Be Your Pet's Medical Advocate

I recently went through a spell of severe back pain and finally broke down and visited my physician. They were kind, listened to my concerns, prescribed some different pain management options, and then recommended that I go and have by back radiographed (x-ray).

Once I left the office, however, communication totally broke down. The doctor's office called the next day and said, "The X-rays are abnormal you need a MRI." I called the radiologist and was informed that the MRI was listed at $2,000.

I nearly pooped myself.

So I called back the doctor and I tried to get them to tell me what we were looking for, what was abnormal about the x-ray, and what kind of treatments we were going to consider. This was a lot of money. They were, unfortunately, totally unable to explain what they hoped to accomplish with this diagnostic, only to say that it was important and they needed to look at the "tissues." Seriously. $2000 and all I get from you is you want to look at the "tissues?" I was a bit upset.

I had the MRI (As it turns out, it was only $500 due to insurance negotiated discounts - who says our medical system of insurance ain't screwed up?). Afterwards my doctor's office called back to tell me that the MRI was abnormal and that I could be sent for injections for the bad disk if I wanted to. Seriously, that was the extent of the discussion. This left me even more frustrated.

I had to call back and insist that I talk to my RNP and discuss what the goals of thearpy were, what the expectations are for treatment, and what the actual diagnosis was. Point was, I had to GO AND SEEK OUT this information. I nearly had to drag it out of them.

I had to be my own medical advocate.

I have never had problems with this office, in fact I really like this group. I still like them, but they dropped the ball on this one.

I had seen the x-rays. I had a copy of the MRI made before I left the office so I was able to look through them and see what was up. I also had enough knowledge to know what we were looking for. What I did not know what how this would be handled in a human. I needed my physician's office to actually take the time to explain the plan. Why the recommendation for steroid injections? Surgery now? At what point do we consider it? Physical therapy?


Gee, Aaron, Why are you boring us with this long sob story about your back?

Because this experience was a reminder for me to NOT do this when I am working with my clients. I know this kind of thing happens every day both in human and veterinary medicine. It is easy to loose touch when the patient is not sitting in the room in front of you. I try very hard to keep up communication and take the time to explain, and I think I'm better than most. But I am sure that I have dropped the ball from time to time and have probably left some clients confused or with a feeling of being "out of the loop."

Your medical care and your pet's medical care is a TWO WAY STREET! It involves both the medical staff and you! I don't believe for a second that my doctor's office was trying to be lazy. But I do think that they did a terrible job this time communicating diagnostic findings, assesment of those findings, and a coherant plan with the patient. I had to take the responsibility to get the information.

You should handle your pet's medical care the same way. Hold your veterinarian and their staff responsible for giving you the information you require to make informed decisions. Make sure you are comfortable with the direction your pet's care is taking. If you don't understand something, call them back. Make for darned sure you have been given the information you need. We're all on the same team.


AMH

A Quick Influenza Update

I received an e-mail not long ago about a cat being diagnosed with H1N1 influenza. You will all remember that H1N1 is the "swine" flu as opposed to the H3N8 dog/horse influenza. I've checked into it and there have been a couple of cases of cats and a couple of ferrets with confirmed H1N1.

At risk of sounding redundant: DON'T PANIC!

We know that influenza virus can jump species. It's why we have the H1N1 epidemic to begin with, right? So it stands to reason that there would be instances where the virus jumps from people to cats.

Is it scary? Yes. It is. We always pay close attention when something like this happens. When there are inter-species jumps we always investigate and see if there is any difference in the virus, type of infection, or incidence.

Is it common? No, It's considered rare. I'm sure there are cases out there we don't know about, but if you consider there are two cat cases compared to many thousands of human cases, it's rare.

Has the virus mutated? NO. Genetic analysis says the virus has not changed, it just happened to infect a different species than we would have expected.

I assume we are going to see more of these. The cats and ferrets infected have all recovered from the infection and it is essentially the same story for them as it is in us or dogs.

Interesting...

AMH

The Deadliest Insect on Planet Earth

I didn't forget my blog. I left the influenza post up a bit longer because I kept getting questions from folks about it.

We've had a TON of rain here lately and thanks to that, we've had a TON of mosquitoes. You may or not be aware, but the mosquito is considered the most deadly insect on Earth. Specifically, the female anopheles mosquito because she carries malaria. But there are many other genus of mosquitoes that are quite capable of transmitting other diseases as well.

Now, to be fair, the mosquito is not inherently evil. Annoying, itchy, and somewhat disgusting to look at, but the same could be said about so many of us from time to time. Mosquitoes get the bad wrap on this one because they are blood feeders and they feed on multiple hosts over the course of their lives. This means that they, in essence, swap blood from one individual to another.

Certain parasites have taken advantage of this biological fact. Malaria organisms hitch a ride with mosquitoes and infect another person via the mosquito saliva in an infected bite. Heartworm is another example. Larva are picked up with a blood meal, molt twice in the mosquito, and then infect the next animal through the bite wound from the mosquito. Most viruses can't hitch a ride with mosquitoes, but there are some notable exceptions - mainly West Nile Virus and the equine encephalitis viruses.


Different mosquitoes have different preferences in what they feed on. Some only feed on birds, for instance. Others will freely feed on anyone including dogs, cats, people, and horses. The feeding habits of a mosquito will decide what kind of threat that particular buggar represents.

I will often see outdoor cats with little crusted bumps on the ears and upper nose, and similar areas on dogs where the ears fold over or on the bridge of the nose. These can be little bites from mosquitoes or flies and may be an indication that repellent would be appropriate.

How to protect you and your pet:

Avoidance. Mosquitoes are active near dusk and dawn. They don't like to be out in direct sunlight and don't like high winds. If you are having a hard time with mosquitoes (like we are lately), then avoid keeping your dogs and cats out during that time.

The second line of defence will be repellents. There are fewer repellent options for dogs than there are for people. Any permethryn containing product will likely be repellent to mosquitoes. Bayer's Advantix and the Vectra 3D are examples of products that have "repels mosquitoes" on the label. I've also had folks tell me they've had good luck with the Avon Skin-so-Soft products. Spray a wipe and then wipe the fur of the dog, specifically getting the tips of the ears. In theory DEET should work, but I just don't think DEET is safe. You must wash it off and that makes it impractical for most owners on a day-to-day basis.

DON'T FORGET YOUR CATS! There are even fewer options for cats than for dogs. All of the permethryn products labeled for dogs will likely kill your cat, and that's just counter productive. There are pyrethryn products that may work, and the Skin-So-Soft trick may work. You must be more careful with all of the flea, tick, and mosquito control products in cats.

MOSQUITOES WILL GET INDOORS, TOO! Having an "Indoor only" dog or cat does NOT mean that their risk of heartworm disease is eliminated. All cats and all dogs should be on preventative year round - especially those dogs and cats living in more temperate climates.

The moral of the story is that many owners forget about mosquitoes if they are not outside being bitten. Mosquitoes happily feed on your pets and they do carry with them the potential for disease. Keep your pet current on preventatives and, if appropriate, use a safe repellent for your pet.

AMH

Canine Influenza - Yet ANOTHER flu bug

It is rather exhausting to hear so much about influenza. There is a fine line between caution and panic. The media has make this line difficult to identify. My goal here is to prevent as much fact as possible with an occasional injection of opinion.

Influenza is a HOT topic. When words like pandemic and enzootic are used it tends to make people very nervous. The moral of the story: Be cautious, be aware, but DO NOT PANIC.

The Virus:

The images above are all of influenza type A virus. Influenza A virus are further characterized by their H and N subtypes. Swine influenza is H1N1. Horse is H3N8. Seasonal flu is H3N2. The canine influenza that is causing all of the current panic is the H3N8 subtype of virus. This is because there was a jump at some point in history from the horse to the dog.

The current episode of canine influenza is dated to 2004 when there was a rather dramatic epidemic in a racing greyhound population that killed many dogs. Although we have seen influenza steadily since then, serum samples taken from dogs as early as 1999 have been positive for H3N8 virus. Those may have been previous jumps or they may represent the same virus we are seeing now. It's hard to know what used to be around when we weren't looking for it back then. All we can really say is what is here now and keep looking to know what is here in the future.

Transmission/Infection:

The disease is transmitted in exactly the same ways that the human influenza is transmitted. It's stinkin' contagious and is capable of spreading quickly through dense populations. Dogs infected with virus typically have a 2-5 day incubation prior to showing symptoms. They are then "sick" for a period of approximately 5 days. The cough may last weeks longer.

Dogs shed virus several days prior to showing symptoms. This is part of the frustration with the disease because dogs can infect others long before we even know they are sick.

The disease appears to be enzootic (permanently in a population) in Florida, New Jersey, New York, Colorado, and California. It has been diagnosed in 31 states (including Texas) but is still spotty in those states and has not been shown to be permanently in the population.

Transmission is most reliable in situations where a dog is in a larger population of closely housed dogs. This includes: boarding, grooming, dog shows, traveling with the family, dog parks, day care, and racing greyhounds.

Disease Symptoms:

Nearly every dog exposed will become infected. Of those dogs 80% will show some symptoms. Of those dogs 95% show little to no disease and what they do show is limited to:

Cough (deeper, chesty cough)

Mild fever

Lethargy

Nasal Discharge

5% of infected dogs will become more severely ill and those dogs may develop:

Pneumonia

Anorexia

and in rare cases hemorrhagic disease and death.

Greyhounds appear to be exceptionally sensitive to the virus and they nearly always develop more severe disease.

These statistics are smackingly similar to human influenza, yes? I think most dogs are actually at lower risk of exposure than many humans. We humans are such social creatures and are always interacting with random members of our species. We touch door handles, shopping carts, phones, hands, and breathe the same air on public transportation. Aside from the dogs in the at risk population listed above, your dog is probably in a much more controlled environment than you are.

Treatment:

Supportive care. Plenty of water, controlled environment (don't leave a sick dog outside in the cold, wet weather), and watch closely. If the cough is severe enough we will use cough suppressants. If we are dealing with a very young dog, very old dog, or dog with history of cardiopulmonary disease, we may use an antibiotic. Notice how this sounds exactly like how we would treat any old "kennel cough?"

In a few, very sick dogs veterinarians have tried Tamiflu. There are no controlled studies to prove if this works and there are few dogs that are sick enough to warrant treatment. It is NOT recommended for prevention of disease!

Prevention:

Avoid high density situations if there is a local outbreak. Use common sense and if a dog has a cough - DON'T TAKE HIM TO THE PARK OR TO DAYCARE! My daughters have to stay home from school with a fever. Doesn't matter how good they feel. Any fever, vomiting or diarrhea and they have to stay home. It is encouraged that a child with a severe cough not be sent to school. Same concept goes for your dog.

And now the big question: What about the vaccine? Not to sound too redundant, but this is yet another hot topic. Here are a few facts about the vaccine:

• It has only existed on the market for a few months. It looks like it will be a safe vaccine, but it's still new.
• The vaccine is not labeled to prevent disease or eliminate infection - it is designed to reduce severity of clinical signs, shorten disease course, and reduce shedding of virus
• It requires an initial dose followed by a booster 2-4 weeks later. It must then be boostered annually.

As with any vaccination of its type, protection will not happen until around 10 days AFTER the SECOND vaccine. So you must plan ahead if you want your dog "protected" prior to entering a boarding facility. You need a MINIMUM of 24 day lead-time and closer to 5 weeks is recommended.

Which dogs should get the vaccine? High risk dogs (see the above list) and especially high risk dogs traveling to or living in the areas of NJ, NY, CA, CO, or southern Florida.

Your veterinarian may have identified a local outbreak of influenza and may feel that vaccination for your pet is important regardless of where you live. Always follow your primary care veterinarians recommendations regarding what vaccinations are recommended for your pet.

I don't have statistics regarding the H3N8 in other countries. I would imagine it is in Canada and Central America, but nobody has mentioned this on my discussion boards. I'll keep looking.

AMH

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AMH