Advice that I am not always taking

     It seems as humans that we have such an advantage to contemplate at a high level and tackle many tasks.  I am not sure that we have it better.  If I want to be observant of the creatures around me, they have some wisdom to impart.

1) "Sleep until rested"

      I was saying goodbye to my cat the other day when I was leaving for the clinic.  I pointed out again the unfairness of her staying home and sleeping and me going to work every day.  I think she could cover a shift occasionally.  In consideration of opposable thumbs, we wouldn't give her surgery days and really keep her appointments light.  She doesn't like other cats, dogs or most humans so we will have to be creative with scheduling.  She thought  I looked tired.  She pointed out that she simply would never get up while still tired and that I should crawl back in bed and sleep until rested.  Other than perhaps the sound of the crack of a can of cat food, there could be little reason to force oneself out of a warm bed.

2) "Run Hard"
      My Labrador, Levi, has suggested a weight control program that I have been slow to start.  He knows I have always watched and been concerned about my encroaching weight.  At 5'7" with shoes (my drivers license says 5'8"), I am the tall one in my family (one of my brothers is about the same height); the center of the family basketball team if you will.  I have often referred to being from a long line of short pudgy gnomes (once unfortunately in front of my mother) with a family history of modelling for yard ornaments and trophies.
     Levi's suggested plan includes completely giving over the control of all caloric intake.  Now he doesn't like this part, but someone else with your best interest at heart decides how much you eat and when.  Other than the occasional counter surfing incident, no more stare downs from donuts and muffins in the staff lounge.  No more debates about whether 3 half donuts eaten separately adds up to less than one donut eaten at once.
     Levi's real genius is in his proposed fitness plan.  First, always want to be on the other side of the door.  If someone opens it and you are out, come in.  If you are in, go out.  Anytime the door is closed, sit and wait for it to be opened.  Cry a high pitched cry if waiting longer than a few minutes.   Second, revere ball.  Carry it with you at all times and drop it, seemingly randomly, and chase it and pick it up again.  Do this several hundred times a day.  Third, ask all life forms to throw ball at any and every moment of the day.  Cats, other dogs, horses, guests and family members all may be able to throw ball.  Cycle between them at about 30 second intervals until ball is thrown.  Fourth, and by far most importantly, run full tilt any chance you get until you drop every day.  When someone finally throws ball, run all out.  Don't consider stopping until just past ball.  Put on the brakes completely at that point and slide well past ball, or roll over, depending on your velocity at that moment.  Don't learn from this.  Pick up ball and jog back to the thrower.  Repeat until unable to move.
 
3) "Live in the moment"
     Our Golden Retriever, Violet, was diagnosed with Lymphocytic Leukemia a few weeks ago.  This is a slowly progressive cancer and she may have many years.  When we told her, she was impassive.  She merely asked if everyone still loved her, which is what she always asks, and she suggested a long group hug, which is what she always suggests.  I have often felt that one of the things animal lovers universally hold dear is their pets ability to live in the moment.  There is little consideration for the past nor thoughts of the future.  Violet doesn't look at the dog next to her and think, "but he doesn't have cancer".  She just endeavors to meet and please as many people as possible this moment and then the next.

      Just as one of the surest signs of life on other planets is that none of it has tried to contact us (I am quoting Calvin and Hobbes); I doubt my animals would switch with me.  It strikes me that I could benefit occasionally from taking some advice from some unlikely sources around me.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)

Outreach Chairman, American Board of Veterinary Practitioners

   

World Rabies Day

Today is World Rabies Day.  

Rabies is a disease that we can end, saving people and animals.  Rabies is the deadliest zoonotic disease on the planet. Every year more than 59,000 people die from rabies. The deaths are mostly in Africa, India, and other parts of Asia where 99 percent of rabies cases are found. One-half of deaths are children under the age of 16.

At Washington State University, the Paul G. Allen School for Global Animal Health is working to eliminate canine rabies worldwide. The WSU Rabies Vaccination Program team vaccinates an average of 300 dogs each day in east Africa. They visit 180 villages every year in seven districts adjacent to the Serengeti National Park. Because of the program, the vaccination zone – a cordon sanitaire – is rabies free. The goal is to use the rabies-free vaccination zone as a model in other parts of Africa and Asia. To learn how you can help please visit http://www.eliminaterabies.wsu.edu.

A donation is made to the eliminate rabies program for every rabies vaccination give at Lien Animal Clinic. Additional donations may also be made through our clinic or directly with WSU.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)

Outreach Chairman, American Board of Veterinary Practitioners

Doctor, What Should I Feed My Cat?

This is a common question posed to veterinarians.  I just finished reading an excellent newsletter from Drs. Wackerbarth and Vaughan at the Hyperthyroid Treatment Center in Edmonds on feeding hyperthyroid cats.  I credit them with the following specifics and for prompting me on the subject.  For more of their information, visit them online at www.felinehtc.com.  Feeding hyperthyroid cats is similar to feeding most older cats so we can consider it in a general sense and in subsequent blogs we will look at feeding for specific geriatric diseases like thyroid disease and kidney failure.

We need to always remember that cats are obligate carnivores.  This means that they rely on the nutrients in animal tissues to meet their nutritional needs.  In the wild, a prey diet consisted of 50-70% protein,  30-50% fat and less than 2% carbohydrates.  A significant portion of their water needs were also met from their diet.  Cats are designed to use proteins and fats as energy, so they need a lot of protein in their diet.  When omnivores like dogs and humans ingest insufficient protein, they can conserve amino acids and use carbohydrates for energy.  Cats cannot switch from protein use.  When their diet is deficient in protein, they will burn their own muscle tissue for energy.

Cats also have specific amino acids that must be in their diet.  Cats don’t have the ability to synthesize arginine, cysteine, methionine, and taurine.  They must eat meat based proteins so they have the full complement of amino acids carnivores require.  Plant based proteins found in higher levels in dry foods are of low biological value for cats for this reason.

Feline metabolism lacks many of the enzymes and pathways needed to utilize carbohydrates.  They can’t store their glucose like omnivores, so they are more hyperglycemic after a meal and carbs that aren’t used are stored as fat.  Cats on higher carbohydrate diets are more prone to diabetes and obesity.

Fats provide energy and are responsible for a diets palatability.  Meat based diets with animal fat provide appropriate fatty acids and needed hormone precursors.

Animal proteins are more expensive than virtually any other ingredient in pet food.  Many canned and all dry foods include plant based proteins and not enough meat.  Whole grains, glutens, and soy are of low biologic value to the cat.  Remember that “grain-free” does not equal “carb-free”.  Potatoes, peas and soy are all “grain-free”. 

Canned foods are energy dense foods.  This is great for thin cats but can lead to weight gain.  So in heavier cats, portion control becomes more important.

So, what should we feed our older cats?

On a dry matter basis, 40%+ meat based proteins, about 50% fat, and less than 10% carbohydrates. {The Feline Nutrition Awareness Effort website has an explanation of Dry matter basis and a calculator so foods can be compared accurately.  http://fnae.org/dmb.html}

Any canned food is better than any dry food.  High quality canned foods with high levels of animal based proteins that contain little to no fruits, vegetables, or grains are the best choice. 

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)

Outreach Chairman, American Board of Veterinary Practitioners

If you could see into others' hearts

     I was commuting in from Vashon several Monday mornings ago.  It was a warm, beautiful morning and I got placed on the very back of the upper deck pointing uphill on the ramp.  Anyone who does a ferry commute knows that is one of the worst spots.  It is too difficult to be comfortable on the incline and hardened island commuters do not go up on deck without a very good reason.  So I sat on the incline, eating breakfast, as I do every morning on my way to work, with my windows open.  I listen to sports radio if the Mariners win and music if they don't.  I listen to a lot of music.  A ferry worker stopped and asked me a question about my car.
     We talked and he told me about cars he had owned and his boat.  He told me about living on his boat and how expensive the Vashon marina would be to moor his boat at.  He told me about his wife.  They had bought the boat together.  It was quickly clear that she was gone now.  He told me later that she had died of cancer 7 years or so ago.  He knows, as part of his being, that he will see her again.  He was such a nice man.  He has literally directed me hundreds of times on the boats and we have never spoken.  We acknowledged each other for a few days after but are now back into our usual roles.  I am a faceless commuter.  He's the worker directing me.  Eye contact is not made.  It is ok to go back to our roles.  We both have our days to manage and get through.
    We bonded for that point in time - two guys talking cars.  He had a story.  Everyone has a story and everyone wants to tell their story.  Everyone has sadness and strife.  The worry in the others around us is unknowable.  It is knowable that it is happening.  A wise man said once, "When you meet a person, treat him or her as if they are in trouble.  You will be right more often than you are wrong."

    A few weekends ago, we held our clinic management retreat.  Sarah, Kas, Johana, Andrea, Beth and I met and talked about our parts of the clinic.  We talked about this very issue and we watched a short video together from the Cleveland clinic called "If we could see inside others' hearts".  It is profound and a real tear-jerker.  Watch it if you have a minute.

https://www.youtube.com/watch?v=IQtOgE2s2xI

It makes one want to vow to cut people some slack, make eye contact, say good morning, thank you, and you're welcome, and try not to take it personally when someone is difficult or unpleasant.  Everyone has their stuff.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)

Outreach Chairman, American Board of Veterinary Practitioners

Taking Your Cat to the Veterinarian

Routine yearly healthy pet examinations are part of good health care and can allow your cats to have longer, more comfortable lives.  But, many cats dislike coming to the clinic; I would even say most.   My cat "Mango" for instance loathes the trip in - no snacks, no litter box, poorly responsive attendants when he inevitably needs to use the non-existent litter box.   The challenge starts with getting cats in the carrier and getting them to the clinic.  If we make that step easier, everything improves. The following information is reprinted from the American Association of Feline Practitioners (AAFP) website.  They are an ongoing wealth of kitty information.

• Cats are most comfortable with the familiar, and need time to adjust to the unfamiliar.  The visit to the veterinarian is often difficult because the carrier, car, and the veterinary hospital are unfamiliar. Your cat will need time to become familiar with new situations, people and places.
• Stay calm. Cats can sense our anxiety and frustrations, and this may cause them to become fearful or anxious.
• Cats do not learn from punishment or force. Give rewards to encourage positive behavior. Try to find treats that your cat thinks are delicious and are motivating.  If your cat is sitting calmly in or near a carrier, give a treat. Likewise, rewards can be given to help your cat become familiar with types of handling that may happen at the clinic.  Play or affection may also be seen as rewards.
• The goal is for your cat to learn to associate the carrier with positive experiences and routinely enter voluntarily.
• Make the carrier a familiar place at home by leaving it in a room where your cat spends lots of time.
• Place familiar soft bedding inside the carrier. Bedding or clothing with your scent can make them feel more secure.
• Place treats, catnip or toys inside the carrier to encourage the cat to enter the carrier. At first, you may see the treats removed from the carrier at night.
• It may take days or weeks before your cat starts to trust the carrier. Remain calm, patient and reward desired behaviors.
• If you still have trouble, you may need to assess the carrier itself. 
• If your cat needs to go to the veterinarian right away, and is not yet accustomed to the carrier: 
• Start by putting the carrier in a small room with few hiding places. Bring the cat into the room and close the door. Move slowly and calmly. Do not chase the cat to get it into the carrier. Encourage the cat with treats or toys to walk into the carrier.
• If your cat will not walk into the carrier, and your carrier has an opening on the top, gently cradle your cat and lower it into the carrier.
• Another option is to remove the top half of your carrier while getting the cat to go into the bottom half, and then calmly replace the top.
• Consider use of synthetic feline facial pheromone (Feliway®) analog spray in the carrier at least 30 minutes prior to transport to help calm the cat.

Coming Home – Cats are very sensitive to smells, and unfamiliar smells can result in one cat no longer recognizing another.  Aggressive behavior can occur when one cat senses another as a stranger. Consider the following.

• Leave the returning cat in the carrier for a few minutes to see how all of your cats react.
• If all cats appear calm and peaceful, let the returning cat out of the carrier.
• If you sense tension between the cats, or if previous home-comings have resulted in conflict, keep the cat in the carrier and take it to a separate room to avoid potential injury from an upset cat.  Provide food, water and litter box for a minimum of 24 hours while it regains the more familiar smell of home.
• If there is still stress after this time, contact the clinic to discuss slower introduction or medication.
• Feliway can help provide the sense of familiarity.
•  For future visits:  Use familiar bedding or clothing with your scent, as it retains the smell of home and helps with reintroduction.  Use Feliway.  Consider bringing both cats to the clinic together. This can prevent future conflict because both cats will carry the scent of the clinic.

The best carriers are inexpensive hard-sided carriers that open from the top and the front, and can also be taken apart in the middle.  An easily removable top allows a cat which is fearful, anxious or in pain to stay in the bottom half of the carrier for exams.  We can often do the exam in the bottom of a well-designed carrier.   Avoid carriers that require a cat to be pulled from or dumped out for an exam. Choose carriers that are sturdy, secure and stable for the cat, as well as easy for you to carry.  Some cats like to see out, whereas others are less anxious when the carrier is covered with a blanket or towel.

You are an important member of your cat’s healthcare team. You can be instrumental in helping your cat have a positive clinic visit and improved healthcare.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)

Outreach Chairman, American Board of VeterinaryPractitioners

Milestones Reached - Thanks Sarah

I found out the other day that I missed an important milestone.  Our head technician Sarah just passed the 15 year mark at the clinic.  Remembering important milestones and personal details of those close to me is on a list of talents I do not  possess.  The list is long and also includes things like singing in tune and dunking a basketball.  Sadly, I may work a lifetime on the list and never improve.

Sarah started at the clinic in 1999 as a volunteer and has essentially been with us the whole time we have owned the clinic.  She rose through our ranks and has been our head technician for a long time.  She is also one of the most skilled technicians I will ever work with.  She has had stints of being my surgery technician and she is as efficient and caring as she is talented.  

She grew up here with us.   She has been there for the growing pains of us becoming bosses.  She was there when were first figured out to have staff meetings every week and when we started the staff newsletter.  She has watched us expand and learn new techniques and was instrumental in developing our policies and protocols for many medical procedures such as chemotherapy.  Sarah watched us fix up the old building, contemplate its replacement, design the new building, move into the new building, and figure out life in the new building.  

There has been struggle and triumph.  I watched as she persevered and studied to became a licensed technician.  I was and am so proud of her achievement.  We have navigated staff upheaval together.  She is a breast cancer survivor.  She is married to a wonderful guy who is her sole mate.   She is an accomplished violinist and I have had the pleasure of accompanying her on the piano.  We once played at an adult music camp together.  She knows more music than anyone I know.  No one loves a “Highlights” magazine joke more than she and she is so funny and shares my sense of humor. She is my friend. Currently, she is pregnant with her first child.

I wish I could manage to acknowledge and thank all those who help me and make my life easier.  It is a daunting task sometimes and I can get caught up in just keeping up.  Sarah has always taken care of me and our patients.  She makes me a better person and doctor and she makes the clinic and those around her better.   

Thanks Sarah, for so many years of dedication and humor and for all that you do for all of us.  I wouldn’t have wanted to try and do this all without you.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)

Outreach Chairman, American Board of VeterinaryPractitioners

The Father Daughter Dance

"Sometimes you can have a whole lifetime in a day and never notice that this is as beautiful as it gets."

·                                 Robin Williams in “The World According to Garp” 

Saturday night was the annual Father/Daughter Dance on Vashon.  My daughter Aubrey and I went for the 6^th time.  She is 17 and I am so very glad she will still attend such an event with me.  This year we had dinner and went to the dance with Steve and his daughter Quinn.  Steve is married to Kristin, one of the clinic’s excellent front staff.  The dance is a splendid event where the daughters get their dads dressed up and go to dinner and then see them attempt dancing.  The last part is not necessarily the good part.  The dance was started by some dads on the island 8 years ago and was sold out again this year.

It was held at the Vashon Country Club and while the dance floor is small there are extensive golf course grounds for the little girls to run around when not dancing.  There is also a lovely deck area where the dessert options may be enjoyed.  The social event is a mix of daughters dancing with dads

and daughters dancing with friends, little girls running about and the non-dancing dads off to the side discussing sports and yard maintenance.  Steve and Quinn and Aubrey and I danced a lot of the night away.  The dance floor area was essentially as hot as the internal core of the sun so we did take occasional golf course breaks.  Steve and Aubrey and I have some rudimentary swing dancing ability and we were not afraid to showcase it.  Aubrey and I have been swing dancing together since she was very little.

I am keenly aware that the remaining number of these dances for me is dwindling.  Aubrey will be a senior next year and has great things to do with her life.  These will most obviously soon involve not living with her parents.  I am both profoundly proud and sad as I watch her write the last pages of her childhood.  It is about living and enjoying the moments and this was a wonderful moment.  I hope to never look back and worry that I didn’t appreciate the moments.  I appreciate them beyond measure.

Quinn is only 9 and this was their first father daughter dance.  I hope Steve has many more.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)
Outreach Chairman, American Board of VeterinaryPractitioners

Julie’s Tree

     It is early Saturday morning and I am contemplating the endless “to do” list that is my life.  All of Comcast is apparently down so I can neither work on stuff nor watch “Sports Center” to see how many times I can catch a replay of the Mariners walk-off win last night.  It has made me pause. My golden Retriever “Violet” and I are having a cup of coffee on our front porch.  To be most accurate, she peed in the yard and rolled in the grass.  We probably both could have gone either way but she doesn’t like coffee and social convention restricts me from her activities.  In between things, she checks in with me to remind me that she loves me and that I am the most important person ever in her life.  I try not to get a big head.  That is what she tells everyone.

     I am looking out on a tree we planted when we moved to our house in 1994.  I don’t actually know what kind it is.  It is a little pathetic that I don’t know; the tree has been in our front yard for 21 years.  When the tree was very small, it was given to us by the dad of a dog named “Julie”.  Julie was a patient of mine that was lost in the early 90’s to Autoimmune Hemolytic Anemia (AIHA).  For whatever reason (infection, drug exposure, cancer, . . .), a patient’s immune system decides to attack its own red blood cells.  The disease is very serious and requires treatment with immunosuppressive drugs and transfusions.  Julie was treated aggressively but her disease was relentless.  Some of the case details are blurred by time but I remember how sweet she was.   I remember the relationship and the trust and can still feel the collective deflation during her decline.  Many patients do survive the disease and today we have better drugs than we did in 1992.  I wonder if she could have responded to the newer medicines.  I think likely not, considering how quickly her disease had progressed, but questions like that often haunt me.  The tree originally went home with Connie and Dr. King because Beth and I didn’t have a place of our own.  A few years later, when we bought our own home, Connie gave the tree to us.

     Julie’s tree is a fixture in my landscape.   I think about losing her and about how she would not have held a grudge for that.  She knew people who cared about her were trying.  Her tree makes me consider all the lives each creature touches and I wonder where her dad is today.  He would be happy to know that she lives on in her tree.  Her presence in the serenity of her corner of our yard gives me hope that nothing good ever truly dies.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)
Outreach Chairman, American Board of VeterinaryPractitioners

Goodbye Friends

We have lost some wonderful longtime patients in the last weeks.  Death is part of medicine and thus our world.  The realities of lifespan play out daily in veterinary medicine.  But, things cycle and sometimes it is harder than others.  I have contemplated blogs honoring my favorite patients many times.  In the interest of fairness, I have not written one.  I didn’t want to leave anyone out.  I have many wonderful patients and owners that make my days worthwhile that I won’t have time or space to mention.  I would never want Prince Charming, Mooshu, or Inca’s moms' to wonder if those special creatures mattered to me.  It just struck me that some of my closest patients were lost in such a short time of late.  These are animals and owners that I have spent countless hours with over the years.

Dingo (2000-2015)

Sundance died last Friday.  Fiona the Friday before that.  We lost Bentley and Hennessey just before that.  Sundance’s brother predeceased him by just a few months as did Bentley’s brother.  These are all animals that I cared for through major medical illness and had come to know well.  They were my friends.  So are their owners.  Everyone at the clinic knew them all well and they had friends in the staff as well.

Sundance and Bentley both were fighting cancer.  Sundance was oblivious to his predicament and wagged his tail throughout his treatment and hospice care.  Bentley’s cancer struck like lightening.  He was also oblivious, as he always was, to infirmity.  He just moved on an enjoyed his time.  Fiona was a funny little creature.  I knew her the least amount of time.  She had been a foundling with a long list of issues.  She persevered though and was adorable.  Eventually, there was just too many issues stacked against her.  Hennessey beat them all for number of ailments conquered.  She had tackled addison’s disease, brain cancer and aspiration pneumonia, among others.  In the end, too much was stacked against her as well.  All of these wonderful beings lived out long lives with their attentive owners.  With each one, we had to contemplate their end of life plan.  With each of their parents, we talked about when it would be time to let them go and how to tell.  I told them, as I often do, that if they did not know if it was time yet, it was because it was not.  When we care so much for another being, we usually come to know how to proceed.

People often empathize with us that this must be the most difficult part of the job.  I appreciate the sentiment but it is not.  It is worse to not make a difference when you think you could.  Being there at the beginning of their lives and taking care of their puppy and kitty needs, then navigating illness and injury throughout life to cruise into geriatric issues is the general practitioners nirvana.  Getting to know their people over a 15 year, or so,  lifespan of their friend, contemplating, diagnosing, treating and fixing ailments is what drives me.  The fact that death will be there at the end is part of the deal.  It is my job to help with all of it.  I want to be there.  Counseling and considering options is an important part of my role and it completes the circle.

I just needed to take a moment and say goodbye to those friends.   You made a difference in our lives.  Thanks for sharing some of your time with me and trusting me and making me want to put my stethoscope around my neck each day.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)
Outreach Chairman, American Board of VeterinaryPractitioners

The Pains of Arthritis

Jack Kraabel

Our Labrador, Jack, was an arthritic old man at the end of his life.  He ran hard until arthritis and age finally slowed him.  Like most Labradors he only had an on and off switch.  It is how it is supposed to be for them.  Arthritis and joint pain are exceedingly common in older patients, especially bigger dogs.  Having perfect joints as an old Labrador is like us dying with money in the bank.  Like most owners, we searched for ways to help Jack in his later years and ended up using multiple medications and treatments to keep him as comfortable as possible.

The signs of arthritis often start with stiffness and soreness after activity and then may progress to lameness and constant pain.  Symptoms may initially be intermittent and advance to persisting constantly.  Chronic arthritis may be due to a single acute injury in the past or to repeated wear and tear on the joints.  Please contact us if you observe pain or soreness in your pet.  Diagnosis will involve a physical examination and possibly x-rays.  The more we know about where a problem is and why it is there, the better we understand our options for treatment.

There are many strategies and approaches to help patients with arthritis.  I like to think of it as a continuum along a patient’s lifespan.  We will have different ways to address issues as the disease progresses.  Early on, at the very first signs of any soreness, we may consider nutritional options to slow arthritis.  Supplements like glucosamine, chondroitin, MSM, vitamin C and fatty acids have natural anti-inflammatory and antioxidant properties and improve cartilage health and joint fluid viscosity.  Supplements have the greatest impact as preventatives and as treatments early on.  A high quality combination product of the above supplements should be started early.  These should be used long term, even if it is difficult to gauge response, in an effort to prevent future problems.

Obesity complicates arthritis.  Extra weight is extra work for the joints.  Thinner dogs move better longer.  We need to strive to keep our dogs at their ideal weight.  

There are several good weight loss diets for older dogs with arthritis that also include added fatty acids and glucosamine to help the joints.  Hill’s Metabolic Plus and Royal Canin Satiety are both excellent diet choices for overweight pets with arthritis.  Please contact the clinic if you are unsure of your pet’s ideal weight or would like help selecting a diet.  As patients progress over time beyond occasional soreness and begin to show lameness, non steroidal anti-inflammatory drugs (NSAIDs) may be prescribed to alleviate pain and inflammation.  Carprofen (Rimadyl), meloxicam, firocoxib (Previcox) and deracoxib (Deramaxx) are the most common NSAID drugs used in dogs.  Human NSAIDs, including Naproxen, Celebrex, and ibuprofen, should not be used in dogs.  Aspirin is often thought of as an alternative arthritis medication, especially at lower doses.  However, aspirin is not a good choice.  Much of the work that has been done to develop other NSAIDs has been done to avoid the side effects of aspirin.  Aspirin will almost always cause some degree of stomach ulceration if used long enough.  Other NSAIDs are safer and more effective.  NSAID usage for arthritis therapy often starts with periodic use.  Pain and ongoing soreness may eventually require daily medication.  These medications are very safe, rarely producing serious side effects.  Routine bloodwork and examinations should be performed to ensure their safety.  Other pain medications such as Tramadol and Gabapentin may be prescribed along with NSAIDs if additional pain control is needed.Other approaches may be helpful for some dogs.   Adequan is a very safe injectable medication that increases the thickness of the joint fluid throughout the body.  It is given by injection weekly at first and then monthly long term.  

Laser therapy also can be helpful in decreasing pain and inflammation in arthritic joints. Typically pets receive laser therapy three times a week for several weeks initially and then monthly thereafter.  We also often refer patients to WellSprings-K9 for swimming therapy and to Dr. Lena McCullough for acupuncture.Newer, novel therapies are available for patients with individual joints that are arthritic.  Stem cell therapy can be used to target the repair of damaged joint surfaces. This therapy uses surgically collected stem cells from the patient being treated.  For more information on stem cell therapy, see a previous blog, “Mojo’s Story”.  Platelet rich plasma (PRP) is a therapy relatively new to small animals but it has been used extensively in people and in horses.  Plasma high in platelets is collected from a patient’s own blood and then injected into an affected joint.  The PRP  utilizes the healing properties of the patient’s own platelets to decrease inflammation.  For more information, see Dr. Nick Paulson’s blog on the subject.Arthritis therapy is a challenging and important part of effective geriatric care.  There are many options and approaches.  Please let us know if you have any questions or concerns about arthritis or pain control in your pet.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)
Outreach Chairman, American Board of VeterinaryPractitioners

Surgical Log. A Typical Wednesday

            The second floor of our clinic houses our kennels, kitty boarding alcove, staff lounge, doctors’ offices, radiology suite, dental tables, treatment area and our surgical ward.  I had the pleasure of helping design the space with Dr. Fritzler years ago and it is a joy to work in.  A client who toured the space referred to it as, “the inner sanctum” and I have called it that ever since.  While most of my week is spent examining patients during appointments, I dedicate one day to surgical and dental procedures.  Wednesday is my surgery day and I will see a combination of dentistry, teeth extractions, routine surgery, diagnostic procedures, growth removals and more extensive surgery.

            The surgical team on Wednesday includes two licensed technicians, Sarah S. and Kirsten H., an assistant, Hilari B., and often one other doctor, Nick Paulson.  This team may vary but this is a team I have had together for some time now.   We work together to accomplish the medical tasks in front of us.  The technicians are your pets’ nurses.  They administer and monitor the anesthesia,  clean the teeth during dentals and take all dental radiographs.  They also administer chemotherapy and prepare animals for surgery.  Assistants also prepare animals for surgery, perform radiographs and other diagnostic tests, hold and recover patients and perform other tasks as they are qualified.  My staff is exceptionally skilled and well trained and we could not provide the level of medical care we provide without them.

            When patients are dropped off the morning of a procedure, it is an emotional and stressful moment for owners when we walk out of the exam room with their pet and head upstairs.  Upstairs is unknown and procedures are unfamiliar and the thought of anesthesia is stressful.  We strive to keep owners aware of progress during and after procedures, though how long a given procedure may take is quite variable and we often find ourselves with unpredictable delays.  Complications or a more involved twist on one animal’s procedure will delay completion of procedures on the remaining patients. 

            Truthfully, there is no typical Wednesday.  I often say that I have quite literally never been bored.  A past Wednesday is a good example as it involved an array of cases.  Moose came in for a dental and tooth extraction.  He broke one of his big shearing teeth in the back of his mouth on his upper jaw.  He was showing no signs of pain; the broken tooth was found on his yearly physical.  On reflection, his mom did think he had been acting differently.  We cleaned his teeth, took radiographs of the affected tooth and surgically extracted it.  Zsuska also had a dental and a similar tooth removed.  She was showing her dad that her mouth hurt.  She is huge and can be aggressive.  Handling her was an additional challenge.  Another older kitty had multiple teeth that needed to be surgically extracted.  These teeth, especially in older animals, can be quite difficult to remove.  It is literally, “like pulling teeth.”  Both animals had a full set of radiographs taken of their mouths.

A pug was in for a minor growth removal.  All the Brachiocephalic breeds (smooshed face dogs such as Bulldogs, Pugs and French Bulldogs) add another layer of complexity to their anesthesia because of their breathing issues.  We have a very specific protocol, developed by Dr. Jeanine Barile, to handle brachiocephalics safely.   Dr. Barile has a strong interest in and extensive knowledge of brachiocephalic medical care. 

Also on that Wednesday, Dr. Nick Paulson performed an abdominal exploratory surgery to collect biopsies and diagnose why a dog was losing weight.  He found Lymphangectasia, a disease that is entrenched in the lymphatic system of the intestinal tract.  It is only diagnosable on biopsy, typically taken during a full exploratory.  There is medication to treat it and the dog should do well.

            We also took several sets of radiographs under sedation, performed an ultrasound on a kitty and removed fluid from around her lungs to help her breathe better.  Kirsten spent time with a golden retriever collecting samples for submission to the Golden Retriever Lifetime Study.  The enrolled animals come in periodically for urine, blood and toenail trimmings to be collected for evaluation. The data will be used to help develop protocols for treating cancer and other diseases in all dogs.

            I enjoy my surgery days, the challenges they bring and their randomness.  Know that everyone who interacts with your pets is skilled and knowledgeable and that we care about our patients and their recovery, comfort and safety.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)

Outreach Chairman, American Board of VeterinaryPractitioners

Marijuana Toxicity

The legalization of marijuana is sweeping the country.  Please keep in mind that regardless of legal status, marijuana is still poisonous to our pets.  Legalization definitely has increased the number of poisoning cases seen by veterinarians.  The pet poison helpline has experienced a 200 percent increase in the number of cases over the past 5 years.

While marijuana toxicity is unlikely to be lethal it still may require medical treatment to recover.  Pets may be exposed to marijuana through smoke, ingestion of the plant, ingestion of foods laced with marijuana such as brownies, candy, butter or cookies, or ingestion of products that contain hashish.  Additional problems may arise if a pet eats products that also contain chocolate.

The signs of marijuana poisoning begin about 30 to 60 minutes after ingestion or much sooner if inhaled.  Signs may include glassy eyes, stumbling and incoordination, vomiting, and pupil dilation.  They may also show signs of excitement and agitation.  Urine dribbling and incontinence may be seen.  More serious symptoms may be changes in heart rate, coma, tremors and seizures.

Recovery may take anywhere from 18-36 hours.  Treatment may involve hospitalization on intravenous fluids, anti-vomiting medications, oxygen, blood pressure monitoring, support of normal body temperature, and even respiratory support in severe cases.  Initial management may involve attempting to induce vomiting and administering activated charcoal.

If you suspect your pet has been exposed to marijuana, please call your veterinarian and/or the Pet Poison Helpline at 1-800-213-6680 immediately.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)

Outreach Chairman, American Board of VeterinaryPractitioners

Dental Care for Cats

What is Dental Disease?

Kittens have 26 teeth, while adult cats have 30. If each tooth can be considered a patient, that equates to a lot of dental care! Periodontal disease is considered the most prevalent disease in cats three years of age and older. The periodontum is comprised largely by the "unseen" portions of the teeth which lie below the gum line, in addition to the gums. Therefore, detection and assessment of periodontal disease can be subtle.

Dental disease begins when bacteria colonize the mouth and a plaque biofilm is formed. Over time, this biofilm mineralizes, and calcifies into tartar. The bacterial population accumulates, which leads to inflammation and results in p
eriodontal disease. Additional factors such as misaligned teeth, systemic disease, nutrition, and genetics may also contribute to disease.

There are four stages of periodontal disease, with Stage One being the most minimal and progressing through to Stage Four. Stage One is the only stage that is considered reversible, through the use of professional and home dental healthcare. This is the reason that the recommended time to begin professional dental evaluations and cleanings is within the first or second year of a cat's life. Professional dental evaluation should be performed thereafter every 6-12 months, and will involve a general examination while the cat is awake, but also may require anesthesia to allow for complete examination. An anesthetized examination will include dental charting, periodontal probing, and  potential intraoral x-rays. Dental procedures (such as teeth scaling and polishing, or surgical extractions of diseased teeth) are often performed at the same time as the anesthetized examination. More frequent dental examinations may be required for patients with severe dental disease; your veterinarian can help to guide you in this process.

In addition to periodontal disease, cats can also develop other dental diseases, including feline odontoclastic resorptive lesions (FORL), stomatitis (widespread inflammation of the mouth), and fractured teeth.

What to Look for?

Signs of dental pathology can include bad breath, dropping food or chewing only on one side of the mouth, facial swelling or draining wounds, bleeding or discharge from the mouth or nose, sneezing, pawing at the mouth, tooth grinding, or discolored teeth. Often there are no obvious signs of dental disease. Most cats with dental disease still eat without a noticeable change in appetite! Discuss your cat's teeth at their routine preventive care veterinary visit.

If you are suspicious of dental disease, an examination by a licensed veterinary professional is indicated.

Home Care

The gold standard for preventative dental home care is tooth brushing. Additionally, a variety of dental prescription and non-prescription diets, treats and toys, along with oral rinses, gels, sprays and water additives have been developed. The Veterinary Oral Health Council (VOHC) provides a list of the specific products which meet certain standards for the retardation of plaque and calculus, and can be found on their website. Home care is not sufficient once dental disease has progressed past Stage One -- only professional dental therapy can effectively treat the more severe stages of dental disease.

Thanks to the AAFP for this information.

Timothy R Kraabel, DVM, DABVP (Canine/Feline Practice)

Outreach Chairman, American Board of VeterinaryPractitioners