Nick Trout is a Diplomate of the American and European Colleges of Veterinary Surgeons and a staff surgeon at Angell Animal Medical Center in Boston.
Wellness: Health Care
April 30 2012
About a year ago, I walked into a busy waiting room, called a patient’s name and was rewarded with the kind of life lesson usually delivered by dogs. A woman in her early twenties (I’ll call her Lauren), with cropped, bleach-blond hair and a healthy tan, struggled to hang onto her frisky retriever’s leash. From a distance, I thought I saw one of her arms in a sling, hence her difficulty, and rushed right in with, “Can I give you a hand?” The question got away from me and found its mark before I realized my grievous mistake — Lauren had no right hand. Lauren was an amputee.
Not my best opening gambit, but, thankfully, Lauren laughed and took me up on my offer. By the end of our consultation, I was completely in awe of her refreshing attitude toward the change in her body’s appearance. She had lost most of her right arm (and she was righthanded) in a car accident, and I loved the fact that she had absolutely no inhibitions about wearing a spaghetti strap top, laughing off her physical limitations and refusing to be defined by them. Her confidence and manner said it all.
It was the first time I had ever witnessed, in a human, a sentiment I have perceived in so many three-legged dogs over the past twenty years. Amputation conjures mental images of civil war, genocide, unsightly stumps and puckered scars from which we avert our eyes, swallow hard and try to act as though we are perfectly comfortable with raw disfiguration. We forget that such talents as sleight-of-hand magic are for people, not other mammals. Sure, reservations and psychological projections are perfectly logical, but our dogs are focused on far weightier matters such as the absence of pain and the ability to ambulate. They remind us that, for them at least, Pride is not a deadly sin.
My job requires me to convey precisely this reassuring message to anxious owners battling two relentless and alltoo- common demons — fear and denial. So when Zoe, a seven-year-old brindle Boxer, and her owner, Ellyn, walked into my examination room, I knew I had my work cut out.
“I’ve been to two other vets,” said Ellyn. “They both think it’s a badly torn ligament in her knee and she needs surgery.”
In my experience, Boxers are always fun, their bouncy and exuberant demeanor a challenge during my hunt for clues as to the cause of a lameness. Perhaps this was why Zoe struck me as all wrong. She carried her right hind leg completely off the ground, her wet eyes conveying a “don’t want to play” attitude.
No one wants to hear, “It’s not a torn ligament, it’s a tumor,” but a brief palpation followed by a set of damning x-rays brought us to a predictable moment in which I would attempt to justify an amputation.
Ellyn looked lost, trying to stay with me, clawing her way back after being felled by my diagnosis and shocking therapeutic option.
“Zoe actually has three really positive factors in her favor,” I told her. “First, the tumor is in the knee joint, destructive but slow to spread to other areas of her body. With an amputation, there is a good chance Zoe might enjoy a normal lifespan. Second, this is a back leg and not a front leg. Since dogs carry about 60 percent of their weight up front and 40 percent in the back, losing a back leg is usually a little easier than losing a front. Finally, and most importantly, Zoe is already a three-legged dog. She doesn’t put weight on her right hind leg. Zoe has completely adapted to life on three legs. Believe me, she’ll be grateful to be rid of a useless appendage weighing her down, causing her pain.”
It took a while, but Ellyn finally agreed to the surgery. On the day of Zoe’s discharge from the hospital, I watched their reunion from afar. Ellyn was visibly nervous, afraid for the transformation in her dog’s appearance, but what impressed me most was this woman’s determination to connect with the dog she loved. When Zoe trotted out, Ellyn never hesitated; she was all about reassurance in her eye-to-eye contact, sneaking a sideways glance at the incision as she fussed and hugged and convinced her Boxer that nothing between them had really changed.
A month or so later, I checked in with Ellyn by phone.
“What have you noticed since the surgery?” I asked. “I mean, when you take Zoe for a walk, does anyone say anything?”
“Sometimes,” she answered. “I passed two women the other day, and the first loved her up and never said a word about her missing leg and it was great, but then another one got all upset and worried about how Zoe could possibly cope, and I found myself getting really angry at her.”
Hmm, I thought. Perspective can be a funny thing.
“And what about your other Boxer? How’s he acting around Zoe?” “Absolutely no different,” said Ellyn. “It’s as though it never happened.”
I smiled, hesitated and said, “I like that,” thinking, once again, it takes another dog to see all that matters, proving a point that what counts hasn’t changed one little bit.
Tasty, disgusting, edible or not— everything’s fair game for curious critters
April 10 2012
Foreign bodies combine mystery, intrigue, incredulity and guilt to make for a fascinating and fickle assortment of surgical diseases. There seems to be no limit to what our pets will try to cram into their mouths; size, shape, texture and taste often playing little or no part in an oral obsession that for many owners can become a difficult and costly vice to curb. So why do our dogs, cats and even ferrets crave foreign bodies, and why are so many of these pets repeat offenders?
Young animals of two years of age or less are most commonly afflicted, and so, like inquisitive toddlers intent on putting everything into their mouths, simple curiosity plays a part. It has been suggested that in dogs, it reflects the need to hunt, that it is instinctive and a throwback to a time when their prey was eaten in its entirety. Some animals appear to enjoy the act of chewing, experimenting with the feel of an object in their mouths. My favorite theory, and one I believe I can safely share with the majority of Labrador owners, is that “it was there, so I ate it.”
Undergarments—socks, stockings, pantihose, panties—often prove to be popular offending items.Here, perhaps, another etiology applies. In much the same way that bear attacks on people may occur more frequently among menstruating females, the olfactory stimulation of ripe underwear of either sex might prove too tempting for your curious pet.
Foreign bodies related to food make perfect sense. Peach pits, corn on the cob and all manner of bones can prove irresistible to the scavenging instinct of a dog. Those little plastic pop-up timers that tell you when your chicken or turkey breast is perfectly cooked are drizzled in tasty fat, and despite being made of tasteless plastic, slip down nice and easy until they reach the small intestine. The teriyaki stick laden with succulent meaty pieces may not go down with quite the same ease, but who cares until the sharp wooden skewer begins piercing its way through a variety of abdominal organs on its errant journey through the abdomen?
For some pets, the object is simply curiosity. How else can we explain the allure of a diamond ring, a needle and thread, a fishhook and nylon leader, a backpack, bottle caps, coins, gold balls, a leather leash that remains attached at the collar, string still tethered to a helium- filled balloon? The list of irrational objects is endless and limited only by one’s imagination.
Occasionally, the problem can become an addiction.Maisie was a two-year-old Weimaraner with a penchant for stones. Her tastes went beyond the occasional pebble, brick end or fragment of rock because Maisie’s drug of choice was the gravel driveway of her home.We’re not talking about one or two rocks, here. Sometimes Maisie might binge on 50 to 100 large pieces of coarse rock that would either accumulate in her stomach or obstruct her small intestine.After her third surgical procedure, the owners realized that it was far cheaper to put asphalt on the driveway than to continue to pay her medical bills.
But sometimes we choose to ignore what our pet’s behavior is telling us. Consider the case of one Golden Retriever who underwent gastric surgery twice after swallowing a tennis ball whole. The catch here is that the dog had two quite separate surgeries to remove the exact same ball.That’s right; the owners wanted her favorite ball returned to them after the surgery, and gave it back to the dog to play with once again.
* * * * *
Inside Snowball's Abdomen, I find things much as I expect; loose, lazy switchbacks of pink bowel replaced by a lumpy knot of bruised intestines. Carefully, I inspect the surfaces of the duodenum and jejunum, looking for purple areas of perforation where the foreign body might have piano-wired its way through the entire wall, allowing digesting food to leak into the abdomen.Most of her guts may look like twisted telephone cord, but the tissues appear to be healthy aside from the presence of a thin linear material trapped inside the intestinal lumen.
I was trained to start at the point of fixation, in this case, Snowball’s stomach. The luxury of pulling a linear foreign body out of a single incision is unusual, especially for an object as intent on getting out the other end as this one, so opening the stomach affords the surgeon his or her first glimpse of the culprit as well as an opportunity to cut the anchor, breaking the drawstring effect and releasing the tension on the bowel.
It takes two more small incisions in the intestine to remove the entire problem, and after everything is sutured up and Snowball is resting comfortably in recovery, I head to the waiting room.The Duggan family sits watching television, but they are up on their feet as soon as they see me approach.
The answer to this mysterious foreign body had been in front of my eyes the whole time. Mrs. Duggan was wearing pumps. Mr. Duggan, a pair of well-worn work boots. Kerry Duggan sported a pair of old sneakers made unusual by one feature common to both feet—crisp, white, brand-new shoelaces. Guess what happened to the old ones?
Wellness: Health Care
February 6 2012
Sometimes I realize I may be getting too old for this job, particularly when I get a phone call from my resident in the wee hours of the morning.
“I’ve got a dog with a broken back,” he says. “Any chance you can give me a hand?”
I could groan, but it would take too much energy. I could say, “Can’t it wait a couple of hours?” but he’s already said the magic words. A broken back is a true surgical emergency, and there’s not a minute to lose if you want your patient to have the best possible opportunity to walk again.
“Sure,” I say, “be right with you.” I hope my robotic monotone and total lack of enthusiasm don’t register with him.
I make the 40-minute commute in silence, and though the fog in my head is beginning to burn off, I feel a low-level exasperation about having to head back to work in the middle of the night. But I perk up when I see my resident and the dog in question.
“Hunter is a Lab/Beagle mix. Eighteen months old. Adopted just two weeks ago. Owner went out for dinner at six, came home at 10 to find Hunter lying in the backyard unable to move¾he jumped through a screen in a second-story window.”
The resident shows me the X-rays: the orderly structure of Hunter’s bony spinal column is crunched and buckled in the middle. This image represents a finite moment in time. Who knows how much distortion and irreversible damage occurred before reaching this point?
“He can’t move his legs,” says the resident, “but he does have deep pain.” Deep pain is the last measurable sensation an animal retains before total paralysis.
“Good,” I say, “then we’re still in with a chance.”
Perhaps it’s the word “we” that gets the resident’s attention. “I was hoping I could do the surgery. That you could walk me through it.” Spinal fractures, which can be tricky, are respected and revered by surgeons in training, and he was up for the challenge.
There are lots of ways to fix these fractures, but the plan we devise for Hunter involves using a combination of pins and sterile cement to bridge and stabilize the break. Aim a pin in the wrong direction, push it in too far, and you risk puncturing the spinal cord (never a good thing) or, worse still, puncturing your patient’s aorta (invariably fatal).
I look at him. Unlike me, the resident was totally awake, excited and hungry for the opportunity. He was me, 20 years ago.
“Sure,” I say. “We’ll do it together.”
And we did, or rather, he did. He repositioned the broken bones and then placed his pins. I guided his hands; I approved pin positions and angulations and told him precisely when to start and stop. But the repair was his, and when we reviewed the postoperative X-rays, Hunter’s spine was once more perfectly aligned.
“Nice job,” I said, and meant it.
In the following weeks, I followed up on Hunter’s recovery, chatting with his owner, Tim.
“Hunter’s doing great, especially when he does his water therapy. He still can’t walk on his own, not yet, but he’s definitely getting there.”
In Tim’s voice I could hear the emotion common to every dog owner who’s had to deal with canine spinal trauma: eternal optimism. When faced with a forecast of slow progress, intense nursing care and an uncertain outcome, a “glass-half-full” attitude is essential.
“He’s always in a good mood. If Hunter never got any better than he is today, if I had to fit him for a cart, I know he’d still enjoy a great life.”
On the night of Hunter’s surgery, my sleepy indifference had vanished the moment I saw a dog in such dramatic need. The responsibility of trying to restore something as fundamental as the ability to walk across a room was a real eye-opener. Better than a double espresso any day.
“Don’t forget,” I had said to the resident after we finished, savoring his excitement and appreciation, “we’ve only created the possibility for recovery. The rest is out of our hands.”
I didn’t want to kill the buzz; I simply wanted to remind him that surgeons can’t play God. Nothing we do with our hands and tools can get a spinal cord to heal if too much damage has been done.
The resident nodded his understanding. I smiled, invested in and thrilled with what had been achieved for Hunter.
“Thanks for your help,” said the resident. “Next time. I won’t have to call.” And that’s when it hit me: I wouldn’t want to miss this feeling for the world.
“Call me anyway,” I said as I got ready to leave. “Remember, no two spinal fractures are ever quite the same.”
Wellness: Health Care
A Vet’s Perspective
October 18 2011
Gilberto had it bad. when I asked, “When did you get Carly?” he recited the exact date he had adopted his beloved Pointer cross from a shelter two years earlier.
“They told me she only had a couple of months to live — cancer — and, for that reason alone, no one was going to take her. Not to mention her problem with other dogs.”
Gilberto and Carly had been sequestered in a private room, isolated from the waiting-room hubbub. She seemed like a perfectly socialized, gentle, malleable creature, though the swelling around her hock gave me pause.
“She was found wandering the New Jersey Turnpike. Her body was covered with scars and there were deep indentations over the bridge of her nose from wearing a muzzle. The shelter thought she had been used as a bait dog.”
“I’m not sure what you mean by ‘bait dog,’” I said.
“Among other awful things, an intact female dog to excite and wind up male dogs before a dog fight.”
Appalled, I shook my head. I didn’t know what to say. No wonder Carly demonstrated fear aggression around other dogs.
“My mother was visiting for the summer from Brazil,” said Gilberto, “so I thought, why not; I’ll give Carly a home and some quality time. It felt like a winwin for both of us, and Carly’s fantastic with people. Naturally, I spoiled her — she got to sleep with me on my bed, she always got the last slice of pizza and where was the harm in taking her out for ice cream? But summer came and went and Carly seemed absolutely fine.”
“What kind of cancer are we talking about?” I asked.
“Breast cancer. The pathology report said it had already spread to her lymph nodes.”
I frowned into a slow nod. This certainly sounded grim. “My friends started ribbing me, telling me I’d been suckered into taking her because of her aggression. But look at her — she’s great.”
Carly was investigating the room, sniffing the air, somehow catching the aroma of low-fat dog treats high on a shelf and out of sight. She seemed as affable a creature as one would ever want to meet.
“I arranged for pet-sitters when I was away from home, and started Carly on a more civilized diet. We also tried working with a behaviorist, with limited success. And here I am, two years later, with a dog who jumps off a bed and comes up lame.”
As touching and miraculous as Carly’s story was, alarm bells were ringing inside my head. The cancer diagnosis was detailed and specific. Shelters do not try to con to secure an adoption.
Carly was toe-touching lame on her right hind leg and, given the high risk of a canine encounter, I figured nothing would be gained by a “best in show” stroll up and down the corridor. Jump off the bed, roll an ankle and hey presto, lameness and joint swelling. But this swelling was all wrong: firm, focal and slightly above the joint. Was the cancer finally back? And if so, was the man who had taken on a death-row dog and treated her to a wonderful stay of execution, now — after all this extra time — in denial?
“There’s something not right with Carly’s ankle. I’d like to take an X-ray.”
Gilberto agreed and we hurried Carly into radiology like we were smuggling a rock star into a building full of restless fans. The films confirmed my suspicion: subtle boney changes suggestive of metastatic spread of a cancer.
“Can I get a copy of the image?” asked Gilberto. “My wife is a pathologist. I’d like her to take a look at the films.”
“Absolutely,” I said, wondering if perhaps he didn’t believe me. For a guy who took on a dog knowing she was going to break his heart, he seemed completely broadsided.
“I would also suggest that we take a series of chest X-rays to see if it has spread to the lungs.” Gilberto agreed. Sadly, the X-rays confirmed the presence of golfball- size masses within the lungs.
I offered the possibility of a biopsy, set him up for a consultation with oncology and, most of all, encouraged him to go home, absorb the information, speak with his wife and then give me a call. In the end, Gilberto chose to manage Carly’s pain with medications at home.
Some weeks later, I checked in with him.
“I almost wish you’d never taken those X-rays,” said Gilberto.
“You were doing your best, but sometimes I feel as though it would have been better not to know.”
I said nothing, but was reminded of the delicate tightrope act we veterinarians constantly perform. Some dog owners seek a diagnosis and treatment at all cost. Others simply seek assurance and support that they are doing the right thing. It’s never easy to find a balance. Gilberto was the kind of pet owner most of us can only aspire to be — selfless, invested and humbled by how much we get back for how relatively little we put in.
“These days, I’m mainly working from home, which is great. I’ve always been into cooking, and recently, I made a big batch of fettuccine Alfredo; Carly loved it. She sleeps beside me every night, and I know she’s doing okay because she still freaks out when she hears a motorcycle.” I hope Gilberto knew that on the other side of the phone line, I was smiling. This remarkable man was being forced to anticipate the loss of his dog for a second time, and he was still awed by how much he stood to lose.
Wellness: Health Care
A vet’s perspective
July 19 2011
Skin lumps can be tricky. we stick them with a needle, suck up some cells, smear the sample on a slide and take a peek down a microscope, but sometimes we still can’t make a diagnosis. This leaves us with the option of surgery on a lump of unknown provenance and the dilemma of how wide an excision to make. If the culprit is benign, the surgery need not be radical. But what if the lump is malignant? Should the surgeon be aggressive, just in case? How on earth do we strike the perfect balance?
From time to time, I am presented with precisely this kind of case. Hannah, a Shar-Pei, was seven years old when her owner noticed an innocuous but slightly pigmented and raised skin mass on her left forelimb. The referring veterinarian had performed a local excision and in doing so, achieved his foremost objective: a diagnosis — in this instance, the troubling discovery of melanoma.
“The margins were dirty,” said Hannah’s owner, Barbara. “Do you think you can get what was left behind, given the location?”
On the extremities of the body, particularly the face and limbs, loose skin is at a premium compared to the chest and abdomen. When doing surgery, a veterinarian’s natural tendency is to take less to ensure that the hole left behind will close. On occasion, some owners will question whether the original surgeon was at fault. Barbara was not one of those owners.
“Sure,” I said, pinching an inch around the scar. “It’s always difficult to decide how aggressive you should be when the lump is a mystery. But now that we know it’s a melanoma, Hannah can also reap the rewards of a treatment not even available in human medicine.”
Barbara looked confused.
I was talking about the first fully licensed anti-cancer vaccine to be approved by the USDA: the canine melanoma vaccine, Oncept™.
“You mean Hannah could have been vaccinated against melanoma?”
“Not quite,” I said.
“The vaccine is therapeutic, not preventive.”
I went on to tell Barbara that melanoma cells express large quantities of a protein called tyrosinase. The vaccine incorporates DNA that expresses a gene for the human version of tyrosinase. When the dog’s immune system recognizes this human protein as a foreign substance, it mounts a response. Fortunately, the human version is similar enough to its canine counterpart that the stimulated immune system attacks the melanoma tumor cells.
“Why not vaccinate all dogs?” asked Barbara.
“Malignant melanoma is quite common, affecting about one in every 20 dogs with cancer, but it’s still not common enough to justify widespread vaccination.”
“So when do we get started?”
“We don’t, or at least I don’t — I’m not allowed. For now, only board-certified oncologists can administer the vaccine: four doses, inside of the thigh, every two weeks, and then a booster every six months. I’ll have you meet with one of our oncologists and she’ll give Hannah her first treatment once she recovers from the surgery.” And this was what we did for Hannah after the pathologist confirmed that my surgical margins were clean.
While the vaccine is primarily aimed at oral melanoma, especially where the tumor is locally invasive or has spread to local lymph nodes, many oncologists are keen to reap its benefits for melanomas in other locations. One of the appealing features of the treatment is its lack of side effects. Some dogs may develop a low-grade fever, but that’s about it. The biggest deterrent may be the price; in our hospital, an initial course of vaccinations will set you back around $2,000.
It is important to bear in mind that the vaccine is not a cure. For dogs with early-stage melanoma, like Hannah, survival times greater than three years can be expected. For dogs with more aggressive types, a median survival of one year might be more realistic (but much improved from the previous expectation of only two to three months with other therapies). Oncologists have also seen periods of remission in dogs with visible spread of the cancer to the lungs.
One of the lessons I learned from my experience with Hannah is that the vaccine appears to be more effective the earlier it is given; sometimes the disease will progress while you are waiting for the immune system to kick in. In removing a bleeding but benign skin lump on a 16-year-old Jack Russell named Charlotte, I snipped off a small lip mass in the spirit of “while you’re at it.” As so often happens, the seemingly incidental lip mass turned out to be the more serious concern when the pathology report came back: malignant melanoma.
“Charlotte’s way too old for chemotherapy or radiation therapy,” said her owner, Ann. I didn’t even try to argue, but I did mention the vaccine.
Guess who booked the first available appointment with oncology!
*Bergman, P. J., et al. 2006. Development of a xenogeneic DNA vaccine program for canine malignant melanoma at the Animal Medical Center. Vaccine 24(21): 4582–85.
Wellness: Health Care
Observation, touch and intuition make up a diagnostic trifecta
Ordinarily, I’ll take serendipity over failure to make a difficult diagnosis every time. The trouble is, in my world, not every diagnosis is desirable, and serendipitous isn’t always the same as positive. I’ll call him Murphy: a rambunctious two-year-old Golden Retriever who bounced into my examination room, all billowing feathers, Hollywood smile and a nose searching for a friendly hand.
“So, he’s a little sore on his left front leg?”
Murphy’s owner, Mr. Crowe, managed a tepid nod. I imagined he was in his 50s—thinning gray hair, goldrimmed spectacles prone to sliding down his nose—but what struck me was his uneasy posture. He stood with his arms folded tightly across his chest as though he were trapped inside an invisible straight jacket.
“It’s both legs,” he said, “worse on the left. Did you not get the elbow x-rays?” I had in fact reviewed the films taken by his veterinarian, images that confirmed elbow dysplasia. “Dysplasia” simply means abnormal growth and, in this context, defines abnormal development of a dog’s elbow joints
“Yes. Thank you. When did you first notice a problem?”
“Last few weeks,” said Mr. Crowe.
“Really?” I said, trying to hide my surprise. “Nothing as a younger dog?”
Most (but not all) dogs with elbow dysplasia show signs of lameness in their first year, or conversely, much later in life, when they develop secondary arthritis. Clearly, Murphy’s timing was off.
Mr. Crowe shook his head, eyes narrowing as he searched my face.
“No. Does that matter?”
The challenge of clinical intuition is not just registering its presence; it is whether you can make sense of it.
“Of course not,” I said, my reassuring smile failing to find its target. “A lot of my patients don’t read textbooks.”
Mr. Crowe’s deadpan stare was my cue to get on with the examination. Murphy played along; the feel of his elbows and the changes on the x-rays jived perfectly with his history and clinical signs. I ended by discussing treatment options, and Mr. Crowe decided to pursue surgery as soon as possible.
A week later, Murphy stood me up, a no-show for our OR date. Mr. Crowe apologized—something had come up. He rescheduled but, once again, on the morning of surgery, he found another excuse. I imagined that Mr. Crowe was torn, vacillating at the 11th hour. So, more than two months later, I was surprised to be greeted by a familiar Golden Retriever, eager to get his elbows fixed.
Looking back, I know I got lucky. Murphy was anesthetized, lying left side up, while an eager technician waited to be told where to clip his fur. As I demarcated a line on Murphy’s skin, I felt a subtle boney bump and decided to chance a new x-ray. What I saw took my breath away: solid bone reduced to fragile honeycomb.
I called Mr. Crowe.
“I’ve found something other than Murphy’s elbow problem, something that’s destroying his left shoulder blade.”
Silence. Then he asked the obvious, and logical, question: “Why didn’t you find it last time?”
“Back then, there was nothing to feel; no lump, and Murphy exhibited no pain.”
More silent deliberation—then, “So now what?”
“We should get a biopsy.”
The biopsy confirmed that in just two months, Murphy’s problem had transitioned from a niggling elbow disorder to a highly malignant bone tumor of his shoulder blade—from low-grade lameness to terminal cancer. Two months earlier, I would have subjected him to elbow surgery and watched him falter through recovery before facing an owner rightly furious at my failure to diagnose the real problem in his shoulder. Fate and Mr. Crowe’s uncertainty had saved me. I wish the same could have been said for poor Murphy.
“His tumor is inoperable. Even if I remove Murphy’s leg, I can’t get it all. And chest x-rays confirm that it’s already spread to his lungs.”
The precept, “first do no harm,” echoed in my mind as Mr. Crowe vented his frustration. “My mother had cancer. It was misdiagnosed. By the time they knew for sure, it was too late.” I wondered if this was the cause of his unease and hesitation. No matter. Armed with this painful new perspective, I had to justify the limitations of what I could offer.
“I wish there had been something to find when we first met,” I said, “but there wasn’t. I looked. I felt. There was nothing, no response from Murphy. I don’t like to lose, but winning at all costs isn’t worth it if Murphy pays the price. I can take his leg, take parts of his lungs, fill his veins with chemo, radiate his body and maybe, if we’re lucky, we can prolong his life a little. But what kind of extra life would he have? Not having a treatment option is our fault, not yours.”
I refrained from mentioning the twomonth delay, the opportunities missed for an early diagnosis. What purpose would it serve? Besides, there was a lesson here for me. If dogs could verbally communicate the subtleties of disease, vets might be less vulnerable to clinical red herrings. When alarm bells ring, we must resist the seductive power of an easy diagnosis. Observation and touch were all I had, and I worked hard to silence intuition.
“Undiscovered” is not the same as “overlooked.” Sometimes, the real culprit bides its time. And sometimes, the only constant I can guarantee, to client and patient alike, is the sincerity of my intent, even when I cannot guarantee a cure.
Names and identifiers have been changed.
Wellness: Health Care
Imagine yourself in a veterinary surgeon’s examination room, bracing for the details of wound care, pain management and an exhaustive (and alarming) list of potential post-operative complications, when the doctor surprises you with an announcement: “With luck, we can avoid surgery altogether.”
Can this be true? Did you and your dog show up at the wrong appointment? Most of us who wield a scalpel for a living hope that the answer is no. In my opinion, surgery should be reserved for cases in which it is, handsdown, the best option — or, barring that, something to fall back on when attempts at more conservative treatment have been exhausted. For me, it comes down to a simple philosophy: if the patient were my dog and there were some decent alternatives to going under the knife, I’d be all for them.
However, things get complicated when we are a little too eager to embrace these alternatives. We become a marketer’s dream, easily swayed by anecdotal “evidence” and vulnerable to the allure of excessive optimism. In these heady veterinary times, as we are inundated by breakthroughs barreling down the medical pipeline, it pays to slow down and cast a critical eye on new options.
Take, for example, stem cell therapy for the treatment of canine osteoarthritis (OA). Debilitating joint pain, particularly when it is secondary to chronic hip dysplasia, accounts for a significant proportion of my caseload (more than 20 percent of dogs suffer from OA), and often spurs discussions about total hip replacement (THR). For the most part, THR is elective, the last trick in the bag when weightloss programs, physical therapy, acupuncture, joint supplements and a long list of nonsteroidal anti-inflammatories are no longer working. Now, a company named Vet-Stem is promoting another unique angle of attack: regenerative medicine.
Basically, the idea is this. Under anesthesia, your dog has some fatty tissue extracted. This sample is shipped to the company’s lab, where it is processed to extract stem cells, which are then returned to your veterinarian. With your dog once again under sedation, these stem cells are injected back into his or her arthritic joints. Over 500 dogs have received stem cell therapy in the past six years with (according to the company’s website) more than 80 percent of owners reporting improvement.
Blame my scientific training for a sense of wariness (and truly, this is not the same as skepticism). It’s just that anecdotes, owner testimonials and feel-good videos of stiff, sore, geriatric dogs transformed into leaping “puppies” make me start hunting for the evidence- based data. When I combed the scientific literature for information on stem cell therapy in dogs, I discovered just two studies, both sponsored by Vet- Stem. Though this gives me pause, the overall results were impressive: statistically significant improvements in lameness, less joint pain and improved range of motion. There are, however, a few points worth noting.
Only 35 dogs were involved in the two studies; all the dogs were also on anti-inf lammatory medications, and the duration of effect was only taken out to 180 days. From my perspective, on paper, stem cells hold lots of promise for the treatment of OA, but I’d like to see more independent studies, more patients and an absence of concurrent medications. I’d also like to know how long a course of treatment is likely to last.
Naturally, the media are quick to tout the possibilities of a sexy new treatment, but when they do so at the expense of tried-and-tested surgical techniques, I find myself beginning to bristle. For example, Time magazine ran a story touting the merits of canine stem cell therapy while attacking the proven option of THR. It suggested that recovery from the surgery would take “up to six months” and would be “four times as expensive” as stem cell treatment.
I practice in a hospital where, all told, stem cell therapy costs about $2,500 and THR about twice as much. Clearly, they are both expensive, and both require general anesthesia. However, THR has been available for dogs since the 1970s and there are hundreds of independent, peer-reviewed scientific articles to back its use as well as define both its benefits and its limitations. If I too succumbed to the easy and powerful allure of the anecdote, I could tell you that the vast majority of dogs on whom I perform THR are taking 30-minute walks twice daily by three months after surgery (and I have observed Labs with normal, full, weight-bearing function the day after surgery!).
Today’s dog owners demand something more than the archetypal, scalpel- happy bravado of a typical surgeon, and rightly so. But please, when seeking alternatives to traditional options, ask questions and demand answers before you write off the proven in favor of something new and speculative. I will continue to entertain alternatives to surgery because I strive to be a surgeon who — as Dr. Abraham Verghese says in the extraordinary novel, Cutting for Stone — appreciates that “the operation with the best outcome is the one you decide not to do.”
Wellness: Health Care
A Vet's Perspective
Part of the appeal of veterinary surgery is the reward of achieving a “before and after” moment for a sick animal. It might be the Dachshund with intervertebral disk disease transformed from dragging a paralyzed hind-end to being able to trot over to greet me. Or the Labrador with laryngeal paralysis who is no longer desperate for air and able to breathe comfortably on a hot summer day. Whatever the underlying problem, when there’s something positive and tangible to show for our efforts, owner satisfaction and a sense of our own accomplishment are givens.
But it was precisely the absence of any possible “before and after” moment for a delicate, two-year-old black Standard Poodle named Vivian — a service dog in training — that gave me pause when her person, Lisa, suggested that a preventive gastropexy for GDV be performed while Vivian was being spayed.
GDV— gastric dilatation and volvulus, commonly called “bloat” — is a bizarre, unpredictable and potentially catastrophic event in which fermented gas accumulates in a dog’s stomach and causes the entire organ to twist and flip over on its long axis. Left untreated, bloat can kill a dog within a matter of hours. Treatment often consists of a gastropexy (or “pexy”), in which the dog’s stomach is sutured to the body wall, preventing it from twisting.
“Hmm,” I said in response to her remark. “It sounds like you’ve had another dog who developed bloat and needed emergency surgery.”
“Actually, it happened to a friend’s dog, and Vivian’s breeder also recommended it,” said Lisa. “I figured if you’re in there doing a spay, you might as well pexy her stomach at the same time. Once she’s healed up, I can get back to her training.”
Lisa, a pretty college student with cerebral palsy, had another Poodle, nineyear- old Ethan, who was also helping tutor Vivian in the art of opening and closing doors, turning lights on and off, and helping Lisa take off her socks and pull her arms out of coat sleeves. In short, Vivian was Lisa’s insurance against a loss of continuity in essential canine care.
My downturned lips, raised eyebrows and nod demonstrated my understanding, but my mind was elsewhere, beyond Vivian’s health and on her role as Lisa’s service dog. Every dog is “the best dog in the world,” and owners never have to justify what makes their animal special to them. If they put their trust in me, I hope they do so with the certainty that I “get” it. However, I confess to feeling a twinge of added pressure when the dog in question works for a living. Vivian was learning all kinds of tasks vital to helping Lisa live independently. What if something went wrong with an elective surgery intended to prevent a problem that the Poodle might never develop?
There wasn’t much more to my examination, which disclosed a perfectly behaved dog in perfect health. All that was left was a discussion of the pros and cons of a gastropexy.
“It’s hard to argue against personal experience or the accumulated knowledge of your breeder, but the procedure will require a longer anesthesia, there will be more than one incision and, on occasion, dogs have minor intestinal problems afterward.”
“It sounds as though you’re not recommending it,” said Lisa.
“No,” I said. “I know that if Vivian did experience GDV, we would both curse the day we decided against taking steps to prevent it. But at the same time, I wonder what the chances are of Vivian developing it. My sense is that the risk is fairly low. If this is true, then it would be like removing a healthy person’s appendix to prevent appendicitis — a surgery in anticipation of a problem that’s statistically unlikely to occur.”
“I’m still inclined to have the pexy done,” said Lisa. “Could you find out more about her risk of developing GDV?” I said I would, and when I did my research, everything changed.
In my search of the veterinary literature, I could find only one scientific study focusing on the statistical likelihood of a purebred dog developing GDV during his or her lifetime, but the results were chilling: 24 percent for large-breed dogs, 22 percent for giant breeds and 42 percent for Great Danes!* Naturally, one should be wary of a solitary study; however, my earlier estimate of the risk was probably too low. When taken in combination with Lisa’s innate inclination toward prevention, we decided to sign up Vivian for both procedures. All went well, and she was released to Lisa’s care the day after the surgery.
The next time I spoke with Lisa, I asked her to tell me what Vivian provided, beyond assistance with the tasks of daily living. “She’s a typical Poodle,” Lisa said, “whip-smart, with a clown’s personality. Vivian is teaching me to be creative, to be silly. I’m normally quite shy and reserved, but when she does something correctly, I gladly make a fool of myself in public singing her praises.”
That was when I realized I might need to accept that sometimes, “before and after” can be equally rewarding when they’re exactly same.
Wellness: Health Care
A few years ago, the Wall Street Journal ran a story that they clearly felt blew the whistle on the “epidemic” of canine knee surgeries in this country: “The number of dog knees undergoing cruciate ligament repair each year in America is estimated to now exceed 1.2 million … Such treatments have helped fuel a doubling of the number of veterinary surgeons in the U.S. in the last decade …” Finger-pointing continued with mention of a scientific report that estimated that U.S. pet owners spent $1.32 billion to treat canine cruciate ligament problems.
It might just be me, but the story left me feeling like I spent my days drifting from one dog park to the next, trolling for customers—throwing Frisbees and tennis balls, attempting to induce knee injuries while doling out my business card.
Injury to the cranial cruciate ligament (or CCL, the equivalent of our ACL) has been recognized in dogs since 1926. This tough, strategically placed band of connective tissue lies within the knee joint and plays an essential role in stabilization. The bigger question is, why does CCL repair surgery appear to be more prevalent now?
The answer necessitates an understanding of what causes the problem, and here things get complicated. We know that certain breeds—including the Neapolitan Mastiff, Akita, Saint Bernard, Rottweiler, Mastiff, Newfoundland, Chesapeake Bay Retriever, Labrador Retriever and American Staffordshire Terrier—are at greater risk. (Vets are actively looking for predictors of cruciate disease, even identifying a genetic basis in Newfoundlands.*)
We know that the problem frequently— 43 percent in one study— affects not one but both knees. We know that the majority of affected dogs are young (less than four years old). We know a CCL rupture or tear can be a traumatic injury sustained during vigorous exercise, but is more commonly precipitated by a minor event such as jumping, which suggests that an underlying weakness of the ligament has been brewing for some time. And then, there’s this weird relationship with sex (or maybe, lack of it). It doesn’t matter if the dog is male or female; the risk increases if he or she is neutered or spayed.
Lest you think there’s a veterinary conspiracy to generate more business, note that body weights of dogs with torn cruciate ligaments tend to be significantly greater than ideal. Sterilization can affect body weight, which, in turn, can a ffect activity. In other words, there are a myriad of interconnected predisposing factors for canine cruciate injury.
To my way of thinking, part of the perceived increase in the number of cases relates to a better appreciation of the disorder, earlier diagnosis and improved surgical options. While vets have been prone to blame canine lameness on hip dysplasia, a recent study showed that nearly one in three dogs referred to a veterinary teaching hospital with a diagnosis of hind-leg lameness actually had a torn cruciate. Our confidence in results obtained with procedures like tibial plateau leveling osteotomy (TPLO) and tibial tuberosity advancement (TTA) has also made us more aggressive in our approach to dogs with partial cruciate tears. When people ask me why we don’t use a cheaper, more conventional repair, akin to a human ACL replacement, I point out an obvious disparity between us and our dogs. As two-legged upright creatures, we stand on a f lat knee joint in which, for the most part, the ACL has little to do, unless we participate in sports like skiing. On the other hand, our four-legged friends have their knees in a permanent state of fl exion—dogs are skiing all the time.
Granted, this is an oversimplifi ed analogy, but imagine visiting your orthopedic surgeon with a torn ACL and telling him, “I don’t mind how you fi x it, but I’m going skiing this afternoon and plan on hitting black diamond runs for the rest of my life.” I guarantee he would be looking for an alternative to a simple ligament replacement. That is exactly what has evolved for dogs.
So when a client with multiple dogs brings yet another patient with a torn CCL, and asks, “Is it me? Am I doing something wrong?” be assured that if I knew the answer, I’d blow the whistle. For now, my best recommendation is to keep your dog lean, provide him with regular exercise and, if you’re really paranoid, do your best to keep him on the canine equivalent of the bunny slope!
*Wilke V.L., Zhang S., Evans, R.B. et al. Identification
Wellness: Health Care
Looking Past a Label
The word “lemon” feels all wrong.
It might work for a car or some other inanimate object that comes with a warranty, but when applied to a cheerful and innocent puppy, it makes me wince. Yet, every week, another fourlegged heartbreaker hobbles or bunnyhops into my examination room and I’m forced to confront this distressing label.
It turns out that some 20 states have so-called “lemon laws” for purebreds — laws that give people the right to a refund, a replacement or some level of reimbursement for treatment of a puppy with a health problem — but in my experience, they’re moot. Whether the dog’s a purebred (who’s covered) or a mix (who’s not), the sentiment is pretty much universal: “It’s too late. She’s part of the family. There’s no way I’m giving up on her.”
I know Bronwyn and Keith — an attractive professional couple and the proud owners of a Mastiff mix they’d named Ben — would agree. And yes, realize I’ve used the word “owner,” which reflects convention, not my philosophy. To be honest, I rather like the approach one of my clients takes; she considers her Puggles to be her “roommates,” a label that nicely captures the canine spirit of independence and defines a relationship in which individuals enjoy sharing their lives and space for whatever time they have together.
But I digress. On this, their first visit, it was just Bronwyn and Ben.
“Keith isn’t here,” said Bronwyn. “He just couldn’t come back to your waiting room … to relive the scene and the memories.”
Bronwyn explained that their first dog together had been Cole, a rescued five-year-old Mastiff/Shepherd mix. Within 36 hours, Cole had gone from a dog suffering from a simple bout of vomiting and diarrhea to one in fatal kidney failure secondary to leptospirosis. “Keith and Cole had an amazing connection. At the end, I had to physically pull Keith away from him — it was so hard for him to let go.”
It was eight months before they could consider getting another dog. This time, they turned to Petfinder.com. “Ben was six months old, in Vermont at a rescue facility. Keith picked him up — yes, I worried that Keith might be a soft touch, prone to falling for a big dog with a black mask and sad, expressive eyes, but it felt like the right time.”
“And when did you start to notice Ben’s ‘Marilyn Monroe’ wiggle?” I asked, referring to the movie Some Like It Hot and Ben’s fine impression of Monroe’s exaggerated hip sway as he walked away from me.
Bronwyn smiled. “At first, Ben seemed afraid and clumsy, a nervous scaredy-cat. He didn’t want to go up stairs or jump in the back of our truck. Keith and I have been online and there’s some frightening stuff out there about puppies and hips. I’m not sure how we’ll cope if we have to go from one heartbreak to another.”
I examined Ben, and he was everything he should be: clumsy and goofy and adorable. But when he walked, the balls of his bony hips jostled too far up and down in their shallow sockets. His hocks resembled a cow’s, his feet turned way out to the side and he threw most of his weight forward onto his front legs. I could feel some abnormal joint thickening around both of his knees, and he was slightly lame on his right front leg as well. Where to begin? So much could be going wrong, so many ways for Bronwyn and Keith to be overwhelmed.
I ordered X-rays, and they confirmed the hip dysplasia we both suspected. As we stood together in front of the blackand- white image, Bronwyn said, “Do I need to be emotionally prepared for how long I can have this love affair with my dog?”
Good question, I thought, but in this instance, it was an easy one to answer.
“No. No, you don’t,” I said. “Sure, Ben has some significant orthopedic problems, but nothing we can’t manage. And I’m not talking about some temporary or gratuitous fix just to keep him around. Right now, he’s happy, loves to play with other dogs and so what if he looks a little clumsy on his back end? If he gets sore, I can give you something to make him more comfortable, and if things change, we’ll rethink the plan.”
Bronwyn’s eyes filled with relief.
“So, you can fix our orthopedic lemon?” she said.
I shook my head. “Orthopedic challenge,” I corrected. As I led Bronwyn and Ben back to the reception area, Bronwyn thanked me and said, “Like I told Keith, what else are we going to do? We’re already in love!”
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