Veterinary Forum | November 2009

NEWS GET CLIENTS TO LOVE YOUR FEES • WEB COMMUNITY HELPS VETS, OWNERS AND PETS

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NOVEMBER 2009 • VOL. 26, NO. 11

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Minimally invasive, minimal drawbacks Handling Skills Can Increase Quality of Care Feline Exocrine Pancreatic Insufficiency Cow Chases in High Places Visit us at www.ForumVet.com

JOHN WAS 58 WHEN HE THOUGHT ABOUT RETIREMENT.

THEN HE THOUGHT ABOUT WHO WOULD BUY HIS PRACTICE. VCA Animal Hospitals

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For more than 20 years, VCA’s hospital purchase programs have given practice owners the freedom to live their lives with peace of mind. More than 475 hospitals in 41 states have joined the VCA family. You have worked hard to create a legacy. VCA’s goal is to continue the success you created.

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Editorial Board ANESTHESIOLOGY Donald C. Sawyer, DVM, PhD, DACVA Janyce Seahorn, DVM, MS, DACVA, DACVIM, DACVECC AVIAN Peter Sakas, DVM, MS BEHAVIOR Debra Horwitz, DVM, DACVB Wayne Hunthausen, DVM Gary Landsberg, BSc, DVM, DACVB

NEUROLOGY Ronald O. Schueler, DVM, DACVIM ONCOLOGY Louis-Philippe de Lorimier, DVM, DACVIM Joseph A. Impellizeri, DVM, DACVIM Gregory K. Ogilvie, DVM, DACVIM, DECVIM-CA OPHTHALMOLOGY Terri Gibson, DVM, MS, DACVO PARASITOLOGY Lora Ballweber, DVM, MS

CARDIOLOGY Andrew Beardow, DVM, DACVIM Robert Hamlin, DVM, PhD, DACVIM

PATHOLOGY Lawrence D. McGill, DVM, PhD, DACVP

DENTISTRY Jan Bellows, DVM, DAVDC, DABVP Edward Eisner, DVM, DAVDC Steven E. Holmstrom, DVM, DAVDC Heidi B. Lobprise, DVM, DAVDC Robert Wiggs, DVM, DAVDC

PHARMACOLOGY Lester Mandelker, DVM, DABVP PRACTICE MANAGEMENT Lowell Ackerman, DVM, DACVD, MBA, MPA Stephen Fisher, DVM Ronald E. Whitford, DVM

DERMATOLOGY Dawn Logas, DVM, DACVD Rosanna Marsella, DVM, DACVD Karen Moriello, DVM, DACVD

RADIOLOGY Victor Rendano, VMD, MS, DACVR Candi Stafford, RVT

EMERGENCY & CRITICAL CARE MEDICINE Nishi Dhupa, BVM, DACVECC ENDOCRINOLOGY Arnold Plotnick, MS, DVM, DACVIM, DABVP EPIDEMIOLOGY John Kaneene, DVM, PhD, MPH EQUINE MEDICINE Joseph J. Bertone, DVM ETHICS Bernard Rollin, PhD

REPRODUCTIVE PHYSIOLOGY Susan E. Piscopo, DVM, PhD SURGERY Sean Aiken, DVM, DACVS A. D. Elkins, DVM, MS, DACVS Joseph Harari, DVM, MS, DACVS Robert G. Roy, DVM, MS, DACVS Don R. Waldron, DVM, DACVS THERIOGENOLOGY Gary J. Nie, DVM, MS, PhD, DACT, DABVP, DACVIM

FELINE MEDICINE Gary D. Norsworthy, DVM, DABVP INTERNAL MEDICINE Anthony P. Carr, Dr. med. vet., DACVIM Richard B. Ford, DVM, MS, DACVIM, DACVPM (Hon) Michael R. Lappin, DVM, PhD, DACVIM Kevin Hahn, DVM, PhD, DACVIM

TOXICOLOGY Sharon Gwaltney-Brant, DVM, DABVT VETERINARY LAW Edward J. Guiducci, Esq. Elizabeth M. Hodgkins, DVM, JD

780 Township Line Road • Yardley, PA 19067 PRESIDENT Derrick Kraemer VETERINARY FORUM (ISSN 1047-6326) is published monthly by Veterinary Learning Systems, a division of MediMedia USA, 780 Township Line Road, Yardley, PA 19067. Single copy: $9.00. Payments by check must be in US funds drawn on a US branch of a US bank only; credit cards are also accepted. Periodicals postage paid at Morrisville, PA, and additional mailing offices. POSTMASTER: Send address changes to VLS, 780 Township Line Road, Yardley, PA 19067. All rights reserved. Reproduction in whole or in part without permission is prohibited. Copyright ©2009 Veterinary Learning Systems.

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NOVEMBER 2009

8

COVER STORY

contents

Minimally invasive, minimal drawbacks Paul Basilio

No longer confined to the specialist’s OR, laparoscopic surgery is growing in popularity.

Cover Image: ©2009 Creatista/Shutterstock.com

Issues in Practice

16

Get clients to love your fees ...............................................6 Yvonne Claire Stecher

When an owner demands to speak to you about the cost of treatment, it can be hard to keep from glowering.

Clinical Report

Handling skills can increase quality of care .....................16 Dr. Sophia Yin

If veterinary staff are able to handle a pet with ease and efficiency, the owner will be more likely to trust the diagnosis.

32

Peer Reviewed CASE REPORT

Feline Exocrine Pancreatic Insufficiency............................20 Dr. Marguerite M. Hoey

A cat presented with weight loss over a period of 9 weeks, despite having a good appetite.

FORUM News

Web community aimed at helping vets, owners and pets.................................................................28 Paul Basilio

To control misinformation about pet care, websites now offer expert opinion and evidence-based answers to client questions.

also in this issue Editorial Board ......................1 Web Contents........................4 Advertisers Index.................29 Market Showcase ................30 Classified Advertising..........31

Veterinary Views

The cat in the cat................................................................29 Drs. Louis-Philippe de Lorimier and Guy Beauregard

During a CT scan of a cat with an injection-site sarcoma, a surprise popped up on the screen.

Most Unusual Case

Cow chases in high places...................................................32 Dr. Celeste Matthews

A rampaging cow chases this frantic veterinarian up a ladder.

To receive breaking news in your inbox, visit ForumVet.com.

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on FORUM CHAT | E-NEWSLETTERS | NEWS | VIDEOS | FREE CE | WEB FEATURES | ARCHIVES | ONLINE STORE

WEB-EXCLUSIVE FEATURES ■ Marines enlist help of ASPCA animal behavior

experts ■ Drug can eliminate parasite that causes babesiosis in horses ■ China drafts its first animal protection law ■ ISPAH sponsors milk producers in Malawi ■ LSU alumni travel to Liberia for the Veterinarians without Borders program ■ Petco launches pet nutrition education program ■ IFAW helps Taiwanese animals after Typhoon Morakot WEB ARCHIVES Conduct a search in our archives for more web-exclusive features, client handouts, articles, forms and videos.

CONTACT US Email your questions, suggestions, breaking news, corrections, or letters to the editor to: editor@ForumVet.com.

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E-NEWSLETTERS RS Veterinary Forum Online, a monthly e-newsletter, provides webexclusive articles and news as well is as a preview of this month’s journal. Sign up at ForumVet.com. com.

NEWS Online tool allows vets to help feral cats ■ Melted plastic found in Nutro pet food ■ Halloween Client Handout ■ Senators introduce veterinary legislation ■

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IN PRACTICE

Get clients to love your fees

By Yvonne Claire Stecher

ces

You are on your way to your next patient and, while tak- Communication is key ing a shortcut through reception, you see Mrs. Smith Whenever clients make appointments, Grosdidier standing next to the desk. She’s holding Mulligan, yester- recommends sending them a letter or an email that outday’s tough surgical case, in her arms. Your top technician lines what you expect to cover during their visit. “Now is all smiles as she discusses the discharge instructions with you’ve set it up in their mind, and they are no longer Mrs. Smith. The technician is smiling because not many thinking that they will be seen for a ‘just a vaccination’ people thought that this case would have a happy ending. visit.” Advise the client to write down, ahead of time, However, thanks to your surgical skill and the incredi- any questions he or she may have about the pet’s health ble efforts of your staff, Mulligan is on his way home. or veterinary care, and tell the client that you want to He’s been given a second chance at life. You smile to make sure he or she gets the most out of the visit to yourself as you walk down the hall, proud to see that cute your practice. little dog going home with his owner.

You can also add more value to your message and inA few seconds later, you hear Mrs. Smith gasp. “Why did crease the personal connection between the practice and it cost $1,500?” she asks. “All he did was eat a little super- the client by including information about a pet’s previous visit. For example, you could say, “The last time we glue.” The warm glow you were feeling starts to fade. saw Buster, he was dealing with When an owner questions the [a, b and c], and now I’d like to cost of treatment, it can be hard “I work with a surgical practice to keep that glow from turning recommend [x, y and z].” This that has an average transaction into a glower. shows the client that you have of $1,400. They get very few been thinking about his or her complaints. The team can focus pet, rather than thinking of the Why don’t they get it? on practicing good medicine When you work hard to pracpet and client as a number in and treating the pets, and they tice great medicine, your staff your database. do not have to defend their fees pulls out all the stops, working “You also want to make clients to every client.” together like a well-oiled mafeel like you’re expecting them,” —Sheila Grosdidier, BS, RVT chine, and your hospital does its Grosdidier said. “Have the dog’s best to offer every reasonable picture appear on the computer service, comfort and advantage to your patients; why screen. Have everything ready when the client walks in. does it seem that some clients still try and nickel and Don’t read through the file as you walk into the examidime you? The answer, according to practice consultant nation room. These steps can help make each client feel Sheila Grosdidier, BS, RVT, may be that they don’t un- unique and special, and it helps to set the tone. You want derstand everything that you do for their pets. to make clients feel like they are a part of a community “We think our clients know what’s going on behind in your practice and that you’re not just moving people the closed doors, but they don’t,” said Grosdidier, a in and out as fast as possible.” speaker and consultant with Veterinary Management Consultants in Colorado. “If you want to cut down on the Use cool tools number of complaints about your fees, you have to invest When it’s time to pay the bill, many clients ask thema little time and energy in explaining exactly what it is selves, “What did I get for my money?” It’s your job to you do, what it is you plan to do and what you have make sure that they know. First, you need to ensure that done,” she says. To justify the costs of quality veterinary your clients know about the wide range of veterinary sercare, you need to make each visit to your practice a mem- vices available to help their pets. Second, before you adorable experience for the client and always reinforce the mit a pet, ask clients if they would like you to go through value of what you are doing. the pet’s treatment plan with you. Then, when the pet is

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High Tech or Low Tech

Right Place, Right Time

While some ideas lend themselves extremely well to “cool” technologies, there are plenty of low-tech ideas that can help make your clients feel special and invested in your practice, according to Sheila Grosdidier, BS, RVT. “I have one clinic that hates technology,” she said. For that practice, she set up a simple program. All it requires is that a staff member takes a picture of the patient each time it comes to the clinic. The practice then has a high school student come in some afternoons to format and send simple communication tools to clients. For new patients, the practice sends a thank-you card with a picture of the patient on it. After a hospital stay, a card with the patient’s picture on it is sent to the client. It reads, “Hope Buster’s feeling better!”

After the puppy/kitten visits are over, clients are sent a “baby album” of photos from each visit. “People go crazy over this kind of thing,” Grosdidier said, adding that it helps to show that your practice is special and cares about its patients and clients.

“Some clients are not looking for high-tech features and services. It’s the up-close and personal services that make an impact,” she said.

Another way to help clients love your fees is to fine tune your follow-up. Many practices make a follow-up call about a patient after surgery, but Sheila Grosdidier, BS, RVT, would like more veterinary teams to ask themselves, “Are we really doing it when it counts?”

“A lot of practices will make that call 2 or 3 days after the pet goes home. A better time to call might be the night the discharged patient is sent home, maybe after dinner, when the pain medication is starting to wear off and the pet is getting cranky.” That’s when a client might be the most appreciative of a call. “Get the timing right,” she said.

discharged, sit with the client and discuss everything that was done for the pet while it was in your care.

Grosdidier has a list of techniques she recommends

practices use to help clients understand the value of proper veterinary care: Use visual tools — Seeing is believing for many clients.

If you can, give your clients a tour of your hospital. Show them your imaging capabilities, the surgical suite and the monitoring equipment. Walk them through your recovery area, and show them how their pet will be cared for by your staff. If you can’t give a tour, take some photographs of these sections of your practice and create a slide show that can run on your examination room computer.

If a client has to admit a pet for surgery, walk the client through the whole process, from the time the pet is (continues on page 26)

Minimally invasive, minimal drawbacks

By Paul Basilio ● Associate Editor

Photo courtesy of Dr. Mayhew

No longer confined to the specialist’s operating room, laparoscopic surgery is growing in popularity among general practitioners because of its versatility, safety and ability to reduce recovery time in postoperative patients.

With more clients choosing laparoscopic surgery for their own medical procedures, it is only natural that they are drawn to minimally invasive surgery for their pets. Compared with traditional surgeries, which require large incisions and can cause collateral tissue damage, minimally invasive surgery offers smaller incisions, which can greatly reduce the surgical insult to patients.

“The great thing about minimally invasive surgery is that there are many simple surgical applications as well as some advanced applications,” says Philipp D. Mayhew, BVM&S, MRCVS, DACVS, a surgeon at Columbia River Veterinary Specialists in Vancouver, Wash. “I have helped teach a few laboratories at some of the larger

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veterinary conferences, and the rooms are full of general practitioners, not specialists.”

Although the number of small animal practices that have purchased laparoscopic surgical equipment and offer minimally invasive surgical options is still relatively small, the field, and interest in it, is growing as laparoscopy becomes more popular in human medicine.

“One of my colleagues in Ohio exclusively performs laparoscopic spays,” Mayhew says. “He says that his clients opt for it, even though it is slightly more expensive. He gets a lot of word-of-mouth business from clients because of his laparoscopic spays.”

Mayhew points out that the number of simple soft

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tissue surgeries that general practitioners can perform laparoscopically is growing, which helps expand the field of minimally invasive surgery beyond the realm of the specialist and into smaller general practices.

Learning curve While it can be intimidating to replace a tried-andtrue surgical technique with a new, unfamiliar one, Mayhew says that the learning curve for minimally invasive surgery is not very steep. “I don’t think performing minimally invasive soft tissue procedures is as complex as performing arthroscopies. Arthroscopy is quite challenging to learn, and it takes a while to get good at it, which is why few general practitioners do it,” he explains. “When I was at the University of Pennsylvania [Penn], I taught residents how to perform laparoscopy. They would do two or three laparoscopic ovariectomies, and they would be off and running, performing them on their own.”

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Port Choices The number of ports used in a laparoscopic procedure is based on surgeon preference and available equipment. The single-port technique requires a specialized type of scope called an operating laparoscope, which has a telescope that transmits the image back to the camera and a port through which you can pass instruments and grasp tissue. Not many people have these, so it is a less common technique.

The two-port technique is usually performed with one camera port and one instrument port. During a spay procedure, the ovary is usually held against the body wall with a transfixation suture while the cauterization device is passed through the instrument port to cauterize and ligate the ovarian pedicles.

The three-port technique consists of one camera port and two instrument ports. It is a little easier technically, but it involves an extra incision. My preference is for the two- or three-port techniques.

—Dr. Philipp D. Mayhew

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November 2009 | Veterinary Forum

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The hardest part, Mayhew says, is getting the equipment to function properly the first time and then remembering how it works during the second procedure. “The physical execution of the surgery is not that difficult if you have the right equipment,” he adds.

When he started performing minimally invasive surgeries at Penn, Mayhew says he had to make do with hand-medowns from human medicine. “We would struggle to do simple things with the equipment,” he says, “but as soon as the school made an investment in modern minimally invasive equipment, it wasn’t difficult to operate at all.”

“The physical execution of the surgery is not that difficult if you have the right equipment.”

—Dr. Philipp D. Mayhew

Converting to closed A few veterinary companies make laparoscopic surgical equipment. The initial purchase can be expensive, but the equipment can be used in a general practice in a variety of ways.

“It’s common for a practice to purchase endoscopy equipment in which the central components — the monitor, camera and light source — are common not just to laparoscopy or thoracoscopy, but can also be used for GI endoscopy and colonoscopy,” explains Mayhew. “All of the ‘-oscopies’ run off of the same technology.”

Thus, when practices are faced with a hefty price tag for laparoscopic equipment, the cost/benefit calculation can be based not only on how many laparoscopic spays must be performed to pay off the equipment but also on the many other areas in which the equipment can be beneficial. For example, some minimally invasive equipment can also be used for the ears and GI tract.

Mayhew acknowledges that the cost and specialized training required to perform procedures may make some practices hesitant to test the new technology.

“We also tell the owners about the possible need for conversion to an open procedure if things go wrong,” he says. “If things go wrong Some specialty hospitals are wary of performing laparoscopic and you don’t have your hands in your patient, spays because they don’t want to step on the toes of referring it tends to be more difficult to fix a problem. veterinarians. For example, in my practice, we don’t advertise However, it is rare to have to convert something laparoscopic spays, even though I have all of the equipment sitlike a spay into an open procedure. I have done ting there. I could do hundreds of minimally invasive spays each more than 100 laparoscopic spays, and I can’t month, but we don’t advertise that because we don’t want to ofremember the last time I had to convert one.” fend the local veterinarian by taking away his or her business.

Minimally Invasive Toe Stepping

—Dr. Philipp D. Mayhew

Pros and cons The time in surgery tends to be longer for laparoscopic procedures than for traditional procedures. “For an average general practitioner who has performed more than 10,000 spays, it is probably going to take some time to get used to laparoscopy,” Mayhew says. “As the learning curve gets better and the general practitioner performs more laparoscopic spays, the magnitude of time difference will decrease.”

Mayhew has met practitioners who believe minimally invasive surgery is a great leap forward in veterinary medicine as well as those who are not yet convinced. Practitioners who favor the surgical technique tend to have had a positive experience with human laparoscopic procedures.

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Videos of minimally invasive surgeries may make the procedure appear as if it is being performed through a narrow keyhole, but the technology does offer several advantages, Mayhew says. “The magnification and the quality of the image are incredible,” he explains. “The cameras now are of such high quality that you can get a crystal-clear image and get a magnified view of the tissue you are working with.”

Minimally Invasive Pearls

Photo courtesy of Dr. Mayhew

There are many tricks you learn after you begin to perform the procedures on your own, just as you did when you first learned open surgery.

The biggest hurdles in learning minimally invasive techniques involve getting over the inherent problems of not being able to get your hands in there. You have to learn to use gravity in your favor to allow organs to move in certain directions to allow access to the structures you are interested in.

You also have to be meticulous about hemostasis, as small amounts of bleeding can impair visualization and cannot be easily wiped away.

Development of good hand-eye coordination and depth perception is important as well. The only way to get better is to practice, practice, practice.

—Dr. Philipp D. Mayhew

November 2009 | Veterinary Forum

13

Measuring pain “Traditionally, we have had very inaccurate, largely subjective indices of pain and stress surrounding surgery in animals,” Mayhew says.

To help convince practitioners that minimally invasive surgeries carry a proven benefit, Mayhew conducted studies at Penn that quantified the postoperative activity of animals that had undergone traditional surgery and compared it with the activity of animals that had undergone a minimally invasive procedure.

In one study published in Veterinary Surgery, Mayhew and his colleagues compared laparoscopic and open ovariectomy. Dogs were randomized into two surgical groups, and their levels of preoperative and postoperative activity were measured by placing an accelerometer on each dog’s collar.

“We found significant differences between postoperative activity in the minimally invasive group compared with the open group,” Mayhew says. “The minimally invasive group showed activity levels that were close to preoperative levels almost immediately after the surgery. The dogs that had the open procedure tended not to return to their normal activity level for about 4 or 5 days.”

Mayhew acknowledges that the results should be interpreted with caution because the measured activity level does not necessarily transfer perfectly to a measurement of pain.

“There are still some people who will say that they want their patients to experience some pain to keep them from running around and damaging the incision, but that is an old way of thinking, and I think most people have moved away from that attitude.”

Mayhew is convinced that a difference in pain levels exists between traditional open procedures and minimally invasive procedures. “I think the area where it makes an even bigger difference is in the chest,” he explains. “If you can avoid a thoracotomy incision, then I think the magnitude of the benefit is much larger. At the end of the day, animals recover well from open spays, but they may not recover as well from major chest surgery. For soft tissue minimally invasive procedures, I think that’s an area where there can be a vF huge benefit.”

For more information: Culp WT, Mayhew PD, Brown DC. The effect of laparoscopic versus open ovariectomy on postsurgical activity in small dogs. Vet Surg 2009;38(7):811-817.

Runge JJ, Mayhew PD, Rawlings CA. Laparoscopic-assisted and laparoscopic prophylactic gastropexy: indications and techniques.

Compend Cont Pract Vet 2009;31(2):58-65.

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Most veterinarians avoid suturing in laparoscopic techniques as it is technically more demanding and time-consuming.

Instead, we use clips that are applied through a port, or we use a vessel-sealing device to cut tissue. These devices crush tissues together, and then we apply a bipolar electrical current that seals vessels and allows the sectioning of tissues without the need for sutures or clips.

Intracorporeal suturing, or suturing inside a body cavity, can be done, but it can be challenging. It’s a new skill set for most surgeons to learn — it’s similar to suturing under a microscope. Few people do this in veterinary medicine, although it is considered an important skill for human laparoscopic surgeons.

—Dr. Philipp D. Mayhew

W W W. A L L E Y C AT. O R G

Education

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Veterinary Forum | November 2009

Photo courtesy of Dr. Mayhew

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clinical REPORT

By Sophia Yin, DVM, MS (Animal Science) Column Editor Special to VETERINARY FORUM

Handling skills can increase quality of care

Photos courtesy of Dr. Sophia Yin

It can be frustrating when an uncooperative or difficultto-handle pet affects our ability to practice quality medicine. Many veterinarians may not know, however, that our credibility can rely greatly on our pet-handling skills.

For example, one of my clients tells a story about how her dog, Viking, was thought to be dog-aggressive as a puppy. It turned out that Viking was fine around other dogs, but the “aggressive” label remained in his file. The next time the client brought Viking in for an appointment, the veterinarian avoided the dog until a technician slapped a muzzle on Viking, without giving my client time to acclimate her dog to the muzzle.

“I was afraid Viking was going to have a bad experience and be fearful as a result,” my client says. “That was the last time I went to that veterinarian. She clearly didn’t know much about dogs.” The same client had a very different experience with another veterinarian. She was impressed by the way the new veterinarian handled Viking.

“She used the least amount of movement necessary to do things like close his mouth, see how far he could turn his head in each direction, and examine his abdomen,” my client said. “She didn’t even need a technician to help — she was able to control him herself. As a result, when Viking was diagnosed with an immune-mediated disorder, I had no question about her abilities, and we readily followed her treatment plan.”

The moral of this client’s story is that if veterinary staff

Figure 1. This cat appears to be comfortable during the examination. She does not need to be scruffed.

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Figure 2. Avoid flipping dogs and cats into position with quick and sudden movements. This will scare many animals.

Veterinary Forum | November 2009

are able to handle a pet with ease and efficiency, the owner will be more likely to trust the diagnosis. In fact, I have received numerous requests from pet owners wondering how to find a veterinarian who can handle their fearful pet in a caring manner, instead of making the situation worse.

The following are some tips for handling pets in a way that can put clients at ease:

Tip 1: Take a moment to assess the pet’s demeanor. Rather than walking in and examining the pet as if it were a piece of furniture, spend a moment talking to the owner while you observe the pet’s interaction with the environment. If the pet is relaxed and soliciting attention, then it is likely safe to handle. If a dog is sitting quietly but making no overtly friendly gestures, then it may be fearful.

Signs of anxiety or fear include panting when the dog is not hot or thirsty, yawning when it is not tired, drooling or licking its lips while it is not eating, shying away, trying to hide and avoiding eye contact. Another important sign is that the pet may be much quieter than normal or may act sleepy when it should not be tired. Fearful cats tend to lie huddled in one spot with their forelegs and tail tucked close to their body. Many veterinarians misinterpret this stationary behavior of dogs and cats as a sign of a calm, well-behaved pet.

Tip 2: Greet the pet appropriately. If a dog is not overtly friendly and does not immediately run to you for affection, avoid staring directly at the dog or leaning over it and reaching into its personal space. No matter how friendly you think you appear, you can look like a giant monster to a fearful dog.

If the dog looks unsure, stand sideways and toss treats in a nonFigure 3. The technician correctly slides the dog chalant manner to see if it redown the front of her legs laxes. Ideally, the dog will come and can hold the dog in to you and choose to make first place if necessary before contact. Some dogs are so fearful reaching the final position.

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Handling a Cat for Jugular Venipuncture (A) If the cat is comfortable lying sternally, have it lie at the edge of the table. Elevate its head by placing a hand on either side of the neck and under the mandible. Fold your fingers under so that they do not block the jugular vein. The legs need not be restrained. If the cat is comfortable, it will hold still. If it is going to strike out in an attempt to cause injury, it will give ample warning (e.g., at first, the cat will strike repeatedly but with low intensity or without claws extended). If the cat jumps when poked with the needle or is tense when restrained in this position, use a different venipuncture technique.

(B) This method of restraint for jugular venipuncture is uncomfortable for many cats. The idea is to keep the cat from clawing by holding its legs down, but this often increases the likelihood that the cat will struggle and bite or claw. Note that Correct with this type of hold, the cat’s body is not well supported. It can easily move its body sideways.

(C) Restraining the head in this manner is also uncomfortable for the cat and provides poor support. Because the clinician’s arms are not along the cat’s sides, it is difficult to keep the cat’s body in A position.

Photos courtesy of Dr. Sophia Yin

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they will not approach you, so your best bet in these cases is to approach the dog backwards and do your examination positioned parallel to it while always moving in a smooth, relaxed manner.

Tip 3: Handle pets gently and provide an environment where they can feel safe. For example, avoid dumping cats out of carriers. Instead, have the owner open the carrier door before you enter the examination room and

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clinical REPORT give the cat a chance to walk out on its own. An alternative is to take the top of the carrier off and perform an examination with the cat in the carrier. Most cats will tolerate a towel placed over their head and body so that they can hide.

Tip 4: Avoid uncomfortable restraint positions: many cats don’t like or need to be scruffed for an exam. To an owner, it might appear as if you do not care about the cat if you walk into the room and grab it by the back of the neck — especially if a hand on the cat’s chest or a strategically placed towel would have been enough to prevent forward movement (Figure 1). In addition, when taking blood from the jugular vein, avoid grabbing the cat’s front legs

and stretching them out. This will cause most cats to struggle. Instead, make sure the cat is comfortable and just hold its head up. If it feels safe and comfortable, it is more likely to hold still.

Tip 5: Provide clear guidance and control: make sure you control the pet by placing your hands in the correct places to keep the pet stationary. For instance, placing a hand on the dog’s collar, even between examination procedures, will often keep it calm, whereas letting the dog move around not only makes it unclear that you would like it to hold still but also may allow the dog to get overly excited, which can make the examination difficult. Overexcitement — even in friendly dogs — can result in nipping, growling and biting if the dog slips into struggle or escape mode. Also note that placing pressure on an animal in the wrong locations will make it struggle more, rather than encouraging it to hold still.

Tip 6: Learn how to support an animal as you change its position. Banging a pet’s head on the table or throwing it on its side (Figure 2) can kill a pet’s confidence in you in a heartbeat, yet this happens regularly in veterinary practice. When animals are correctly restrained during position changes, they should feel supported at all times, so they cannot struggle or hit their head. For instance, instead of flipping or tossing a dog onto its side, slide the dog down your legs (Figure 3).

These are just a few tips that can help you on a daily basis. With each technique that you implement, you can improve the hospital experience for your patients and clients. As a result, you’ll be better able to provide vF quality medicine.

For more information: Yin S. Low Stress Handling, Restraint and Behavior Modification of Dogs and Cats. Davis, CA: CattleDog Publishing; 2009. To see videos demonstrating these techniques go to www.

AskDrYin.com/elearning.

Dr. Yin works at San Francisco Veterinary Specialists in California. Her website is www.AskDrYin.com.

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CASE REPORT

Feline Exocrine Pancreatic Insufficiency

By Marguerite M. Hoey, DVM

andora, a 2½-year-old spayed domestic shorthair cat, presented with the complaint of weight loss that occurred over a 9-week period. The weight loss had occurred despite the cat’s good appetite.

At presentation, Pandora was up-to-date on feline distemper/rabies vaccinations, was FeLV/FIV negative, and lived indoors with another adult cat and an elderly beagle.

The physical examination revealed no abnormalities except a documented weight loss of 2 lb 4 oz over 9 weeks.

The cat’s weight at presentation was 9 lb 1 oz.

The owner was feeding the cats a commercial, dry, adult weight-loss diet ad libitum because the other cat was overweight. Pandora was fed an extra 6-oz can of commercial adult cat food twice daily. There were no reports of vomiting or diarrhea. A complete blood count (CBC), Super Chemistry profile, T4 test, and urinalysis were performed to assess the pet’s overall health. The CBC and T4 results were within the normal range. However, the Super Chemistry profile had a few abnormalities. The laboratory reported a total bilirubin concentration of 0.8 mg/dL (normal: 0.1–0.4 mg/dL) with increases in serum alkaline phosphatase (SAP; 215 U/L, normal: 6–102 U/L) and serum glutamic-pyruvic transaminase (SGPT; 175 U/L, normal 10–100 U/L). The urinalysis revealed a small amount of bilirubin on the dipstick. Based on the history, physical examination, and laboratory tests, the rule-out list at this time consisted of: cholecystitis, cholangiohepatitis, pancreatitis, feline triad disease (liver/pancreatic/ intestinal disease), inflammatory bowel disease, small bowel overgrowth, malabsorption/maldigestion disease, neoplasia, and exocrine pancreatic disease.

Diagnostic imaging, as well as antibiotic and nutraceutical therapy, were recommended. Amoxicillin (100 mg q12h to guard against bacterial translocation) and a vitamin hepatosupport liquid (1 mL q12h) were dispensed.

Ten days later, the pet presented for ultrasonography of the abdomen. The owner again reported that the cat had a “great” appetite with no vomiting or diarrhea. However, the cat’s weight was recorded as 8 lb 6.5 oz — a loss of 10.5 oz in 10 days. The ultrasonographer reported that the liver was hyperechoic. The rest of the image was unremarkable.

A coagulopathy panel was drawn with the goal of performing ultrasound-guided liver aspiration. At this point, the differential diagnosis was expanded to include hepatic lipidosis, lymphoma, and other hepatic infiltrative diseases.

The coagulation panel revealed an abnormal prothrombin time (PT; 40 seconds, normal: 6–11 seconds)

P

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and abnormal partial thromboplastin time (PTT; 60.8 seconds, normal: 10–25 seconds). The platelet estimate was adequate, but the platelets were clumped. The count was 161,000 (normal: 200,000–500,000). The cat was treated with vitamin K1 at 5 mg SC q12h for 36 hours. The coagulation panel was repeated 24 hours later, and all values were within the normal range. Chest radiographs were obtained before anesthesia and appeared normal. With the patient under general anesthesia, the ultrasonographer performed fine-needle aspiration of the liver, after which the patient recovered well.

The pathology report demonstrated moderate to marked lipid vacuolation in the hepatocytes. However, the accumulation of lipids was not considered severe enough to support an interpretation of hepatic lipidosis syndrome. In the pathologist’s opinion, the results were secondary to another metabolic or inflammatory disorder.

One week after aspiration was performed, the patient presented for laboratory analysis and a body weight check.

Pandora weighed 7 lb 14 oz. The owner was continuing to administer the amoxicillin and hepatosupport nutraceutical as previously directed. The owner again reported no vomiting or diarrhea and that the cat continued to have an excellent appetite. Only a chemistry panel was performed at this visit. Increases were noted in the total bilirubin concentration (2.2 mg/dL), the liver enzyme level, and the SAP and SGPT concentrations (464 and 624 U/L, respectively). There was also a mild rise in the cholesterol level (256 mg/dL, normal: 75–220 mg/dL).

Revisiting the rule-out list At this point, the patient had a good appetite, decreasing weight, rising liver parameters on laboratory analysis, and vacuolation of hepatocytes based on fine-needle aspiration. We discussed with the client the best approach for making a diagnosis from the rule-out list. More diagnostic laboratory blood work, specifically a serum feline trypsinlike immunoreactivity (fTLI) test with cobalamin and folate testing, was suggested to rule out exocrine pancreatic insufficiency. Advanced diagnostics, such as endoscopy of the upper gastrointestinal tract with biopsies and an ultrasound-guided Tru-Cut biopsy of the liver, were also discussed. We also discussed the option of exploratory celiotomy to biopsy the liver, intestinal tract, mesenteric lymph node, pancreas, and any other organ deemed necessary. Because the cat was young, the owner thought that exploratory surgery with multiple tissue biopsies would

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B R I E F

Successful Use of Probiotics in a Dog with Chronic Diarrhea Teresa A. Bessler, DVM Buffalo Veterinary Clinic Buffalo, Wyoming

Patient: Kodi, a 14-year-old American Eskimo dog History: When Kodi became my patient in August 2007, he had a 2-year history of kidney disease and was eating Purina Veterinary Diets® NF Kidney Function® canine formula to help manage his condition. He also had a long history of frequent bouts of watery diarrhea.

Therapy Plan: Because of Kodi’s chronic kidney disease, I instructed the owners to continue feeding NF. I also prescribed 1 g of sucralfate twice daily for 5 days to treat a brief episode of anorexia and 250 mg of metronidazole twice daily for 5 days to resolve the diarrhea; metronidazole helped briefly, but the diarrhea returned.

In October 2007, Kodi’s owners made an appointment to have him euthanized because of the chronic diarrhea. Kodi was having fecal accidents in the house, and the owners did not wish to pursue expensive diagnostics. I talked to them about Purina Veterinary Diets® FortiFlora® Canine Nutritional Supplement, and they agreed to try it. Kodi was given FortiFlora once daily, and Purina Veterinary Diets ® Gentle Snackers TM were allowed as treats.

Outcome: Two weeks after adding FortiFlora to the diet, Kodi’s diarrhea had transformed into fairly firm stools. FortiFlora helped resolve the problem. At Kodi’s last evaluation, the chronic diarrhea hadn’t returned.

This information has not been peer reviewed and does not necessarily reflect the opinions of, nor constitute or imply endorsement or recommendation by, the Publisher or Editorial Board. The Publisher is not responsible for any data, opinions, or statements provided herein.

Veterinarian’s Comments I have been recommending Purina Veterinary Diets® FortiFlora® as a nutritional supplement for the past 2 years. I find it to be very effective in cases of acute and chronic diarrhea and in patients on long-term antibiotic therapy. I estimate that I have used FortiFlora in at least 40 patients with a 90% success rate.

I explain to owners that FortiFlora is a nutritional supplement that contains beneficial bacteria and promotes intestinal health.

Owners appreciate that FortiFlora comes in premeasured packages and is simply sprinkled on top of the pet’s food.

FortiFlora delivers good clinical results, and dogs and cats find it palatable; I have not had one owner tell me that his or her pet would not eat it.

Kodi’s owners were very happy with the positive results obtained with FortiFlora.

They told me the nutritional supplement had changed their lives and Kodi’s as well, and they wished they had known about FortiFlora sooner.

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CASE REPORT

yield the best possibility of diagnosing the illness in a timely manner.

The cat was admitted to the hospital for presurgical evaluation. The coagulation panel revealed an elevated PT and PTT (13.2 and 54.1 seconds, respectively) with adequate platelets (173,000). Vitamin K1 supplementation at 5 mg q12h was initiated. The coagulation panel was repeated in 48 hours, and the results were normal. The morning of surgery, an IV catheter was inserted, and fluid therapy, pain management, and an injectable antibiotic were started. Exploratory surgery revealed a grossly pale tan liver; mesenteric and colonic lymphadenopathy; a small pancreas; and normal kidneys, spleen, and intestinal tract. Biopsy samples were procured from the liver, pancreas, mesenteric lymph node, duodenum, jejunum, and ileum. Pandora recovered uneventfully and received supportive care in the hospital for 2 days. The patient was discharged with amoxicillin at 50 mg PO q12h for 10 days.

The biopsy report revealed no significant lesions in the intestinal samples, moderate to marked diffuse hepatocellular fatty changes in the liver, mild follicular lymphoplasmacytic hyperplasia of the mesenteric lymph node, and marked diffuse atrophy and loss of the pancreatic acinar cells/glands and islets. These changes supported a diagnosis of exocrine pancreatic insufficiency with secondary hepatic changes as a sequela of the pancreatic disease.

The results were shared with the owner, and Pandora returned to the hospital after fasting for 12 hours for an fTLI/cobalamin/folate blood test. At this time, the patient’s body weight was 7 lb 3 oz. The laboratory reported a low fTLI test result: 1 μg/L (normal: 12–82 μg/L).

Unfortunately, the cobalamin/folate test was not performed because of an error on the test request form.

Because the fTLI test results supported a diagnosis of exocrine pancreatic insufficiency (EPI), Pancrezyme (Virbac; 1 tsp per 6-oz can of food twice daily) was started.

Although we did not know the patient’s cobalamin level, it was deemed appropriate to institute therapy because of chronic weight loss. Cyanocobalamin injections (500 μg SC once weekly) were administered at home by the owner for 6 weeks. The injections were then given every 2 weeks for 1 month. No other therapies were recommended at this time.

Follow-up Pandora returned to the hospital for a follow-up examination 3 months later. The cat’s body weight was 11 lb, which was appropriate. The owner reported that the cat had a good appetite and produced malodorous, semisoft stools three to five times daily. A chemistry panel and cobalamin/folate sample were obtained after the patient

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fasted for 12 hours. The chemistry panel results were normal except for a low cholesterol level (64 mg/dL, normal: 75–220 mg/dL). This may have been due to improper absorption and/or assimilation of cholesterol secondary to EPI. The cobalamin level was normal, and the folate level was marginally elevated (22.3 μg/L, normal: 9.7–21.6 μg/L). This may have been indicative of an alteration in the intestinal microflora. A trial of probiotic powder, a highly digestible prescription diet, and metronidazole antibiotic was declined by the owner. The owner refilled the pancreatic powder but opted for a generic version.

Pandora was brought in for her annual wellness visit 6 months later. PanaKare Powder (Neogen Vet; 1 tsp per meal twice daily) in canned food had been administered without adverse effects. The owner reported that Pandora had solid bowel movements twice daily. Pandora’s physical examination revealed a body weight of 13 lb 5 oz, which was considered mildly overweight. Blood testing was recommended but declined because the owner thought that Pandora was well and stable. To prevent obesity, the owner was advised not to overfeed Pandora.

Discussion EPI is caused by an insufficient synthesis and secretion of digestive enzymes by the exocrine portion of the pancreas.1 The lack of enzymes leads to nutrient malabsorption in the lumen of the small intestine.1 The pancreatic secretions are also responsible for proper intestinal mucosal transport mechanisms.1 The lack of digestive enzymes leads to maldigestion.1 EPI is relatively rare in cats.2 Chronic pancreatitis is the most common cause of EPI in cats. Chronic pancreatitis can destroy the exocrine and endocrine portions of the pancreas; therefore, EPI is often accompanied by diabetes mellitus.2 Other causes of EPI in cats include congenital pancreatic hypoplasia, flow obstruction of enzymes due to neoplasia, and duct loss due to surgical complication (cholecystoduodenostomy). The cat in this report most likely had congenital pancreatic hypoplasia.1 In cats, the most common clinical signs of EPI are diarrhea, polyphagia, and weight loss.1 Some cats may also have vomiting and anorexia.3 The feces may be voluminous, greasy, malodorous, pale, and loose, and defecation may be frequent.3 The cat may have a greasy haircoat, especially in the perianal region and on the tail. The cat in this report presented for polyphagia and weight loss.3 Routine laboratory tests (CBC/chemistry/urinalysis), abdominal radiography, and ultrasonography are generally not helpful in diagnosing EPI. The most reliable blood test for cats is the serum fTLI test. Values ≤8 μg/L are consistent with EPI.

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CASE REPORT

The cat in this report had elevations in liver parameters on routine blood tests. Alterations in metabolism due to nutrient deficiencies from EPI may have contributed to these abnormalities. This cat also had repeatable abnormalities in the coagulation profile.

Improper absorption of fat-soluble vitamins due to EPI and insufficient activity of digestive enzymes in the lumen of the intestines may have interfered with production factors needed for coagulation. This was corrected by vitamin K1 supplementation. This cat was diagnosed with EPI via biopsy of the pancreas during surgical exploratory laparotomy. During the postoperative period, a fTLI test was performed, and the results were low. If the fTLI test had been performed before surgical exploration, EPI could have been diagnosed sooner. The surgical biopsies did eliminate other more common feline diseases from the differential list.

Therapy for EPI in cats is based on enzyme replacement. Powdered preparations seem to be the most effective.1 One teaspoon of powder per meal added to a commercial cat food is the initial dose. The meal does not need to be preincubated with enzyme before feeding.

Polyphagia and diarrhea tend to resolve quickly, and the dose of enzyme replacement powder can be titrated to effect.1 This cat responded favorably to a brand-name

enzyme replacement powder and was switched to a generic version without repercussions.

Many cats with EPI may have small intestinal bacterial overgrowth, leading to an increased number of bacteria in the proximal small intestine.2,4 These bacteria produce an increased amount of folate and either use cobalamin or interfere with absorption of it in the ileum.4 Subsequently, these cats may have marked decreases in serum cobalamin.4 This cat did not have its serum cobalamin or folate measured when the fTLI test was performed because of an oversight in completing the test form. The results of the intestinal biopsies did not reveal any abnormalities.

Because cats with EPI commonly have depleted cobalamin stores, the decision was made to supplement Pandora, even though her intestinal biopsies did not demonstrate structural abnormalities that would hinder absorption of the vitamin. The following dose is required to replenish cobalamin in cats: 500 µg SC once weekly for 6 weeks, followed by twice monthly for 1 month, and then once monthly.5 This cat received the initial six injections and the two bimonthly injections. The owner chose not to pursue the monthly injections because the cat was stable and well.

Since EPI, in most cases, causes irreversible loss of pancreatic acinar tissue, a complete recovery is unlikely.1 However, with appropriate therapeutic intervention and monitoring, most patients gain weight, pass normal stools, and thrive. Many can have a normal life with a full life span.1 Although EPI was on the differential list in this case, it was not a primary concern because it is rare compared with the hepatic and gastrointestinal disorders that are more common in young cats. Exploratory surgery with multiple organ biopsies was deemed to be the best intervention for making a diagnosis. Once the biopsy revealed pancreatic atrophy, the fTLI test was performed, and the results were low.

This case illustrates the challenges of working through a differential diagnosis. Pandora continues to receive the pancreatic enzyme powder daily and is doing well. vF References 1. Steiner J, Williams D. Feline exocrine pancreatic disease. In: Kirk’s Current Veterinary Therapy XIII. Philadelphia: WB Saunders; 2000:703-704.

2. Washabau R, Holt D. Pathophysiology of gastrointestinal disease. Textbook of Small Animal Surgery. Philadelphia: WB Saunders; 2003:546-547.

3. Webb CB. Secondary gastrointestinal diseases. In: Feline Internal Medicine Secrets. Philadelphia: Hanley & Belfus; 2001:120-121.

4. Ludlow C, Davenport D. Small intestinal bacterial overgrowth. In: Kirk’s Current Veterinary Therapy XIII. Philadelphia: WB Saunders; 2000:639.

5. Marks S. Update on the diagnosis and management of feline pancreatic disease. Waltham Feline Medicine Symposium. VIN Library; 2003.

Dr. Hoey is affiliated with the the Arlington Dog and Cat Hospital in Kearny, N.J.

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IN PRACTICE

(continued from page 7)

dropped off, through surgery and recovery. Show the client a picture of each stage of the pet’s treatment. When the pet is out of surgery, call and say, “Buster’s fine,” or email the client a photo of the pet in recovery, along with a simple message, such as, “Everything went well,” Grosdidier recommends.

Visual tools can also be particularly valuable during the discharge process.

Grosdidier encourages practices to create a digital presentation of a pet’s surgical experience. For example, include a copy of the pet’s radiographs and photos of the pet being brought in for surgery and in recovery. “At the discharge appointment, you can then have your technician say to the client, ‘Let me take you through what we did for Buster today,’ and use the presentation as a visual aid to reinforce all of the things you did for the pet,” Grosdidier said.

Provide access — “A client who is paying $1,500 for a surgery should be able to call someone who is standing in front of his or her pet and can say, ‘He’s still under anesthesia,’ ‘He’s fine,’ or ‘The doctor is still with him. He’ll call you at 4:30 PM and let you know how it went,’” Grosdidier said. “If a patient is in an emergency situation, the client should also be able to call someone at 3:30 AM to find out how the pet is doing so that he or she can go back to sleep.”

Having access to a practice website or pet portal, such as the customized pet portal service offered by VetStreet, can also help clients feel like they have a direct connection to the people and services that they need. Pet portals allow clients to access basic pet health records, review recommendations, click on links to veterinarian-approved medical information and purchase needed products and prescriptions online.

Shine at discharge and follow-up — You can be an absolutely brilliant surgeon or practice the best medicine, but if a client leaves your practice feeling confused, the two of you are working at cross purposes. To ease confusion, Grosdidier believes it is essential to schedule a discharge appointment to help enlighten your clients. Rather than merely bringing pets to the front desk and reciting routine discharge instructions, try to bring clients into a quiet examination room away from the bustle of the clinic. While a technician can handle client instructions, the doctor can poke his or her head in and say, “Buster did well today. Lesley is the surgical technician who was with him, and she will go over my discharge instructions. She’ll explain the pain medications we’ve given him and how we’re going to keep him comfortable tonight. Buster will need to come in again in 7 days.”

This accomplishes two things. First, a focused setting makes it easier to ensure that the client understands your discharge instructions. Second, the client can speak with a person who was involved in the pet’s procedure.

Most clients find that connection reassuring.

But is it practical?

Grosdidier says that she sometimes encounters opposition from veterinarians who think her recommendations are too time-consuming to implement with regularity. In reality, however, these routines don’t take long to set up or to follow. And the bottom line is that clients who spend $900 on dental work for their pets should feel like they are getting their money’s worth. “The feeling you should strive to leave clients with is, ‘They do a heck of a job. It might be a little more expensive than the practice down the street, but it’s fair when you consider all that they do,’” Grosdidier said.

When clients walk out the clinic door with that thought in their heads, it makes your job much easier and more enjoyable. vF Yvonne Claire Stecher is a writer, editor and communications consultant in N.J.

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2. Rubin J, Walker RD, Blickenstaff K, Bodies-Jones S, Zhao S., Antimicrobial resistance and genetic characterization of uoroquinolone resistance of Pseudomonas aeruginosa isolated from canine infections., Vet microbiol.

2008 Mar 4; [Epub ahead of print] SPAH-MO-96a

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news

Web community aimed at helping vets, owners and pets

By Paul Basilio Associate Editor SAN FRANCISCO — In the vast and shifting world of direct-to-pet-owner websites, well-intentioned but misinformed advice can lead owners down the wrong path for veterinary care.

This misinformation can result in confrontations in the examination room, loss of clientele and substandard care for the pets caught in the middle.

To combat this, websites that offer expert veterinary advice about pets and pet ownership are attempting to sift through the online “noise” to bring owners rational, evidence-based responses for popular questions about animal care.

DogTime.com, a “hubsite” of more than 450 pet publishing partners and 360 animal care blogs, was launched to provide a web-based community where dog owners can interact and share stories about the challenges and rewards of caring for a dog, including advice on when to seek veterinary care, the importance of wellness and how others have dealt with caring for a dog with a chronic illness.

“It’s like going to the dog park to the millionth power,” said Simon Tonner, vice president of marketing for DogTime Media. “There are many people out there who are passionate about their pets and are eager to share advice and relate their experiences.”

DogTime has assembled a panel of veterinarians to offer authoritative answers for pet owners — some-

28

Veterinary Forum | November 2009

thing that is lacking in most online pet communities. Owners with questions regarding pre-adoption concerns, the needs of puppies, nutrition, geriatric care and more receive answers from licensed veterinary professionals who take care to acknowledge that their advice is no substitute for a trip to the dog’s veterinarian.

According to Tonner, the site is always looking for more veterinary experts to answer owners’ questions.

Saving dogs DogTime recently launched a campaign to help link dogs in shelters with potential owners across the country.

Members of the community at Facebook.com can install the “Save a Dog” application on their profile page and “virtually foster” a dog. People who visit participating profile pages will see pictures of dogs that are up for adoption, read their stories and search for other adoptable dogs in the area.

“People can type in their zip code, enter their age or breed pref-

erence and have access to more than 70,000 animals that are living in shelters across the country,” Tonner said. “The rescue community has been enthusiastic about this. It’s a new way for volunteers and organizations to receive additional exposure for their dogs and increase the chances of adoption. We are on track for 1 million Save a Dog users by early next year.”

Insurance questions DogTime also features a pet insurance center, which presents a side-by-side comparison grid of more than 40 pet insurance policies. Interest in pet insurance has been expanding over the past few years, but owners still have many questions about which policy would be best for their pet.

The grid includes the benefits, approximate cost and restrictions of each plan, allowing consumers to compare the options.

“We have a section of the site where owners can ask an insurance expert,” Tonner said. “When people look at the grid, they can get a general idea of what the main points are, but some people will have questions specific to their pets, such as breed restrictions and pre-existing conditions.”

The open nature of the Internet lends itself to multifaceted discussions that can benefit both veterinarians and dog owners. “When our experts offer their opinion or advice, the community will offer their input and begin an open discussion,” Tonner said.

“That is the beauty of the open forum.

It creates a dialogue that provides value for everyone.” vF

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There were five other people in the room and only one, an intern, saw the shape of the cat as well. The other four awkwardly looked at us.

They are probably not very good at seeing shapes of bunnies in cloud formations, either. vF

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November 2009 | Veterinary Forum

29

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30 Veterinary Forum | November 2009 VF1109_Classifieds 30

10/22/09 9:49:28 AM

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Salary: $51,876 - $90,783 annually, depending on education and experience (comprehensive benefits package). Application requirements: Official DCCCD application for employment (www.jobs.dcccd.edu), resume, unofficial copy of graduate transcripts. Deadline for all applications (electronic/non-electronic) and other required documents is open until filled. Resume and unofficial transcripts may be faxed to 972860-8279, emailed to CVCHR@dcccd.edu, delivered in person or mailed to: Cedar Valley College, Human Resources, 3030 North Dallas Ave., Lancaster, TX 75134. Please include position number (030909051) on all documents submitted. For complete job description information and online application please visit our web site at: www.dcccd.edu/Business+Community/jobs. htm. To send supplemental information email apply@dcccd.edu. Employment opportunities are offered by the Dallas County Community College District without regard to race, color, age, national origin, religion, sex, disability or sexual orientation.

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VF1109_Classifieds 31

10/22/09 9:49:35 AM

most

UNUSUAL CASE

Cow chases in high places

By Celeste Matthews, DVM Talbotton, Ga.

© 2009 Holly Matthews

I

Dr. Matthews remembers the crazed cow with her mixed-breed hound, Lucy.

32

was alone, trapped and sitting at the top of a rickety ladder in an old barn. I had been stuck there for about 30 minutes, encouraged to stay put by the enraged Santa Gertrudis cow that was in the stall under me.

My client, Mr. Smith, had asked me to check the cow because she was lacking normal interest in her newborn calf. I had treated the elder cow several times before, and she had always been reasonably gentle. However, when I entered her stall that day, she ran so fast at me that I had to jump up the ladder to safety.

The cow appeared to be stark raving mad — she bellowed like a rabid animal and shook slobber in every direction. The poor calf was cringing in the corner, afraid to come near her mother. The crazy cow alternated between making threatening motions toward her calf and menacing me from the bottom of the ladder.

I did not have my phone, so I did the sensible thing and waited at the top of the ladder for someone to arrive and help.

After what seemed like an eternity, I heard Mr. Smith’s truck approach the barn. He hollered, “Hello,” and I answered back. I was glad to be rescued but a little embarrassed at my circumstance. He opened the barn door, and the cow charged at him. This gave me a chance to come down from the ladder and run out the back door to safety.

By some miracle, Mr. Smith managed to get the cow to chase him into a smaller stall, where he was able to trap the cow and escape from the stall. After the cow had been confined and everyone was safe, my first inclination was to leave with my hide intact, but the pitiful little calf inspired me to try to help his insane mother.

My first thought was rabies, but Mr. Smith was one of the few farmers in the area who actually vaccinated his cows against the disease.

I remembered reading that cows with low blood sugar tend to act insane. When you read about it in a book, hypoglycemia in a cow seems like a mild problem. I suspect that the authors of these textbooks have not seen the condition from the top of a ladder.

From the safety of the main hallway of the barn, I tossed my lariat at the cow’s head. To my amazement, I lassoed her. She let out a terrible bawling sound and charged at me, hitting the wall instead. I took this opportunity to tether her to a post. After that, the cow concentrated on trying to get loose rather than trying to kill me, which was an improvement.

With her head secured, I was able to draw a blood sample for testing. I decided to treat her with some glucose, just in case low blood sugar was the problem. She continued to struggle, rant and rave while I administered the glucose, but when the treatment was through the cow began to quiet down.

Within 10 minutes, she was standing still. Her eyes no longer seemed to be shooting sparks of fire at me. I removed the tether, she walked over to the feed trough that was in her stall and began to munch a little hay. I guided the calf back to his mom, and rather than attack him, she continued to eat. The calf stood next to his mom and began to feed. vF It turns out she just needed a little “sugar.”

Veterinary Forum | November 2009

We believe you re too good to be micromanaged. We believe in providing more resources, not taking them away. We believe a econd opinion, or third, or fourth, can make yours even stronger. We believe in getting out of the way and letting doctors be octors. We believe you own your career. We believe you went to vet school for a very furry reason. We believe people need eterinarians as much as Pets do. We believe you’re better at your job when you’ve had some time away from it. We believe in iving you the tools you need to do your job. We believe no matter how good you are, you can always get better. We believe t xcellent doctors make excellent colleagues. We believe mentors can learn as much as mentees. We believe in saving the lives f Pets and improving the lives of vets. We believe that you should be focused on your patient, not your paperwork. We belie hat flexible hours make for refreshed doctors. We believe cats aren’t the only animals that purr. We believe we’re helping fam es along with their Pets. We We believe believe experience experience is is powerful powerful medicine. medicine. We believe in providing more resources, not takng them away. We That you’re a healer – not an administrator. yours even stronger. We believe in getting out of the way and etting doctors be doctors. We believe you own And that the right resources make good doctors great. for a very furry reason We believe people need veterinarians as much as Pets do. We believe you’re better at your job when you’ve had some time aw om it. We believe in giving you the tools you need to do your job. We believe no matter how good you are, you can always g etter. We believe that excellent doctors make excellent We We believe believe you you should should look look forward forward to to work. work. mentees. We beli That your your practice practice isis part part of of who who you you are. are. be focused on your patient, not your paperwork. W n saving the lives of Pets and That elieve that flexible hours make for refreshed doctors. We But that your loved ones at home need you too. We believe we’re elping families along with their Pets. We believe you’re too good to be micromanaged. We believe in providing more resourc ot taking them away. We believe a second opinion, or third, or fourth, can make yours even stronger. We believe in getting o f the way and letting doctors be doctors. We believe you own your career. We believe you went to vet school for a very furry eason. We believe people need veterinarians as much as Pets do. We believe you’re better at your job when you’ve had some me away from it. We believe in giving you the tools you need to do your job. We believe no matter how good you are, you c lways get better. We believe that excellent doctors make excellent colleagues. We believe mentors can learn as much as ment We believe in saving the lives of Pets and improving the lives of vets. We believe that you should be focused on your patient, ot your paperwork. We believe that flexible hours make for refreshed doctors. We believe cats aren’t the only animals that pu We believe we’re helping families along with their Pets. We believe you’re too good to be micromanaged. We believe in provid ng more resources, not taking them away. We believe a second opinion, or third, or fourth, can make yours even stronger. We elieve in getting out of the way and letting doctors be doctors. We believe you own your career. We believe you went to vet chool for a very furry reason. We believe people need veterinarians as much as Pets do. We believe you’re better at your job when you’ve had some time away from it. We believe in giving you the tools you need to do your job. We believe no matter h ood you are, you can always get better. We believe that excellent doctors make excellent colleagues. We believe mentors can earn as much as mentees. We believe in saving the lives of Pets and improving the lives of vets. We believe that you should b ocused on your patient, not your paperwork. We believe that flexible hours make for refreshed doctors. We believe cats aren’ Banfield, believeyou’re in our too veterinarians. he only animals that purr. We believe we’re helping families along with theirAtPets.

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