoscopic examination and biopsy once we are pretty convinced some form of inflammatory bowel disease is present. Most of our clients refuse to take this step, either because we are not able to satisfactorily explain the advantage of knowing what is going on or because of a reluctance to spend the money and the time to see a specialist. It is still the best option, though.

When clients refuse to take the steps necessary to make a diagnosis through biopsy, we take a "trial and error" approach to inflammatory bowel disease. I like to try dietary changes first, when possible. I like three different dietary changes and sometimes have a hard time deciding which ones to try first. They are 1) a low fat diet diet (Hill's w/d tm) 2) a diet containing easily digested ingredients that has essential fatty acid supplemenation (the "hair ball" formula cat foods, Science Diet Sensitive Stomach (tm) for dogs 3) hypoallergenic diets (Purina HA (tm), Hill's z/d (tm)). I usually try them in about the order I listed them. Once in a while other dietary changes help, like increased fiber or low residue diets (Iams Low Residue tm). Other vets have diets they prefer to try, too. If dietary changes work, great. If not, we move on.

We always try deworming patients with a broad spectrum dewormer. We favor fenbendazole (Panacur Rx) but there are others. If we have any suspicion that tapeworms are present we use a tapeworm medication. There are no really good over-the-counter tapeworm medications, so buy one from your vet.

If deworming doesn't work, we move on to metronidazole, an antibiotic that may also have an immune modulating effect in the intestinal tract. This medication also kills giardia, as fenbendazole does. It doesn't hurt to be sure this parasite isn't present. If diarrhea and/or vomiting stop when we use metronidazole we will often try it for twenty to thirty days before stopping. If the diarrhea immediately returns, we try other immunosuppressive medications or we move on to other treatment modalities.

We usually try sulfasalazine (Azulfidine Rx), tylosin (Tylan Rx) or tetracycline at this point. Sometimes we try one right after another, hoping to find an antibiotic that will work, since this avoids taking the next step, which is treatment with corticosteroids.

When we have tried the rest of the therapies without much success, we try corticosteroids. If these work well we might try other immunosuppressive agents in canine patients, such as azathioprine (Imuran Rx). Usually for cats, if we have to go to something else, we try injectable corticosteroids, such as methylprednisolone acetate. For some reason this seems to work better in some cats even though it shouldn't really matter, in theory.

I am really reluctant to use corticosteroids for life without being pretty sure they are necessary. While I can get close to that point with this trial and error approach, I really appreciate the clients who let us pursue a diagnosis before we get to the point that corticosteroids are the only treatment left.

Anesthetic Monitoring

Many veterinary hospitals use anesthetic monitors such as pulse oximeters, continuous blood pressure monitors, electrocardiograms, respiration monitors and electronic thermometers. All of these are very helpful and it is good that monitoring is being used. However, we pretty firmly believe that the best monitoring method is a full time anesthetist (in our case, not a specialist) in the room with the patient. For several years we have been blessed with the ability to provide this level of care and it has made a significant difference in our ability to provide safe anesthesia for patients. We were not doing bad in the past, staying above the reported average of one anesthetic death per about 500 patients, but we still had an anesthetic death in the practice about once a year. After my wife graduated from veterinary school and took up monitoring our patients throughout surgery, we have lost two patients in ten years to anesthetic related death. We'd like to do even better, obviously. If your veterinary hospital has an experienced veterinary technician monitoring anesthesia or offers the option of a veterinarian monitoring anesthesia, definitely take advantage of that option, if possible.

One of my daughters was born approximately nine weeks premature. She was attached to a number of monitors, one of which sounded an alarm about every ten seconds for over an hour. I watched her carefully while the nurses spent the entire hour trying to figure out what was wrong with the monitor, since the alarms were obviously false. There are times when having monitors is worse than not having them. No one but me looked at my daughter for that entire time. We have two anesthetic monitors and an electronic thermometer for tracking body temperature, but I trust Moe over all them because she is smart enough to look at the patient first and the monitor second when an alarm goes off.

Chronic Allergic Bronchitis and Asthma

Dogs tend to get chronic allergic bronchitis, especially cocker spaniels. Cats tend to get asthma but sometimes do have chronic bronchitis that closely resembles asthma.

It is usually possible to get a pretty good idea that bronchitis or asthma is present based on a physical examination, the history of the illness and X-rays. It is helpful to do a tracheal wash procedure or bronchoalveolar lavage (BAL) but these procedures require anesthesia and are often non-rewarding, so many of our clients prefer to skip them. In this case, I am pretty comfortable with that decision until treatment fails, but I will grudgingly admit that I think it is a little better to at least make one good attempt at a tracheal wash or BAL.

We have almost no luck treating dogs with chronic allergic bronchitis with any medications other than corticosteroids. This is one of the few instances in which we will use corticosteroids in low doses on a daily basis when that works significantly better than every other day therapy. It just seems like we usually can't control allergic bronchitis in dogs without corticosteroids and often can not obtain good control without low doses of corticosteroids on a daily basis.

In cats with asthma, corticosteroids such as prednisone are also the mainstay of treatment. We have been trying asthma inhalers lately, as well as terbutaline injected subcutaneously during acute attacks. We are having some success with both therapies but doing a little better with the terbutaline. We dispense this to our clients with directions on how to use it and allow them to treat their cats at home. This gives clients an option in emergencies and saves some trips to the emergency veterinary clinic or to our clinic in a panic. Terbutaline comes in ampules and must be stored in these. The ampules are small glass vials that must be broken carefully to obtain the medication, so there is a learning curve associated with the use of terbutaline but most people do well with it. The dosage is 0.01mg/kg given subcutaneously.

Inhalers can be used by placing an anesthetic mask, a pediatric chamber or just a simple toilet paper tube over the cat's mouth and nose and discharging the inhaler into the "chamber". This is held over the cats nose and mouth for about five seconds to ensure that a breath or two is taken. We have only had three or four clients try this technique, so far, but it seems to work.

Dental Care

Many veterinarians will tell you that it is not possible to do a good dental cleaning without anesthetizing the patient. For many patients, this is true. I have a hard time doing a good job cleaning a dog's teeth with the patient awake. I was determined to learn to do this and tried for over a year to hand scale almost every dog's teeth during physical examinations. I think I was truly successful in about two patients that entire time. When I first made these attempts, I didn't even bother trying cats. I just assumed it wouldn't work. However, when I did try to scale cat's teeth, I discovered that I could do it pretty well at least half the time. I was perplexed by this until I really thought about it. Cats have fewer teeth than dogs and they develop tartar first on the upper premolars, almost all the time. These are easy to reach in cats and cat tartar often comes off in a solid block with minimal effort. Most cats will let us gently plane the roots under the gumline and we can really get teeth very clean. I now make an attempt to clean every cat's teeth during yearly physical examinations and I really think it has been very beneficial for our patients. It doesn't preclude having to clean teeth under anesthesia but it does limit the need for this. Many cats have odontoclastic lesions (dissolving of the tooth right at the gumline) that are sensitive to pressure and when we find these, we do leave those teeth alone or recommend removal if they are very sensitive. I really think that dental scaling is possible in a slight majority of cats and that it is worth making the effort to try to hand scale teeth in cats during a yearly physical examination procedure. I fall right in line with the rest of the crowd when it comes to dogs. In the great majority of cases it is best to anesthetize dogs and do really good job of the teeth cleaning procedure.

We Are Trying to Fix the Question Answering Delays....

I have been running about 10 to 12 days behind on email right now. I have started trying to scan my email on a daily basis and pick out urgent questions, but I am not very good at this, yet --- especially when I am far behind. Up until recently, I simply read my email as I answered it, so I didn't get any follow up questions until after I answered the original ones. This was easier to keep track of for me but the new version of Eudora makes it a little easier for me to keep track of mail. Hopefully, it will help the situation some.

I am finishing up some personal obligations right now that may also help to straighten the email delays. I have resigned as chairman of the board of the local youth center after five years, which will free up several hours a week. It will be completely paid for on March 17th, so it is a good time to pass on the responsibility. This year I am president of my Rotary club but the Rotary year ends in July. When I become past -president, several more hours a week will become available to me. If this is not sufficient to allow me to keep up with questions, we will post a note on the site to that effect. Should that happen, we want to remind all of you that we do have a "no questions asked" refund policy and we will refund subscription fees at any time up to the last month of the subscription.

We truly appreciate your support of the web site. Both Michal and I really think it is important to keep most of the information we produce available for free, so that pet owners who can't afford to support our site have access to the information. With your help, we are able to do this. We really do hope that you feel good supporting that effort. Only a few of the people who visit the site ever realize that it is you folks who pay for it to be there. We wish to thank you for this effort on their behalf.

Copyright 2000

TierCom, Inc.
P.O. Box 476
Cobbs Creek, VA 23035

Opinions expressed are solely those of Michael Richards, DVM, author.