A Lesson Learned From "Marley and Me"

I have never read the book or seen the movie. There are two topics I just can't tolerate in print or film when it comes to my reading or viewing for fun, and those are cancer and the death of a pet. My wife knows this - I get really (embarrassingly) emotional about those topics - so we don't watch movies about a beloved pet dying or a person struggling with cancer. So, I've neither read nor seen "Marley and Me." However I do know that (spoiler alert!) Marley dies. I also have been told that Marley dies of a condition called "GDV" (Gastric Dilitation and Volvulus).

Now, I don't know if "Marley and Me" is based on a true story, but if it's not, GDV is a creatively-dramatic (and horrible) way for a protagonist-pet to die. I hope I never see another case of it during my career as a veterinarian. Some of the most agonizing deaths I've seen were patients with GDV.

In GDV, the stomach becomes distended with gasses and/or liquid ("bloat"). Then the distended stomach twists on its axis. This gives the air/liquid no way to escape and also severely compromises the blood flow to the stomach. As a result, the stomach becomes more distended and at the same time the stomach wall starts to die. The dog is in unimaginable pain.

Despite a lot of misinformation on the internet and other places, we really don't know much about what causes GDV. We do know that it it occurs almost exclusively in large, deep-chested dogs (German Shepherds, Irish Setters, Golden Retrievers, Dobermans, Great Danes, etc...) Once a dog develops GDV, the only hope is through emergency surgery, and even with that the prognosis is fair to guarded at best.

The good news is, we now have an effective method to prevent GDV. It is a preventive surgical procedure called gastropexy. A gastropexy is where a veterinarian attaches the stomach to the body wall so that it is unable to twist. We usually do this surgery at the time that the pet is spayed or neutered. Dogs with gastropexys are twenty-nine times less likely to develop GDV. So, in my mind if you have a new puppy that is a high-risk breed for GDV, doing a gastropexy at the time of spaying/neutering is a no-brainer.

Who knows? If we were offering gastropexys during the time "Marley and Me" was written, the story might have had a happier ending.

Leptospirosis Is Sneaking It's Way Into Your Life

There is an infectious disease "out there," and it is trying to find you. It's called Leptospirosis, but we call it Lepto for short. It is caused by a bacterial organism of the same name. It can affect most wildlife species, domestic livestock, dogs, and people. It is a pretty horrible infection to acquire, as it usually infects the kidneys, and sometimes the liver.

This bacterial organism loves water, and is passed in the urine of infected mice, rats, deer, cows, raccoons, dogs, people, etc... Once the organism gets into a wet environment, it will thrive. As water moves, so will the bacteria. Your dog can become infected simply by sniffing or licking the moist grass after a hard rain. We used to think of this as a "rural" disease, but recent statistics show that urban dogs are at higher risk than we thought - probably due to transmission by rats and mice.

The disease is not easy to diagnose because the symptoms are vague, and mimic a number of other conditions. This is especially bad because the longer it takes the veterinarian to diagnose your dog, the longer your family will be unsuspectingly at-risk for acquiring the infection from the dog. There is a veterinarian near my practice who lost a kidney to Lepto.

The best way to protect your dog from Lepto is via vaccine. The vaccine is not 100% protective, but greatly reduces the risk for infection. The new Lepto vaccines (at least the ones we use) are much safer than the old vaccines from 10 years or more ago. We still occasionally see some soreness or lethargy in smaller vaccinated dogs, but it is usually self-limiting. It definitely beats getting Lepto! We do not feel that vaccination is necessary for dogs leading extremely sheltered lives (ie never go outside, potty indoors on papers, do not go for walks outdoors, etc...)

Spaying, Neutering, and Cancer: The Controversy

A week or so ago, a retrospective study on the effects of spaying and neutering on age of onset of cancer and behavioral disorders in Vizslas was published in the Journal of the American Veterinary Medical Association. This study suggests that, in the Vizsla (which is a relatively-uncommon purebred dog), the risk for developing certain cancers and storm-phobias is significantly increased if the dog is spayed or neutered. This follows a similar study in Golden Retrievers published last year which showed an increased risk of certain cancers and orthopedic conditions in dogs which have been spayed or neutered. Both of these studies were peer-reviewed (the gold standard), and in my opinion, properly done, and should be taken seriously.

Understandably, there has been a bit of an uproar calling for "us" to stop, um "mutilating" our pets with these horrible procedures (spays and neuters) which rob them of their reproductive organs and make them get cancer and other debilitating diseases. I am not trying to belittle these concerns, but before we rush to judgement, we might want to gather more information. I own two Golden Retrievers, and I want them to live the longest, healthiest lives possible. For that matter, I want all of my patients to live the longest, healthiest lives possible!

There certainly appears to be some serious disadvantages to spaying and neutering, at least in Vizslas and Goldens. (Note: these studies also suggest that early-age spay/neuter may increase the risk even more.) Another study suggests that neutering male dogs can increase the risk for prostate cancer. However, when we look at life expectancy (which is kind of important, wouldn't you agree?), the picture is a little different. The Golden Retriever study did not look at life expectancy, and the Vizsla study showed no difference in life expectancy between spayed/neutered dogs and intact dogs. So even though the S/N dogs were getting more cancer, they were getting less of something else - which made it a "wash." A more comprehensive study, looking at ALL dogs and cats (purebred and otherwise) was also published last year. There were 2.2 million dogs and 460,000 cats in this study. In this one, they looked at life expectancy in S/N pets versus intact pets. Guess what? S/N dogs of all breeds live 15% longer, and S/N cats live about 50% longer.

Does this mean we should mindlessly continue to recommend spaying and neutering all dogs and cats? Or should we crucify those who advocate spaying and neutering? Well, I for one don't want to judge anyone. There is still a lot to learn, and as more studies become available we will know more. Society (including companion animals) has benefited tremendously from the S/N "movement." How? Since routine spaying and neutering of pets has grown in acceptance (starting around 1970), the euthanasia of unwanted animals in shelters has declined from 24 million to 4 million. As a guy who "moonlights" at an animal control facility, I can tell you that's huge.

I will not bore you by listing all the benefits to the individual pets from spaying or neutering, although I've already mentioned the longevity study. But they are there, and they are documented. At my practice, we are keeping an open mind. Maybe we will be doing vasectomies and hysterectomies (a spay is an ovariohysterectomy, and a neuter is a castration) some day. But please be assured that we want very much to do what's best -we will recommend for your pet what we would do for our own.

$20 Chemical Neuters

A local television station recently ran a story about a "new" chemical neutering agent for dogs. I believe it's called "Zeuterine." I didn't see the story, but I've been told that it claimed that male dogs could be "neutered" with this product for about $20. Understandably, I have received quite a few inquiries about this since the story ran. Here is my response to one such inquiry, as posted on Facebook:

A very similar (maybe even the same thing?) injection was marketed to veterinarians several years ago called "Neutersol." It is a caustic agent, which, when injected into the testicles, causes them to necrose (it destroys the tissue). It had a lukewarm reception after more vets started using it. There were/are two main drawbacks: it decreases testosterone levels only about half as much as neutering (many dog-owners neuter their dogs to decrease testosterone-driven behaviors), and a portion of the dogs developed complications such as abscesses and self-mutilation - some of these had to be subsequently neutered. My humble opinion is that it is a very useful tool for decreasing dog overpopulation in third-world countries, and even poverty-stricken areas in the US. It is not something we will use for our clients' pets for the reasons stated above. Once this injection starts being more widely used, we will know a lot more. Maybe it will be a significant upgrade from it's predecessor, but that's not what I'm hearing yet. Stay tuned...

New Year's Resolutions for Cat Owners

Cat-owners (of which I am one), are a unique bunch. We love our cats (every bit as much as dog-owners love their dogs), but we tend to be more "hands-off" with their care. This is probably because cats don't complain much, especially if allowed to stay in their routine. They tell their humans, "You do your thing and I'll do mine. I'll let you know if I need anything." And they do, especially at 6:00 AM when they are ready for us to WAKE UP! However, cats are not necessarily keen on change, even if it's for their own good. They detest going to the vet, having their food changed, meeting new cats, etc... This is another reason we cat owners are hands-off: We don't want them ticked off at us. 

So cat-owners are a tough crowd for us veterinarians. When "what is best for the cat" doesn't jive with "what the cat wants", they are caught in the middle. "Do I really want to incur Garfield's wrath, just because this guy in the white coat says I should?" Trust me, I understand. But there are so many things that cat-owners could do better for their cats, that it really is worth it in the long run to make some changes. So here are my New Year's Resolutions for cat-owners:

1.Bring your cat to us at least once a year, no matter what! I know your cat hates it. I know she never goes outside. I know she seems perfectly healthy. But cats are the very best at hiding illness. It is very common for me to see an extremely sick cat, and have the owner swear that they brought her in as soon as they noticed a problem. Many of these problems have actually been chronic, and have pushed the cat to the breaking point, at which time my job becomes a lot tougher, and the outlook for the cat is much worse.

2.Put your cat on heartworm/intestinal parasite/flea medicine every month. Even indoor cats get parasites. Heartworm infection in cats is extremely difficult to diagnose, but can definitely shorten the cat's life by causing asthma-like symptoms, wasting disease, or even sudden death (I've seen it happen.) Cats can also carry intestinal worms, with no symptoms, which are contagious to her owners (gross!) Prevention is easy - there is a once-a-month topical product (no pills!) called Revolution which protects your cat against all these parasites.  

3.Give your cat canned food, at least once in a while. The more we learn about feline medicine, the more we discover the value in treating many chronic conditions with certain "prescription" canned foods. The dietary therapy is often more effective than drugs (really!), and soooo much easier....as long as the cat will eat it. Yes, some of these diets also come in a dry form, but the canned food is almost always more effective. The biggest obstacle is trying to get a cat that has always eaten dry food to switch to canned (did I mention that cats hate change?) So, get your cat used to eating canned food, at least once a week or so. It may pay off later.

4.Feed your spayed/neutered adult cat about 30% less than the label says. AAFCO feeding guidelines are based on studies done mostly on non-spayed, non-neutered cats. We know that a spayed or neutered cat has about a 30% lower metabolic rate, and so needs fewer calories. Having said that, every cat is different, so the nutritional plan for your cat should be discussed with your veterinarian!

5.Play! All cats need physical and mental stimulation. They are predators by nature and are physiologically healthier if allowed to "scratch" their predatory "itch." Strings, feather toys, and laser pointers all provide the stimulation needed to help keep a cat healthy. Here is a link to a terrific website regarding environmental enrichment for indoor cats: http://indoorpet.osu.edu/cats/.

My Dog Just Had A Seizure!

One of the most awful and disconcerting things a pet owner may suffer is watching their pet experience a grand mal seizure. These seizures are often violent, and the pet seems to be dying right in front of you. They usually fall over, their eyes roll back in their heads, and there are uncontrollable body movements. In addition, some will urinate and/or defecate on themselves. It is a terrible, terrible thing to see.

The good news is that a single seizure is rarely as serious as it appears. They usually last no more than a couple of minutes (although they seem to last forever), and after some recovery time, the dog returns to normal. As with most medical problems, there are some exceptions.

Some dogs who have a seizure, only have a single one, and then are fine. For this reason, I usually do not do a full work-up on a young adult dog who has had a single seizure, has no other symptoms, and has a normal physical exam. However, if a dog is less than a year old, older than five years old, has other symptoms, or has had more than one seizure; that dog will need a full work-up.

By far, the most common cause of seizures is a disease called Idiopathic Epilepsy. Epilepsy usually first appears in dogs between the ages of one and five. There is no known cause, but certain breeds seem to be predisposed. There is no test for epilepsy, so the diagnosis is made by ruling out other causes of seizures. So, what are some other causes of seizures? The list is long, but includes: head trauma, toxins, metabolic disorders (low blood sugar, kidney disease, liver disease), congenital brain disorders (such as hydrocephalus), cancer, meningitis, heart disease, and "stroke." My typical work-up for a seizure dog includes an ECG, CBC, blood chemistries, blood pressure, and a thyroid test. If these tests are all normal, but the dog is showing other neurologic symptoms or is not responding to treatment, I refer the dog to a specialist who can do more advanced testing such as CT scan or MRI.

My first choice anti-seizure drug for epileptics is phenobarbital. Phenobarbital is very effective in most cases and is fairly inexpensive (the dog will be on medication for life). There are potential side-effects of phenobarbital which include transient sedation, increased appetite, and most significantly - liver toxicity. The liver problem is uncommon, but we closely monitor liver values on our patients who take phenobarbital. For those patients whose seizures are not adequately controlled with phenobarbital, I usually add potassium bromide. When combined with phenobarbital, potassium bromide is a very effective anti-seizure drug, and is also fairly inexpensive. Dogs on potassium bromide have an increased risk for pancreatitis.

There are newer anti-seizure drugs on the market, which are significantly more expensive. However, these drugs tend to have fewer side-effects, and are sometimes effective in patients not responding to (or who are having side-effects from), phenobarbital or potassium bromide.

A recent study showed that the sooner an epileptic dog is put on medication, the better the medication will work, and lower doses will be needed. Historically, veterinarians (including myself) tended to not start anti-seizure drugs until the patient was having seizures with unacceptable frequency ("unacceptable" was based on the owner's tolerance, but I often would suggest that more than every two months was "unacceptable.") Since the newer information has come out, I strongly urge that my epileptic patients start medication after the second seizure. Being able to use lower doses of anti-seizure drugs (lower-doses = less chance for side-effects) with better results is definitely in the best interest of the patient!

Well-Thought Complaints From a Client, And My Response

As the owner of a fairly large (4 DVMs, 35 support staff) suburban veterinary practice in the year 2013, I occasionally get complaints from disgruntled clients. Yesterday I received a well-written letter from a client which was clearly thought-through, and significantly, logical. I appreciated the feedback, and the opportunity to respond. Here is her letter, followed by my response and a comment or two.

Dear Horseshoe Lake Animal Hospital,

Thank you for the care that you provide my pet.  I appreciate the work that you have done in the past and currently, but I feel that I need to communicate my feelings as customer feedback.  When I first began bringing my pets to your clinic, I felt that the care was great and the price was also reasonable; however, in recent years I really dread bringing my pet to the clinic, because it’s difficult to leave without a $200+ bill and significant guilt for treatments may be as well.  I have several examples from my pets’ histories to call from. 

One day I brought my dog in for severe diarrhea.  She was examined and I was asked if I wanted a giardia test.  I said if you feel that the test is necessary, then give it to her.  The end result was that she was negative for giardia but she was given flagyl (Metronidazole) to take at home.  My frustration with this incident is that she was given the treatment for giardia even though she as negative.  I understand that the treatment for severe diarrhea with a protozoal or anaerobic bacterial etiology would be Metronidazole.  I do not understand why the giardia test is necessary if she is going to be given the treatment for it despite the test outcome.  It was a waste of your time and my money to do that test when she was going to receive the medicine regardless. 

Secondly, each time I visit for a well animal visit, there are many options for tests and extra vaccines that are presented to me.  Of course I want my dog to have good treatment and prevention of disease, but I feel that my pet is probably not at high risk for many of these diseases because she is indoors most of the time (example: Leptorspirosis vaccine).  I feel guilty for refusing each time I say no to a test or a treatment, but I suppose if I accepted everything that is offered or recommended, I would leave with a $300-400 bill.  This is more than I typically spend on my family of 4 per year for healthcare clinic/hospital charges. 

In addition, I feel that some of the medications are overpriced and that, since you have your own pharmacy, the option to have the meds filled elsewhere is taken away.  For example, some antibiotics and generic medications at Schnucks pharmacy and many other pharmacies are free or next to nothing in price, yet I pay a premium to have them filled by the pharmacy at the clinic.  I know some veterinary medications are not carried at standard pharmacies, but some are.  In those cases, I would appreciate your recommendation to have the script filled elsewhere.

Most recently, my pet came in with a limp.  I thought I established before the appointment that the cost of treatment is an issue for me.  Two to three weeks prior to the appointment, my dog hurt herself while chasing a rabbit (or other creature).  The injury happened acutely.  After examining my dog and feeling an effusion around the knee, the veterinarian order 2 films- one of the knee, and one of the pelvis area.  Understandably, he was trying to rule out a hip; and given the acute onset of the injury the knee was the most likely culprit.  To save cost, it seems prudent to only order 1 x-ray, and if that comes back negative, to order an additional film if necessary.  When patients don’t have insurance to help offset the cost (and even when insurance is available), prudent management of diagnostic tests and films is necessary.  Maybe ordering 2 x-ray views in this situation was the same cost of ordering 1 (I could not tell definitively from my bill); but coming away from the appointment, I felt that maybe this could have been an unnecessary cost and I find myself frustrated at myself for agreeing to x-rays at all.  At this visit, I also had to reject two of the three therapies that may help my animal based on cost and this also made me feel terrible.

Please understand, I don’t question the excellence of care given to animal at your clinic.  The veterinarians and the techs are amazing with the animals.  However, to keep coming to the clinic I need to feel that you are also considering the cost to the “parents” of the patient.  Sometimes I feel like I’m being taken advantage of by the number of tests and preventative treatments that are strongly encouraged.  I feel like there might be a money making aspect to some of the recommendations. I would just like to feel the vets are doing their best to keep the cost of care down for the “parents”.

Thank you for your consideration.

Sincerely,

(Name Withheld By Dr Hall)

My response:

Dear (Name Withheld),

Thanks so much for your letter.  I am always appreciative when clients have the courage to voice their opinions to us, even if they are unhappy.  I would like to address your specific concerns as much as possible, and also speak to the “big-picture”.  By the way, thank you for your nice words about the care that your pets have received at Horseshoe Lake Animal Hospital.

I will start with the occasion that you mentioned when (name withheld) was tested for giardia, and then given Metronidazole anyway.  My guess would be that the Metronidazole was prescribed for its anti-inflammatory effects on the large and small intestine, and not anti-protozoal.  If (name withheld) would have tested positive for giardia, this would have changed things in two; and possibly three ways.  First, a follow up giardia test would have been indicated to make sure the infection was cleared.  In our experience, giardia is probably the most difficult parasite to clear from the body.  Second, giardia is potentially contagious to people.  We always have a conversation with our clients about zoonotic risk when their pets have giardia.  And lastly, Metronidazole is no longer considered the treatment of choice for giardiasis in dogs.  Had (name withheld) tested positive, the doctor probably would have prescribed fenbendazole.  I hope this explains why we would not consider the giardia test to be unnecessary.

Your second concern involved the tests and extra vaccines that are presented to you at annual wellness visits.  You specifically mentioned leptospirosis.  There is a national advisory commission that meets every few years to determine the best vaccine recommendations for companion animals.  This commission has currently determined that there are four “core” vaccines (vaccines that all patients should receive) for dogs, four “non-core” vaccines (vaccines that should be administered to at-risk patients), and numerous non-recommended vaccines.  “Lepto” is considered non-core by the commission, and therefore by us. However, lepto has become so pervasive that the Veterinary colleges at the University of Missouri and Purdue University (among many others), consider it “core”.  The fact is, just about any dog that goes outside faces some risk, and dogs that travel away from their homes (like going for runs/jogs) are at increased risk.  I hope you understand that preventable diseases such as leptospirosis can be devastating to a dog’s health, and like giardia, lepto is contagious to people.  Our focus is always going to be putting the best interest of the pet and family first. 

Having said that, we never recommend vaccines from the non-recommended list , and we do not recommend a non-core vaccine for a pet with no risk factors, but we will have the conversation to determine risk. 

You may also be referring to the “wellness testing” recommended at each annual visit.  We do believe in the value of wellness testing for our patients, and have hundreds of experiences where early disease detection has benefited them.  My personal physician orders labwork on me every year, even though I perceive myself to be healthy.  Since many patients age so much faster than humans, and they can’t talk to us, I believe that wellness testing is even more important for them.  I do understand that many pet owners cannot or choose not to spend their dollars on wellness tests, which is why these things are optional.  But we at least owe it to you to make you aware of the benefits so you can make an informed decision. 

There is a mention of writing prescriptions for our clients to take to human pharmacies in order to save money.  We do write or call in prescriptions for our patients on a daily basis.  However, there is even some concern on our part about this practice.  Dogs are not small people, and in many cases the biological activity and dosing of drugs is dramatically different between people and pets.  You may be aware of the pharmacist in Tacoma who talked this client out of giving the dosage of medication the veterinarian prescribed for her dog, telling her it could kill the dog.  The dog suffered needlessly because the owner was afraid to give the medication. 

Lastly, regarding your recent visit with (name withheld), you are correct that I suspected a problem in her knee.  But after practicing for almost 30 years and seeing some really awful things from missed diagnoses (usually pathologic fractures from undiagnosed bone tumors), I want to make sure not to miss something obvious.  I do not always order x-rays for limping dogs (although I probably should), especially if I think it’s just an arthritic issue or a soft-tissue injury based on history and physical exam.  (Name withheld)’s history of acute onset single-leg lameness with minimal improvement in over two weeks suggested something other than arthritis or soft-tissue.  

Any radiologist will tell you that when radiographing any body part, two views should always be taken.  In (name withheld)’s case, I wanted the V-D view to also include the hips (pelvis) since that could easily be incorporated into the V-D view of the knee.  This is standard procedure and gives us “more bang for our buck”.

In summary, I am truly sorry that you are frustrated with the costs involved in the care of your pets at our hospital.  I hope that this helps you understand that every decision that we make is driven by what is in the best interest of our patient.  I assure you that surgical correction of (name withheld)’s knee is reasonable therapy (and may become imperative at some point), but I felt that conservative treatment also had a good chance at helping her, and I always prefer that over surgery, when feasible.  If my recommendations are based on what makes the most money, I would have chosen to recommend surgery.

I do very much appreciate your feedback, and I hope we can do a better job of explaining your options, and why we are recommending (or just discussing) them moving forward.  It is my true and sincere hope that (name withheld)’s knee will do well, and that she will be running around normally in the future.

God Bless,

Dr. David Hall

The only thing I would add is that she mentions that she has the potential to spend more for her vet visits than on her family's healthcare in a year. This conveniently overlooks the THOUSANDS of dollars that she or her employers are spending annually on health insurance, which then pays most of their medical bills. I've seen my health insurance premiums, and I've seen the medical bills before insurance. No one can reasonably assert that veterinary care is anywhere close to the cost of human health care. I assure you, no one at my practice (including me) is getting rich. And by the way, I'm not complaining: I make a good living, and I don't mean to suggest that veterinary care should cost as much as human health care.