Wellness: Healthy Living
A fast-growing rehabilitation option
In February 2012, cheri wells adopted Duncan, a Rottweiler with lupus, from the Pasco County Animal Shelter in Land O’Lakes, Fla. Thin and frail, Duncan was almost too weak to stand up when he urinated.
Wells, determined to find a way to combat Duncan’s progressive autoimmune disorder, first consulted a holistic veterinarian. The next stop was Rocky’s Retreat Canine Health and Fitness Center in Orlando, where she hoped that hydrotherapy could help her pup regain muscle strength and just generally feel better overall. In choosing this option, Wells (and Duncan) took advantage of a form of physiotherapy long used by humans and more recently applied to animals.
Canine water therapy takes place in either a heated lap pool or a smaller Plexiglas® tank with an underwater treadmill; whirlpools are also sometimes used. In the lap pool, the therapist may swim with the dog, who is usually strapped into a life vest, or manipulate and exercise the dog’s limbs while he or she rests in the warm water. The therapist may also join the dog in the treadmill tank, though here, the role is to guide and keep the dog on track. The dog enters the empty tank via a ramp; once the door is closed, the tank is filled with warm water to a depth appropriate for the dog’s size and therapy needs. The treadmill is then activated, and the dog walks at a steady pace, supported by the water’s buoyancy, which unloads weight on the joints and encourages a full range of motion.
Pool or tank, both approaches effectively increase circulation and joint flexibility and decrease pain. Essentially, fundamental physics makes hydrotherapy effective. Water’s resistance increases the demand placed on the muscles as they propel the limbs through the water, making it effective for building strength. In addition, the viscosity of the water— its frictional resistance—is thought to increase sensation and limb awareness, thus helping a weak dog find his or her balance.
Horses were among the first animals to benefit from hydrotherapy; those in the equine rehab field would swim their patients in large pools to restore them to their former galloping glory. Following their example, Greyhound trainers also employed the method. Today, rehabilitation (much of which focuses on hydrotherapy) is among the fastest-growing areas in vet medicine.
“What we originally thought would be a ‘boutique’ area of veterinary medicine has become very popular. We use it frequently, especially for the treatment of chronic arthritis, cruciate ligament surgery [post-operatively] and neurological deficits. Virtually any neurological or orthopedic problem can benefit from aquatic therapy,” says Darryl Millis, DVM, DACVS, professor of orthopedic surgery and director of surgical service at the University of Tennessee, Knoxville. UT is one of only two educational facilities in the U.S. to offer a certification in canine rehabilitation. (The Canine Rehabilitation Institute in Wellington, Fla., is the other.)
In 1993, Dr. Millis and David Levine, PhD, a board-certified physical therapist who teaches at UT, Chattanooga, began to consider alternative rehabilitation methods. “We were trying to think of ways to incorporate exercise and aquatic therapy for dogs, and we needed an aquatic therapy modality other than swimming, which can be too much activity for an early postoperative patient or a very arthritic dog,” explains Millis.
“We ran across an underwater treadmill for people while searching the Internet for rehabilitation products. I called the company and asked if they would consider making one for dogs. We worked together to modify the human treadmill for canines, and were the first to have a self-contained unit. One of the key concepts that we contributed was the open appearance of the treadmill; dogs will not walk into a solid wall. We also learned that [being able] to closely monitor the water level and carefully control variable speeds were important in the rehab process,” he says.
Marti Drum, DVM, PhD, who works with Dr. Millis at UT, became interested in animal rehab and sports medicine when she was just 12 years old. “I saw some cutting-edge therapies being done on U.S. equestrian-team horses, and it seemed like something I would like to do. I believe that the water is very efficient in providing targeted exercise to the affected limb. In general, a joint has greater overall range of motion when the water level is at or just below the joint,” she says.
Many conditions lead pet owners to try hydrotherapy, among them, issues associated with aging, arthritis complications, paralysis and mobility, chronic pain, pre- and post-surgical rehabilitation, obesity, dysplasia, and behavioral modification. Conditions such as hip dysplasia and osteochondritis can be aggravated by weight-bearing exercise, but greatly benefit from the relative weightlessness of water. Practitioners like Sherri Cappabianca, Cathy Chen-Rennie and Bobbie Werbe utilize Millis’ design daily. Cappabianca, who owns Rocky’s Retreat, worked with Duncan. Since opening her company in September 2011, her growing list of tank triumphs has only strengthened her resolve to promote hydrotherapy in her community.
“We have had incredible success with dogs who were so arthritic when they came to us that they couldn’t walk. Dogs who deal with obesity or suffer from fear and aggression issues benefit immensely from learning to swim. Some clients tell us that we give them their puppies back,” explains Cappabianca.
Chen-Rennie opened The Rex Center in Pacifica, Calif., in 2009 to serve San Francisco Bay Area dogs in need of safe, nurturing exercise options. Onethird of her clientele are elderly dogs. She loves the way they just relax and enjoy the warm water. “You see dogs who used to love to swim. We have a 13-year-old Lab who literally leaps an inch when he sees the pool,” she says. Werbe, who’s an RVT and Certified Canine Rehabilitation Practitioner, is affiliated with Circle City Veterinary Specialty and Emergency Hospital in Carmel, Ind. She and her clients have zero doubt about the restorative, lifechanging power of aquatic therapy. Kim Tikijian took her 14-year-old yellow Lab, Maggie, to see Werbe after her hind legs began failing. Calcifications along Maggie’s spinal column were short-circuiting messages from her brain to her legs. At Circle City, Werbe developed a plan to strengthen the muscles surrounding Maggie’s problem spots.
“Maggie is much stronger than she used to be and only rarely has symptoms of weakness. She naps long and hard after sessions but wakes refreshed and ready to romp with her siblings. I truly believe that Maggie would not [be] able to support her weight if it had not been for Bobbie and the treatment she provides,” says Tikijian. As with most things, people have adapted to this aquatic trend as the benefits and results presented themselves. Millis says that various veterinary schools have begun rehabilitation services at their teaching hospitals within the last five years. “Many colleges have sent technicians and veterinarians to our courses and facilities to learn. In fact, we had administrators and vets come in from Thailand [earlier this year],” he says.
To ensure that momentum furthers progress already made, the next wave of veterinary professionals must embrace rehab and hydrotherapy as a mainstay. Dr. Jennifer Au, assistant professor of small-animal surgery at Ohio State University, says she occasionally runs into people in the field who don’t understand the efficacy of this approach. “As an orthopedic faculty member, I talk to all of my clients about rehab, and I lecture as much as possible about it in classes and at continuing education seminars,” she says.
While education is no doubt the most serious component, UT has its own public-relations poster girl to teach the value of the underwater treadmill. Mabel, a plucky, 67-pound, fiveyear- old Beagle mix, was left at a Knoxville animal shelter in December 2011. Angela Witzel, DVM, PhD, DACVN and chief of nutrition services at UT’s Veterinary Medical Center, adopted Mabel and promptly put her on a slim-down plan that involved both calorie restriction and exercise.
Mabel spends 30 minutes every other day on the underwater treadmill. She initially struggled, but the water helped her drop some of her bulk, and she was able to move more easily. Now, Mabel has lost almost 42 pounds, and her new, lean body has inspired many. She has her own Facebook page, and several local news channels have covered her journey to health. Pictures posted around campus show a happy hound running with smiling students, and videos document a disciplined girl in the tank walking off the pounds that piled on during her days of overeating.
“I am thrilled that people seem to care so much about her story, because [reducing] pet obesity is my passion. Mabel loves to go for walks now,” says Witzel. “We gave her a break from the underwater treadmill and her weight loss plateaued, so it was back to the pool. Let there be no doubt, the UTCVM rehab department works.”
Beyond tank design and the science of motion, hydrotherapists work to restore their patients to optimal health. Worried pet owners, searching for options and answers, turn to this new modality to relieve their dogs’ discomfort. In Duncan’s case, Cappabianca gave Wells four beautiful months with her Rottie before he died of a severe infection. The experience had such a profound impact on her life that she founded LoveyLoaves Rescue (lovey loaves.com), a nonprofit organization dedicated to rehabilitating disabled dogs.
“Every milestone Duncan reached was celebrated, and he was so proud. His life touched everyone he met. You really have to have an experience with aqua therapy in order to believe and appreciate the amazing healing that occurs through the rehab process,” says Wells.
News: Guest Posts
Book Review: Dog Food Logic
How wonderful if you could pose this question just once in your dog’s life and receive a perfect answer that would last a lifetime. Imagine if there were a ‘right’ formula, and once you know it, you could feed your dog forever and ever on the same exquisite diet. Your dog, in return, would be the happiest and healthiest doggie camper there ever was.
Unfortunately, “What should I feed my dog?” is not the question we should be asking. In fact, “What should I feed my dog” is akin to the infomercial that comes on at 3 AM informing you that if you just buy this Mega-Blast Belt (for three low monthly payments of $19.99), six-pack abs will follow. Both fall into a quick-fix category — the “right” product, the “right” answer — that unfortunately doesn’t exist.
Instead, the question that will last you a lifetime is, “How should I feed my dog?” This is where Linda Case, M.S. comes to the rescue. I don’t mean to be superhero-y about it, but Case’s new book, Dog Food Logic: Making Smart Decisions for Your Dog in an Age of Too Many Choices is a unique work designed to help readers make informed, science-based decisions on what and how to feed our beloved companion dogs. As one veterinarian offers, “Dog Food Logic cuts through the noise and chaos and provides pet owners with a rational, science-based approach to evaluating their pets’ dietary needs and their feeding choices” (The Skeptvet Blog).
Linda Case knows a thing or two about animal nutrition. She earned her B.S. in Animal Science at Cornell University and her M.S. in Canine/Feline Nutrition at the University of Illinois. She maintains the well-received blog, The Science Dog, and has written numerous books on companion animal nutrition, training and behavior. I had the pleasure of meeting her at the Cats in Context conference at Canisius College in 2013 (Case spoke on cat nutrition, and I gave a talk on research into whether dogs and cats in the home can be friends — they can).
But back to dog food. If you are expecting a dry read on dog nutrition and diet, you’ve come to the wrong place. Dog Food Logic is a page turner, jam-packed with real-world examples that you can easily relate to. Case unpacks label claims, fad diets and the wonderfully persuasive field of pet food marketing. What does it mean when a food is ‘recommended by veterinarians or breeders?’ Who is Chef Michael, and should you trust him? And who’s keeping our dog food safe?
Throughout the book, Case discusses research into canine nutrition and diet in a way that is easy to digest, if you’ll pardon the pun. For example, studies have investigated:
This is just the tip of the iceberg, and since I can’t possibly summarize all the topics and findings covered in Case’s book, the above are intentional teasers. To find out more, read the book.
Case, L. 2014. Dog Food Logic: Making Smart Decisions for Your Dog in an Age of Too Many Choices. Dogwise Publishing.
Case, L. The Science Dog blog.
Hecht, J. 2013. Dogs and Cats in the Home: Happiness for All? Dog Spies and Do You Believe in Dog?
McKenzie, B. The SkeptVet blog.
This article first appeard on Dog Spies, Scientific American. Used with permission.
Wellness: Health Care
Diagnosing and dealing with a common canine ailment
My first patient of the day is a soft, five-year-old Cavalier King Charles Spaniel named Chelsea. She peers suspiciously at me through half-open eyelids as her family describes the goopy eye discharge that goes away with topical medication but recurs as soon as treatment is discontinued.Chelsea’s not interested in playing ball as much as before, and spends most of her time curled up in her bed snoozing—behavior hardly expected from a champion ball-catcher.
I take a closer look at her eyes with my slit lamp and see thin blood vessels growing within what should be crystal-clear corneas. Instead, they’re a hazy gray, and the conjunctiva—the mucous membrane that covers the exposed portion of the eyeball and lines the inside of her eyelids—is red and puffy. I use special little paper strips divided into millimeter increments to measure Chelsea’s tear production and find that she has less than a third of what she should have. I then apply a topical stain that coats her cornea in a rough and patchy pattern. The combination of Chelsea’s clinical history, her eye exam and the test results gives me a diagnosis: keratoconjunctivitis sicca (KCS), also known as “dry eye.”
KCS is just one of the diseases that can affect the precorneal tear film that keeps the cornea and surrounding eye tissues healthy. The precorneal tear film provides oxygen and nutrition to these tissues and carries away debris from the surface of the eye. Much of the time, KCS is caused by an immune-mediated problem that creates inflammation within the tear glands and reduces the amount or quality of the tears they produce.Some drug interactions and systemic health conditions such as hypothyroidism may also affect the tear film, as can damage to the nerves that stimulate these glands to work properly. Additionally, the movement of the eyelids spreads the tear film across the cornea, so a dog’s inability to fully blink can also affect eye health.
Any dog can develop KCS, but some breeds seem to be predisposed. Shih Tzus, Lhasa Apsos, and Pugs top the list in my practice, but it’s also common in English Bulldogs, Westies, Cocker Spaniels, Yorkies, Pekinese, Boston Terriers and Cavaliers like my new friend Chelsea. The brachycephalic (squishedfaced) breeds often have big buggy eyes that are more exposed to the world, so they need even better tear production and quality than a breed with deeper-set eyes, such as a Standard Poodle or Collie.
What happens if your dog doesn’t produce enough tears? Just like Chelsea, he can develop red, irritated eyes that are painful and inclined toward bacterial infections and corneal ulcerations. Superficial corneal ulcerations can rapidly turn into deep ones that need surgical treatment to save the eye. If KCS is left untreated, the cornea will often become cloudy, with scarring over the surface and blood vessels growing across it. The corneal surface can even pigment and become so opaque that it obstructs vision. Fortunately, there are medications available to control the immunemediated inflammation within the tear glands.Notice I said control, not cure. By suppressing the inflammation in the tear glands, the medication allows your dog to produce more of his own tears.
The most important factors in treating KCS are consistently applying the medications as prescribed and following up with your veterinarian to determine if the treatment plan is working as expected. Don’t give up if you don’t see instant improvement; it may take several weeks of consistent application of medication before you see a difference. Chances are your dog will respond to medication relatively quickly: Don’t stop, reduce or change the medication until you follow up with your veterinarian. Your dog will look better because you’re treating the KCS, not because the KCS is cured. Stopping the medication allows the inflammation to recur, and you’ll have to start all over again. Keep repeating this cycle and those poor little tear glands may scar to the point where they can’t produce the tears needed even with treatment.
As for Chelsea, she went home with medication, and I received a call a couple of weeks later reporting that she was back to her energetic, ball-playing self. That’s news that keeps me happy!
Wellness: Health Care
An alternative to annual "jabs"
For most of us who share our lives with dogs, making sure they are vaccinated tops the list of preventive-care tasks. We mindfully take our puppies or newly adopted dogs for their recommended vaccines. We routinely return to our veterinarian or vaccine clinic when that postcard or email arrives, reminding us that our dogs are due for booster shots. We know vaccination offers critical protection from diseases such as canine parvovirus, canine distemper virus, rabies and more.
However, many of us question the concept of “routine” when it comes to vaccinations. While grateful for the protection that vaccines offer, we are increasingly aware of their possible unintended consequences. That’s where titer testing comes in.
Titer tests are among the tools that dog owners and veterinarians can use to help minimize the risks of both infectious diseases and unnecessary vaccinations. Simply put, these tests can tell you if a previous vaccine is still protecting your dog. If it’s still working, you don’t have to revaccinate.
Dr. Evelyn Sharp of My Personal Vet in Santa Cruz, Calif., has used titer tests with her own dogs since she began practicing veterinary medicine in the mid-1990s. The first dog she regularly tested was her Border Collie mix, Ace. Titers showed that the protection provided by Ace’s initial puppy series and one-year booster lasted the rest of his life. With the recent availability of in-practice titer-test kits—VacciCheck from Biogal Laboratories and TiterCHEK from Synbiotics Corporation—titer testing has become even easier to do.
Because the newer titer-test kits are affordable, accurate and can be run inhouse (rather than by a lab), Dr. Sharp now suggests titer testing as part of preventive care. With the information she gets from the titers, she can provide a customized vaccination protocol for each dog, keeping the dog well protected while minimizing the risks of over-vaccination.
The most recent American Animal Hospital Association (AAHA) Canine Vaccination Guidelines say that reported side effects from vaccines vary from injection-site reactions, lethargy, lack of appetite and fever to more serious adverse events, including allergic reactions, autoimmune problems and, rarely, sarcoma or other tumors. The decision about when to vaccinate requires a riskbenefit analysis. Most experts agree that vaccines are critical to the overall health and wellness of our dogs (and cats), but many also agree that giving a vaccine when it is not needed exposes animals to unnecessary hazards.
So what exactly is involved in titer testing? A “titer” is a method of measuring antibodies in a blood sample for specific diseases. Your vet will draw a small amount of blood and then run that blood through the test. Titers are usually expressed as a ratio; if the titer number is high, it means that your dog has enough antibodies to fight off that specific disease and is considered to have immunity from infection. For many of our dogs, that immunity is the result of a previous vaccine. However, immunity can also develop because a dog had the disease in the past. Either way, a high titer means your dog is protected.
If the test shows a low titer, your dog may not have immunity. The interesting and perhaps odd detail (odd, at least, from a layperson’s viewpoint) is that a low titer is not completely definitive. A dog may still have some protection. Still, the accepted standard with the in-house test kit is that a low titer means that you and your veterinarian should discuss revaccinating.
Just as vaccine prices vary, the price of a titer test can also vary from veterinary practice to veterinary practice. According to Dr. Sharp, the VacciCheck tests three diseases—parvovirus, distemper and adenovirus (canine hepatitis)— and generally runs between $45 and $80, which is a little more than most vaccines, but not unreasonably high.
AAHA vaccine guidelines say that titer testing is an appropriate way to check for immunity to parvovirus, distemper and adenovirus. However, it is not recommended for canine leptospirosis, bordetella or Lyme disease, because these vaccines only provide short-term protection.
Rabies vaccines do provide long-term protection, and the titer tests for rabies are also considered to be a very accurate measure of immunity. However, vaccination against rabies is mandated by law and at this time, no state in the U.S. accepts titer-test results in lieu of vaccination history. If your dog bites someone, she will still need to be quarantined, even if a titer test shows she has immunity. Specific types of rabies titer tests are used, however, when moving to rabies-free countries or regions—for example, Hawaii, Guam, Japan, New Zealand or Great Britain. In this case, the rabies titer test will help qualify a dog for a shorter quarantine.
Along with using titer tests to check for immunity to parvovirus, distemper and adenovirus in a previously vaccinated adult dog, titers are also a good option for a newly adopted dog whose vaccination or health history you may not know. In addition, a titer test may be used to make sure young puppies have responded to the initial vaccine series and are fully protected. If a pup did not respond, the vaccine may have been compromised, the mother’s immunity may still be active or the pup may be a non-responder (meaning she will not have an immune reaction to vaccines). Your veterinarian can help you decide on the best course of action if your pup does not have an acceptable titer.
Another place titer tests are gaining momentum is in the shelter environment, although with a much different goal than when used with individual dogs. There, titers are being used to help separate low-risk and high-risk dogs and cats during a disease outbreak. Shelter dogs who have a high titer to the outbreak disease—meaning they are at low risk for infection—can be separated from the higher-risk animals, and they may be considered adoptable. (You can learn more about titer testing in shelter environments by visiting maddiesfund. org and searching for “titer tests.”)
While vaccinating animals against infectious diseases is critical to protecting individual dogs and communities at large, over-vaccinating is also a real concern for those of us who share our lives with dogs. Titer tests give us another tool and can help when it comes time to discuss vaccines with our veterinarian and make the best health-care decisions for our dogs.
Wellness: Health Care
Back from the Brink
The first time I saw Mugsy, he was under anesthesia, prepped for surgery; huge patches of skin over his legs, chest and flanks were beginning to slough and surgical intervention was required. “Is that what I think it is?” I asked Dr. Khorzad, the ER attending in charge of the case.
“Yep. Necrotizing fasciitis,” she replied, avoiding the more sensational and fear-mongering synonym: “flesh-eating disease.”
Mugsy was a gregarious, four-month-old male Shar Pei who had suddenly developed a dime-sized swelling on his chest.
“I thought it was just a bug bite,” said Mugsy’s owner, Chuck. But within 24 hours, his boisterous puppy had collapsed and become septic, and he was in excruciating pain.
Though the media plays up the concept of invisible bugs munching their way through tissue, the disease typically starts out with a minor injury, or even no identifiable trauma. Bacteria inoculated under the skin produce toxins and protein-destroying enzymes capable of cleaving skin from underlying fat and fascia.
“Now he’s doing better,” said Khorzad, as one of our residents began removing dead and dying flesh. “Good job I didn’t reach the owner when I wanted to put him to sleep.”
Her comment sent me backtracking through Mugsy’s history to discover how a failure to communicate had saved the dog’s life.
Shortly after his admission, Mugsy had taken a turn for the worse; his blood pressure plummeted and his pain became intractable. Given his blood work, clinical parameters and response to therapy, Khorzad was convinced that Mugsy could not survive. Ready to recommend humane euthanasia over suffering, she called Chuck, urging him to get to the hospital as soon as possible. But Chuck didn’t pick up. Every call went to voice mail.
It turned out that Chuck was in the middle of a “Tough Mudder” event, running up and down an intense army-style obstacle course in rural New Hampshire. When he finally listened to his messages some five hours later, he jumped into his car and headed straight for the hospital, still covered in mud. Amazingly, by the time he arrived, Mugsy had done the unthinkable. His puppy was more comfortable and his fever was beginning to subside. Mugsy actually wanted to eat.
Chuck told me, “When we first came through the ER, I lay down with him and said, ‘If you’re going to fight, I’ll fight with you.’ As weak as he was, he placed his paw on my hand. I knew he didn’t want to give up. During the race, I wore an armband with his name on it. I didn’t know whether I would be strong enough to complete the course, but I reckoned that if Mugsy could fight, then so would I.”
Roughly one in four people die from necrotizing fasciitis; many are subjected to multiple surgeries, including limb amputation. Fortunately, in dogs, nearly 90 percent survive. Mugsy required only one major procedure, managed to keep all four legs and came back to make a full recovery. Today, he is a healthy one-year-old, with a few lengthy scars to show for his brush with death.
I asked Chuck and Dr. Khorzad what they learned from the five hours that made all the difference.
“I know what would have happened,” said Chuck, “but Dr. Khorzad was always totally up-front with me. A while back, I got in a car accident and damaged the tendons in my hand. Doctors said I’d never catch a baseball in a glove again. Guess what?”
Chuck didn’t dwell on the kismet of being incommunicado. It was enough to be an optimist, a fighter—and, as he said, “it’s not over ’til it’s over.”
I know how it feels to see a dog you had given up on, a lost cause, come back from the brink of death. It’s a humbling and haunting experience. Dr. Khorzad did not make a mistake. Hindsight is not a prognostic tool. She made a call in real time, and as I see it, her fallibility defined her honesty, prioritized her desire to stop suffering. She saw the lesson as a new perspective on future cases.
“As the years pass, I am more and more willing to give a chance to the cases that have a low chance of recovery.” It’s the mindset of a clinician who never ceases to be amazed by the power of canine determination. It’s the silent whisper in an ear, the invisible tap on the shoulder, the reminder that—as was the case with Mugsy—it’s not over ’til it’s over.
Wellness: Health Care
Palliative and hospice care making strides
My first contact from Stryker’s family came via email: “He was just diagnosed with anal cancer and also has a lymph node that is affected. We don’t think we want to put him through two surgeries. Would it be possible to set up a time for you to visit him?”
Stryker, an exuberant eight-year-old chocolate Labrador, met me at the door with a stuffed manatee in his mouth. Tail wagging and full of energy, he was not what one might expect to see during a hospice intake exam. As his family and I gathered on the floor, Stryker vied for my attention. His caregivers’ eyes misted up as they told me about their goals for him and their fears about his diagnosis. Meanwhile, Stryker rolled around, tongue lolling, grabbing various toys. His expression said, Why are you sad? Let’s play!
My examination of Stryker confirmed that there was indeed a large mass occupying the space where his anal sac should be, on the inside left wall of his rectum. The only thing that made the process challenging was the vigorous side-to-side movement of Stryker’s tail. His people watched me, concern and love for this dog evident in their furrowed brows. Stryker’s only concern was my finger in his rectum.
Over the course of about two hours, I heard the family’s story. When Stryker was diagnosed, aggressive surgery was recommended in the same day. His family wasn’t sure they wanted to put him through the procedure, and they needed more guidance, more time to think. When they asked about other options, they weren’t given any, other than my least-favorite phrase in the veterinary vernacular: “Well, you can always do nothing.” Could those really be the only options, aggressive surgery or nothing? It seemed implausible. And fortunately for all of us gathered on the floor that day, it was.
The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” In my work as a veterinarian exclusively dedicated to geriatrics, hospice and palliative care, I increasingly find myself mapping my own professional purpose to this definition.
Transitions between geriatric care, palliation and hospice are often blurry, to say the least. In an attempt to extract meaningful data, I maintain a spreadsheet of all the patients I have seen; in it is a column in which I try to categorize the nature of the case. I can tell you that it’s not always easy to assign a label. I can also tell you that when I started focusing exclusively on end-of-life care, I had no idea how desperately needed palliative care really was. It became very clear very quickly that people were euthanizing pets—beloved family members, according to more than 80 percent of Americans—because they felt they had no other choice.
These animals were in pain, I was told. I agreed. But when I asked what kind of pain-management strategies had been implemented, the answer was usually “none.” Attempts to alleviate pain and other physical symptoms such as diarrhea, incontinence or decreased mobility were woefully inadequate, or well-intentioned but poorly implemented, with little guidance or followup. I was meeting families who were at their breaking points, and who could blame them? No one wants to live with a vomiting, whining, confused animal who’s in pain and turns the living room into his favorite place to urinate.
But what if these symptoms could be minimized or eliminated? I am increasingly finding that people are willing and able to implement simple solutions to help their pets and preserve the bond they have with them when it is most threatened.
Examples of palliative medical interventions that can help pets with lifelimiting symptoms include:
• Antibiotics for chronic skin, dental or urinary tract infections.
• Anti-anxiety medications for psychological distress associated with limited mobility, nighttime pacing or signs of cognitive dysfunction.
• Pain medications in specific combinations for advanced multimodal pain relief.
• Skilled use of narcotic and non-narcotic medications for adequate pain relief. (This means that your care provider must have a current DEA license.)
• Physical-medical modalities such as heat, massage, physical therapy, laser and acupressure to improve mobility, comfort and muscle tone.
• Complementary therapies such as acupuncture, herbs and homeopathic remedies to address a wide variety of clinical signs. (A credentialed professional trained in these modalities should provide these services.)
• Appetite stimulants to boost caloric intake and improve overall well-being, if appetite is a primary issue and can be improved without undue negative consequences. (The pros and cons of stimulating appetite and an in-depth discussion of the goals of nutrition for each individual patient must take place. This is a tremendous source of stress for people, as well as an important philosophical conversation within hospice care.)
• Mobility aids, environmental enrichment and in-depth assessment of the home environment and other living spaces of the patient to identify areas that may have a negative impact on the animal’s quality of life, and developing strategies to improve them.
Stryker’s care plan involved all of these elements, plus counseling for his family regarding their goals, expectations and hopes for him. The psychosocial aspects of this type of care cannot be underestimated. With a comprehensive care plan, euthanasia is no longer such a low-hanging fruit.
I should say up front that I am not a fan of talking people out of euthanasia. As I make very clear when I lecture veterinary students about communication at the end of life, once people have made that decision, they have given it a tremendous amount of thought— more than they may let on during a traditional veterinary appointment. Once people have reached the place where they are willing to intentionally end the life of their companion animal, I think the best thing I can do is to support them through the process and provide bereavement support after the fact.
That said, this epidemic of euthanizing pets because of the perception that there is no other option breaks my heart a little each time I see it. Striking a balance between supporting people, not rocking the boat of a lifetime relationship with a family veterinarian and honestly responding to families when they look at me wide-eyed and ask “Is there anything else we can try?” is dicey. It’s something I’m becoming better at on the fly, as well as something that drives me with the determination of an Olympian-in-training to develop the best palliative care practice possible, and help others do the same.
As is the case with human hospice and palliative care, early provision of services is key to providing the most comprehensive care and enabling the entire family to benefit from it. People sometimes say, “Someone told me about you, but I’m not sure if my pet is ready for your services yet.” My response is, “If you are already asking the question, your pet is ready now, and likely, so are you.” We don’t have a specific timeline for pets as we do for people, largely because we don’t have a Medicare hospice benefit that will only kick in at a designated time. Far more practically speaking, the question is, what is “terminal” in a pet whose life we can legally end at any time? The definition is murky at times, and this complex ethical terrain is a source of great stress for many people. (Not to mention a fascinating and fulfilling career for me, as I help them navigate it.)
For Stryker’s family, a terminal diagnosis was the catalyst for seeking palliative care and hospice without really knowing what that would entail. Palliation became end-of-life care at some ill-defined point in our journey together. “Doing nothing” ended up being pretty involved, thank you very much. As a result, Stryker’s family reached their goal of giving him a birthday party and celebrating his life before facing his death. Stryker was also able to relax in a custom doghouse built into the deck (constructed while he was in hospice care).
During this fragile and personal time, I became part of Stryker’s family, honed my own clinical skills to provide the best care I knew how, and reaffirmed my decision to take the road less traveled in my professional life. Seven-and a half months after our initial meeting, we gathered again on the floor in the presence of a stuffed manatee, told Stryker that he was the best dog ever and said good-bye.
Spencer on the move!
Spencer is a two-year-old rescued Bulldog who had been paralyzed in his back legs since he has been a puppy. Linda Heinz found him on her back door step, but how he got there remains a mystery. She took him in and gave him a loving home. Her vet thought that Spencer’s injuries sadly pointed to abuse he had suffered as a young pup. He never had a chance to walk like other dogs. But Linda decided to take him to Tampa’s Westcoast Brace and Limb company and asked them to make a prosthetic to help Spencer to walk. Even thought they had never had a canine patient before, they were definitely up for the challenge and fashioned custom braces outfitted with green Crocks for rather adorable “feet” for him. As soon as Spencer was fitted with his new feet, off he went, running up and down the hallways at the clinic, he seemed to never get enough of this new walking sensation. See how Spencer got his “legs,” and how his pal, a blind pig named Porkchop, greeted him.
News: Guest Posts
At her intake at a shelter in April 2012, Bean was a pup with a familiar profile: a Pit Bull whose family could no longer care for her. But it wasn’t long before someone at the Humane Society of Silicon Valley in Milpitas, California did notice something unusual about her.
It was her lack of “boing,” says staff member Finnegan Dowling. “No Pit Bull puppy should be that mellow.”
Bean also had a stiff walk. When she was excited, she hopped like a bunny. They took her for x-rays, but even sedation didn’t relax her joints enough to get pictures, Dowling says, and the vet referred her to UC Davis for an MRI scan.
There, Dr. Karen Vernau, chief of the Neurology and Neurosurgery Service at the Veterinary Medical Teaching Hospital, discovered that her hip joints were improperly formed. Bean’s determined spirit wasn’t lost on Vernau, but her chances of adoption seemed slim.
The five month old pup was suffering from muscular dystrophy, a progressive and currently incurable disease that would affect many parts of her body.
According to notes in Bean’s file at the Humane Society, she was scheduled for a procedure at Davis on May 25. By the 29th, she was diagnosed with myopathy, a neurological condition. But somewhere in between those dates, Dowling says, Dr. Vernau’s relationship with her patient “went from obligation to affection.”
Vernau and her family decided to adopt Bean. As the vet told a reporter, “We didn’t intend to go down this path with her, but she just sucked us in.”
This happy ending was only the beginning of Bean’s harrowing medical story.
Gradually, things got worse. Surgery to correct her hips was followed by relief—then new problems. A massive hernia called for another surgery. Her swallowing improved, but the muscles in her esophagus were failing and there were bouts of vomiting so intense she would sometimes choke and pass out. Bean grew thinner as she struggled with aspiration (food getting into her respiratory tract when eating), which caused pneumonia.
Her vets sought help from colleagues in human medicine, a multidisciplinary approach the university encourages through its “One Health Initiative.” They included Dr. Stan Marks, a gastrointestinal specialist, and Dr. Peter Belafsky, an expert in human swallowing and airway disorders, and others.
With help from the biomedical engineering department, Bean had been fitted with a feeding tube that allowed her to eat several times per day. It worked beautifully, according to Dr. Marks.
But it didn’t stop the vomiting.
Since the vomiting put her life at risk, Belafsky concluded that they would have to stop it by removing her larynx.
Belafsky, who performed the second documented human larynx transplant, knew how profoundly such problems affect a person’s quality of life. And it was clearly true for Bean.
Her surgery, which lasted more than three hours, was the first ever canine laryngectomy. The procedure is typically used to treat human cancer. According to Belafsky, the separation of her breathing and swallowing tubes will prevent food from getting into her lungs when she eats or vomits.
The lessons learned in Bean’s treatment will impact human care, and vice versa, Belafsky said in a press conference after the surgery. Belafsky hopes she will inspire human patients who have also lost their voice and now breathe through a hole in their neck. She may just get a guest membership in the “Lost Cords Club” for people who have had a laryngectomy.
After all, Bean is only two years old, but has slept out more than 100 rounds of anesthesia and undergone eight surgeries and countless other procedures. Her “can’t do list” is long. Can’t bark, breathe or swallow normally. Forget gobbling down a treat, and she can’t swim without drowning due to the tracheostomy tube.
But the list of things she once endured, the choking and pneumonia, has been tossed.
Now when she accompanies Vernau to the hospital, she serves as ambassador and teacher, allowing students to experience canine tube feeding.
At home, Bean is learning new ways to enjoy life, which still holds plenty of the good old stuff – balls to chew, cushy beds, and a loving family that includes two other dogs.
Watch this video about Bean's surgery and recovery.
Wellness: Health Care
It’s about time.
Every so often after an exhaustive consultation, I am the lucky recipient of a peculiar compliment: “I wish you were my doctor!” When I was a young veterinarian, I was thrilled to be held in higher esteem than my colleagues in human medicine. Now, years later, I see the sleight of hand in a trick that flatters my profession at the expense of another.
It’s all about time. Time is critical to people’s sense that their dogs are receiving better quality heath care than they get, not least because much of what vets do takes longer. Veterinarians deal with “signs,” clinical findings that we touch, hear, see, smell and, if we’re unlucky, taste. MDs have the additional benefit of “symptoms,” their patients’ verbal communication of abnormal sensations or changes in bodily functions. This means that MDs can pick up on subtleties, aches and twinges, whereas dogs have to wait until a problem becomes grossly visible, palpable, malodorous, audible or debilitating to a sufficient degree that people finally realize something is not quite right.
Denied the luxury of the spoken word, veterinarians can only interpret the language of animal signs. Pediatricians, who encounter similar problems with young children, are forced to interrogate parents for answers, but similarities end when we approach a dog who does not share his owner’s regard for the man or woman in the white coat. In my world, nothing happens when I say “open wide,” hoping to inspect canine tonsils. Examinations require trust, trust takes time and, with so many new smells and sounds, the distractions are endless.
No wonder our style of medicine seems more personal. Dog owners feel less hurried because, thankfully, we don’t have a choice. I’m certain MDs are just as sympathetic, but they can save time via direct communication—and, for the most part, are less likely to be bitten.
Another major factor in veterinarians’ favor is the relatively small number of animals we serve compared to the volume of people seen by MDs. In an article in the Boston Globe, Judy Foreman (a nationally syndicated health columnist) made some interesting comparisons between two quite different Boston hospitals: Massachusetts General and my place of work, the Angell Animal Medical Center. Mass General sees 1.5 million outpatients a year, compared to about 50,000 at Angell. Patients at Mass General speak about 60 different languages, proving that the spoken word is not always that helpful (although that’s 60 better ways to communicate than I have), and its average number of inpatients at any given time is 800, compared to about 60 at Angell.
What this all means is that vets have more time for their patient and the spokesperson paying the bill. Fewer inpatients mean that blood tests, biopsy results and radiology reports are quick to turn around and their interpretation and communication to the owner is faster, all of which reinforces our superior service. We have more time to discuss the case, to leave written updates, to take pages, to return calls promptly, to go over discharge instructions in more detail. No wonder we look good. In my world, veterinarians are reimbursed for time spent with the family as well as the patient. It is an integral part of the service we offer.
Clearly, the human medical profession has taken notice of the superior patient satisfaction among their veterinary counterparts. A company called Customer Service University (CSU) has produced a 13-minute video called It’s a Dog’s World that highlights the consequences of poor healthcare service. Bob and his Golden Retriever, Max, are injured while out for a walk. As the CSU website boasts, “Bob is treated like a dog at his healthcare facility, and Max gets the royal treatment at his vet’s office.” The unfortunate logic of “being treated worse than a dog” is not lost on me, but I believe most viewers will find some unsettling truths in a tale that ends with Bob’s wife thanking an anonymous doctor for a followup call; the attentive clinician is unmasked as the vet when we hear suggestions on ways to hide medication in dog food.
These days, I have an answer ready when an owner drops the “I wish you were my doctor” compliment: I offer a smile, shake my head and say, “I’m pretty sure your dog would disagree. Ask his opinion the next time I take his temperature!”
Dog's Life: Lifestyle
Dog-related plans for 2014
Years ago, my sister’s New Year’s resolution was to give up New Year’s resolutions, and she was one of the few people who stuck to her plan. (Success rates are generally less than 10%.) Her secret was resolving to do something that she wanted to do anyway. If your resolutions for 2014 are dog-related, make success more likely by choosing to focus on one or a few things that are of real interest to you.
Simple ideas for dog-related resolutions are plentiful. Here are 10 possibilities.
1. Leave that cell phone in your pocket on walks so that you are truly present and spending time with your dog. It’s the time you spend together that builds the relationship, and this is one of the easiest ways to enjoy each other’s company.
2. Try a new activity with your dog. Classes in agility, tracking, fly ball are common in many areas. Hiking, weight pulling, dock jumping, herding, lure coursing and canine freestyle are just a few of the other possibilities.
3. Provide better nutrition for your dog. This is a big task for most of us, but even a few simple steps can make a difference. Try a higher quality dog food, add fresh vegetables to your dog’s diet or vow to measure your dog’s food for every meal so there’s no risk of overfeeding.
4. Give back to the canine community. There are so many ways to help out such as walking an elderly neighbor’s dog, volunteering at a shelter or rescue, fostering a dog, or giving money to an organization that improves the lives of animals.
5. Teach your dog something new. Practical training skills such as walking nicely on a leash, waiting at the door or a solid stay all pay big dividends. Other possibilities are to teach your dog a new game so you can play together more. Fetch, tug, find it, hide and seek, and chase games are all options, though depending on your dog, not every game may be a good fit.
6. Make plans for your dog in the event that you die first. Financial planning so you can provide for your dog when you are no longer here as well as making arrangements for someone to be the guardian for your dog are two important steps.
7. Give your dog more exercise. This can be daunting so plan to make one small improvement to start. Perhaps add 10 minutes to a weekend walk or set up a play date with a dog buddy a couple of times a month. When it comes to increasing activity, every little bit helps, so taking one step in the right direction is a wonderful goal at this, or any, time of year.
8. Take better care of your dog’s teeth. Consult with your veterinarian about a dental cleaning or about brushing at home. Dental care helps improve overall health and can make your dog’s breath more pleasant, too.
9. Make plans in case of a medical emergency. Whether it is putting aside a little in savings each month or investigating pet insurance, the peace of mind that you’ve got it covered in the event of an emergency is worth a lot.
10. Go new places with your pet. Novelty is great fun for most dogs, so try to go a few new places this year. Perhaps a new pet store or a new hiking trail will provide your dog with an experience that is really enjoyable.
Love them or hate them, New Year’s resolutions are common this time of year. Do your plans for 2014 include any dog-oriented New Year’s resolutions?
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