When It Gets Personal

It's hard to be a doctor. There are a lot of decisions you have to make that affect your patient's life and well-being. Test results can sometimes be interpreted in different ways, and different combinations of results can mean different things. Not every case is clear-cut, and many are difficult to figure out. Many decisions have to be made on the path to a proper diagnosis and treatment. It's never an easy thing to do. It's even harder when its your own pet.

My oldest cat, Perceval, is 16. The summer before I started vet school I was working for a veterinarian in my home town. A litter of three kittens was dropped off for routine leukemia testing and vaccinations, and we did those services. The "owners" never came back for the kittens, and we quickly discovered that all of the information they provided was completely bogus. I ended up keeping one of those kittens, and he's been with me ever since. He has moved with me across the country several times, and has lived with me in seven homes in five states. In his 16 years he has seen us add two cats, two dogs, two kids, and a wife (not in that order!) to the family. He has taken these changes with quiet grace, and is older than any pet I have ever had.

Over the last couple of months he has started vomiting with increasing frequency, beyond what a cat normally will do. In the last several weeks we've started noticing that he has seemed very thin, quickly getting worse. He's always been a thin, lean cat, but this has been much worse. He is normally around 9 pounds, and last year was as low as just over 8. Today he weighed in at 6.6 pounds.

I took him with me to work today and ran a battery of tests. I ruled out kidney and liver failure, heartworm disease, hyperthyroidism, and several other diseases. Unfortunately, I wasn't able to make a specific diagnosis, and am still scratching my head. I have it narrowed down to two likely possibilities, and a host of lesser possibilities. One is inflammatory bowel disease (IBD), which is very treatable with steroids and diet. The other is cancer, especially intestinal lymphoma, which will require surgical biopsies for a definitive diagnosis. I'm beginning treatment for IBD and will see how he responds before taking the next step.

Situations like this are very difficult for a vet. No matter how close I am to a patient or a client, there is always a clinical objectivity that I can maintain. That's much harder when it's my own pet, especially one that has been my friend for a decade and a half. I'm faced with the prospect of possibly only having a few months with him or even less depending on what happens in the next few weeks. That's not easy, and it makes any decisions even harder. I've been faced with this on my own pets in the past, and it's never easy. At times like this, a vet is more of a client than a doctor, but has to play both roles. Vets can definitely sympathize with our clients because we are faced with the same decisions with their own pets. As I make choices about Perceval, I will have to weight the chances of successful treatment versus the cost. And yes, I do have to pay for services and medicines even if it's discounted, and I'm far from wealthy, so I do have to worry about money.

When it's personal like this, it's not easy. But I also don't want to turn over his care to anyone else, even though I completely trust my associate. I just need to go through the diagnostic process, try various treatments, and pray.

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Puppy strangles

By request, I am posting about a disease called puppy strangles, otherwise known as juvenile cellulitis. While we don't see cases of it every day, it is nonetheless not rare.
Affected puppies are usually between one and four months of age. with symptoms that are often quite shocking in appearance. They include a swollen face, ears, muzzle, and spectacularly enlarged lymph nodes. The symptoms are consistent with other diseases and must be differentiated from a severe bacterial or fungal infection and mange (Demodex or Sarcoptes mites under the skin). Puppy strangles can be quite painful, unlike the other diseases just mentioned.
While it may appear that these dogs have some sort of infection, true puppy strangles is an auto-immune disease, meaning that the puppy's own immune system has, for some reason, gone a "little haywire". Therefore, treatment involves the use of prednisone, as an immunosuppressant, for cure. Within one to two weeks of treatment, affected puppies respond very favorably. The disease is curable and does not recur.

Puppy with juvenile cellulitis, or strangles (photo from the Pet Health Library).

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"Doc, There's Something Stuck In His Throat"

The longer I practice, the more surprised I get at certain things. One of them is the number of people who think that their pet has something stuck in their throat.

The situation normally begins something like this. A client brings in their dog because he has been coughing. The pet may or may not have been chewing on a bone or a stick or paper or something like that. The cough is sporadic and not constant and has been going on for a few days. The main concern that the client has is that the dog has something stuck in its throat and that's the reason for the cough.

In order for something to cause a cough, there needs to be irritation in the trachea. Yes, things can get caught there, but it's not a simple thing. If some sort of object is stuck in the trachea it is VERY irritating. This won't cause several days of occasional coughing. This will cause pretty frequent and pretty severe coughing. It may also cause difficulties breathing depending on how big the object is. However, this situation is very rare. In 12 years of practice I have never seen a coughing pet that actually did have something stuck in the throat, yet I frequently have clients who think this has happened (including today).

Now that's not to say that it isn't possible. I've read cases of tracheal foreign bodies or obstructions, and have spoken to colleagues who had to deal with such a case. But it's definitely not a common occurrence.

So if your pet has problems with coughing, definitely take him or her to your vet. But don't automatically assume that something is stuck in the throat. Odds are that this is NOT the case and there is another cause. Listen to your vet and follow the recommended diagnostics and treatment.

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Dogs in the news

Today, The Globe and Mail reported that a 4 month-old Lhasa Apso, sealed in a bag, was found in a Toronto dumpster. Nice, eh? A maintenance worker heard the whimpering of the poor animal and discovered it in the refuse bin. The adorable little puppy is up for adoption at Toronto Animal Services.
On the opposite page in the Globe, you can read about how another two dogs, belonging to one owner, were likely deliberately poisoned in Whitby Park. This after a weekend of deliberate poisonings in nearby Port Perry. These dogs had ostensibly eaten treats laced with ethylene glycol (antifreeze). It imparts a sweet taste to anything so would be undetectable in an already-sweetened treat. It causes acute and often irreversible kidney failure. It is treatable if detected early, and fatal if left undetected. A Boston Terrier, one of the intoxicated dogs described above, has already died. I cannot imagine the devastation and utter sadness that has been wrought upon this dog's owner.

The culprit who tossed the puppy in the bin, left to suffocate, should never be permitted to own a pet, of any kind, ever again in his/her life. Period. Of course, add a massive fine or jail time... let authorities figure that one out.
Please, let authorities find the s.o.b. who has been killing our dogs and and be harpooned (literally?) with the harshest sentence possible.

Not a dog, not a cat, not a guppy, not a newt. People should be banned from owning any animal after found guilty of any act of cruelty towards animals.

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Puppy Watches TV

Tonight my wife and I were sitting on the bed, each of us on our computers, with the movie Eight Below on the TV. For those of you who haven't seen it, I highly recommend it. The story is about an Antarctic researcher and his sled dogs. He has to be flown off the base, and the dogs end up getting left behind to fend for themselves for an entire Antarctic winter. Much of the movie follows the dogs on their struggle for survival.

As is typical in our household, both dogs are up on the bed, almost crowding us out. Guinevere was very relaxed and just about asleep. Then we hear a little growl, and then see Inara's head and ears perk up. For those of you who have seen the movie, this was during the scene where the dogs are facing the leopard seal. Inara was watching it very intently, and started barking at the TV. Every time the dogs were not in a scene or it was on a commercial, she didn't seem to care. But when the dogs were prominently featured, she was watching the movie more closely than my wife and I were. It was one of those moments that comes along rarely, and we were cracking up laughing at her interest and antics.

It really is fascinating to me how different dogs can have different reactions. One of my dogs when I was growing up would sometimes do this, but I don't remember it being as consistent in one evening as with Inara. Guinevere has never done this, and really doesn't even seem to notice that the TV is even on. For whatever reason, this movie really grabbed Inara's interest, and she was responding to the dogs.

Now we're going to have to try this with Snow Dogs or 101 Dalmations!

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Pet Mythbusters, Part 2

I did an entry on misconceptions about pets several months ago (in December), and thought I would address a few more.

Cats need to drink milk.
Dairy products aren't inherently harmful, but also aren't good. A dog's or cat's digestive system changes after weaning. The structure of the lining of the intestine alters to no longer be able to absorb lactose, the main sugar in milk. So once a pet has weaned (about 5 weeks old in dogs and cats), they develop a sort of lactose intolerance like some humans have. A little cheese, milk, or ice cream isn't a big concern, but enough can cause problems. Thankfully, these aren't serious problems, and are usually limited to diarrhea or vomiting. So the old image of a cat drinking from a bowl of milk or cream isn't really proper, and is nothing that a pet owner should be doing.

Giving garlic to a dog will repel fleas.
This is a common recommendation, and you can find many internet sources and discussion groups that will talk about it. The problem is that there is no scientific basis for this. In fact, studies have checked the effectiveness of garlic as a flea prevention, and found that it does absolutely nothing. I have read more than one scientific study that confirmed that garlic supplements do nothing to keep fleas off a dog. While it won't hurt, there really is no benefit at all to it, and there are much more effective ways to prevent fleas.

Have you ever wondered if those old remedies, recommendations or stories are true? Send me your questions and I'll answer them!

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Finding A Balance

Sometimes one of the hardest things to deal with is a patient with numerous problems at the same time. Like my patient today. Actually, I was filling in at a different location than I normally work, but I had good notes from the other doctor to follow. Spice is a 12 year old poodle who has had chronic ear infections, a low-grade heart murmur, and has recently started having seizures. Oh, and recently he had some pretty dramatic increases in the liver values in his blood tests, indicating that there was something really wrong with the liver. On top of all of that, he has some pretty bad arthritis and needs to be on pain medication daily or he can't easily get around. Think this little guy has enough problems?

Let me give you a better idea of the specific problems and decisions that he and his owner face. His seizures are controlled by phenobarbital, and if he doesn't take this medicine every day, he will seizure multiple times per week. Phenobarbital can have several side-effects, and a large part of that relates to damage to the liver. When a patient is on this medication, the liver values need to be regularly tested. Most pain medications fall into a category called non-steroidal anti-inflammatory drugs (NSAIDs). In humans these are things like acetaminophen, ibuprofen, and naproxen. Pets take medications like Rimadyl, Etogesic, and Deramaxx. One of the problems with NSAIDs is that they can cause damage to the liver. When we start a patient on either of these medications, we check the liver values first to make sure there aren't any pre-existing problems.

When Spice was first evaluated for the seizures, his blood tests were normal, but they didn't stay that way. Two of the main values we look at are alkaline phosphatase (ALKP) and alanine transferase (ALT). Normal values for ALKP are about 70-212 and for ALT are 10-100 (these normal ranges can vary depending on the lab or equipment being used). When Spice's values were checked in January, they were normal. A month later, the ALKP was over 1200, and the ALT was almost 400! A really, really big jump, and a pretty scary one.

The dilemma is that he needed to be kept on phenobarbital to stop his seizures and needed Etogesic to control his severe arthritis pain. However, either of these could have been affecting his liver. Now, we didn't start the Etogesic until after the lab results were run, so that wasn't the initial cause. But the doctor at the time was hesitant (and rightly so!) to use any NSAIDs. She decreased his dosage of Etogesic, hoping to find a balance between controling his pain and not hurting his liver.

Today we rechecked his values. His ALKP was 388 and his ALT was 109. Those were considerably better than before, and were almost 1/4 of the previous values! However, they weren't normal. I talked with the owner about the options and the risks. Analgesics other than NSAIDs weren't a good option, as they could cause an increase in sedation, especially in conjunction with the phenobarbital. The Etogesic at a full dose did help with his pain, but could harm his liver. We couldn't take him off the phenobarbital or he would start seizuring again. Really, there were no easy solutions.

This is the kind of difficult decision that we sometimes face as doctors, as well as pet owners. We want our pets and patients better, but somtimes that's not easy. Do we take him off pain medication to help his liver, leaving him in unmanageable discomfort? Or do we put him on the analgesics, controlling the pain, but potentially shutting down his liver? Definitely between a rock and a hard place. And I can't say that there was a single right or wrong answer. Any choice could be a good one or could be a wrong one. And I'm not here to tell you that we made the right decision, because we really don't know yet. I wanted to bring this up as a case where there really is no easy or clear-cut choice, and we have to just do our best.

What we ended up doing was increasing the Etogesic to a dosage that will control the pain and hoping for the best. He will have his liver values checked in two weeks. If they haven't gone up considerably, we'll keep him on those medications and try to manage any side-effects. If they go up dramatically again, the owner has a hard decision as we can't keep him on pain medications.

Nobody said medicine was easy.

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A Pen From Heaven

I posted this earlier this week on my other blog, The Christian Ninjate. I don't know how many people read both, so I thought it was worth repeating here.

God works in some pretty cool ways sometimes. The Bible talks about the little ways that God talks to us, but we're always looking for the big things.

Last week I was really struggling with my life and happiness. Without going into the details right now, work and life were really getting to me. I've been trying to work through it, and do pray and seek God's guidance, but it isn't always easy. I know that He has plans for me and that He is always watching me, but it's hard to feel that sometimes. I often say that I'm not worried that God has something good in mind for me...I just wish He would let me in on the plan.

That's why I was surprised when I was finishing up with a client and happened to look down on the ground. Against the wall in the exam room was a pen. I picked it up and noticed the crosses and "Jesus fish" on it. I asked the client if it was hers, and she said no. So I ended up keeping it. I had been wanting to have a new pen that showed my Christianity, and this one was perfect.

But what was really cool was that the pen had a clear "window" in the barrel. When you click the pen, it rotates through four different scriptures. All of them are very encouraging and uplifting, and all talk about how God is always with us. It came at just the right time, and really reminded me of God's love. I have no idea where it came from, or how it ended up on the floor in my exam room. But I am 100% certain that God arranged for it to be there.

Sure, it's not your typical way for God to speak, but it is quite fitting. It's so nice to know that he really does pay attention to us!

Oh, and here are the scriptures on the pen. Remember them whenever you think that God isn't with you.

Be still, and know that I am God. (Ps 46:10)
Lo, I am with you always, even unto the end of the world. (Mt 28:20)
I can do all things through Christ who strengthens me. (Phil 4:13)
The Lord is my shepherd; I shall not want. (Ps 23:1)

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A Cut Below The Rest

If you've been following this blog for a while, you'll have seen me mention that everyone should have several hundred dollars set aside in an emergency fund for their pets. Today I saw yet another validation of this idea, as well as a validation of my policy against unnecessary euthanasia.

A client had a 3 year old female rottweiler mix that had received a nasty gash on her leg. She had already been to the local emergency clinic earlier in the day, and they had quoted her around $700 to suture it up. She came to us for a second opinion, concerned that they were a bit high on their pricing. When she first called, she seemed to downplay how bad the cut was, so we didn't know what to expect.

The dog was very calm and nice and overall looked to be in very good health. The owner didn't know what had happened, but Lady did go outside in the woods on her own, and it may have happened then. When I looked at the wound, I was surprised at how huge it was. The laceration was on the inside of the left hind leg, and was at least 8 inches long. It was straight and smooth, so something very sharp had cut her. She was a very, very lucky dog, as it was extremely deep, almost to the muscle, and the wound ran directly over where the femoral artery and vein lie. Another 1/2 inch deep and it would have had a good chance of slicing through these major vessels, resulting in pretty rapid death from extreme blood loss.

As deep and bad as it was, it was something that was completely fixable, and would heal well with stitches and antibiotics. It was a bad enough wound that a sedative and local anesthetic wouldn't be good enough. This dog needed full general anesthesia and a pretty long time to sew up. I gave the owner a quote of about $670, not far off from the emergency clinic.

This hit the owner pretty hard, as she simply didn't have the money for the procedure. We bandaged the wound to help protect against further contamination and were going to give the owner a few days to figure things out. However, she knew she wasn't going to be able to come up with even part of the money, and asked my tech about putting Lady to sleep. When I found out about that I was very startled. This was not a terminally ill pet, but one that was in great condition and with a problem that could be easily fixed. All it would take is some money.

Remember the idea of a emergency fund for your pet? This is a perfect example of when it would come in handy. But because she didn't have any money available, the owner was looking at making the hard decision of putting a young, healthy pet to sleep.

I simply couldn't bring myself to do that, and told her that we would refuse euthanasia under these circumstances. However, we also couldn't leave the wound open, as it would be very difficult to heal without stitches. We have a policy that is used rarely, but I felt applied in this situation. We offered to have her surrender the dog to us, relinquishing custody. Thankfully, she agreed.

Instead of being put to sleep, my associate will be stitching up her wound in the morning. Lady will be staying with us for at least a week as we try to find her a home, or possibly turn her over to one of the local no-kill shelters for adoption. It's not a great option, but her wound will be treated and she won't be put to sleep.

Remember, folks. Be prepared for the unexpected with your pets.

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The Heartworms Just Keep Coming

Last year I wrote an entry about heartworms not just being a problem in dogs (if you weren't here then, read it right here). I swear, I'm starting to get extremely paranoid about heartworm disease. In the past two weeks, I've had five different dogs that have tested positive. That's more than I think I've ever had in such a short period of time. Today it got worse. I had my first heartworm positive cat in 12 years of practice.

I've known that cats can contract heartworms since veterinary school, so it didn't totally surprise me. I've also tested cats over the years, and have always had negative results. But this one was most definitely postive. Want to know why he came in to see me? Sporadic vomiting for the past three weeks. And as surprising as it may seem, vomiting is one of the leading signs of heartworm disease in cats.

Here's a quick review of heartworms in cats. Felines are many times more resistant to heartworms than dogs, and so are much less likely to get it. However, when the become infected, they had fewer worms so it's harder to detect. In an average infection in a dog there may be 30-50 worms. In a cat it may be 1-3. Even if we find it, we're still a bit up the creek. There is approved treatment protocols and medications for dogs, but not for cats. So cats are less likely to contract heartworms, but if they do it's harder to find and we have no way of treating it.

The worms live much shorter lives in cats than in dogs. So the goal is usually to control any symptoms and hope that the cat outlives the worms. This isn't a very satisfying answer to be able to give a client, but I had to have just that kind of conversation today. Thankfully the cat doesn't seem to be too severely affected, so we're hopeful for a good outcome.

Remember how I've been up in arms about owners not putting their dogs on prevention? Now I get to do the same thing for cat owners. The larval heartworms are carried by mosquitoes, so even indoor cats are susceptible. Spend the money and put your cats (and dogs) on heartworm prevention! And if your cat is vomiting and your vet recommends a heartworm test, please do it!

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A Matter Of The Heart

One of my favorite memories from veterinary school involves a little puppy with a severe heart condition. The puppy had a patent ductus arteriosus (PDA), which is a very serious disorder. When the fetus is in the mother the blood bypasses the lungs since the lungs have no oxygen in them. Instead of the blood pumping into the lungs, it passes from one side of the heart to the other. When the baby is born, this ductus arteriousus is supposed to close down, allowing blood to flow completely into the lungs.

In rare cases the ductus arteriosus remains open. Some of the blood bypasses the lungs, not picking up oxygen. So the puppy's blood has less oxygen than it should, potentially starving the body and tissues. If this continues for long enough, it can be life-threatening. The only cure is surgery. The most common way is to open the chest, get to the heart, and tie off the PDA. This will allow the blood to completely flow through the lungs instead of bypassing them. In recent years there is another procedure where a mesh is passed through the vessels without open-chest surgery, closing the PDA internally.

Well, back to the story. This puppy was brought in by a man who looked like a stereotypical biker. He had a leather jacket, big bushy beard, and numerous tattoos. If you encountered this guy on a dark street, you'd be very worried. And you definitely wouldn't want to get on his bad side or get into a fight with him. In other words, a potentially intimidating person.

You certainly can't judge a book by its cover. He was an extraordinarilly nice and caring man, especially when we found out why he was there. You see, he had adopted this puppy from a shelter knowing that it had a PDA, and knowing that the surgery would be about $2000 (at that time....more expensive now). He knew that the puppy would die without surgery, and knew that most people wouldn't adopt it knowing it had such a serious condition. So he adopted the puppy because nobody would take it home and have the surgery done. He truly wanted to help this little puppy who had a bad heart. Thankfully, the biker guy had a very, very good heart.

The puppy had his surgery (one of my favorite surgical experiences, as I was allowed to ligate the PDA!), recovered perfectly, and went home with his new owner. That man taught me how someone could love a dog unconditionally, and how much generosity a person could show. I also learned that you need to talk to someone and not judge them based on appearances. I sometimes wonder what he and the puppy are doing, or even if the puppy is still alive (this was 13-14 years ago). But I have every confidence that he continued to give that little pup a great, loving life.

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Death By Chewing Gum?

This is one that many people may not know about. Last week a client called because her dog (about 16 pounds) got into her purse and ate an entire pack of chewing gum. She thought she had remembered something about it being poisonous, so she called my office. We had her check the package, and indeed it did carry the toxic ingredient. Thankfully, we were able to help her induce vomiting right away, managed to get the gum out of the stomach, and after some observation the dog was fine.

Xylitol is an artificial sweetener found in many products, but most commonly sugar-free chewing gum. In dogs it can cause a sudden drop in blood sugar, sometimes as quickly as 30 minutes, but also as long as 12 hours after ingestion. The hypoglycemia often appears as stumbling, weakness, incoordination, or other neurological signs. However, vomiting is usually the first sign of toxicity. There is also evidence that xylitol poisoning can lead to liver failure. In fact, liver disease and death are emerging as the more severe consequence. The affect on the liver can also cause severe disfunction of the blood's ability to clot properly.

Xylitol is also found as a sweetener in other products, so it's not just limited to chewing gum. The ASPCA Animal Poison Control Center has reported this poisoning after eating cookies, muffins, and cupcakes. What is interesting is that other artificial sweeteners such as saccharin, aspartame, and sucralose are generally considered safe.

This is a prime example of how animals metabolize things differently than humans. Something that is perfectly safe for people, can be potentially deadly in a pet. At first it seems like something as simple as chewing gum couldn't possibly do any harm. But this is a serious risk, and should be treated as a real danger. If you see your dog chewing gum, it could be more than just a lark. It could mean a sudden and expensive trip to the emergency room.

Here is an article on xylitol poisoning from the Animal Poison Control Center. Be warned that it's designed as continuing education for veterinarians, so a layperson may get lost in some of the language.

Xylitol Poisoning

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Horner's syndrome 2

When you type "Horner's syndrome" and "dogs" in Google's search engine, VetBlog shows up on the first page. Considering this syndrome is not uncommon, many people have posted questions on this blog in the comments section of my previous post on Horner's syndrome.
Due to its popularity, I have decided to post again on this subject.

Horner's syndrome (or Horner syndrome) is not a disease but rather a constellation of clinical signs resulting from a lesion to the sympathetic branch to the eye. The symptoms are 1) a droopy eyelid, 2) miosis (a constricted or smaller-than-normal pupil), 3) enophthalmos (a sunken eyeball) and 4) a protruding 3rd eyelid or nictitans.
The sympathetic branch (in this specific case) is a a part of the nervous system that courses down the spinal cord, does a U-turn at the upper thoracic spine, and then courses back to innervate the eye. It is responsible for doing the opposite of what we see in Horner's: bulging eyes, wide pupils, retracted 3rd eyelid, and eyelids that are kept up. You're correct if you've come to the conclusion that this occurs with either a "fight or flight" response. When an animal is frightened, its sympathetic nervous system kicks in.
Ok, enough anatomy!
Again, Horner's is not a disease but the manifestations of an underlying disease process, or its idiopathic.
Idiopathic Horner's syndrome means that no underlying disease can be found and the symptoms typically resolve in a few weeks or less.
Due to the coursing of the sympathetic branch through the middle ear, otitis media (or infection of the MIDDLE ear) often results in Horner's syndrome (and often accompanied by facial paralysis, from the 7th cranial nerve being concurrently affected). Middle ear infections often result from an outer ear infection that ruptures the eardrum, and then spreads to the middle ear. This needs to be diagnosed correctly so that proper long-term treatment can be instituted.
Horner's is rarely caused by tick-borne diseases and an underactive thyroid (hypothyroidism). Growths (especially polyps in cats) and tumors can also cause Horner's syndrome.
Protruded discs in the neck or upper thoracic spine can also cause Horner's syndrome.
A CT scan or MRI is not always necessary to make the diagnosis, but may be the most accurate. The prognosis depends on the underlying cause. It can range from excellent with middle ear infections, to grave with tumors.
Please keep posting on this subject - I hope I can continue to help you out.

If you see your pet with these symptoms, please contact your vet.
(note the droopy eyelid, the constricted pupil, the prolapsed 3rd eyelid - the sunken eyeball can't really be appreciated in this photo)

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Practice makes perfect

I don't know how to tell this story modestly, well, because it was simply impressive and exhilarating (how's that for modesty?!). I was sitting in a café this morning reading some notes on canine rehabilitation when a young woman approached me and asked me, half-jokingly, if I could help her rehabilitate her anxious and aggressive dog, Chico, a middle-aged Chihuahua. He was sitting outside on the deck barking his head off, with the owner's other more psychologically-stable dog. We shared a chuckle when I told her that I was reading about physical rehabilitation therapy and not about dog behaviour.
However, I did offer to try something, with no guarantee that it would help - something I learned from watching and reading (-sigh!) the Dog Whisperer. Cesar Millan would certainly classify this dog in the "Red Zone."
I asked the young woman to wait in the coffee shop while I met with Chico outside on the deck. I approached both dogs, very closely, said not a word, and allowed them to smell me. After a few seconds they settled down, there was no barking, no growling, just calmness. That is when I reached down and gently held Chico by his collar with one hand, while I held the leash with the other. He literally freaked out for about 30 seconds. Growling, baring all teeth, he desperately attempted to turn around to get a piece of me. When he realized that his actions were in vain, I picked him up, sat on a bench, and plopped him down on my lap in a sphinx pose. Any little growl or manifestation of aggression was quickly corrected with a gentle tug on his leash, a quick and firm touch to the back, and a silencing "shh" or "tss."
I continued this for at least 10 minutes. Only while the dog was calm, would I say his name, give him a loving scratch on the head and muzzle, and gently stroke his fur and massage his back. I immediately felt a connection to him. Was I crazy or was this little devil starting to like me?
His owner was astounded (as was I). She said that nobody had ever sat with him like we were. It seemed like we were old friends.
Now was the second important test. Would Chico bark incessantly when the owner would leave him alone on the deck, as he had always done? I put Chico down, picked him up again, at which point he again freaked out and tried to get me. I quickly repeated what I had previously done: a very gentle correction and he was back on my lap, quiet and calm. I put him back down without notice, and told the owner to follow me back into the café.
We stayed inside for at least 5 minutes, our eyes and ears never leaving the dogs. Not a peep out of Chico. That was the first time Chico was quiet while he waited outside for his owner to return. I left her with a few tips so that the dog continues to improve.
We were elated. Internally, I was glowing.

I would not have attempted this with a dog much larger than this one.

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Weedy Worries

Over the last few days we had a good, steady rain, one of the best ones in quite some time. Our area has been under a drought for well over a year, so it was nice to see. Spring is here, and I can see trees and bushes starting to bloom.

I can also see the clover and weeds springing up in my yard. This is one of the downsides to home ownership. I love the way a well-kept yard looks, but I'm not very good at doing it myself. It takes time and money, and I don't have a lot of excess of either. In the winter I could look at the relatively dead foliage and plants and not worry about it. But now that my grass is growing and the weeds are springing up in my flower beds, I can no longer pretend that my yard is doing okay.

It's so frustrating to have to deal with this. I mean, grass should just grow, right? And it should all look a uniform green. Unfortunately, it's not that easy, and over the years I've discovered that weeds are much easier to grow than grass. Every year I have to worry about it, and every year I seem to be less successful. But I just can't bring myself to give up and grow a healthy yard of crabgrass.

Within the next week or two I'm going to head down to Lowe's and spend money on weed killer, fertilizer, and grass seed. Then I'll spend a couple of days spreading these concoctions on the yard, and a few weeks of watching and waiting for them to work. If I'm very lucky, I'll see a bit of reduction in the weeds and may be able to keep things about the same. At this point, I've started to think that this is about the best I can hope for. Or maybe I'm just being too pessimistic.

One of these days, I'm just going to put in astroturf.

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Shrieking Kids

I often tell people that when someone goes into veterinary medicine because they don't like dealing with people, they are in for a very rude surprise.

Clients with young kids are a bit unpredictable. When the kids are well-behaved, I like to talk to them and interact with them. Sometimes I'll let them listen through my stethescope and participate in the exam. I give talks to schoolkids, so I don't mind answering their many questions. However, the rambunctious kids make me cringe. Sometimes there will be several in the room, pulling on the pet, opening cabinets and drawers, climbing on the exam table, and otherwise making it almost impossible to carry on a conversation with the parent.

A few days ago I was getting ready to go into a room to see a puppy for its vaccine boosters. Through the door I could hear that the mother and her son were not getting along well at that moment. Repeatedly I heard him just about scream "I don't like you!" to his mom. She would reply in an almost equally loud voice, "I don't care!" It would often go back and forth like that and we could hear it through the closed door.

Gathering up my courage I went into the room to see the little boy (probably around three years old) and his little sister (less than a year) acting fairly well behaved. As I started examining the dog and talking to the mother, he started aggravating the little girl. Mom kept telling him to stop, and he kept doing little things (some of which she ignored). The girl was crying and getting more upset, especially when he took her shoes off. At that point she screamed, reaching a frequency and octave that I swear went past human hearing and echoed through the room and my head.

I finally got done with the exam, vaccinated the dog, and left the room. After that client I came to several conclusions.

1. Some parents really need to learn good parenting techniques.
2. Despite their occasional problems, I have REALLY good kids!
3. I now understand why some animals eat their young.

Veterinary medicine is definitely not a profession for anyone who doesn't like dealing with people!

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Onions And Dogs

Last month I wrote about how onions are very toxic to cats. Here is a related question....

I know that onions are not good for dogs. But what if you use tomato sauce that was made with onions (it's a thin, consistent sauce - no onions present but was cooked with onions during preparation). Is that safe to use?

I make lots of dog treats for my dog and his buddies and just checking on whether I can use some homemade tomato sauce in a I normally bake.

One of the very interesting things about animal physiology is the differences between superficially similar animals. On the first day of vet school we had one of our most important lessons. And it was pretty simple. "Cats are not small dogs." Our class even had t-shirts printed with this saying. There are some very significant differences in the way dogs' and cats' bodies work, and you can't always assume that what is good or bad for one would be the same for the other. Medications that are perfectly fine for a dog can potentially kill a cat.

Onions are like this. No, they are not good for dogs, but they are nowhere near as toxic as they are to cats. Even onion powder can be potentially deadly to cats, and so should be avoided at all costs. However, only whole onions or whole garlic cloves are potentially dangerous to a dog. Even then it would take quite a bit.

If this was for a cat, I wouldn't take the chance even if it's just small onion particles. However, for a dog, something cooked in onions should be just fine.

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Preparing For Epilepsy

Christina sends in this question. It's a long one, and so is my answer, but this is a great topic for discussion.

My husband and I are looking to adopt our first dog soon, and one online listing in particular has caught our eye. This dog is being rehomed because he has idiopathic epilepsy, which I understand means that he has seizures without any known cause. He is currently on phenobarbitol and potassium bromide but still seizes about once a month, usually at night while sleeping. We don't object to taking in a dog with special needs, in fact we would be happy to, but we want to be absolutely certain that we can handle this particular condition before we commit. I have done a lot of research already, but as much as I want to help him I'm still not sure if this would be getting in over our heads. What advice do you have about living with and caring for an epileptic dog? Give me the lowdown dirty facts, please - I've seen a lot of "you and your dog can still live a normal life" but I know that there would be bad days as well as good, and I feel it would be unfair to the dog if we didn't know that we were prepared for both. I'd also like to know the hard facts about what seems to be called a "continuous seizure" - most sources I've found just say "if your dog has a seizure longer than 5-10 minutes or more than 3 seizures in one day, take him to an emergency vet immediately." Of course I would do that, but I'd like a little more information about how common a continuous seizure is among epileptics, and what to expect at that ER visit and after it.

Sounds like you've certainly done your homework, Christina! I wish that I could give you some easy answers, but this can be a complicated subject. First, you are right that epilepsy usually doesn't have a known cause. There are definitely some disorders that can cause neurological signs (including seizures), such as hypoglycemia, meningitis, brain tumors, certain kinds of liver disease, and so on. When we talk about idiopathic (a fancy medical term for "we really don't know what the heck is causing it") epilepsy, it's a "diagnosis by exclusion". This means that we rule out other causes with various tests, and when we come up empty we say it's this kind of epilepsy.

In simple terms, a seizure is caused by misfiring of neurons in the brain. This causes signals to be sent in unpredictable and uncontrollable ways. If the seizures only last a few minutes, they really aren't directly harmful. The concern is if they go on for a longer period of time, such as what you found. Five to ten minutes is a good rule of thumb to consider, though there isn't a hard rule about this. If the seizure starts to go on longer, we worry about possible brain damage, muscle fatigue or damage (from the contractions), arrythmias of the heart, and simply a worsening of the underlying causes. When a dog goes into a prolonged seizure (status epilepticus), or when seizures happen back-to-back with little rest inbetween, you should definitely go to the emergency clinic. There are ways to stop most seizures, but it requires IV medications, and then continual monitoring. If you end up with this, expect to leave your dog at least overnight. They will probably do IV fluids and anti-seizure medications, ECG, blood testing, and general supportive therapy. Obviously, this won't be cheap, and you should have at least $1000 in a savings account set aside in case this happens. You also won't be able to qualify for pet insurance as this is a pre-existing condition, so you'll have to do the costs on your own.

Every case of epilepsy is different. Some cases have seizures only a few times per year, and in these cases probably don't need medication (my own dad's dog has seizures like this). When seizures start happening every month or more often, I recommend medication. The main medication used is phenobarbital, and needs to be used twice daily every day to be effective. Unfortunately, this medication does have the potential to be toxic, so at a minimum you will need to have phenobarbital levels and liver values checked at least twice per year. Potassium bromide is usually used in conjunction with phenobarbital when the latter doesn't control the seizures and you have reached the maximum safe dosage. Monthly seizures when on both of these can indicate a very severe case that may end up worsening, or a case where one or both medications may need to have the dosage increased. There are a few other antiepileptic medications out there, but these two are the most commonly used.

I wish I could tell you exactly what to expect, but that's hard to do, even if you were one of my clients. These can be unpredictable, and can worsen with time. It does sound like this will be a more difficult case to manage, but as long as you are expecting that it is likely manageable. Besides considering the health situations and emergencies, you definitely need to be financially prepared for regular monitoring, medications, frequent vet visits, and emergency visits. This is definitely more than simply an emotional commitment! Also be prepared to watch your beloved pet seizure for several minutes uncontrollably, with you not being able to help. This can be heart-wrenching, even if you know it will stop and it's not harmful.

Here's my best recommendation for you. Find a vet that you really trust (if you don't have one already), and pay for an office visit to sit down and consult with him or her. With a special needs case like this, you will be working very closely with your vet and seeing him/her a lot more than with an average dog. You want your vet to know all of the details, and find out directly what his/her comfort level and expertese is with a case like this. If you decide to take this dog, try to get all medical records possible and give a copy to your vet. Then allow your vet do to a thorough workup, including complete blood chemistries and phenobarbital level. Heck, you may find that the dosages can be tweaked a bit to improve the seizure control! But your vet will be the best person to help you make the decision as to whether or not you want to take this on.

I admire you for even considering this! Good luck!

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A dog in a wheelchair

Today on 1010 AM, CFRB, John Moore was commenting on a story he heard about, in which a 3 year-old, paralyzed dog was in a wheelchair, and whose owners had to "squeeze" him several times daily in order for the dog to urinate. The host commented that he would not be willing to devote so much time and energy to a paralyzed dog and would have had him euthanized instead.
Many callers phoned in to convey sympathy and understanding for these owners' willingness to do so much for their beloved pet.
Firstly, I am not condemning this man. I believe he is neither heartless nor callous. Some people simply would not be able to do these things, whether constrained by money, time, energy, whatever. I would never judge. For something I believe as innocuous and simple as giving my cat insulin twice daily, may be just too much for some pet owners. The extent of what people are willing to do for their pets depends on many factors. What's good for one may not be good for another.
In this case, it appears the owners realized that their pet is 3 (and not 13), has a whole life ahead of him, and do not seem burdened by the care that is required to sustain their pet.
If pet owners in a similar situation, however, are negatively impacted either physically and/or mentally, their health and lives cannot be trumped by those of the pet.

How beautiful is this? I see no suffering here...

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For Pete's Sake, Put Them On Prevention!

You'll have to excuse me for a moment as I rant a bit. I almost did this yesterday, but can't hold back today, as it is really bugging me.

Today I diagnosed my fourth case of heartworm disease in a week. To put it in perspective, from May to December of last year (an 8 month period), I diagnosed 8 cases, making an average of 1 per month. Now in a week, I have a month's worth of cases. The worst part is that each and every one of these cases was 100% preventable. Four dogs were allowed by their owners to get heartworm disease. Each of those clients did know about the disease, and had chosen not to put their dogs on prevention. The owners in essence gambled with their dog's lives and lost. Rather than purchasing prevention, they decided that they would rather take the risk. Unfortunately, their dogs are the ones that really loose out.

It's not uncommon for me to hear clients talk about not getting heartworm prevention because they can't afford it. And in the current world economy, I can understand finances being tight. But I bet that those same people eat fast food at least once per month. For the cost of a single value meal and a milkshake at McDonald's, they could have bought heartworm prevention!!! Now that "savings" of not buying prevention is going to cost them either around $1000 for treatment, or cost them the lives of their dogs.

I have to admit that situations like this really frustrate me. This is all about choices and priorities. When you get a pet, you accept responsibility for that pet's health and well-being. You are the one who makes the choices, not the dog or cat. You also make the decisions as to how your money is spend. The huge majority of my clients CAN afford heartworm prevention. But some of them choose not to. They don't want to give up that trip to Burger King, or that video rental, or that Starbuck's caramel macchiato in order to prevent a fatal disease in the dog that they profess to care about. I would bet my next paycheck that I could take 99% of my clients who say they can't afford heartworm prevention and find $10 per month in their budget.

So please, please, please put your dogs on heartworm prevention. It's inexpensive and can save a life. It's your choice as to whether or not your dog gets a fatal disease.

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Eeewwww!

Last night my wife and I were sitting down playing a game and just enjoying some quality time together once the kids were asleep. To keep Inara and Guinevere quiet (as they were extremely distracting with their play), we gave them each a rawhide strip. Both dogs love these, and it was a great way to keep them occupied. Guinevere is pretty quick to go through one, but Inara really takes her time. She spent a good couple of hours chewing on hers, until it was a soft, extremely slimey consistency. Perfect for a dog, but not so much fun for a person.

It became more fun when she jumped up on the couch with the gooey rawhide in her mouth, and jumped right onto my wife. Despite being a vet's wife, she doesn't have a high tolerance for these sorts of things, and was freaking out about it almost touching her. She also was getting nauseous at the thought of the oozing, slimey surface. Inara chewed on it for a while, before she got shooed off the couch. Not too long after, she jumped back up, turned around, and lovingly faced my wife with the well-chewed rawhide dangling from her mouth. My wife used a catalog to scoop it up and throw it to the floor, follwed quickly by the puppy.

It's interesting how we have different perceptions of what is "good" than our pets do. Many dogs will eat feces, rummage through garbage, sniff each other's rears, lick their own genitals, and other things that we see and go "eewww!" While I agree that many of these things are disgusting, and we shouldn't be ashamed of our human standards, we also need to understand that to a dog these things are perfectly normal and even fun or delicious. We shouldn't get mad at them for exhibiting a natural and rewarding behavior.

However, I think my wife will think twice before letting Inara have a rawhide when we're around her. :)

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Those Wacky Clients

One of this blog's readers is also a veterinarian, and recently posted about one of her clients. Check out this very interesting story right here. I have to say that her story tops any of the ones I have. But that doesn't mean that I don't see some strange clients. Part of dealing with the public is seeing those quirky, strange, or downright insane people that make you wonder what in the world kind of medication they're on.

Once I had a client who insisted on talking about her various medical disorders, especially of the skin. I think she talked to us more about her own problems than her dog's. The worst part was that she always insisted on showing us the lesions, and asking if we thought the scabs in her hair were due to mites.

Several years ago we had a client who started nursing her daughter while in the exam room. That wasn't too bad, and breastfeeding is perfectly natural. However, her daughter looked to be about 6 or 7 years old. While I know some people believe in this, I don't know that a vet's office is really an appropriate place for this.

Last year we had a client who thought it was cute when her little dog nuzzled and licked on the skin on the underside of her breast. As is typical in these situations, she was doing it in the exam room right in front of us.

You know, I'm noticing that most of these "odd" clients confound us with their own bodily or mental habits.

People like this definitely help keep the job interesting, and are DEFINITELY not something we're taught about in vet school!

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Following Big Sis

My new puppy, Inara, is now four months old, and has fit into the family very well. We're still getting through the housebreaking, but it's getting better. Our adult dog, Guinevere, has fully accepted her, and it's great to see them playing together. In fact, we've had to move some things off shelves because they play so hard and fast we've been worried things will come tumbling down.

One of the greatest things to watch is how little Inara follows Guinevere anywhere. Wherever Gweny goes, Inara tags along. When they go outside, Inara is right behind her "big sister". In fact, it can be a bit annoying to Gweny. There she is, sniffing around, looking for the right place to pee, and as she squats the puppy sticks her little nose right in that spot. A bit disconcerting to say the least! We've actually started letting Guinevere go outside by herself just to have a little peace to potty.

Tonight this really helped us. Inara was outside with my wife and took off running around the back of the house. She lost sight of her and came inside to get my help. I took Guinevere with me, figuring that when Inara saw her she would come running for big sis. Luckily, Inara ran back around to the front porch and we quickly got her back in. But I'm sure that my plan would have worked.

It emphasizes to me how much dogs are pack animals, and how important those relationships are to them. Inara has bonded to Gweny in a great way, and really looks to her for guidance. We're hoping that some of Gweny's training passes on to her "little sister" and quickly. That's how wild canines learn...by watching their packmates. And in our case, it also shows that our little pack is coming along just fine.

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The Shark-Mouthed Dog

Many small breed dogs are prone to retaining puppy teeth. These teeth normally start falling out around four months old, and take around two months for all of them be replaced by adult teeth. Many of my clients are surprised when I tell them that their puppy's baby teeth are coming out, but I try to warn them so they don't panic when little Fluffy's incisor suddenly goes *plop* onto the floor.

As I mentioned, it's not uncommon for some of these teeth to stay in the mouth. In these cases the baby tooth stays in place and the adult tooth comes in right next to it. Sometimes this can cause the adult tooth to emerge abnormally, causing it to press into the gums of the opposite jaw, or otherwise causing a misalignment. Most of the time, though, it doesn't appear to be a major issue at first. The long-term problem is that these teeth are far too close together, and tartar tends to accumulate much faster around the retained baby teeth. We recommend removing them if we detect them being retained when the puppy is spayed or neutered, but sometimes we do the surgery before we see whether or not the teeth will fall out.

Today we had a little poodle about a year and a half old who had retained many of these teeth. Normally, only one or two fail to fall out, and usually these are the canine teeth (the long teeth in front, also called "eye teeth"), but sometimes include incisors. This little dog had retained three of the four baby canines, as well as six incisors (out of a total of 12). Looking at the front of his mouth made me think of the multiple rows of teeth you see in a shark's mouth, and so we started calling him "the shark puppy". Luckily, he was very sweet and didn't live up to the attitude behind such a name. And thankfully the owner gave us permission to pull the retained teeth, which had also accumulated an extreme amount of tartar in such a young dog.

So little Bailey left the hospital today with a normal-looking mouth, having lost nine teeth that should have fallen out about a year ago. He has a good "smile", no longer the double-rowed grin he would show us before. Though I see retained puppy teeth almost every week, this was one of the worst, and one of only a couple that had such a prominent double row. Unfortunately, I didn't have my camera at work, because this would have made a great visual to post here!

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Dog left in van

Michou, a handsome, grey, curly-haired, little poodle, spent 19 days in a van at a Vermont airport while his owner was vacationing. Pascal Bellon, the said owner from a charming little town in the Eastern Townships of Quebec, told authorities he did not know the dog was in the car.

His fine: $100. Authorities could not prove he wasn't telling the truth so he got off with a slap on the wrist.

Michou lost 50 percent of his weight over 19 days of starvation, dehydration, and freezing temperatures. There was an outpouring of both compassion for the dog and outrage with the fine against the owner.
I know humans are an imperfect species, but I wish we weren't quite so imperfect.


A sufficient fine? Where are those tough laws now (see previous post)?

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Toughest animal cruelty laws in Canada

On March 1, 2009, the government of Ontario amended animal cruelty lesgislation, last changed significantly seven years after the Titanic struck an iceberg and sank on that fateful night in 1912. Ninety years ago, these laws were avant-garde, showing a society that was ready to care for its animals as well as its hungry, sick, and homeless human citizens.
The new legislation sees increased fines and tougher sentences brought upon those who harm animals. Veterinarians are now required by law to report cases of suspected animal abuse, the government assuming all responsibility for liability.
Strangely, animals used in law enforcement will have separate (and likely increased) protection. Why not a seeing eye dog? Why not an eighty year-old whose only companion is her Golden Retriever? Why not my cats whom I care for deeply?
I am elated and proud of the changes brought on by the government of Ontario. Now why not set the bar high enough to view all animals as equal, regardless of whether or not that animal has a "job"? Punishments for cruelty or causing distress in animals should be severe in every single case, regardless of species and use of that animal in contemporary society.

From a very early edition of a publication of the Toronto Humane Society

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No, It's Not Ear Mites

Does your dog have itchy ears? Does she shake her head a lot and scratch at the ears? Does he have a bad odor and dark "goop" coming from his ears? If this is your first time having a dog with "bad" ears, there is a better than average chance that you'll think it's ear mites. And if you think that the problem is due to mites, you might go to your local pet supply store, pick up some over-the-counter ear mite medicine, and start using it. You might then be a bit surprised when the problem keeps going on, despite a few weeks of treatment.

Some of you are nodding a bit sheepishly, as you have done this very thing. And I know it happens commonly, because a couple of weeks ago one of the people in my church asked me about this, and I had two clients on Saturday that thought the same thing. Admittedly, it's probably a valid mistake, because the average pet owner is more likely to hear about ear mites than ear infections when talking to other pet owners.

Ear mites do happen, and do cause intense itchiness and debris in the ears. However, they are extremely uncommon in dogs. I have been practicing for almost 12 years, and over that time have seen somewhere between 5 and 10 dogs with ear mites. However, I see dogs with ear infections just about every day, and during the warm parts of the year I'll easily see 5-10 ear infections in one day! In cats the ratio flipped around...itchy ears in cats more commonly indicate mites than infection.

There is no quick, easy way to just look at a dog or cat and tell whether it is mites or an infection. Both problems have identical symptoms, and can have a very similar debris. The ear mites are just barely microscopic, so with good magnification from an otoscope, a vet might be able to see them in the ear canal if there are enough of them. The definitive way to diagnose the problem is to get a swab of the debris from the ears and look under the microscope. Ear mites are very easy to find, and many times you can see the juveniles, adults, and eggs. Infections are just as easy to diagnose, as the bacteria and yeast are obvious with a good stain.

So the next time your dog starts shaking his head, don't automatically assume that it's ear mites. Odds are strongly against this diagnosis, and you should take him to your vet. Once there, allow your vet do to proper diagnostics so that the problem can be quickly treated.

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The Wonder Of Fevers

My family has been fighting off illnesses this week. Our daughter was sick and had a fever in the beginning of the week. She recovered after a few days, but last night our son started a fever, getting up to 102 (F) at one point. My wife took our daughter to the doctor to rule out strep throat, and it turns out that it's just a virus and nothing to worry about. It's inconvenient (I'm staying home from church this morning to stay with our son), but not a real concern.

My son is a curious person, and this morning he asked us how we knew he had a fever. As my wife explained it to him, I started having one of my moments where I thought of things in a somewhat skewed way. I started thinking about how cool and wonderful fevers were.

Mammalian and avian bodies have an internal thermostat, and regulatory processes that try to keep the body at a set temperature. The actual value varies by species (humans about 98-99, dogs and cats 101-102), but the body shouldn't range temperatures significantly. The body changes the internal environment to keep in that range. Shivering generates muscle movement and therefore heat to try and increase the temperature if it gets low. Sweating uses the principle of evaporation to draw heat from the body if it gets too warm.

A fever is different. This response is the result of the body generating more heat internally in response to an infection. What I find interesting and cool is that this is actually a good thing! Bacteria and viruses that affect a given species (humans in my kids' cases) survive best at a normal body temperature. When the body's temperature rises past a certain level, the germs will die. Therefore a fever is a part of the body's immune response, and is specifically designed to help clear the body of microorganisms.

What I find so cool and beautiful is the simplicity of this process. We think of fevers as undesirable because they make us feel bad. However, they are actually beneficial (if they don't get too high), and a pretty neat way for the body to heal. A body's immune response can be complicated, involving various antibody responses and white blood cells. When you look at the intricacies of this process, it can be very detailed and sometimes confusing. But turning up the body's thermostat is very simple by comparison, and a great way to make the body's environment hostile for invading microorganisms. And the fact that so many species utilize this method is also amazing to me. God did a great job of designing such an elegantly simple system to fight infection.

Yes, this means that we really should let a low-grade fever run its course. By taking medications to lower our fever we might feel better but we may be slowing the healing process. I also want to make sure that everyone understands that I'm talking about low-grade fevers. High fevers can be extremely dangerous, as the body can reach a temperature where proteins start to break down, and you can end up with serious or even fatal brain damage. But a mild fever is beneficial, and we sometimes just have to suffer through the discomfort in the short term in order to get rid of the infection sooner.

So the next time you, your family member, or your pets run a slight fever, keep in mind how wonderful this is!

Yes, I think strangely sometimes. My wife would certainly agree....

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