Vetinfo Digest             April 1999

This issue

Who's Who at the Vet's
Talk to the receptionist:
Causes of High Blood Sugar in Pets
Arthritis in Pets
National Pet Week
Spot and Duke

 

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* * * *

Who's Who at the Vet's

There are a number of different staff members at most veterinary hospitals.
Knowing the responsibilities of each one can be very important to pet
owners trying to get the best care for their pet. There are many instance
when seeking information or help from the proper staff member is much more
rewarding than trying to talk to the veterinarian on a busy day.

Of all the vet's staff assistants, the one with the most control over the
client's interaction with the veterinarian is the receptionist. This is the
person who handles the flow of traffic in and out of a veterinary office.
She determines who gets appointments on any given day. She answers the
phone most of the time. At most practices, the receptionists really
represent the heart of the practice. Make sure you stay on good terms with
him or her!

Veterinary assistants are usually persons trained by the veterinarian to
perform tasks in the practice that do not require a certified (or licensed)
technician. Holding pets for examination, organizing and cleaning
veterinary tools and instruments and running simple lab tests are all tasks
that might be delegated to the veterinary assistant. A veterinary assistant
with a few years experience will know a great deal about basic pet care but
may not know as much as a technician who has attended college level
training courses.

Licensed (or certified) veterinary technicians have attended two (or more)
years of college level training enabling them to provide professional
assistance to veterinarians. Technicians monitor anesthesia, administer
medications and treatments, take patient histories and provide most of the
same type of care that people associate with nurses at a human hospital.
Licensed veterinary technicians (LVTs) and certified veterinary technicians
(CVT) are the only employees who really should be referred to as "vet
techs" or have "technician" on their name tags. At some veterinary
practices unlicensed employees are referred to as "techs". In most states
certified technicians are issued a license that should be on display in the
veterinary office. Take a moment to look for it. I can't speak for all
practices and for all technicians but all three of the certified
technicians that we have employed over the years we have been in practice
have been compassionate and extremely knowledgeable. They often provide the
in-depth information clients needed to deal with patient care after
hospitalization or surgery and are often the best source of information at
our hospital for progress reports on hospitalized patients.

Veterinarians have at least two years of college experience prior to
applying to veterinary school and four years of training at a veterinary
college. Currently, there are 27 veterinary colleges in the United States
and veterinarians may practice in the U.S. After meeting certification
requirements for foreign graduates. Veterinarians may be associates, who
are veterinarians hired by a practice who are not owners or partners. Some
practices hire new graduates from veterinary school almost every year and
others tend to keep associates for a long time, eventually allowing
progression to partner or owner within the practice. Veterinarians are
required to post their license in most states and it is a common practice
for vets to display a diploma or other proof of graduation from veterinary
school. After a year or two in practice it doesn't make much difference
which school a vet graduated from. Keeping up with the changes in
veterinary medicine takes a lot of effort and is far more important in the
competency of a vet. It is hard to judge how hard a vet is working at
staying current. Some practices do post continuing education certificates.
If your vet's practice does this it can give you an idea of your vet's
special interests and skills.

Knowing who you really need help from at the veterinary office can make a
big difference. Take the time to get to know the staff at your veterinary
hospital.

* * * * *

Talk to the receptionist:

These are some important points to think about when dealing with a
veterinary receptionist.

Many clients call my office and ask for me. They refuse to speak with
anyone else. Usually they have to wait a while before I can find the time
to return the call. Lots of times the conversations I have with these
people go about like this:

"Hello, this is Dr. Richards."

"Hi Doc, I think that my cat is sick, do I need to bring her in?"

"Yes. Let me put the phone on hold and have Jennifer set up an appointment
for you."

Sometimes we have available appointments when these people first talk to my
receptionist but don't have appointments by the time I call back. If these
clients had realized that the receptionist was the right person to talk to
in the first place, it would have saved them a lot of time.

At other times, making the mistake of not talking to the receptionist can
be dangerous to a pet's health. Some people appear to be afraid of making a
decision to come to the veterinary office without direct reassurance from
the vet that it is necessary. If these people have the misfortune of having
a very ill pet and calling on a busy day, they can put their pet at risk
while they wait for the vet to return their call. If your pet seems to be
very ill or has a problem not related to a previously diagnosed illness, it
is very likely that your vet will need to see your pet prior to giving
advice or prescribing medication. Get an appointment while you are on the
phone with the receptionist. Don't wait for your vet to tell you it is
necessary to come to the office when you have an emergency.

Your veterinarian's receptionist should not make diagnoses or give medical
advice over the phone. It is really hard for an experienced receptionist to
resist doing this. After a year or so on the job almost every receptionist
knows the answers to the common questions that are asked. They know that a
pet probably has tapeworms when you are seeing little white worms in a
pet's stool or small "rice grains" stuck in the hair around your pet's
rectum. They know a lot about many diagnoses and treatments. Despite this,
it isn't legal for the receptionist to make the diagnosis or prescribe the
treatment for this ailment. Don't expect the receptionist to do that for
you. If the receptionist suggests that you need an appointment to see the
veterinarian or that you need to speak directly with the vet, you almost
certainly do.

Be nice to the receptionist. There is a simple concept about receptionists
that a lot of clients never seem to fully understand. If you want an
appointment to see the vet or you want to speak to the vet, you have to
have the receptionist's help. If the receptionist knows that you are going
to be difficult when you come to the office, you won't get to come as often
and it is less likely that your wishes will be accomodated. And the
receptionist usually puts the charges in the computer or ledger.

Once in a while, a receptionist will make a serious mistake in evaluating
the risk to a patient of waiting for an appointment. If you know that you
have an emergency it is important to make that clear to the receptionist.
It is also important to remember that many people call the veterinary
office and claim to have an emergency sufficient to require an immediate
visit. Most of them are not real emergencies. The receptionist may not be
swayed at all by an emotional appeal. You need to provide an accurate
assessment of the situation. "My dog has a deep cut that has been bleeding
for ten minutes," or "My cat's tongue is blue and she is making gurgling
sounds," are statements that will help the receptionist see the need to fit
you in immediately. "My dog has a cut," or "My cat is breathing hard,"
don't work as well. If you know that it is urgent that your pet be seen,
don't take no for an answer. You may need to ask the receptionist which of
the nearby veterinary hospitals he or she recommends for emergencies when
your vet can not help. Usually that will get you to the bottom line very
quickly. If the receptionist makes a recommendation to go to another
hospital go there. Sometimes your vet really is involved in a major surgery
or already tied up by another emergency. If she knows there is time to see
you but it is just inconvenient, she'll fit you into the schedule when
there is an urgent need to.

Receptionists spend a good part of the day listening to people complain.
You can make their day by simply resisting the urge to make a comment about
the cost of the veterinary care that day. A significant number of clients
treat my receptionists with a great deal less respect than they treat me.
Not only do I notice, they do to. Every vet I know values his or her
receptionist very much. Treat them like real people! Being nice to the
receptionist may someday help save your pet's life.

* * * * *

Causes of High Blood Sugar in Pets

Common Causes:

Diabetes Mellitus (cat, dog)
Stress (cat only)
Cushing's Disease (dog)
Drug Therapy:
Corticosteroids (prednisone)
Progesterone
Megestrol Acetate (Ovaban Rx)
Fluid therapy containing glucose

Less Common Causes:

Blood drawn immediately after eating
Pancreatitis
Pheochromocytoma (dog)
Kidney failure
Test inaccuracy -- false elevations can occur when cephalexin is being
administered to pets
Drug Therapy -- diuretics, heparin, thyroxine, chemotherapeutic agents

* * * * *

Pseudomonas Ear Infections

Ear infections can be very frustrating to treat, especially when
Pseudomonas bacterial infection is present. These are some treatment hints
for this particular problem.

Look for an underlying cause. In most cases Pseudomonas is a secondary
invader, taking advantage of an ear damaged by another disease process or
disorder. The most common underlying cause is allergic skin disease.
Treating the allergy may help as much as treating for the Pseudomonas. In
cats, ear mites are a common underlying cause of infections.

Fluoroquinolone antibiotics such as Baytril (Rx), Orbax (Rx) or Dicural
(Rx) are among the best antibiotics for treatment of Pseudomonas infection
in ears. It is necessary to use high dosages of these antibiotics, though.
Veterinarians may be tempted to use the low end of the dose range due to
the cost of these newer antibiotics but that may be a case of being "penny
wise and pound foolish". Oral Baytril should be used at 20mg/kg -- a dose
that is 4 times higher than the minimum. It may be used once daily when
used at this dosage, though.

Some vets prefer to make ear drops from the injectable form of Baytril.
There was a recipe for this in the Compendium for Continuing Education in
August 1998 if your vet needs it.

Silver sulfadiazine ointment is also reported to work for many cases of
Pseudomonas infection. The recipe for this ointment is also in the
Compendium referenced above.

After infection is under control it can help to rinse the ears of
susceptible dogs with solutions that help to reduce reinfection. We
recommend white vinegar mixed with equal parts of water (or diluted as much
as 1:3) in our practice.
 

Differential diagnoses for Low Blood Sugar in Pets

Common Causes of Low Blood Sugar

False decrease due to blood not being separated promptly for lab
submission (very common error)

Liver disease, esp. Portosystemic shunts and cirrhosis

Hunting dog hypoglycemia (unknown cause)

Toy breed hypoglycemia in puppies

Severe bacterial infection (sepsis)

Insulin administration

Less Common Causes of Low Blood Sugar

Insulinoma (cancer of the pancreas)

Laboratory error

Polycythemia (too many red blood cells)

Hypoadrenocorticism (Addison's Disease)

Kidney failure

Cancers other than insulinomas

Starvation

Liver enzyme deficiencies (glycogen storage diseases)
 

Arthritis in Pets

With all the options available for arthritis in dogs that are currently on
the market, it is easy to get confused about the best way to treat
arthritis. The situation is simpler in cats, but still a little confusing
due to treatment difficulties. In approximately ascending order for
complications the options are:

Treating arthritis without the use of medications can sometimes be
accompished.

In both dogs and cats the most effective method of relieving arthritic pain
in overweight pets is weight loss. Weight control should be part of the
plan for treating any pet with arthritis.

Moderate exercise can be very helpful in slowing the loss of function
associated with arthritic conditions. It is best to encourage exercise on a
regular basis rather than just on weekends or sporadically during the week.

Accupuncture is practiced by some veterinarians and may be helpful in the
treatment of arthritis. Success may vary, based on the clinical case
reports I have seen, but if your vet is an experience accupuncturist I
don't see any reason not to try this technique.
 

Glucosamines, chondroitin and combinations of these products may be helpful
in controlling arthritis. These products seem to be safe to use. It is
still hard to find conclusive information on their effectiveness but if
they seem to be helping, continue to use them.

Aspirin is reasonably safe to use in dogs. It may cause ulcers in some dogs
and should be used after consultation with your vet. If a dog on aspirin
stops eating it is very important to stop the aspirin and tell your vet
immediately. Aspirin can be used in cats but this must be done very
cautiously. Your vet should always be involved in any decision to use
aspirin for arthritis in a cat. We have used aspirin every 72 hours in
cats without problem and other veterinarians have reported no problems with
every 48 hour use.

Adequan (Rx), an injectable medication approved for use in arthritis in
dogs has few side effects and works well for many dogs and cats. It is
somewhat costly and the need for injections means that several visits to
the vet are necessary for initial use and then periodic visits for
maintenance.

There are two new medications for arthritis, carprofen (Rimadyl Rx) and
etodolac (Etogesic Rx). There is a small risk of liver damage associated
with the use of carprofen and probably with etodolac, too. Watching
carefully for signs of inappetance or lethargy with the use of these
medications is important. Your vet might want to do lab testing for liver
disease prior to the use of these medications or after starting the
medications. Despite the small risk of liver disease these medications are
usually safe and are very effective.

Corticosteroids such as prednisone can be helpful in some cases of
arthritis, especially those caused by immune system disease. These
medications have a lot of side effects and should be used as a last resort.
When the next choice really seems to be euthanasia, there is no reason that
I can see not to try corticosteroids. Not all dogs and cats experience side
effects from these medications and many pets benefit from them for several
months to several years.

* * * * *
National Pet Week

May 2 through May 8th is National Pet Week this year. The American
Veterinary Medical Association (AVMA) encourages veterinarians to
participate in National Pet Week and many veterinarians hold activities or
practice promotions during this week. You might want to check and see if
your vet is holding a health fair or offering some sort of promotional
incentive during this week. Popular national pet week promotions include:

Sponsoring fund raisers for charitable causes relating to pets.

Pet parades and pet carnivals.

Rabies vaccination or spay and neuter promotions.

Some vets prefer to put their promotional energies into longer term
projects, such as:

Sponsoring public service announcements relating to veterinary medicine.

Arranging for pet visitations at nursing homes or other extended care
facilities.

If your vet does offer National Pet Week activities you might want to check
them out. If not, you may be able to contribute to the long term projects.
We like to promote educational activities in the school system and we
appreciate suggestions from clients for activities that children would
enjoy and also learn from. Your vet might be looking for ideas, too!
 
 

Spot and Duke

The first practice I worked at after graduation was also located close to
the shores of the Chesapeake Bay. It has a thriving sailing community and
there were a number of residents who lived on their boats full-time. Most
of these people used one marina as a home base and sailed around the Bay
for a while, until they got tired of it, and then moved on. They would be
our clients for a year or two on the average.

One of these sailors was an older man, John Smith, who lived on his
sailboat with his two dogs, Duke and Spot. Duke was a huge Labrador
retriever and Spot was a brown pit-bull with one white spot in the middle
of his forehead. As I chatted with their owner, I asked about the sailboat
and learned that it was a 23 foot craft that had been designed with a solo
sailor in mind. The dogs and the boat had made a number of trips up and
down the inland waterway and had sailed around the Caribbean Sea as well.
I joked with Mr. Smith about how many years the Chesepeake Bay had been
explored by John Smiths and other sailors. I think I was one of a long list
of people who had made that connection, based on his wan smile as he
pretended to be amused.

Mr. Smith needed to leave the dogs for boarding as he was leaving the boat
and flying home to the MidWest for a brief visit. We hadn't been expecting
to keep the dogs but there was room in the kennel facility and I took them
in. Usually the receptionist handled taking dogs into the clinic. Mostly
because she was better at getting directions from people about the need for
special care or other concerns that owners might have. But the clinic was
busy and I took the dogs in on my own.

I just assumed that two dogs that lived on a 23 foot sailboat full time
would get along. So I put them in the same run. I hadn't even turned around
when I heard a fierce cry from Duke that quickly degenerated into an actual
scream. Spot was obviously stalking Duke and obviously had the intention of
fighting with him.

Fortunately, I was close enough still to open the kennel door and let Duke
out before Spot initiated his charge. As I slammed the run door shut he
lunged against it, now growling and barking furiously. He was obviously
disappointed that I hadn't let him finish his attack.

Spot was a holy terror to board. The veterinary hospital had large
fiberglass cages with aluminum doors in the kennel room. These were no
challenge for Spot. He ate the door off his cage and was attempting to chew
through the door of Duke's cage when we checked on the them later in the
day. We put him in the hospital cages, which were stainless steel and had
stainless steel doors. He managed to mangle a couple of the doors but never
successfully got out. We went home late, hoping to limit the time he had
to destroy his cage while we weren't there. We literally ran into the
building the next morning to make sure that he had not managed to chew
through the doors and get to another dog.

When Mr. Smith got back from his trip I told him what had happened. As I
said, "I really thought it would be OK to put them together," he told me
that he was pretty sure he had said that they had to be kept separately. I
asked him how he could live on a boat with a dog that was that aggressive
towards the other dog without one of them getting killed. I was thinking
that it had to be pretty difficult.

"Oh, I just keep Spot outside on the deck all the time and I keep Duke in
the cabin," he said. Neither one of them seems to mind. Spot likes barking
and growling at everything and frankly, in some of the ports we sail to I
am glad that people see him on the boat."

Not being able to let this go, I asked, "How do you keep Spot onboard when
the weather gets rough? You must get into some rough seas now and then."

"Doc, Spot gets so seasick when the water gets the least bit rough that he
just lays around the cabin and lets Duke be. I almost wish it was always
rough sailing!"

We saw Spot and Duke on and off over the next couple of years. They never
did learn to live together. In fact, Mr. Smith brought Spot in one day
specifically because he wasn't growling at Duke and didn't even try to bite
him on a couple of occasions when he had the chance. We carefully examined
Spot and decided that he probably had a brain tumor based on his neurologic
signs.

This was the first time we had seen a behavioral change that was an
improvement associated with a brain tumor and we were concerned that we
were wrong because of that. A trip to the neurologist confirmed our
suspicion. Spot lived for several more months and got so calm towards the
end that he even stopped barking at the cats at the marina. I had always
thought that behavioral changes associated with brain tumors would result
in aggression due to pain or fear that the pet might feel. Spot's
experience taught me to think about brain disease in a new light. It is a
marked change in behavior that matters, not whether it is a good or bad
change.

* * * *

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