pet connection

There are all sorts of pluses and minuses to the world of veterinary medicine when compared to human medicine, but in one arena veterinarians come up clear winners. In all but the most vanishingly rare situations, dogs don’t get heart attacks.

Dogs almost never develop the same sort of hardening of the arteries (known as atherosclerosis) that makes middle-aged men and women clutch their chests, drop the 3-wood and shuffle off this mortal coil. Human medicine has all the shiny toys, insurance money and human-life-is-so-important stuff going for it that make veterinarians green with envy, but I thank my lucky stars every day that I don’t have to deal with heart attacks. The canine equivalent, at least in my opinion, is probably a phenomenon known as ‘spontaneous hemoabdomen.’ Your average veterinary ER probably sees two or three of these types of cases a week, and as the pet population ages they are bound to become even more common.

The thing about hemoabdomens that makes them so frightening for pet owners is that they seem to come out of nowhere, and they hit like a random, unforeseen lightning strike on an otherwise sunny day. One moment their dog may be happily cavorting in the yard, and the next they’re lying on gurney in a veterinary ER fighting for their lives.

In most cases, a tumor on the spleen (which may have been growing for weeks in the abdomen without being detected) ruptures and starts to hemorrhage internally. Dogs can bleed to death within a few hours if the bleeding continues unchecked. They can be quite literally felled in their tracks.

The bleeding is internal, and there is no evidence of bleeding that can be seen externally by the pet owner.  All they know is that their dog was fine one minute, then collapsed and couldn’t get up the next. No blood in the stool, none in the urine, none anywhere; just a big pool of blood building up inside the abdominal cavity.  Blood that should be circulating and bringing oxygen to tissues is suddenly pooling in the abdomen. Shock and low blood pressure set in almost immediately.

The signs are typically a sudden onset of weakness and inability to get up. These can happen in any breed of dog, but the majority are in dogs that share a genome with German Shepherds. Golden Retrievers, sadly, probably take the #2 spot. Any dog over eight years old that’s related to a German Shepherd or Golden is potentially at risk for a a spontaneous hemoabdomen, and this disease should be considered in any dog of this type who has a sudden episode of unexplained weakness.  If you check their gums, they are often as white as a sheet.

In about three quarters of the cases, the ruptured mass on the spleen is due to an aggressive malignancy called a hemangiosarcoma, a really nasty cancer that grows out of blood-forming organs (the spleen is a tongue-shaped, flat organ that sits on the left side of the abdomen, all snuggled up to the kidneys and other giblets). Hemangiosarcomas love to grow rapidly, spread to other parts of the body and, worse, they usually eat powerful chemotherapeutic drugs for lunch. They are just a miserable type of cancer to have, and most patients with them are not around for long, even with a full-court press of medical intervention. I hate making the diagnosis of hemangiosarcoma because it usually means I have just completely ruined someone’s day and pronounced a death sentence for a patient.

For that lucky one out of four that doesn’t have a hemangiosarcoma, they likely have a benign and slow-growing tumor called a hemangioma that just decided to break open and start bleeding (we keep the names similar to confuse the tourists).  These, fortunately, can be completely cured through surgery.  You still have to deal with all that life-threatening hemorrhage and accompanying scariness, but at least you get good news when the biopsy comes back.

The survival rate for dogs with hemangiosarcoma is, on average, about 3 months (with emergency surgery to stop the bleeding). That time span can be doubled with the help of powerful chemotherapy, which is an option that all owners should be offered. We tend to not be as aggressive with chemo for our pets as they are with people, so that can mean fewer side effects. For some folks, six months of good quality life is a blessing, while for many that is nowhere near enough to justify the medical high-wire act that must happen to even hope for a little survival. The word ‘cure’ is almost never uttered in the same sentence as the word ‘hemangiosarcoma.’

To be honest, many owners decide to not pursue surgery when we make the diagnosis of hemoabdomen, and I can’t blame them.  They are usually looking at a 75% chance that their dog has a disease that will very likely kill them inside of 90 days. The alternative is a fast and painless euthanasia, or, in some special cases, a death at home.  Despite all the drama of this disease, it is usually totally painless and I will honor requests to take pets home to die if the owners are educated about what may happen. For those that elect to pursue treatment (I would say about 1/3  opt to treat), the goal is to take them to surgery as soon as they are stabilized. This means blood transfusions and other methods to try and make them the best anesthesia candidate we can.

All of this comes at owners with dizzying speed. I am often in the unenviable position of trying to get them to make a timely decision on a very expensive, delicate matter with little information and no guarantees. As I hinted at (and took some heat for) in last week’s post, lengthy Q & A sessions in the middle of this type of crisis only makes the prognosis grow more dim for the patient as their lifeblood seeps into their abdominal cavity.

However, I recognize the need for people to feel that they have made the best and most informed decision that they can in this scenario. I try to answer as many questions as time permits for the patient, and steer them to make a decision if we start covering the same ground repeatedly. I want to note one important point right here. This is an excruciatingly difficult point in the lives of pet owners, and it becomes a critical juncture for me to talk to the owners, hear their concerns, and help them make the best decision we all can, given the imperfect information we have on hand. Unfortunately, in this case the patients simply don’t have time for anything but a rapid decision.

The cost for surgery and ICU aftercare can easily run into the thousands (many will hit the $5,000 mark before discharge), and many will have post-op complications that can escalate that amount even higher.

I had one case several years back where post-op complications kept the dog in the hospital for a week, at a cost of over $10,000. The biopsy came back shortly after discharge and was what we all feared worst: hemangiosarcoma. The dog, owned by a very nice and caring MD, lived for another month before the cancer grew back and caused more bleeding. For most of us, $10,000 for another month of life would never fit the budget (or, for some people, their concept of what is right), but for this man, he assured me it was the best month he ever had with his dog. They hiked, they fished, they lounged on the couch eating Doritos and drinking Yoo-Hoo. They did everything but go 2.7 seconds on a bull named Fu Manchu. They lived like the dog was dying, and got everything out of it they could. He was happy with his initial decision and told me, as I put his dog to sleep, that he would have made it again.

For a bad outcome, that’s a pretty good way to look at it.

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A visit to the veterinary hospital can be a stressful thing, even on a good day. The patients are stressed, the owners are stressed, and even the doctor is stressed sometimes.  This stress gets distilled and compounded when that visit is unplanned and involves a trip to the emergency room.

The stress we see in our patients only contributes to the disease process. The stress response is good for you if you are being chased by a mountain lion or, perhaps, a rogue clown; your heart races to get more blood to your muscles, your airways become larger to get more oxygen into your system, your pupils dilate so you can take in more visual information.  The end result is you can run faster and see better and, with a little luck thrown in the mix, outrun the venomous and razor-sharp talons of the rogue clown and pass on your DNA to the next generation.

However, if you are sitting in cage recovering from being hit by a car, the stress response can work against you, or even kill you if the meridians all align in the wrong way. That same adrenaline that courses through your system to raise your heart rate also raises the amount of oxygen that your cells consume, leaving little left over for healing. The same cortisone that your glands produce to get you through a crisis can impair healing and cause blood clots to form in some very bad places (see last week’s post on blood clots for more information).

Stress also makes animals harder to handle and more unpredictable. I have seen many patients behave in new and interesting ways when they are ill or faced with a yahoo in white labcoat coming after them with a thermometer.  Pet owners are almost always shocked when their lovable lapdog becomes a snapping, snarling beast when illness or injury set in.

I am not talking here about situations where we are looking for general anesthesia, like surgery or a dental cleaning. I am talking about the routine handling of patients for relatively minor things. A bandage or cast change, small wounds that need care, or diagnostic procedures like x-rays or ultrasounds can be done quickly and safely with some sedation, but often end up being messy and dangerous power struggles with uncooperative patients.

I can’t blame them. Patients want to protect themselves, and are naturally (and understandably) resistant to having strangers like the aforementioned yahoo do things to them, especially when they don’t feel well.

In order to take some of the anxiety out of the equation and hopefully make things go a little smoother and safer for everyone involved, we often turn to sedatives to help calm them.  Technically, we use the term ‘chemical restraint’, and we have several choices to select from when we are looking for a little something to calm our patients.

The sedatives of today tend to be far safer than ones used in years past, but there are still risks, as there are with with any medication. Some of them can cause low blood pressure, some of them can actually increase anxiety (just like for some people a glass of red wine makes them sleepy, while for others it causes them to strip to their Hello Kitty boxers and start belting out Ethel Merman tunes) and some can have no effect. I have rarely encountered a problem with my sedated patients, however, and some of the newer sedatives are actually reversible, meaning that an antidote can be given in case of a problem or when the procedure is over. I think in the vast majority of cases I have helped make whatever it is we are trying to accomplish go easier with less stress to the patients, my staff and myself, but I do understand that some owners are nervous.

It seems like I encounter a little resistance when I suggest that we use sedation for someone’s pet. Properly managed and monitored, doing a procedure is safer with sedation than having to try and stress out a patient, or use excessive physical restraint.

What has been your experience with sedation for your pets? Do you feel it is overused? Unsafe? Or do you think it helps take the edge off of what has the potential to be an unpleasant experience?

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Ask any pet sitter if they have any stories to tell and chances are you’ll get an emphatic, “Yes!” Just about every pet sitter I’ve ever met has at least one funny, scary, or downright bizarre story to tell. I know I do!

Not long after I started my pet sitting business I signed a client who had two absolutely gorgeous, fun, black Labs named Jessie and Remmy. They were only about a year old and, like most labs, full of energy. Unlike most labs though, they had an owner who doted on them and treated them like a king & queen. He even decided to rent the house he did because it had a pool for the dogs! He enjoyed it too, but I’m sure the dogs got more use out of it.

My regular routine with Jessie and Remmy was to take them out for a few hours each day, Monday through Friday, to wear them out. But, every now and then their guy would go out of town and I’d spend the night at his place with the dogs. I was more than happy to take care of them. Not only did I get to hang out with some great dogs, but we usually spent time in the pool, too! It was definitely more of a treat than work.

Here’s where the fun begins . . .

I was asked to take care of Jessie and Remmy for about 48 hours while their guy went away for the weekend. I picked them up early in the day and took them out to a few places to wear them out. We went to the park, to my house, then back to the park again. Eventually I made my way over to my client’s house with two extremely worn out dogs. I was looking forward to spending some time relaxing in the pool, followed by a good movie snuggling on the couch with two big lap dogs.

We barely got in the house when Jessie flopped on the kitchen floor to snooze. Remmy wasn’t interested in snoozing though. He decided he wasn’t all that worn out after all, and insisted I let him play in the back yard. When I opened the sliding glass door, he ran to the pool, dove in, and snagged a floating tennis ball. Then, just as quickly, he climbed out of the pool and headed back to the house insistent on me playing with him. He was so cute that I couldn’t turn him down. As I stepped outside and closed the sliding door behind me I had a mini panic attack. I suddenly remembered that the safety bar on the door was sometimes a bit troublesome. I turned around just in time to see it falling into locked position. I reached for the door, but some strange force was holding me back and making me move in verrrrry sloooooow motion. Contrary to what Mick Jagger said, time was not on my side. The bar was faster than me. It slipped down and, SNAP! I was locked out.

I stared at the door in disbelief for a few seconds until Jessie, who was still inside, woke up and came to the door wanting out. I looked up at her, and at the same time I caught a glimpse of my keys and cell phone, both lying on the kitchen table. Not good…I muttered a few words about how careless I was and went to look for the hidden key that would open a door to the garage. From there I’d be able to get into the house and all would be well.

No such luck.

Just as I reached down to get the key, I remembered the owner telling me he wasn’t hiding a key outside anymore. I pushed that thought out of my head, hoping he changed his mind. Unfortunately, no matter how hard I looked, the key just wasn’t there.

I walked back to the door and stood there staring at the darn thing. I probably looked as pitiful as my dog Archie does when he stands at the back door waiting for it to open! No matter how hard I stared, it just didn’t open. As if having my telepathic skills fail me wasn’t bad enough, mosquitoes started biting me. Mosquitoes love me. I do not love them back. It was clear they had conspired against me. One of those nasty little buggers had spread the word that I was locked in the yard with no way out. I swatted mosquito after mosquito, leaving my legs dotted with little splats of blood. I felt a sense of power though, when I thought of a way to put an end their family picnic. I slipped into the pool, where I planned to stay until I figured out how to get out of the yard or my clients came home. Relief!

I soon got bored with the pool and realized I wasn’t interested in spending the night there. So I got out, went to the fence and started yelling. I went from one side of the yard to another, yelling for the neighbors to come out and help me. Nobody came! I went to the front where I could peek through the bushes to see the street. When somebody drove or walked by I yelled. I could barely see them, so I knew they couldn’t see me. And because of the way the house was situated, they had a hard time hearing me. From their body language I could see repeated instances of “did I hear something?” The person would stop and look around. I’d yell again, even louder, but they’d give up and keep walking.

By this time, the mosquitoes had invited their out of town relatives. I gave up and went back to the pool.

I stood in the pool, up to my neck in water, looking around the yard for something that might help me escape. Nothing. I imagined the newspaper headlines, “Woman Turns into World’s Biggest Prune” or “Woman Eaten Alive at Mosquito Family Reunion.” Neither one appealed to me, so I decided to give the yelling game one more try. I went to the fence, peered through the bushes, and as soon as I saw a woman walking by, I belted out the biggest “HELLLLLLLLLLLLP MEEEEEE!” I could muster. You may have heard me, in fact.

It worked! The woman stopped. I yelled again. She turned and walked slowly toward the yard. I kept yelling and she kept coming. I started jumping up and down almost like an eager Jack Russell! Somebody was coming to let me out. I was so excited! Finally, the woman came close enough that she could see me and I knew I wouldn’t be mosquito bait very much longer.

Getting out of the yard didn’t happen instantly but it did happen. My rescuer handed me her cell phone and I called my brother, who came over with tools in hand. After taking the fence apart, he was able to wind a twisted coat hanger through the door to lift the safety bar and slide the door wide open. Freedom never felt so good!

I did get to watch a movie later that evening and cuddle on the couch with the dogs. But, I also spent time rubbing Benadryl cream on all the itchy mosquito bites. It wasn’t the last time I spent the night with Jessie and Remmy, but it was the last time I ever walked out of a client’s house without my keys and cell phone.

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It was time. We let Bella go a few hours after we got home from visiting my sister in Santa Fe on Tuesday. I had scheduled an appointment for her with our veterinarian for the following morning, based on what the pet sitter had been reporting to me about her condition, but she was clearly unhappy, so we went ahead and took her in late that night.

She had been slowly deteriorating. I almost euthanized her last week before we left, but she rallied–again–and I couldn’t bear to do it. I am sad that I was gone those last few days, but in a way I wonder if it was necessary. Maybe my absence helped her to detach and to be ready to go. Maybe I am just trying to make myself feel better. It did help to have the neutral opinion of the pet sitter, someone who didn’t know Bella except from staying with her for a few days.

It was a gentle passing. I held her in my arms while the very nice veterinarian administered the injections. Jerry was right by my side.

Twyla seemed upset after we got home and the next morning, so I called to see if Bella’s body was still available for viewing. I’ve heard that it helps some animals to realize why the missing one is gone, so I took her and Harper in to say their farewells. As it turns out, they were completely uninterested, giving a quick sniff and then retreating under the chairs in the exam room. It was therapeutic for me, though, to get to see her one last time. They brought her in arranged as if she were in a bed and it just looked like she was asleep. And at peace. Before we left, I tucked a treat inside the blanket with her.

Good night, sweet Bella.

Photo and painting by Terry Albert.

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It seems like lately, every case has devolved into a battle over money. Understandably, people have less and less disposable income, and that’s what veterinary medicine depends upon to get animals fixed up and to keep the lights on in the clinic.

But this ever-present issue seems to have reached a boiling point of late. It is hard to actually get things done for a patient when every dollar has to be scrutinized and justified. I don’t mean to say that I blame pet owners for watching their pennies (or, as my mom always says saving your chavos, which sounds vaguely off-color to me), as everyone has felt the pinch since things went all whoopsy a few years ago, but since we depend on owners to foot the bill for tests and treatments, the path forward to the blush of full health has become strewn with thorny weeds lately.

Now, when I discuss a certain test or treatment, instead of the usual “OK, let’s go with that” I am more often not met with a wall of questions and requests for predictions.  “Will the treatment work?” “What will the tests show?” And, or course, the eternal “Why no pants?”

If every single test needs to be justified, and I have to engage in a lengthy conversation about each and every item on an estimate, it is hard to move forward and get things going. Again, I don’t blame people for making sure that I don’t run roughshod all over their budgets (I have one myself, and try very hard to stick to it), but it really slows down the process.

I thought for a while that pet insurance might be the answer to this conundrum, but I am not sure anymore. It seems to have lost momentum recently, and the number of insured pets that I see seems to have stayed steady at about 5% for the past couple of years. It could be that the discretionary income just isn’t there for the monthly premiums, or that people haven’t been happy with the product. Or maybe it’s something else. I’m not sure.

Another thing that has been noticeably different in recent months is what we call the ‘stop-treatment’ point. This is the financial limit that people apply to a course of therapy.  They may start the testing or therapy process, but call it quits far sooner than in prior years.  As an example, most owners used to be willing to give their pets three or four days, on average, in ICU to recover from a serious illness or injury, at a cost of five to six hundred a day.  Recently, it seems like we have 48 hours on average to accomplish this task, sometimes even less.

What has been your experience? Have you been less willing to give it a go, and have your pets treated? Have you been more cautious with green-lighting tests and therapy, or quicker to try treating the symptoms rather than diagnosing what’s wrong?  Have you had to stop treating, or even make the heart-rending decision to euthanize a pet because there was no end in sight to the hospital bill?

We are all in this messy financial unpleasantness together, and someday things will improve, but please share your thoughts about changes in the way you have approached the cost of veterinary care in recent months.

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