Keeping score of kittens

Last week I worked in a kitten nursery — a small building off of a larger shelter, full of underage kittens (mostly orphans, some with moms). Although this shelter has literally hundreds of kittens out in foster care, kitten season in the South is so intense that they have this separate building just as a nursery, with its own staff and volunteers (and for these two weeks, its own vet! With consultations from the main shelter vet, of course).

Cats seem to take the approach to reproduction that you should make as many babies as possible, and if not all of them make it, that’s life. Outdoor, unowned kittens have about a 75% mortality rate. Cats are mostly very good moms, but kittens are just so little and fragile. After a few days of kitten deaths I became almost manic. I would not lose more kittens! I started keeping score, me versus kitten death.

• Feral mom is too scared to take care of her neonatal kittens. I give her a place to hide and some time to figure it out. I give her too long, and her three kittens die. Three points to kitten death.
• A cat is brought in while in labor. It becomes clear that things are not proceeding, so we take her to surgery. Three kittens survive. I sit with them for two hours trying to get them to nurse. They do, a little bit, but their mom doesn’t recognize them as hers since she wasn’t awake when they came out. One dies. I foster the other two onto a receptive mom with her own four kittens and spend another hour making sure they learn to nurse on her and can defend their nipples from their week-older foster siblings. So far, they are still alive. Two points to the Dog Zombie, one point to kitten death.
• Six kittens in a little cage feel funky for several days, just sitting around and not playing like normal little fiends. I give them fluids for several days but they don’t perk up. We start them on antibiotics that are good for GI disease, because they have diarrhea and deworming hasn’t helped. When a new cage opens up, I move three of them into it, so everyone will have more space. I coddle them with fluids and medication to make them not feel sick to their stomach. At the end of the week, two of them are playing and three of them are eating. Three points to the Dog Zombie. (The other three are holding steady. We’ll see.)
• One kitten is a little lethargic and dehydrated one evening. I give her fluids, but I am not worried about her. The next morning she is found dead. I do a necropsy and find that she had pneumonia. This is weird, because she didn’t have an upper respiratory infection, so where did it come from? But her lungs were definitely funky. I panic and give her cagemate antibiotics that are good for pneumonia, since whatever happened to her, it happened so fast that I want to prevent it rather than wait and see. One point to the Dog Zombie?
• One kitten fades fast and dies. (One point to kitten death.) His cage mate starts to fade the next day, lethargic and dehydrated. I necropsy her brother and find a bad infection in his GI tract. I start the living kitten on antibiotics that are good for GI infections and leave orders for lots of warming pads and fluids. She does not survive the night. A second point to kitten death.

Those are only some of the stories. I have learned all about antibiotics for head colds and stomach bugs, I tell you what. And I have learned that a roomful of kittens becomes much less cute after the first hour of dealing with it. But they will still make you manic trying desperately to save them all. You can’t save them all. But you also can’t stop trying.

...or you could zeuter the dog, instead

The dog was on his back, sedated on a table. I was not wearing a surgical cap or a sterile gown. I held the first testicle between two fingers, pushed the needle in, and injected a little less than a milliliter of a mixture of zinc gluconate and L-arginine. Then the second testicle. And now the dog was non-surgically castrated. In a few weeks, once he was rid of the sperm he had already made, he would be sterile for the rest of his life.

This product, Zeuterin, is newly released in the US market, just starting to make its way into veterinary clinics. I was part of a one-day training at a low cost spay/neuter clinic which has partnered with the company as an early adopter. On the one hand: if we can avoid doing surgery on dogs, why wouldn't we? Isn't an injection better than cutting? On the other hand: if you have to sedate the dog for the procedure anyways, and surgical castration is so very quick and simple, what's the benefit of zeutering rather than surgically neutering them? And is the benefit to the dog (healthier) or to the human (faster and/or cheaper)?

I'm considering a few different populations of dogs: owned dogs being brought to a clinic, shelter dogs being altered on site, and owned dogs being altered on an outpatient basis. The answers to the above questions will differ for each population.

• Sedation versus anesthesia: Surgical castration of a dog requires full anesthesia. Zeutering requires only sedation, and in some calm dogs can be done without even that. A dog will recover more quickly from sedation than from anesthesia, so he'll be able to go home earlier in the day. (Important in a clinic and for outpatients; not important for most shelters.)
  
• Time: You'd think that an injection would be faster than surgery, but it isn't clear that this is so. A trained high volume surgeon will perform a castration (a very simple surgery) in just a minute or two. The injection has to be given slowly and the needle has to be positioned precisely. The time difference may not be significant.
  
• Cost: Zeuterin is expensive! It costs $10-25 to neuter a dog with this product, depending on the size of the dog. I don't think anyone really knows how this compares to surgical castration, which doesn't have clear costs per animal. How much is your surgical suite costing you, and how valuable is it to keep a dog out of it? How much does it cost to sterilize a pack of surgical instruments? For shelters where every penny is counted, the cost of the product will matter more than in a veterinary clinic where an owner may not mind a difference of $10 one way or the other.
  
• Using technicians: Technicians can't perform surgery. That requires a veterinarian. But a technician can give an injection. The spay/neuter clinic where I learned to zeuter are currently only allowing vets to zeuter, but they expect to start using technicians in this role as they become more comfortable with the procedure. Saving the veterinarian's time is a big bonus. Vets are expensive!
  
• Testosterone reduction: Surgically neutering a male dog reduces his testosterone level by 100%. Zeutering him reduces it by 50%. Which is better? Hard to say! We don't really know yet whether zeutering will reduce unwanted behaviors (roaming, peeing on things) the way neutering sometimes does. (But we tell people that really training is better for that sort of thing anyway.) And is it healthier for a dog to have all of its testosterone, or only half? Testosterone is a steroid which affects metabolism and various physiologic process in many ways. I'm guessing that it does some good things for dogs and some bad things, and only time and a lot of research will tell whether it's better to have 50% or 0% of normal levels.
  
• Aesthetics: Zeutered dogs still have their testicles, although atrophied and therefore somewhat smaller in size. Good or bad? Opinions will differ on that one.
  
• Complications: Surgical complications can include anesthetic death and bleeding, but complication rates for this simple surgery in healthy dogs are very low. Complications with zeutering include the development of ulcerations or even necrosis of the scrotum. These complications are also expected to be low when the procedure is done correctly, but again, it's too soon to know exactly how that will shake out.

So is there a place for zeutering in veterinary medicine? I think there is, but it's not clear yet exactly what it will be. I'm not convinced that that place is in a shelter (though some shelter vets disagree with me). I'm also not convinced it's in a general practice veterinary clinic for the average owner, although I think some owners will prefer Zeuterin both for avoiding general anesthesia and for maintaining a higher testosterone level, and of course for keeping the dog's balls. The place I really see this product is for performing neutering outside of the veterinary clinic, for example, in low income areas of the US where the population has difficulty getting their animals to a veterinary clinic, either for lack of transportation or for lack of enough committment to follow through with an appointment for surgery. In other countries, trap-neuter-release programs may also find a great benefit to being able to do this procedure in the field.

(Posted by a bleary DZ at the fabulous but overwhelming ScienceOnline 2013 unconference.)

Hey, want to get rid of those ovaries, cheap?

A few months ago I was watching a general practice veterinarian perform a dog spay. And I was surprised by how slow he was. He seemed hesitant, not confident in his technique, and he took a good forty minutes to finish the surgery. He commented to me, “I only do about one spay a month. Most of the animals we see these days were spayed before they left the animal shelter.” This made me wonder: if I had a dog that I wanted to have spayed, where would I take her? To someone who only performed this complicated surgery once a month? Or would I actually rather have her spayed at a shelter, by someone who does multiple surgeries a day, even though she is less likely to have high quality anesthesia management and individual attention there?

The answer to the question of how to offer high quality, high volume spay and neuter services to the general public is veterinary clinics focusing entirely on spay and neuter, and not offering general health care. One model clinic of this type is Humane Alliance in Asheville, NC. This sucessful non-profit clinic was founded in 1994, before much of the rest of the shelter community had woken up to the fact that high volume spay/neuter is an important component of reducing pet overpopulation. Today, 25% of the animals they surgerize are privately owned and come in on appointment. The other 75% come from shelters, rescues, and feral cat trap-neuter-return operations within a sixty mile radius of the clinic (transportation is provided by the clinic). On any given day they may have 100-125 animals in the building receiving surgery.

The Humane Alliance model was so successful that other clinics began coming to them for help. In 2005, Humane Alliance began accepting applications for National Spay/Neuter Response Team (NSNRT) members, member clinics designed on the Humane Alliance high volume model. They define “high volume” as at least 5,000 surgeries per year, though they note that most clinics perform at least 7,000. With a profit margin of about $2-3/surgery, this nets the clinics a profit of about $10,000/year, which is enough to keep them afloat. Today, there are 110 NSNRT clinics, and five more are expected to be operational before the end of the year. Humane Alliance helps the clinics every step of the way, from the design of their business plan, to the list of medications to have on hand on opening day, to sending staff members out to work on site at the new clinic for the first week.

Do these clinics provide spay/neuter surgery in the style of shelter surgeons? In some ways, yes, because their protocols are very much oriented to high volume, with the expectation that one surgeon will handle up to dozens of animals a day. But the quality of the care is extremely high. Arguably the most dangerous part of surgery is going under general anesthesia, and these clinics do not skimp on their management of this aspect of surgery, down to the details of keeping the animals extra warm on a heating blanket while they wake up.

I like this vision of the future: veterinarians who are specialists in spay/neuter surgery, working in clinics that are focused on this one complicated procedure, providing services of higher quality and for lower cost. Making spay/neuter more affordable and more accessible can only be a good thing for pet overpopulation. Unfortunately, the reaction of many general practice veterinarians is not so enthusiastic. Because these types of clinics charge much less for surgeries (often well under $100), veterinarians at full service clinics often fear that their clients will be stolen from them by clinics offering less expensive services.

Is it a realistic fear? I don’t think so. Full service veterinarians offer full service: wellness care, and management of sick animals. Spay/neuter clinics offer a one-time interaction with the client. Full service veterinarians may indeed lose spay/neuter business, but I contend that those services don’t comprise a large part of their income to begin with. The rest of their services aren’t threatened.

I think these clinics are going to continue to expand, and become an accepted part of the way veterinary medicine is practiced. The old adage “good, cheap, fast: pick two” is disproven here. This is the place I would take a beloved animal to have surgery.

Mobile veterinary practice and federal drug restrictions

Mostly, when I took my cats to the vet, I would cram them into a carrier while they protested and drive them to a clinic. It was a rough trip for them, so rough that at one point I called a travelling vet to come see them at home. What a difference: they were more confident in their own territory, and got to deal with the stressful physical exam without having first been stressed by a car ride and a wait in a room full of dogs. More and more small animal mobile practices are cropping up these days. Of course, a significant percentage of large animal practices have always been mobile. It is prohibitively expensive to transport cows to a clinic, hugely stressful for the animal, and may be impossible if the cow is too sick to walk. Most horses are also treated on site rather than at a clinic, except for referral cases which are seeing specialists.

So in my mind, mobile practice is good for small animals and essential for large ones. Unfortunately, the Controlled Substances Act, passed by Congress in 1970, limits where controlled substances can be carried. The act apparently has not been applied to mobile veterinary practices until recently, but the Drug Enforcement Agency (DEA) appears to be changing its practice this year, as mobile veterinarians in California report that they have received notices that their activities are illegal.

Mobile veterinarians, both small and large animal, routinely carry controlled substances for pain relief and euthanasia. Non-controlled alternatives do exist, but are much less effective. For example, one cow vet reported that to remove a cow’s eye, he was no longer able to use sedation or powerful systemic pain relief in the form of an opioid, but would have to rely on local anesthesia (lidocaine), which he felt was insufficient to manage the animal’s discomfort during the procedure. Another cow vet reported that he was falling back to using a .22 Magnum for euthanasia.

The regulations do allow for veterinarians to carry the amount of medication that they expect to need during the current day for a planned procedure. This does not allow for unplanned procedures (the animal who unexpectedly requires euthanasia) or unexpected increases in dosage (the animal whose pain is clearly not controlled by the expected amount of medication, or, worse, who requires more than the expected amount of euthanasia solution). Veterinarians also cannot predict how much sedation and pain relieving medications to bring for a day in a mobile spay neuter clinic, to which animals may arrive without appointments.

The DEA contends that only Congress has the power to change the wording of the Controlled Substances Act. Obviously, we can ’t expect such change to happen any time soon. In the meantime, we can wait and see how the DEA proceeds.

JAVMA News

Journal of the American Veterinary Medical Association

June 15, 2012, Vol. 240, No. 12, Pages 1384-1407

doi: 10.2460/javma.240.12.1384

Perceptions of snoring pugs

Researchers at a veterinary hospital were studying the prevalence of particular diseases in different breeds of dogs, and owner recognition of the diseases. They asked the owners of 285 dogs about a particular respiratory disease. 31 dogs met the criteria for the disease, and 19 had difficulty breathing according to the owners’ answers, but only 18 (of 31) owners believed that their dogs had respiratory disease. So far, so good — veterinarians need to educate better about this disease (and I’m here today to help with that). But the really interesting part is this: of the 17 dogs that had been referred to the hospital for suspicion of this exact disease, 7 owners (41%) stated that their dogs did not have respiratory disease — the disease that they were seeing a specialist for that day.

What is the disease? Brachycephalic obstructive airway syndrome (BOAS). This is a common disease among the flat-faced dog breeds, especially pugs, bulldogs, and Pekinese. These dogs have been bred to have flatter, more human-like faces, but as their muzzles have shortened, the soft tissue in the back of their mouths has not. They are left with excess tissue in the back of their throats which significantly blocks airflow (elongated soft palate). They also often have tiny nostrils (stenotic nares). These two physiologic handicaps together cause so much resistance in the path of the air moving from nose to lung that eventually the inside of their throat can become further deformed, increasing the resistance to airflow (everted laryngeal saccules).

Points used to measure the length of a dog’s skull (A,B) and muzzle (B,C). Compare the labrador retriever’s B,C length (top) with the pug’s (bottom).

So yes, this makes it hard to breathe, and if you want to see for yourself, try this experiment: squeeze your nostrils shut so that only about 1/4 of the normal space is left. Keep your mouth closed. Now exercise. And imagine breathing that way for your entire life.

I think it is probably a lot like when you are very congested and trying to sleep: you can’t sleep with your mouth open, but when you close it you can’t get enough oxygen. A lot of these dogs constantly pant in order to get enough air. 100% of them snore at night, and 32% snore while awake, compared to 21% of normal dogs who snore at night. The noises pugs make are certainly unusual — when I walk in to a veterinary clinic I know if a pug is in the room before I see it. A lot of people find these noises cute. What these researchers found surprising was how many people found the noises normal.

Normal for the breed, that is; the owners who stated that their dogs did not have respiratory disease wrote things like “No, but he is a pug!” Breed-specific problems have come to be considered not problems simply because they are expected. I have had veterinarians tell me that they recommend dogs for corrective surgery for BOAS simply based on the breed. When I asked one surgeon what criteria she had used to recommend surgery for our six month old patient, she replied, “He’s a bulldog.” (Those owners agreed to the surgery, but initially hesitated because they were concerned that widening their dog’s nostrils would change his appearance.)

Where to place the blame? I feel that veterinarians are doing very little to make this problem clear to owners (as much as we will shake our heads in despair in the back room when the owner is not around). One of my daily tasks in veterinary school was to write up an assessment of the health status of my patients. If I had a flat-faced patient with loud breathing, I would certainly note that in my list of physical characteristics. But I did not include it in my list of problems which needed to be addressed. The dog was invariably in the hospital for some other problem, and I knew that I’d be considered obnoxious, if not a troublemaker, if I called out this other problem which everyone was aware of and no one was trying to address.

I’ll do better in the future, and I hope that other veterinarians will start talking more to their clients about the reality of the problems these dogs face. It is upsetting that a veterinarian can refer an owner to a specialist for dealing with BOAS without making clear to the owner that the dog has a disease. Just because the dog has always had the problem, and just because the problem was intentionally selected for, does not mean it is not a disease. Dog owners need to start pushing back on breeders and buying only puppies who breathe quietly (awake and asleep!). Breeders need to start selecting for somewhat longer muzzles, long enough that dogs can breathe properly.

And the dogs who are already out there with breathing problems? If your flat-faced dog makes loud noises when he breathes, particularly when he is awake, he probably isn’t breathing comfortably. If your primary care veterinarian doesn’t think your dog has a problem, get a second opinion from a veterinary surgeon (someone who preferably has a title ending in “DACVS” to indicate that they are a surgical specialist). Dogs who can’t breathe comfortably don’t have a good quality of life. It seems obvious, but sometimes we need to say it.


Packer, R. (2012). Do dog owners perceive the clinical signs related to conformational inherited disorders as 'normal' for the breed? A potential constraint to improving canine welfare, Animal Welfare, 21 (1s) DOI: 10.7120/096272812X13345905673809

Spaying dogs and cats: how much should I take out?

Spaying of dogs and cats is such a common and important procedure that it is the only surgery you are guaranteed to get to do all by yourself (twice!) at my veterinary school. Traditionally, vets have taken out the whole package (the uterus and both ovaries). Leave the ovaries in, and the animal still goes into heat, even if she can’t get pregnant, and you are liable to have an irritated owner on your hands. But is there a good reason to take the uterus out, or can you leave it in? More and more veterinarians are starting to think that less is more.

The commentary “Ovariohysterectomy versus ovariectomy for elective sterilization of female dogs and cats: is removal of the uterus necessary?” provides an overview of the current arguments for and against ovariectomy (removing only the ovaries, abbreviated OVE) versus the more traditional ovariohysterectomy (removing the uterus and the ovaries, abbreviated OVH).

The reasons to leave the uterus in are pretty obvious. You can make a smaller incision if you are only taking out the ovaries, and smaller incisions are obviously preferable where possible. While you’re at it, you can center your incision over the ovaries instead of having to center it further towards the animal’s tail so as to get the uterus as well. The ovaries can be difficult to fully visualize, as they can be tucked deep into the abdomen; placing the incision further towards the animal’s head makes it easier to see what you’re doing, so you can be sure to get the whole thing and not leave little bits of ovary behind. If you leave little bits behind, the animal can still go through heat cycles. This happens more often than you might think.

Finally, removing fewer organs leaves fewer chances for the surgeon to make a mistake. Mistakes do happen, especially with less experienced surgeons. Specifically, a surgeon could ligate (tie a suture around) something that should not be ligated, like a ureter. (Tie a suture around a ureter and the animal is going to have significant problems with one kidney, to say the least.) Alternatively, a surgeon could fail to sufficiently ligate something that needed that ligation to stop bleeding, resulting in hemorrhage into the abdomen. These complications would theoretically be somewhat less common with OVE than with OVH, because, with fewer organs to tie off before removal in OVE, fewer ligations are required.

Unfortunately, research has not yet been done to assess the frequency of such complications with OVE, so the benefit is just theoretical. Moreover, we have no evidence that the smaller incision in OVE makes any difference to the animal’s pain levels. Post-spay animals do not appear to require less pain medication after OVE compared to OVH.

Another consideration in choosing OVH over OVE is pyometra, a disease most commonly found in unspayed animals. As an animal ages, its uterus becomes less able to fight off bacterial invaders, and infection of the uterus can be a big (life-threatening) deal. To avoid the problem, remove the uterus.

However, although the causes of pyometra are not fully understood, we do know that it doesn’t happen unless progesterone levels are elevated, as happens during the estrous cycle. And animals without ovaries don’t get elevated progesterone levels unless we give them progesterone, something we don’t generally do to dogs and cats. This means that animals who have only their ovaries removed won’t get pyometra, even though the uterus (the infected organ in this disease) is left behind, because they won’t be going through heat cycles which result in elevated progesterone levels.

In practice, veterinarians do sometimes see animals who had only their ovaries removed get pyometra — but only if little bits of ovary were mistakenly left behind (ovarian remnant syndrome). So if you remove the ovaries properly, the animal will not be at risk for pyometra. And, as discussed earlier, it’s theoretically easier to remove the ovaries properly if you center your incision over them and leave the uterus in place.

The authors conclude by arguing that OVE is the preferable procedure, due to the theoretically reduced complication rate. Personally, I really like the less is more approach to surgery; if you can leave it in, I think you should. But I do wish we had some more solid evidence in support of OVE. Time for some clinical studies comparing the two procedures!

DeTora, M., & McCarthy, R. (2011). Ovariohysterectomy versus ovariectomy for elective sterilization of female dogs and cats: is removal of the uterus necessary? Journal of the American Veterinary Medical Association, 239 (11), 1409-1412 DOI: 10.2460/javma.239.11.1409

Surgery rotation vs ambulatory rotation

Surgery: Get yelled at if you hold your hands below your waist, even for half a second, while you are sterile
Ambulatory: Perform surgeries on manure-encrusted surfaces

Surgery: Why would people who are in the operating room just to observe want chairs?
Ambulatory: Spend 1/3 of your day sitting in a comfy truck seat

Surgery: Discover that it rained when you see wet ground upon leaving for the day
Ambulatory: Discover that it is raining when you have to change into your coveralls standing under the open sky

Surgery: Your patients have names like “Sweetie-Boo” 
Ambulatory: Most of your patients are addressed as “Boss” or “Girl,” except for one who acquires the name “The Cow We Had to Take to the Vet Clinic”

Surgery: Special room to scrub in, covered in signs with complicated procedures for doing so
Ambulatory: Scrub in using soapy water in a bucket

Surgery: Dress is business casual
Ambulatory: I consider most of my t-shirts too nice to wear (you have to be prepared to get poop on everything)

Surgery: You think your patient has developed feline idiopathic cystitis? Don’t worry about it. We don’t do internal medicine, just surgery
Ambulatory: We do internal medicine, surgery, theriogenology (reproductive medicine), dermatology, cardiology, neurology, ophthalmology, population medicine, public health

The curse of the missing uteruses, part three

The first dog I ever tried to spay had no uterus. (She had already been spayed.) And the first cow I ever did a reproductive exam on had no uterus. (She was a freemartin.) That should be enough missing uteruses for one lifetime. But no.

On a recent shelter medicine externship, I was spaying a kitten. On this externship, you get to spay several animals every day, and I had gotten comfortable enough at it that I was hoping to get through the entire surgery without ever asking for help. To understand what I was doing, you have to understand a little about cat uteruses. Human uteruses are one big sac, probably because we tend to have just one or two babies at a time. Cat uteruses are divided into two horns, each with an ovary at the top, and the horn and ovary are attached to the body wall to hold the whole contraption in place. The horns of pregnant cats fill up with kittens, all in a row.The two horns come together at their base, where there is a little uterine body, which connects to the cervix and from there to the vagina and the outside world. To spay a cat, you cut each ovary and horn away from the body wall. Then you have loose horns, and a base which still attaches to the cervix and vagina and outside world. You cut across the base, and then you have a free uterus and a spayed cat.

So I opened this kitten up, careful to make my incision very short. Longer incisions make visualizing your work easier, but obviously are more painful for the animal, and I had just been criticized on my previous spay for making too long an incision. I used my spay hook to fish around in the abdomen, found the first uterine horn and ovary, pulled them out, and cut them away from the body wall. I traced the now-free uterine horn back to the uterine body.

Finding the first horn is hard: you dip in with the spay hook and blindly bring stuff up, mostly intestines, which you have to repeatedly shove back in until you finally get the organ you’re looking for. Finding the second horn is easy: you follow the first one back to the uterine body, and then pull the second horn out where they both split off from the base. Except in this case, I couldn’t find it. I pulled on the uterine body, which should have made the horn pop out, but no go. I pulled harder. The uterine body started to fray. Oops! I didn’t want it to break before I could find the second horn. I had a moment of indecision: I really, really wanted to get through this whole operation without asking a vet for help.  And the problem was probably just that I had made the incision too small. But I had seen too many episodes of ER in which overconfident students got into trouble in exactly this way, and if the uterus split apart before I had a chance to put a suture around it to stop any bleeding, that could potentially be dangerous for the kitten. So I called over Dr. Vine.

Dr. Vine assured me that my incision was an excellent size, and pulled on the uterine body some more. It promptly broke off in her hand. (I congratulated myself on setting her up for dealing with that situation instead of getting myself into it.) It was not a big deal, in the end: she hunted down the stump and we put some suture around it. And she said: This cat only has one uterine horn. It only has half a uterus.

Freakish! And cool. And do you know what? Cats that only have one uterine horn always, 100% of the time, have two ovaries. So if you don’t go hunt down that second ovary, they will still have heat cycles. (They won’t get pregnant, of course, but cats in heat are no fun to have around.) Dr. Vine asked me where I thought the ovary might be. I suggested, in my usual precise fashion, “Somewhere sort of near the... kidney?”

It turns out that that was exactly the answer she was looking for, because, even weirder: about 50% of cats who have only one uterine horn also have only one kidney. And this cat was one of them.

In the end, we found the ovary, just sitting there not really near anything, and we removed it. One more missing uterus for my collection, or half of one. These things come in threes, right? Does this experience count as my third missing uterus, or just two and a half?

Land of eyeballs: ophthalmology rotation

I was really surprised at how interesting I found my ophthalmology rotation. Two weeks of eyeballs should have been mostly boring and creepy, right? But it turned out to be rife with my favorite kind of veterinary ethical issue: how we breed dogs.

Take the several bulldogs we saw who had so many facial wrinkles that their skin was folded over their eyes and rubbed against their eyeballs. (They also had yeast infections in the depths of their wrinkles, but that was a problem for a different department.) These dogs required surgical intervention to cut off the worst of the wrinkles. If they did not receive the surgery, they would be extremely uncomfortable (they all came in with red, squinty eyes), and would eventually get corneal ulcers which would proceed to infections and possible removal of the eye in question.

We also saw a raft of brachycephalic (flat-faced) dogs whose faces were so flattened that their eyes bulged out. Some of them could not completely close their eyelids. Their eyes were at risk for damage just due to being so out there in the world and unprotected. In the opinion of the ophthalmologists, pug owners all need to be given special eye care instructions when they acquire their new dog.

I asked the owner of one of the dogs that required surgery about where he had gotten the dog. He replied that the dog came from a breeder. I suggested that he get in touch with the breeder to let her know about the necessary surgery, so that she could use that information to help her choose wisely which dogs to breed in the future, and try to avoid producing more puppies with the problem. He replied in surprise, “I thought this was just a breed-related problem.”

Yes, these are breed-related problems. But breed-related isn’t synonymous with inevitable. It doesn’t mean we can’t try to avoid them as we create more dogs of that breed. Veterinarians can and should be more clear with their clients about this. They don’t have to be confrontational to do it! They don’t have to imply that the client made a mistake by purchasing the dog. They can instead look to the future: here’s what we can do to make the breed better.

The art of dog breeding: Puppy has two daddies

Not just every puppy has two daddies. How would it happen?

It’s a long story, so stick with me. Let’s say you’re deeply involved in the dog world, and love a particular breed of dog. You breed to improve that breed. You have a young bitch that you are considering breeding. You start out by taking this bitch to dog shows, doing that circuit until the bitch has earned her championship after a number of wins at different shows. This shows that the bitch is conformationally excellent enough to be worth breeding. You may also work with the bitch in some other area, like competition obedience, tracking, or agility.

When the time comes to breed, there is more work to do. You have to make sure the bitch is genetically good material. You know what problems are common in the breed, so you test for those. There are some problems (like hip dysplasia) which are so common that breeders test for them in almost every breed; there are some that are more rare. Some tests are genetic tests done on DNA samples. Some are just the sorts of tests any vet might do to see if the levels of different chemicals in the blood are within normal ranges, or if they are suggestive of certain conditions. All these tests have to be done on both sire and dam.

Who’s the sire? You should pick out a sire that complements this bitch well. No animal is perfect. If the bitch’s biggest failing is her less than perfect hip conformation, then the sire should have really exceptional hip conformation, to balance that problem out. They should not be too closely related, either.

The right sire may live across the country or across the world from the bitch. If he’s far away, artificial insemination will be necessary (although some animals get transported quite a distance for sexual liaisons, and some bitches are artificially inseminated even though the dog is in the next room). When exactly should this occur? If the dog is prime breeding material, his semen will be very expensive, not to mention the fees for implanting it (more on that later). So you want to do it as few times as possible.

It’s also important to know as precisely as possible when the bitch ovulated, because this helps predict when she will give birth. So ovulation prediction is an important part of this process. It involves blood tests over multiple days, done by a veterinarian.

Once you know what the bitch’s three fertile days will be, how will you get the semen in? You can choose natural service (the old fashioned method), artificial insemination into the vagina, or intra-uterine insemination (surgical insemination directly into the uterus). This last approach is the most reliable, although of course it is also the most invasive and expensive.

If you don’t choose natural service, you may be getting either fresh semen (from the dog in the next room), fresh chilled and shipped overnight (from somewhere on your continent, collected the previous day), or frozen (from anywhere in the world, and possibly as venerable as twenty years old). Why would you artificially inseminate fresh semen, if the dog is right there? Some bitches can be cranky if they don’t approve of the dog on offer, and there can be violence. The owner of an expensive (or well loved!) stud dog might not wish to risk his injury.

Now it comes down to it. Many breeders will have spent thousands of dollars to get to this point. Some will have spent tens of thousands. They really, really want to have a successful impregnation. The fresher the semen, the more reliable it is. If the best possible sire is only providing frozen semen for whatever reason, the chances are significant that the bitch will not get knocked up. So what do you do?

On the bitch’s first fertile day, you use the frozen semen from the preferred sire. You hope that all her eggs get fertilized by this semen, but if some are left over, you call in the backup sire, someone local who can provide fresh semen. Hopefully any eggs that failed to get fertilized by the first sire will get handled by the second. You may well end up with puppies from each sire in the litter, but that’s fine; you can DNA test them to know who’s sired by whom. And that is how a puppy can have two daddies, or, at least, a litter can.

(Note: I skipped over the numerous ethical issues brought up in this story. For today, I just wanted to share with you some of the surprising tools available to dog breeders today.)

Bringing them back from the edge

When I was on my small animal medicine rotation a few months ago, I had a patient with bad kidney disease. This little dog was sixteen years old — about a hundred years in human terms — and very frail and thin. I got into the habit of calling her “Grandmother,” because she seemed so venerable. None of us had very high hopes for her long term recovery, not even her owner; we were just trying to give her a shot at a few more weeks of life by rehydrating her with IV fluids.

Two of the residents disagreed about our goals for this dog. One of them wanted to send her home as soon as possible, arguing that she didn’t have much time left and shouldn’t spend it in the hospital. The other argued that we should give the dog a few more days to wean her off of her IV fluids properly before sending her home, to give her the best chance. The second resident ended up handling the case, and the dog stayed in the hospital for those few extra days for some extra care before going home.

This week I encountered the same dog (and the same resident) in the hospital for a recheck. I hardly recognized the dog, and not just because I had never expected to see her again. She had put on weight and looked filled out and healthy. She was moving around the hospital under her own steam (when she was my patient, I had had to carry her outside to pee) with a happy trot. She was bright-eyed and curious. Her owner reported that she was even playing sometimes.

“Look,” the resident said, “sometimes we really can bring them back from the edge.”

At age sixteen, this dog doesn’t have much time left no matter how you look at it, but that doesn’t mean it was time to give up on her. The lesson had personal meaning for me. My fifteen year old cat, Kai, is currently battling kidney disease, heart disease, and stomach cancer (gastric lymphoma). Each of these diseases is serious; each has almost killed him at one point. Each time I have to decide whether to continue with him, I ask myself whether I am being silly, whether it is time to give up. The treatments are not invasive, but is there any point to them when I may just have weeks left with him? Then I look at how good his quality of life is (he steals food off my plate, sneaks outside when I am not looking and eats things he shouldn’t in my back yard, and uses foul language to tell the dogs what he thinks of them) and remember the lesson of the little sixteen year old dog. Sometimes, even when things look bleak, animals can make a remarkable recovery for a little while. If the treatments are not invasive and the animal is not in pain, it can be worth trying.

How to give a horse his eye medications, or, What is an SPL?

One of my patients on my Large Animal Medicine rotation had a very sick eye, for which he needed approximately 9187346 medications every few hours. Getting eye meds into a horse is not easy. Their eyelid muscles are so strong that we routinely nerve block their eyelids before doing eye exams, because otherwise it would be impossible to hold their eyes open. This is, of course, not practical for hourly medications. But they hate having things put in their eyes (who doesn’t?), and they can throw their heads up very high in addition to squeezing their eyes tightly shut. This particular horse was especially tall, as well, and could hold his head well out of my arm’s reach.

The solution in these cases is to put in a sub-palpebral lavage (SPL). “Palpebral” is the science word for “having to do with eyelids,” so an SPL enables you to lavage (wash) underneath an eyelid. This is how it works: you take a big needle, which you stick through the horse’s upper eyelid coming from the underside (the side facing the eye). You use the needle to pull a slender tube through the eyelid, so that its end is sticking just under the eyelid, and the rest of the tube runs up over the horse’s head and down its neck. You affix the far end of the tube to the horse’s mane, with an injection cap on the end. In my hospital, a popsicle stick is involved in the tube/injection cap/mane connection, to stabilize the entire apparatus.

Now when you want to give an eye drop, you can use a syringe and needle to inject it through the injection cap into the tube. You then inject air after it to push it through the long tube and into the horse’s eye. They do find this annoying, and once they learn the routine, will dance around in an attempt to not let you actually stick the needle into the injection cap on their neck. However, getting at their neck is worlds easier than getting at their eye. My patient was relatively good for the whole thing, so that I could do it without asking anyone else to hold his head. He always got a cookie after each medication administration (which added up to a lot of cookies in the end). When it was over he would immediately stick his nose agaist my shirt to get his treat. The SPL was annoying for all concerned, but so much better than the alternative.

Shelter medicine externship

I recently spent two weeks of elective time at a shelter medicine externship at a different vet school. Half the time was spent in academic pursuits on campus — going to journal club, going to talks and lectures about shelter medicine, etc. The other half was at the shelter, doing high volume spay/neuter, temperament tests, treating sick animals.

Highlights:

• Pulling worms out of a kitten’s butt (“Wow, can I?”)
• STRAY GOLDFISH. It is more amusing not to explain, but I will say that it was found in a ditch in a grocery store parking lot.
• Ratlings! Five week old foster rats came in for a visit. They had been well socialized and were extremely friendly. I badly wanted to adopt one, but suspected it would not get along with my cat.
• Seeing exactly how fast 8 week old kittens recover from spay/neuter surgery. Spay surgery is no small deal, but those girl kittens were literally climbing the walls of their cage 30 minutes later. I am sold on pediatric spay/neuter.
• Helping to set up play groups of shelter dogs and getting to watch them play together. It was lovely.

Shelter medicine is in large part population medicine, or herd health. Of course you do need to pull the occasional worm out of the rectum of a kitten, but you also need to think about how to keep animals out of the shelter in the first place, and how to keep them from getting sick once they are there. Daily rounds in my vet school’s small animal hospital are about the specifics of what diagnostics were done on an animal yesterday and what needs to be done today; daily rounds in the shelter were about why an animal hadn’t been moved to the adoption floor yet or how to deal with the placement of a feral cat. I knew that shelter medicine had a large preventative component to it but was not prepared for quite how large the component actually was. I was enthusiastic; I really like this kind of medicine.

The case of the jaundiced terrier

It was 6:30 am on the last Saturday of my small animal medicine rotation. I had one patient in the hospital to care for that morning, but I was also scheduled to take pick-ups that day — taking on as new patients half of the animals who were transferred to the medicine department that morning from the emergency and critical care department. A rotation mate of mine would take the other half. The transfer list had two animals on it, and since I had gotten to it first, I could pick which I wanted. Feeling relatively bright-eyed and bushy-tailed after a slow week with not many cases, I chose the Boston terrier whose one-word problem (about all the transfer list has room for) was that she was “jaundiced.” Jaundice, or having yellow skin and mucus membranes, suggests a liver problem, as the liver is failing to process your yellow bile acids. I hadn’t had a liver patient yet, and figured it was a good chance to learn something new.

The Boston was in A ward, the ward for sick animals. (Healthy animals who are in for elective surgery and the like end up in B ward. Animals on the other end of the spectrum go into the intensive care unit.) I read her chart. She had come in to the ER the previous morning for lethargy, not eating, and not acting like herself. No blood work had come back from the lab yet. The ER had ultrasounded her abdomen and seen no free fluid in there, which suggested that any liver disease was not far advanced. They had heard a heart murmur, and she had looked yellow to them.

I did my own physical exam. Yellow: hmmm. Maybe I could see that her inner lips looked a little yellow. Maybe not. I chalked this up to my inexperience and wrote “mild jaundice” on the physical exam form. Heart murmur: hmmm. Maybe I could hear it, maybe not. It was a little hard to hear over the sound of her breathing. I thought I could hear some swish to her heart, though. Come to think of it, her breathing was awfully loud. Now, Boston terriers have very flat faces, which makes breathing difficult for them at the best of times. But looking at the depth of her breathing, I thought I saw “increased respiratory effort.” It isn’t something you’d necessarily expect in a liver patient, but I wrote it on the physical exam form with a question mark after it.

The resident on the case, Dr. Crow, took a look at the Boston next. “Did you appreciate jaundice?” he asked. I hemmed and hawed. “Maybe she’s a little jaundiced... I’m not sure,” he said. Oh. Um, good. “Did you actually hear her heart murmur, or just write it down because the ER heard it?” I said I sort of thought I heard it but it was difficult. He nodded. “I’m not really sure I hear it either,” he said. Emboldened, I asked about her respiratory effort. “Yes,” he said matter of factly, “that’s elevated respiratory effort.” I was unsure whether to feel good that I’d noticed, or bad that there had been any question in my mind.

We talked about why a dog with liver disease might have trouble breathing. Dr. Crow walked me through the idea that since the liver is involved in clotting, the dog might have thrown a blood clot into her lungs. We sent her off for x-rays of her lungs. While she was gone, her blood work came back: all of her liver enzymes were significantly elevated. This happens when the liver is so unhappy that it starts to leak enzymes, and when the bile backs up because the liver isn’t processing it properly.

When the Boston came back from radiology, Dr. Crow asked me, “So what do you think about her radiographs?” Her lungs looked terrible. She was having even more trouble breathing, so we put her in an oxygen cage. Dr. Crow called an emergency and clinical care faculty member over to talk through the case. The problems with her lungs were spread too far for him to still suspect one clot. We had submitted a request for clotting tests, but weren’t going to hear back for several hours, as it was a weekend. Dr. Crow and the faculty member decided to do a quick ultrasound of the Boston’s heart. Heart failure can also cause fluid to get into your lungs and make it hard to breathe.

We took the Boston out of her oxygen cage, put her on her side, and put the probe on her chest. And there it was: a big lump on her heart. “Well,” the faculty member said, “I think you just found her problem.” Cancer.

Dr. Crow suspected that the mass was a chemodectoma, a type of cancer to which Boston terriers are particularly prone. However, the cardiology service did a consult on her, and they thought it was more likely to be hemangiosarcoma, because of the speed with which it had appeared and because of its exact location on the heart. Hemangiosarcoma is a very bad diagnosis; animals don’t live very long even if it is excised, and it was going to be impossible to cut it off of this dog’s heart. It is not very responsive to chemotherapy, either.

I asked the cardiology faculty member why he thought the dog’s liver enzymes were elevated. We batted around some ideas, but in the end he shrugged: this was not the dog’s primary problem. And cancer, as the saying goes, can do anything it wants.

The Boston’s owner came in to visit her, and Dr. Crow explained the situation. He said that she was having trouble breathing because fluid (probably blood) from the mass had built up inside her pericardium, the sac around her heart. We could drain that fluid (do a pericardiocentesis) and send her home. If it was actually a chemodectoma, she might do well for a while. If it was hemangiosarcoma, she was likely to have some very serious issues in the next few days.

The owner, after a great deal of soul searching, elected to euthanize the dog. If she had chosen the pericardiocentesis, she would still have had to leave her dog in the hospital for at least 36 hours, to make sure that the pericardium did not fill right back up with blood. If she had then taken the dog home, she would have had to deal with the possibility that the dog would have had little to no time before something else bad happened. Few owners want to deal with the chance of their dog being unable to breathe, and having to rush back in to the hospital with a dog in the car that might go into respiratory arrest. I suspect I would have chosen the same thing.

I learned from this case, as I had from so many others during my medicine rotation, that the one-word summary of an animal’s problem can lead you down the wrong road. And yet every time I am drawn in by the easy answer. I suspect that learning to keep an open mind is part of learning to be a good clinician.