Even Yet More Flea Problems

These were posted as comments on a previous topic on the same day, and I thought they were worth addressing.

When I got my dog she didn't have fleas. There are no other animals in the house & I put Frontline Plus on her immediatly. This is her second month of treatment (I put the med. on two days before the month was up) and she is still COVERED! HELP!

Fleas don't suddenly appear out of nowhere. They are animals, and therefore have to come from parents. This could mean that your dog did have fleas, but just too few to notice. If that isn't the case, then your dog picked them up while outside. Stray dogs and cats, as well as wild animals such as squirrels and deer, can all harbor fleas. If one of these animals walks through your yard, flea eggs will drop off. When you let your dog outside to use the bathroom, the newly hatched fleas will jump on her and start feeding. At first it may be only a flea or two. But since a single female flea will lay dozens of eggs per day, this number can grow exponentially. A couple of fleas brought in on one day can become literally hundreds of fleas a month later! Regardless of the cause, you now have to deal with the reality. Go back to the steps I've mentioned previously: treat her every month, don't over-bathe, treat your house, and treat your yard. It may take a few months, but if you are consistent with all of this, you can get it back under control.

Next question....

My parent's dog has an autoimmune disorder from flea bathing & flea treatments. My dog (I live in another city) has fleas & I've been using Frontline Plus regularly but it isnt working. Im afriad/dont know what else to do. I know autoimmune disorders are rare, but it is a huge concern for me. What else can I do?

First, I would have to seriously question whether or not an autoimmune disorder is caused by flea control products. I have never heard of this, have never seen it reported in any of the journals, and can't imagine how this is even possible. An autoimmune problem happens when the body's immune system begins attacking the body. This can result in skin disorders, destruction of blood cells, and so on. Most of the time this happens spontaneously for unknown reasons. There is speculation that some vaccines or medications may be a cause, but there is no good proof for this claim. To create an autoimmune problem, the product would have to somehow over-stimulate or otherwise upset the body's immune system. There are NO flea control products on the market that do this! In fact, most flea control products remain on the skin and are never absorbed into the body in order to even contact parts of the immune system. If a vet has said that the flea treatments are the reason for the disorder, I would get a second opinion. It also depends on exactly what kind of autoimmune disorder, as there are several and they are all different.

There has been no documented proof that Frontline isn't effective. As I've explained before, it's not my first choice in flea control, but I don't think it's useless. You can always try a different product such as K9 Advantix or Vectra. But I would also go back to the steps I've outlined for full flea control (do a search of my blog). As I mentioned before, a study showed that supposed "failure" of the flea products was actually due to the owner not being fully compliant. The more I look into this subject, the more I'm convinced that any failures lie in inappropriate expectations or inappropriate actions on the part of the client.

Fleas are pretty pesky little critters!

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Allergy Options?

Elizabeth sends in the following situation...

I have a 2.5 y/o Siberian Husky. She does a lot of "reverse sneezing" and also hacking, coughing up phlegm and swallowing hard. We have taken her to the vet for this several times and they have done x-rays and blood tests and treatment for nasal mites, she doesn't have any abnormalities in her heart, lungs, chest, or anywhere else, she is otherwise healthy and up to date on all her shots. Her throat seems to be swollen; she can still bark, but wooing and howling seem to be more difficult. We've tried using an air filter and humidifier, but I think it may be an allergy to something in the house (mold in the walls or under the floor maybe, or possibly a sewage smell that has been prevelent since last winter) since she is ok outside and in other buildings. I keep the house super clean and wash her blankets regularly (with dye and fragrance free detergent and no softener) so I don't think it's dust. Allergy medicine helps a little with the sneezing, but not with the coughing or the phlegm. The only thing that has helped has been steroids, when she was on steroids she was fine. I know that it isn't good to keep a dog on steroids because of potential health risks, so is there anything else that would have the same anti-imflammatory effects as steroids without the harmful side effects? My vet hasn't been able to suggest anything besides different allergy medications and more tests and x-rays, but I can't afford to pay the hundreds or thousands of dollars those tests would cost.

Right off the bat this is a strange type of allergy situation. Most allergies in dogs present as skin disorders, especially irritation and itching. Allergic bronchitis is possible, but uncommon. However, based on your description I wonder if this is more of a medical "reaction" than an "allergy". Unfortunately, there isn't anything simple or easy that you can do at this point.

My first recommendation is to have allergy testing done. A general practitioner can send blood to an outside lab for analysis, and the cost is usually around $200-300. Intradermal testing can be done by a dermatology specialist, though the discussions I've had with specialist and a review of the literature leads me to believe that the two methods have very similar efficacy. Even though a skin disorder isn't the main problem, the tests will still identify a sensitivity to the tested allergens, including molds and mites. If you can discover a specific cause, you might be able to try and remove it from the environment with specialized cleaning of the ducts, mold removal, or hypoallergenic filters.

If the test doesn't give any specific answers or if you cannot eliminate something from your home, there aren't many choices. Antihistamines only work in mild allergy cases, and will likely not help your situation. Cyclosporines help if there is an allergy disorder, but aren't really anti-inflammatories. Unfortunately, the only effective reducers of inflammation are steroids. While I agree that chronic steroid use is a last resort and can cause many side-effects, I also think that they definitely have their place. If this is the only form of effective therapy, then you really don't have many alternatives.

I wouldn't ignore this situation and would really look closely into the underlying cause. There might be something harmful for the humans in the house, and your dog is particularly sensitive to it. Most people are familiar with the canaries in a coal mine analogy. For those who don't know the stories, coal miners would take canaries in cages into the mine. When the fumes became toxic, the canaries would die, warning the miners of the danger. Since a canary was smaller, it would succumb to the toxins before a human, giving the man a chance to leave before they had problems. Nowadays we call animals like this "sentinels", and look at them for a variety of situations. It's possible that your dog may be a sentinel for a mold or other problem that could affect the rest of the family. Look into this to help your dog and the people around her.

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Super-Dooper Pooper Scooper

The last few days here in the Atlanta, Georgia area have been pretty crazy. We've had unprecedented rain and flooding, worse than anyone has seen around here before. Major interstates have been closed due to the extent of the water. Incredible damage has been done, and several people have died. Yesterday was probably the worst of it, but today people have still found themselves unable to get to certain areas because neighborhoods and roads are flooded.

This affected our ability to get staff safely to work, and we were extremely short-handed today. For the first couple of hours at work it was me and two other doctors and nobody else. We finally ended up with two receptionists and one tech for most of the day, and then one of the receptionists had to leave. Most of our clients came in, so things got a bit crazy without our support staff. As the hospital manager and the most experienced person, I ended up doing jobs I normally don't do. I answered phones, checked people in and out, cleaned kennels, swept and emptied trash, and so on. It was so unusual that one of my receptionists took a picture of me with the dust mop.

While it may seem a little strange for the lead veterinarian in a hospital to do all of these jobs. However, I wasn't always a vet. When I was 14 I started working for a local vet in the kennels, cleaning, walking, and bathing. My parents called me a "super-dooper pooper scooper", and really that's what I was. I worked my way through the roles in a veterinary practice, including treatment assistant, receptionist, and really any job you can do in a private practice. So thought I haven't done these kind of jobs regularly in well over a decade, I've still done it longer than anyone working for me. It's not that hard to step back and fill those roles when needed.

Today was one of those days. I firmly believe in teamwork and supporting each other. We had more doctors than paraprofessionals, so I acted as a fill-in, covering the gap wherever needed. I think that it's important for managers to lead by example, showing those under them how they want everyone to behave and act. I also think it's unfair to ask someone to do something you aren't willing or able to do yourself. So that's why my staff may sometimes see me doing things like this.

And it all goes back to the training I received as a teenager. You never forget those early jobs.

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Psychological unhealth... in dogs

Okay, okay, I'm giving in to the masses! A New Year, a new post...

It took me years as a practicing veterinarian to begin thinking about the psychological well-being of dogs. A healthy person is one who is free of disease: both physical and mental. A human patient suffering from general anxiety disorder, schizophrenia, or even a serious phobia, without cancer or diabetes, is still a sick patient, n'est-ce pas?
Therefore a dog who is hyperactive, untrained, phobic, or suffering from aggression (for example, fear aggression), is not a healthy dog. These conditions need to be recognized (the hardest part), discussed (the second hardest part), and treatment needs to be instituted.
How many vets recognize this? This is why the consultation starts in the waiting room. Veterinarians must recognize these issues immediately. The disservice is to let such patients go without having addressed the (sometimes easily) manifestations of poor doggy mental health. "Ok, he's now vaccinated, bloodwork is normal, no parasites..." Nope, not enough.
I want my patients to trot into the consultation room, be calm (to a realistic extent), sit when they're told to sit, and who obey their owners.
The dog who wants to take my face off will be given a poor bill of health as far as I'm concerned. That said, his prognosis is far from grave.

Depending on the context, this dog may require treatment.

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Pulling Up Seedlings

Several years ago I heard a great analogy from someone in a leadership class. I've always taken it to heart, and wanted to share it here.

Tim (his real name) grew up in the southwestern US where the climate is a desert. He moved to Portland, Oregon, which is a temperate rainforest biome. He had never seen greenery like that and was fascinated by it. In a flowerbed at his home one spring he noticed some evergreen seedlings growing. Never having seen things growing like this, he saw it as something special. His wife told him that he needed to pull them up soon or it would be too late. He didn't really listen to her, and continued to watch as the seedlings sprouted and grew bigger and bigger. After several weeks of watching this, he finally realized that the seedlings had become saplings and were quickly taking over the garden. But as he worked on digging them up, he discovered that this wasn't an easy task. If he had pulled them up when they were small, it would have been quick and easy. Instead, by waiting too long and allowing them to grow, he suddenly had to deal with thick, long roots that required a lot of effort and sweat to dig out.

Problems in the workplace are like seedlings. They can seem small and innocent at first, and they don't really cause any serious issues. But if you allow them time to grow, they become big enough to take over the workplace. By the time this has happened, these problems are firmly entrenched and are difficult to remove. The key is to handle problems early and not wait until they are big. Too many managers and leaders avoid problems because they hate confrontation. Rather than solving the problem they wait until it grows big enough that they can't igore it. But by then it's too late for a simple fix.

And yes, this entry is inspired by some problems in my own work that I'm having to handle. Thankfully, I learned that lesson and am not waiting too long. Ahhh, the joys of managment.

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Flu Facts And Fiction

Flu season has started, and this brings up questions every year. Now that swine flu has become prominent in the media, this is even more of an issue, and makes people concerned about their pets and human families. So I thought that I would address some of these things with some facts and help correct some misconceptions.

* Regular influenza causes 250,000-500,000 deaths globally every year. Swine flu (H1N1) caused a little over 3,000 deaths last year. Yes, there is a growing concern, but it's not necessarily a worse disease. Seasonal flu leads to death in less than 0.1% of infections. Swine flu leads to death in 0.007-0.045% of cases. So someone please tell me why the world seems up in arms about swine flu.

* Swine flu does not infect pets, and cannot be transmitted between dogs, cats, and people. You simply don't have to worry about it. Likewise, seasonal flu cannot be transmitted to pets. With one exception....

*Ferrets are very susceptible to the human influenza virus, and anyone with these as pets need to be very careful if anyone in the family is diagnosed with flu.

* There is a canine influenza virus. It is NOT contagious to humans. We're just starting to learn about this disease as it is newly emerging, having been first identified in the pet population in 2005. Almost all dogs who are exposed become infected. Of these infections, about 80% result in clinical signs and 20% are asymptomatic carriers. Canine flu is fatal in less than 8% of cases. Unfortunately it resembles kennel cough and similar upper respiratory diseases and is difficult to specifically diagnose, so it may not be identified by a vet. There are no common antivirals for dogs, so care is usually supportive and nonspecific. A vaccine was just recently approved, but hasn't become wide-spread yet. I haven't personally diagnosed a case yet, but I'm starting to recommend testing more, and I may have overlooked it since it can seem like other diseases.

Other than the ferrets I mentioned, you don't have to worry about flu going between pets and people, so there is no need to panic. But if anyone in your family has suspicions of having the flu, see your doctor right away and make sure to practice basic hygiene.

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Twenty-First Century Medicine

Yesterday's entry has made me think more about where we have come in veterinary medicine. I have been in practice for over 12 years, but have been around the profession for about 25. I've seen a lot during that time, and can imagine what retired vets think. Technology can be great, and has helped improve the quality of medicine and treatment. Here are a few things that really hit me on this topic.

Radiology--Decades ago it was uncommon for a vet to have x-ray equipment in their practice. Then it became routine, and eventually automatic processors were created that developed films quicker and easier than hand-dipping them (anyone remember that?). Now we have digital radiography. This is common in human medicine, and is increasing in veterinary medicine. Digital "films" eliminate the need for physical films and processing fluids. You have an instant image, and can retake it quicker if it's not quite what you want. The doctor can also magnify any portion of the image and change the contrast to make it easier to see something. You get faster, better images. I expect this to be the norm in about 10-20 years.

Ultrasound--Once used only by specialists, this equipment is now priced in the range that a general practitioner can afford. There is more training needed to use it properly, as the images take a fair bit of interpretation, but there are classes on this at any major continuing education meeting. Ultrasound is much better at imaging soft tissues than x-rays, and can give you and idea of what is going on inside an organ. I forsee this being indispensable to a vet within a generation, like basic radiography is now.

Laser surgery--No longer part of science fiction, it's uncommon but not rare to have many surgeries performed using a surgical laser rather than a scalpel. There is debate as to whether or not it is that much better than standard surgical methods, but those who use it are very impressed with pain control and healing. I don't think this will ever be wide-spread, but it will continue to grow in popularity.

Vaccinations--We don't normally think of a vaccine as "technology", but there is actually a lot of high-tech science involved. Over the last several decades vaccines have changed radically, now using only parts of the bacteria or virus, including sections of DNA. Vaccines have become safer, more effective, and longer-lasting.

Computerized records--Many practices are going "paperless", keeping all medical records on their computers. This means you never have to worry about handwriting or lost files, and it makes it easier to store and search. You can also pull up a patient's history from anywhere in your practice, save digital images, and so on. Very high-tech practices have laptop-sized wi-fi pads that the vet can carry around and use to access the computer system. All of medicine is moving in this direction, and within a decade paper files will likely be the exception rather than the rule.

The Internet--I remember many years ago when the vet I worked for did cardiology consultation by attaching a phone receiver to a special box and sending ECG signals over the telephone lines. Now we can send digital images and videos of ultrasound over a high-speed internet connection to any vet or specialist in the country. We also have several veterinarian-only web sites where we can exchange information and consultations within seconds. Vets are no longer limited to discussing cases within their practice or their city. They have world-wide information and colleagues at their fingertips, allowing better exchange of information and therefore much higher levels of patient care.

Now, I want to be clear that technology is only a tool. It will never take the place of a strong education, experience, and good judgement. But these tools allow us a higher standard of care than even dreamed of a 50 years ago. I'm excited to see where the profession will be by the time I retire in another 25-30 years.

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School Interview

As a veterinarian, it's common for me to get questions from children about my job. Often this is for a school project of some sort, as is this set of questions I received today. I know that I've answered similar topics before, but there are a few different ones in Megan's list that I thought would be interesting to address.

Im doing a project for school, and I have to interview a veterinarian,

so if you dont mind, can you answer these following questions.

Describe your job?

Well, I'm a veterinarian. I examine pets, perform diagnostic tests, determine the cause of a disease or injury, recommend and perform treatment (including prescribing medications), and perform surgeries.

How does knowledge of science affect your job?
Very strongly! Medicine is completely grounded in science (or, it should be). Veterinarians have to have extensive knowledge of anatomy, physiology, immunology, microbiology, pharmacology, parasitology, and many other "ologies" related to the biological functions of numerous species. We have to understand how the medications we give affect an animal's body, including any side effects. We have to understand how certain combinations of drugs may affect a body. We also have to be able to read and understand current and changing scientific theories and data, as medicine is not a static field and is always changing.

Describe any specific regulations that has a scientific basis?
Many aspects of veterinary laws are related to the science of practice. For example, in every state I have practiced in it has been part of the law that we cannot remove a tracheal tube from an anesthetized patient until they are swallowing. This is because at a deep state of anesthesia part of the trachea could block the opening, suffocating the animal. Once they are swallowing the muscles are able to prevent this from happening. There are also laws that require us to report certain diseases to allow state and federal authorities to track various serious or rare infections.

How do you see technology affecting your job in the nexf 5-10 years?
Ultrasound is becoming much more frequent in general practice, and will continue to do so. New methods of developing vaccines will continue to evolve and expand, leading to safer vaccines of longer duration. There is also some exciting research in using stem cells to aleviate arthritis problems. In just the last 10 years I have seen many changes in using technology, such as digital x-rays, and expect that trend to continue.

What special education or training is required to perform your job?
Veterinary school is the main requirement, and is a four-year doctoral program with intense training in medicine and surgery on virtually all types of animals. Many vets then go into specialty programs to focus on one aspect of medicine, such as surgery, internal medicine, oncology, dermatology, and so on.

What kind of highschool training, post secondary or on the job training have you had or would be helpful?
Experience working for a vet prior to vet school gave me many basic skills, and is a requirement for entry into many vet schools. I started working for a vet when I was 13, and this really helped me learn the profession.

What kind of mathmatic skills are needed for your job?
I was required to take calculus, though I still couldn't tell you why or even what calculus is (despite the fact that I made an A in the course). Basic algebra is used daily, but I rarely need anything more than that.

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Yes, You Really Are Doing It Wrong

This week I was reading an interesting article in one of my journals. One of the premier flea experts, Dr. Mike Dryden (whom I've mentioned before) has been doing a study on flea control. He went to Florida, the state with the biggest flea problem in the US, and visit the homes of around 30 people who were having flea problems and said that their flea prevention products weren't working. Dr. Dryden studied the environment and what the clients were doing to control the fleas. In every single case, he found that there was a problem with client compliance. The lack of flea control was not a problem with the product itself, but with how the client was using it or how they were treating (or not treating) the environment. Remember, these were all people who thought they were doing things correctly and were convinced that the products simply didn't work.

This is yet further proof to me that these products really are very effective. Every single day we talk to clients who honestly believe that the prevention we sell them isn't working. But I can find fault with how they are using things in well over 90% of the cases. Just today we had someone call our hospital complaining about Advantix. They had put a single dose on a week ago and were still seeing fleas. This was their first time using any flea products this year. We had to have a long discussion with them about expectations and the flea life cycle. Dr. Dryden's study supports this view of clients simply not doing what they should be.

Unfortunately, it's hard to convince them of that. Flea control can be much more complicated that people realize, and waiting until you see fleas is too late. Check with your vet and find out when flea season begins in your area (or if it is year-round), and then start using a veterinary-recommended product at the beginning of the season before you see fleas. If you see fleas despite using these products, be sure to talk to a vet who truly understands all of these factors and get advice. The data continues to mount that if a product doesn't work it's not a failure of the prevention, and you really are doing something wrong.

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How Much Could You Spend?

I've often said that any pet owner needs to have at least $500 set aside for sudden animal health emergencies. When we removed the kidney from the cat last week, the owner's bill was around $1500, and they're looking at another thousand or two in chemotherapy. This morning we received a report from the local emergency clinic for a patient of ours that had never been spayed, and ended up with a serious uterine infection. Several days, numerous lab tests, emergency surgery, intense hospitalization, and $4000 later, the pet went home.

Last month I posted a poll asking how much you could spend right now if your pet had a serious illness or injury. Here are the results after 41 votes:
Less than $100--2%
$100-400--34%
$500-999--14%
Over $1000--50%

This isn't a scientific study, but the results surprised me. Sixty-four percent of the people taking the poll could spend over $500 on their pet. I wish these people were my clients!

Veterinary care isn't as expensive as human medical care, but it's not cheap if your pet becomes suddenly and seriously ill. A $4000 bill is far beyond what most people can pay, but it's still a fraction of the cost if the same thing had happened in a human.

Oh, and here's another plug for preventative care. That $4000 emergency clinic visit would have been completely and utterly avoided and the pet would never have been at this risk if they had spayed her when she was younger.

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Geeking Out

One of the favorite pursuits of geeks around the world is attending conventions. For anyone who doesn't know about this, imagine thousands of people getting together to dress in costumes or geek-related t-shirts, browse comics, fairies, or sci-fi gear, meet celebrities, and attend panels on various related topics. One of the largest of these conventions is Dragon*Con, held every Labor Day weekend in Atlanta, Georgia. An estimated 30,000-40,000 people descend on the downtown area, taking over all major hotels. This year the big draws were Leonard Nemoy and William Shatner of Star Trek fame. Besides them, there were a few dozen other celebrities of lesser or simply different fame.

And that's where my family was this weekend! Smack in the middle of all of that geeky chaos. From Friday through Monday we hung out with friends that we only see once or twice a year, took around 100 photos of the goings-on, and ogled at the great costumes. Every aspect of fandom is represented at this multi-genre con: Star Wars, Star Trek, Stargate, Lord of the Rings, comic books, anime, paranormal investigation, TV, movies, horror, novels, artists, and just about anything you can think of. It's something we look forward to every year, and have already purchased our tickets for 2010 (it's cheaper if you do it this early). Even my kids enjoy it, because they get to be in costume and have their pictures taken.

Tomorrow I have to go back to a normal life, but here's a glimpse of another side of this vet's life.

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A Bit Twisted

I think that most medical professionals have a slightly twisted sense of humor and idea of what is cool and exciting. Veterinarians are no exception.

I am currently mentoring a new graduate veterinarian, and today she had an interesting case. A five year-old cat came in with a large mass in her abdomen and was acting lethargic. After blood tests and x-rays we determined that she was overall in good condition, though thin and dehydrated, with an unknown mass involving the spleen, kidney, or something else in the belly. The owner agreed to do exploratory surgery and try to remove the mass.

We got in and quickly discovered that the very large mass was actually the right kidney. All of the other abdominal organs appeared fine and the left kidney looked good. But the right one was about 3-4 times the size it should be and was slightly irregular. Having more experience, I was the primary surgeon but she was also scrubbed in and assisting. Both of us had wide eyes and were excitedly trying to determine what it might be attached to and how we could get it out. There was definitely a sense of excitement as well as some slight anxiety. In the end everything else looked good, we were able to tie off all vessels without causing any other problems, and the affected kidney was removed.

When we closed her up and had a chance to examine the kidney better post-operatively we noted that it had a relatively normal general anatomy and structure, but was diffusely enlarged with a loss of the distinction between the different parts of the kidney tissue. For my vet readers, the renal pelvis was normal, there were no cysts or abscesses, and there was no obvious difference between the renal medulla and cortex (the rest of you get that?). The tissue was white and slightly irregular. We're pretty certain that it's cancerous and have submitted tissue samples to our diagnostic lab for analysis.

Now the twisted part of this was how excited we were. "Woah, that's a huge kidney!" "Oh, my gosh, I can't believe how big it is!" "Wow, that was a really cool surgery." "Man, I wish we could do more things like that." "I can't wait to see what the biopsy shows!" Here we were, having finished an hour-long complicated surgery, with a critical (though stable) patient who was going to have a long recovery and likely had cancer, and we were acting like kids in a candy store! I was practically giddy at the same time that I was worrying about the kitty. My entire staff was taking turns looking through the surgery window, and then while we were sectioning the kidney after surgery there were at least three cell phones being used to take pictures!

Please understand that we still have compassion and understanding, but this is a common attitude among vets and others in the medical field. We go into these professions because we have a great interest in anatomy, physiology, and disease processes. Most of what we see is pretty routine, and we could do many of these cases in our sleep. For example, I will see at least 3-5 ear infections almost every day, especially during the warm, humid months. We we see something different, it's very interesting to us. It makes us remember why we wanted to do this job in the first place. Sure, we might be a little twisted, but it's a GOOD kind of strange.

Oh, and the kitty recovered well and went home tonight for observation at home. She will come back tomorrow morning for fluids and further monitoring. Her prognosis is guarded to fair pending her biopsy results. We're hopeful, though.

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