VetInfo Digest     October 1999

 

This Month:

Inconsistent Advice
 
Diabetes mellitus

Some people you just can't work for....

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This month's notes:

There are times in practice when a client and a veterinarian just don't
have the proper "chemistry".  Most of the time this is no one's fault. It
just works out to be the case.  In some cases, it is just bad luck. Read
about one of those times in "Some people you just can't work for...", in
this issue.

Diabetes mellitus is the second of several "hot" topics that we receive a
number of requests for information about.  This one would require a lot
more space to discuss than we can provide in a single issue of the VetInfo
Digest so we hope to put more information on this condition in the
subscriber area over the next few months.

We finally got a working search engine back on the vetinfo.com web site. We
apologize to all of you for the delay.
We are nearly recovered from the effects of Dennis and Floyd on our
computer systems. Again, we thank all of you for your patience in waiting
for responses to questions during the loss of power and the time it took to
restore information from the hard disk failure.
 

You Don't Follow Your Own Advice....

Several of our subscribers, and even a couple of clients of the practice,
have told me recently that I don't always give consistent advice on the web
site. Or that I don't always practice in exactly the manner outlined on the
web site, in the case of our clients. And these people are right.

Why  don't I give consistent advise all the time? The most honest answer is
that it is harder to actually practice veterinary medicine than it is to
give advice about it. There are many reasons for this but the three that
really lead to inconsistency are time limits, the difficulties of
communicating with clients in a consistent manner and monetary concerns.

I tend to be a compromiser when it comes to practice. I treat cases
differently, depending on the owner's circumstances, the pet's overall
health and other things that crop up during an office visit. I make a real
effort to tailor treatment to the needs of the pet and client I am working
for at the time. That isn't necessarily the best style of practice but it
is the way I feel comfortable with decision making. I favor the pet's needs
whenever possible but will, when necessary, work within the client's needs,
too.

There are a lot of veterinary hospitals that try very hard to establish a
practice standard for various conditions and do not vary much from their
standard approach to treating a problem. These practices are probably the
most successful at avoiding the trap of "ignoring their own advice".  This
can be good or bad, though.  It is good if the practice puts the patient's
needs first and has a clientele that can afford that style of practice. It
is bad when the practice routinely puts the owner's needs ahead of the
pet's or uses this system to ensure that practice charges stay high.

Some veterinary hospitals use an approach to medicine based almost entirely
on limiting the cost of procedures for the client, or attempting to meet
client expectations in some other way, but staying centered on the client's
desires. This can produce a very consistent approach to practice but the
patient may not be better off for it.

It is necessary for a veterinary practice to make a profit.  I have known
several veterinarians who were incredible humanitarians but who could not
stay in practice because they could not afford to. They simply couldn't
bring themselves to charge enough for their work for the practice to
survive.  This means that a practice has to see a number of clients and
their patients each and every day.  Once in a while this produces a
situation in which there simply isn't time to cover all the side effects,
discuss all the ramifications of surgical procedures or spend time looking
for references relating to a particular patient's condition during a
routine office visit.  This is understandable but it is important that you
recognize that you didn't get all the information you needed or that the
information you did get conflicted with information from previous visits.
If you recognize that there is "more to the story" than your vet had time
for on that particular visit, you may have to take charge of the situation
yourself and call your vet back to ask why there was an inconsistency. Or
to say something like, "I know you were very busy the other day when Spike
was examined but I think you told me not to bathe him this visit and you
told me to bathe him last visit, can you check on which way you want me to
go with this?"  Your vet shouldn't mind this type of phone call and should
take the time to talk to you. If you happen to hit another busy day when
you call, ask your vet to call you back at a reasonable time. Do talk to
the receptionist prior to insisting on talking to the vet -- often this is
the quickest way to get a return phone call and sometimes the answer to a
question is already in the medical record.

Sometimes, the inconsistencies are due to actual differences in the way one
patient should be treated compared to another. Sometimes they are due to
changes in opinion about what the diagnosis is. They may be the result of
attending a seminar in which the speaker gave persuasive arguments for or
against a diagnostic test or treatment procedure that has influenced your
vet's thinking. Before worrying about whether your vet is paying attention
to your pet, ask why there is an inconsistency.

This week, I had to tell a client that I was simply wrong in my initial
diagnosis of their pet's condition, despite having lab results that were
highly supportive of the diagnosis I made. This is hard, especially after
several hundred dollars worth of diagnostic work, but you are entitled to
know when that happens.  It is frustrating to spend a great deal of money
pursuing one diagnostic option only to find out that it isn't the real
problem. Realistically, though,  there simply isn't any way that your vet
is going to pick the right disease or disorder at the onset of the
diagnostic process in every case. Medicine is pretty frustrating in that
regard.

The last situation that arises is the problem of information that I simply
do not have enough personal experience or in-depth understanding of to have
a solid opinion about. In these cases, I sometimes fluctuate between
interpretations of the information or between levels of understanding until
I finally get a grip on the information. While this is happening it can be
a little confusing for everyone. This is a time to keep asking the
questions that come to your mind until you get a good consensus between
your vet at home, our advice and whatever other sources of information you
can find that seem reliable.

If you notice that I have changed from one position to another on advice
that I give or if you feel that there is an inconsistency in treatment from
your vet at home, don't panic --  call or write and ask why.  You may find
that there is newer and better information available than even a short time
previously.

I know that it is confusing when the "experts" don't agree or when an
"expert" fluctuates in opinion over information or clinical findings. Long
ago I had to give up on the idea that there is a single right answer in
medicine. There are sometimes many right answers and sometimes no answers
at all.  Until that changes, I guess we'll have to keep calling it
"practicing" medicine.

Don't feel guilty about asking questions and please keep pointing out when
I don't appear to be taking a consistent stance or when I don't appear to
be following my own advice that has been posted previously. That is good
for me and it could help both of us get to a deeper understanding of the
complexities of some problems. The same is true for your own vet, too.

* * * * * * * * * * * * * * * * * *

Diabetes Mellitus

The term diabetes is used to describe diseases in which the primary symptom
is increased urination. There are actually two disorders that can lead to
this symptom, diabetes mellitus (sugar diabetes) and diabetes insipidus,
which occurs due to a deficiency in anti-diuretic hormone that is produced
by the pituitary gland. When someone says their pet has "diabetes" it is
almost always safe to assume they mean diabetes mellitus but it is good to
remember that there is actually more than one form of diabetes. In this
article, everything that follows is related to diabetes mellitus.

I was going to try to write a comprehensive review of diabetes, similar to
the issue about hyperadrenocorticism, but after getting to about the eighth
page, with no end in sight, I decided to try to cover the highlights in
this issue and to work on the rest of the review to put on line at a later
date. There is a great deal of information available on the subject of
diabetes in dogs and cats. If what is presented here conflicts with
something else you have heard or if you have questions about what is
presented, feel free to write to me at mervet@inna.net.

First, there are major differences between diabetes mellitus as it affects
cats and dogs.  In dogs, it is almost always necessary to treat diabetes
with insulin, a condition referred to as "insulin dependent diabetes
mellitus" or IDDM. In cats, it is possible to treat diabetes with dietary
changes and hypoglycemic medications about 30 to 50% of the time,  a
situation referred to as non-insulin dependent diabetes mellitus" or NIDDM.

There are predisposing factors that can influence whether a susceptible pet
will develop diabetes. Obesity contributes to diabetes by increasing
insulin resistance in the tissues and contributing to some changes in
metabolism that also favor diabetes. Obese pets with the necessary genetic
tendency to develop diabetes, especially obese pets who do not exercise
much, are more prone to developing diabetes than normal weight pets. This
is true for both dogs and cats. Dogs are prone to developing diabetes due
to chronic pancreatitis. It is hard to diagnose chronic pancreatitis in a
cat but it does appear that cats prone to this condition are also more
susceptible to pancreatitis. Pets with chronic pancreatitis problems should
probably be tested on a regular basis for sugar in the urine or for blood
sugar levels. In dogs, hypoadrenocortism (Cushing's disease), including
hypercortisolism from prolonged use of corticosteroids, makes diabetes more
likely. Cats are not very prone to hyderadrenocorticism but may still
develop diabetes if corticosteroids  are administered chronically and in
response to the administration of megestrol acetate (Ovaban Rx) for skin
disorders.  These predisposing factors can be controlled, to some degree,
in veterinary patients. It is important to use corticosteroids only as
directed by your veterinarian and as infrequently as possible.  Megestrol
acetate administration should be a last resort for cats with skin disease.
Weight control can be  beneficial in reducing the tendency towards diabetes
in dogs and cats.

Dogs appear to develop diabetes due to immune mediated destruction of the
beta cells in the pancreas that produce insulin. Consequently, when dogs
develop diabetes they tend to have an absolute lack of insulin and it has
to be supplemented by injection. In cats, there are several mechanisms by
which diabetes appears to develop. Some cats have immune mediated disease
similar to that seen in dogs. Other cats have deposition of amyloid, a
protein that results from excessive amylin production in the pancreas,
which inhibits the function of the insulin producing cells. The deposition
of amyloid happens gradually and there is usually residual function of the
beta cells for some time. In addition, amylin itself causes some
resistance to insulin's effects in the skeletal muscle. If the cat is
obese, insulin resistance in the tissues contributes to the lack of control
over blood sugar. Since cats can not communicate how they feel and since it
is often difficult to tell if a cat has an increase in urine volume in cat
litter, cats probably get treated for diabetes much later than humans with
similar underlying causes for their diabetes.  All of these factors
together contribute to the need for insulin administration in many cats.

So in dogs, it is usually necessary to consider the use of insulin whenever
diabetes is diagnosed. In cats, there is some chance that diets to control
obesity, provide moderate fiber and with appropriate carbohydrate sources
may help control sugar levels sufficiently to eliminate the need for insulin.

Making the initial choice in therapy for cats is therefore a more difficult
decision for the veterinarian and pet owner.  It may be best to start with
insulin therapy in many cats, even though the ultimate goal is wean them
from it. Insulin therapy is useful while working to control obesity, for
instance. In addition, there is some evidence to suggest that in cats with
blood sugars over 360 mg/dl experience "glucose toxicity", in which the
high blood sugar levels further inhibit insulin production. Supplementing
insulin at the start of therapy helps to overcome this effect. The down
side of early insulin therapy is that owners must expect insulin needs to
change and must be vigilant about watching for signs of hypoglycemia that
may occur as the cat's need for insulin decreases in response to weight
loss, elimination of the glucose toxicity and other effects of dietary
changes.

To sum this up, it is my impression that many of the endocrinologists in
veterinary medicine favor initial use of insulin in diabetic patients whose
blood glucose is consistently over 360 to 400 mg/dl, even if the ultimate
goal is to use oral hypoglycemic medications and dietary changes to control
diabetes over the long term.

Another early choice that must be made in treatment of diabetes is to
decide whether to use once daily or twice daily injections of insulin. The
current trend in both dogs and cats is toward twice daily injections right
from the start in the treatment of diabetes in both dogs and cats. An
owner's circumstances obviously influence this decision since some owners
simply can not be available to give injections on a regular every twelve
hour schedule. This is another situation in which it may be better to start
out with a more aggressive approach and back off to the desired option,
later, though. Most cats are easier to regulate on twice daily insulin
injections and once this is accomplished it is easier to change to a once
daily insulin protocol in a well-managed diabetic patient than in a patient
with recently discovered, unregulated diabetes. In dogs, our experience has
been that twice daily insulin dosing is almost always necessary in order to
achieve good control over the blood glucose levels over the course of the
entire day.

The effect of diet on diabetes continues to be an area of research in
veterinary medicine, but there are a few things that appear to be well
established at this time. First, it is better to control calories and keep
cats from becoming obese in the first place, if at all possible. In
multiple cat households this can obviously be a difficult task and even for
single cat homes there are feline patients who can make life pretty hard
for their owners when food is withheld from them. But there is not much
question that obesity is a predisposing factor to the actual development of
diabetes in patients prone to developing it.  Most cats require about 30 to
35 calories per pound of body weight per day for maintenance. In obese cats
it is usually acceptable to feed 20 to 25 calories/lb/day in order to see a
gradual weight loss. Dogs generally require less calories, varying from
about 25 calories/lb/day in large breeds to about 30 calories/lb/day in
smaller dogs. It is safer to restrict calories in canine patients but they
should not be cut back more than 40%.  It is possible to determine the
calories in most dog foods by calling the manufacturer or in some cases, by
reading the bag or can.

Feeding schedule is very important when dealing with diabetic pets. The
best feeding schedules involve multiple small feedings throughout the day.
For cats that are used to nibbling all day, this is an easy schedule to
manage except that owners must remember to restrict the total amount of
calories -- so it may be necessary to feed small amounts and refill the
food bowls on a schedule, rather than leaving food out all day. For cats
that are fed canned foods or have regular "meal times" it is best to try to
feed four meals a day, with two of them occurring at the time of insulin
injection and the other two evenly spaced in-between the injections. For
dogs, in which controlled feeding is almost always necessary, it is better
to feed four meals a day, if possible. If not, try for at least three meals
a day, with two of them occurring at the time of insulin injection and the
third one early in the afternoon, if possible. Obviously, this conflicts
with many owner's work schedules. In this case, using nutritionally
balanced treats to spread out the caloric intake over a longer period may
be useful. Try very hard to keep the caloric intake the same from day to
day, though.

The ingredients in the food are important to consider, too. High fiber,
high carbohydrate diets are considered to be optimal for diabetic patients.
There is some research into the best carbohydrate ingredients with rice and
wheat seeming to cause more problems with blood sugar elevations after
meals and barley, corn and sorghum favoring a lower blood sugar after
eating. Some people believe that chromium supplementation is beneficial in
pets with diabetes but I couldn't find a controlled study supporting this.
There is some evidence that supplementation of L-carnitine may be helpful,
especially in obese patients where it has appears to aid in weight control.
 (Much of this information is from the a symposium review published by
Iam's entitled "Recent Advances in Clinical Management of Diabetes
Mellitus").

In cats it is reasonable to make an attempt to use oral hypoglycemic
agents, the most common one being glipizide (Glucotrol Rx). This is easier
for pet owners but there is still a need for blood testing and monitoring
of the patient.  Initially, it is a good idea to monitor blood glucose
several hours after administration of the first dose of Glucotrol and then
at least weekly for four to six weeks. In most cats a response to this
medication will occur within this time frame. If there is not a sufficient
response then a switch to insulin must be made. After establishing that
glipizide will benefit a patient, based on control of blood glucose, it is
necessary to test blood sugar levels or urine sugar levels on a regular
basis, at least every 2 to 3 months. Most cats that initially respond to
glipizide will eventually need insulin therapy because the beta cell
destruction continues despite glipizide therapy. There have been cats who
were maintained on oral hypoglycemics for at least a couple of years,
though.  Glipizide works a lot better in conjunction with dietary and
weight control.  Cat usually require 5mg of glipizide every 12 hours.

The type of insulin to use is also a decision that must be made when
treating diabetic pets. There are three classes of insulin, based on
duration of effect.

Regular insulin has the shortest duration of effect and fastest onset. It
is rarely, if ever, used to treat diabetic patients on a maintenance basis
but does have some use in treating complicated cases of diabetes mellitus
in the early stages, especially if the pet must be hospitalized due to the
severity of complicating factors.

Lente insulin and NPH (stands for "neutral protein Hagedorn" insulin) are
intermediate insulins in duration of action, usually hitting their peak
effect in 4 to 8 hours after administration and exerting insulin effects
for about 12 to 18 hours, depending on patient response. Peak effect and
duration of action both occur outside the usual ranges in some patients.

Protamine-zinc insulin (PZI) and ultralente insulin are longer acting
insulin preparations. They have a peak effect that is not much later than
the intermediate insulins (perhaps 10 to 12 hours, although it was hard to
pin this down in researching the insulins) but their duration of action is
usually several hours longer. In cats, PZI insulin has been the long time
standard for once daily use and is still favored by many veterinarians. It
has ordered through the veterinarian at this time, which is a minor
complication for some people. Ultralente insulin has not been highly
successful in cats or dogs, in our experience, in controlling diabetes on a
once daily schedule. There are some veterinarians using combinations of
lente and ultralente insulin and reporting reasonable success, though. If
once daily injections are an absolute necessity for your pet, ask your vet
about PZI, ultralente or combinations of lente and ultralente insulin. If
you can handle a twice daily insulin injection schedule it is probably
better to go directly to that schedule and skip the attempt to use once
daily insulin, in most pets.

Adjustments to insulin dosing are best made by evaluating the blood glucose
curve. This is just a graph of blood glucose levels taken at 2 to 4 hours
over the course of the day. It is ideal to use 2 hour intervals and to test
for 24 hours, at least once in a while, but this is difficult for most
veterinary practices to accomplish. The goal is keep blood glucose levels
between 80 mcg/dl and 180mcg/dl, for as much of the day as possible. It is
often impossible to stay within these guidelines for the entire 24 hour
period. It is important to avoid blood glucose levels of less than 60
mcg/dl and above 250 mcg/dl. At the low end, the drop in blood sugar to
very low levels may set off the body's defense mechanisms for keeping sugar
in the blood, resulting in a  "rebound" of blood sugar to high levels. This
effect is referred to as the Somogyi phenomenon. At the high end, blood
sugar levels over 250mcg/dl contribute to cataract formation and are in the
range where the body is not able to adequately maintain immune function,
tissue repair and other vital functions, resulting in poor health if the
levels stay above 250 mcg for more than four to six hours in the entire
day.  Monitoring of blood sugar levels by plotting glucose curves is the
only really accurate way to assess whether the insulin level is too high or
too low -- since either situation can result in blood tests with high
glucose levels.

Glucometers, machines to test blood sugar levels at home, are sold at most
pharmacies and many larger retail stores such as Wal-Mart and K-Mart. Most
pet owners are capable of using these machines to aid in the control of
diabetes in their pet.  A drop of blood is placed on a testing strip and
the strip is placed in the machine to measure the blood glucose. Many of
the machines require that the strip be placed in the machine prior to
applying the blood drop, which makes the procedure a little more
complicated. It is possible to get blood from the ear margins, lips and
back edge of the foot pads. Dogs are generally easier to get blood from
than cats but owners of both species have succeeded in drawing blood for
regular insulin testing. There is a web site devoted to home blood sugar
measurement for pets (http://members.atlantic.net/~bobj/bgtest.html) and it
has helpful tips for pet owners wishing to monitor their pet's blood sugar
at home as well as detailed information on many aspects of diabetes in
pets. There is almost no question that blood levels taken at home,
especially in a pet not too disturbed by the process, are more likely to be
representative of "true" blood sugar levels than those taken a veterinary
hospital where the pet is stressed and may not be eating as well.  Having
the ability to test blood sugar at home also offers a strong advantage when
hypoglycemia is suspected. If it is possible to immediately measure the
blood glucose an accurate determination of the need for glucose
supplementation can be made, avoiding the situation in which clinical signs
noted by the owner are actually from hyperglycemia due to poor insulin effect.

The home blood glucose meters tend to read blood glucose levels as slightly
lower than the same sample tested using in-office dry chemistry machines or
reference labs. This is OK, since the trend in sugar is more important than
the actual value and since it is probably better to err on the side of
caution for low blood sugars. If an at home glucometer reads 40 mg/dl of
sugar and the actual value is 60 mg/dl and the owner treats for
hypoglycemia when it isn't necessary to do so that is better than the meter
reading 60 mg/dl and the blood sugar actually being 40 mg/dl and the pet
not receiving treatment for hypoglycemia. We usually compare our lab values
to the client's glucometer using the same blood sample once or twice in
order to get an idea of the variance between the samples. Your vet would
probably be willing to do this, too. There is some chance this is an
artifact of the method in which the blood is obtained, since veterinarians
tend to draw blood from a vein while owners usually use a small needle or
the lancet devices that come with the glucometers to obtain blood samples
from a capillary or marginal ear vein. In cats, an easy way to identify the
ear margin vein is to shine a flashlight through the ear and look for the
red line along the ear margin. Almost all of our canine patients will allow
blood sampling from the inside of the upper lip (or the lip margin).
Obviously, in a dog, it is necessary to be cautious until it is established
that the patient won't get upset and try to bite when working around its lips!

In some cases, insulin therapy just doesn't seem to work well. When this
happens, it is necessary to review the pet's circumstances, the client's
understanding of the instructions and the veterinarian's choice of insulin
type and evaluation of the glucose curves.

The first area of concern is care for the insulin itself.  Insulin should
not be shaken to mix it up. Rolling the bottle across the palm of one hand
until the insulin appears to be mixed will help to preserve consistent
strength. If the bottle of insulin will last more than 30 days, it should
be kept refrigerated. For pets that will use an entire bottle of insulin in
less than 30 days it is OK to keep the insulin at room temperature. Insulin
is sensitive to heat and it can not be carried around and left in the car
on a hot day unless it is protected in a cooler. If you are using diluted
insulin it only has a reliable shelf life of 30 days. A new batch must be
diluted once a month. Make a note of the expiration date on new bottles of
insulin. Sometimes the expiration date is close enough that it is not
possible to use the whole bottle of insulin before it expires. Due to the
fragile nature of insulin it is a medication that really should be used
only when it is in date.

Administering insulin should be done in a consistent manner. It is best to
keep the times of administration as close to 12 or 24 hour intervals as
possible. Insulin should be injected under the skin, not into the skin
itself and not into the muscle underlying the skin, unless your vet advises
using a different method of administration. Where to make the insulin
injections is an area of slight controversy.  Many veterinarians routinely
use the area between the shoulder blades to make injections since there are
fewer skin nerve endings in this region but it may not be the best area for
insulin injections due to inconsistent absorption of insulin from the
tissue that underlies this area. We advise clients to use either flank (the
area between the rib cage and the rear leg) to make injections but we are
not absolutely certain that this is actually better.

It is important to review with your veterinarian or the pharmacist the
amount of insulin to draw up in the syringe. Make sure you understand this.
If you think that you administered only part of in injection, due to
movement of the pet or putting the needle through the skin it is usually
best just to give the portion of the insulin that remains rather than
trying to "guesstimate" how much was lost. The sugar level will restabilize
as time goes on if you skip a dosage but giving too much insulin can lead
to major complications.

After determining that the insulin is not being harmed by improper care and
that the administration techniques are adequate, careful reevaluation of
the blood glucose curve is necessary. In pets being monitored at home, the
owner should be cautious that the correct amount of blood is being placed
onto testing strips and that the machine is set to the proper strips (most
won't run unless they are).  In pets being monitored at the veterinary
hospital it may be necessary to try to determine how much stress is
affecting the results. Cats can sometimes elevate their blood sugar into
the 250 to 300 mcg/dl range just by getting really upset. Since they often
do not like confinement or blood collection, there is a real possibility
that in-clinic lab work will error on the high side of blood glucose
measurement.

Changes in the pet's lifestyle can impact insulin needs, as well. Sometimes
pets that were not doing much prior to insulin therapy will feel well
enough to resume normal activities and begin to exercise more. Dogs that
exercise more often need less insulin. To me, this seems to be the opposite
of what would be expected, so it is important to remember it when adjusting
insulin dosage for changes in exercise. It is difficult to regulate insulin
in dogs that have intermittent high intensity exercise and periods of
inactivity. Try for regular moderate exercise, if possible.

All of these things impact on the use of insulin to control diabetes in
dogs and cats. There are many other factors that there wasn't room to
discuss in this month's issue of the VetInfo Digest.  This is a topic that
we will present more information on in the future.

* * * * * * * * * * * * * * * * *

Some People You Just Can't Work With (or For):

There are clients and patients who veterinarians just can't work for,
despite perfectly good relationships in everything except veterinary medicine.

I used to work for a client in my area who was named after a famous
Virginian. Mr. James Madison was a very good client. He paid for his
animal's care while I was still on the farm. He called me before their
problems turned into disasters. I did good work for him and I charged him
fairly. We liked each other. But fate was not with us.

After performing a few minor procedures at his farm, Mr. Madison called me
to palpate a couple of his mares for pregnancy. In horses, it is possible
to feel the uterus and discern whether or not a horse is pregnant by
inserting an arm into the mare's rectum and feeling around the abdomen
until the uterus is located. Naturally, some horses are not very fond of
this procedure. As James led the last horse out to be palpated he warned me
"Shadow can be a little flighty."

I approached Shadow's rear end and took hold of her tail, I felt her bunch
to kick. The best procedure in this instance is usually to step in close to
the horse's rear end and just let her kick you. It hurts, but it protects
the head and major organs from serious damage. But I was pretty sure that I
had time to get out of the way, so I backed up quickly. This was a mistake.

Her left hoof hit me squarely in the chest and her right hoof hit my face,
just below the right eye. Fortunately, her left foot was leading and I was
already traveling backwards pretty quickly when the right hoof hit. I had a
nice laceration and instant swelling around my eye, looking a little like a
prize fighter who was losing the big fight. I landed hard on my rump, about
ten feet from Shadow's rear end. After a few minutes, I got up and finished
palpating Shadow. She was pregnant. I always liked feeling the movement of
a developing foal but the reward wasn't quite worth the effort this day.
Mr. Madison was very concerned about my well being as I left, apologizing
profusely for Shadow's behavior.

The next time I went to the Madison farm I was supposed to geld a stallion.
He was a pretty gentle horse and I wasn't anticipating any problems. He
stood still as I found an injection site over his jugular vein and placed a
needle into it. As I started to inject the xylazine sedative I told James
that sometimes horses reacted badly to the sedative and he should be ready.
He nodded his head. Unfortunately, he didn't unwrap the lead from around
his hand, though. The stallion reared up suddenly and staggered backwards
several steps on its rear legs. Mr. Madison was hanging from the horse's
halter by the lead rope, firmly wrapped around the fingers of his left
hand. As the stallion moved backwards it encountered a ditch and toppled
over, releasing the pressure on Mr. Madison's hand, but not before one of
his fingers was broken. The stallion took one last lunge, rolling up and
out of the ditch towards my practice vehicle, a Datsun pickup . One foot
went through the passenger side window and made a serious dent in the top
of the cab. My wife was sitting in the car at the time.

I hollered "Get out of there!" and Moe didn't move an inch. Our daughter
was in her car seat in the rear seat of the king cab and she wasn't leaving
her. The errant foot cracked the front window of the Datsun, from the
inside. I grabbed the stallion's head and rolled him over, away from the
truck. And back in the ditch. Where he finally lay still enough to give him
an anesthetic agent. We couldn't move him and there was just enough water
in the ditch to make it possible for him to aspirate water. Moe held his
head up and I went ahead and castrated him before he woke up. Mr. Madison
wrapped his hand with an Ace bandage and helped as best he could to keep
the rear legs out of the way. My daughter slept on in the car seat,
undisturbed by the whole episode. This time I was very concerned about Mr.
Madison's health and left profusely apologizing for the stallion's reaction
to the sedative I had administered.

Mr. Madison was persistent. He called me again a couple of weeks later when
one of the mares snagged her skin on a nail protruding from the barn,
producing an eight or nine inch tear on her chest. Mr. Madison let my
assistant hold the lead this time. I gave xylazine with no problem but this
time used a local anesthetic to allow suturing the wound.  The procedure
was going really well and I was almost done when I ran out of suture
material. I asked my assistant for more and then reached back over my head
for it, without looking. The horse in the next stall had become curious
about what we were doing and was leaning way over the partition to see. I
smacked his nose with my hand. He reacted by running out of the stall,
right through the stall door. A piece of the door entered his chest and
exited behind his shoulder blade. It was an ugly wound.

I finished suturing the mare and then spent an hour or so repairing the
little gelding. I didn't even try to ask for payment on his wounds. There
had been too much bad luck in the last few weeks at the Madison farm for
that. I did charge for the mare, though.

Mr. Madison walked to the truck with me and settled up the bill. He looked
a little uncomfortable. Finally, he said "Doc, I really like you. And
everything you have worked on has done OK. But I got to tell you, Doc, I
just can't call you again. I'm an old man and there's too much excitement
when you work around here."

As time has gone on, I have noticed that there have been two or three other
clients whose pets I just couldn't treat without inducing some sort of
disaster in their household or experiencing unusual reactions to
treatments. I'm not sure why this occurs but I have to agree with Mr.
Madison about the solution. When a couple of office visits get "too
exciting", I'm usually hopeful that the client will decide I'm not the vet
for them. Sometimes the chemistry just doesn't work.
 
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The VetInfo Digest is published by TierCom, Inc., P.O. Box 476, Cobbs
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