Most Things in Life are Better Together

I saw Dr. Fritzler’s lab coat across my desk chair the Tuesday morning.  Dr. Zawacki had to leave urgently the day before so Dr. Fritzler saw her afternoon appointments.  Beth doesn't see scheduled appointments anymore.  Her duties in management, book keeping, and business tasks, along with her responsibilities at our other practice, eventually made her decide, a few years ago that she couldn't practice regularly anymore.  She and I had practiced together for 15 years or so and it was great.  It was never too much togetherness.  We saw each others patients and always had each others backs. 

When she stopped practicing, it was a particularly hard transition for me.  For so many years, I would finish an appointment on a Thursday (I am off on Fridays) and say to the owner, "the doctor that will call back tomorrow is my wife".  It was fabulous continuity.  I would be home with our kids and she would call me with a list of my patients and we would go over what was next for each of them.  I felt like I was present even when I was off. 

           

 
 We have a wonderful set of doctors that do a great job following up on my patients.  I just sometimes miss practicing with her.  We can't go back.  And, we don't want to.  As the clinic has grown, we evolved in our different directions - me into medical director and she into hospital administrator.  We belong in these roles.  But, for a few hours that day, we weaved in and out of our rooms together, in our separate appointments, and we were practicing side by side again.  It was nice to step back for moment and remember that time.  

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

Vice President, American Board of Veterinary Practitioners

To see more of our blogs, go to www.lienanimal.com/blog/

The Next Generation of Veterinarians

We found out this week that our own Sarah Kwon has been accepted to the Washington State College of Veterinary Medicine class of 2021.  Sarah has worked tirelessly towards veterinary school admission and this is a culmination of many years’ effort.  

Sarah has been my assistant for several years and she and I work very closely on patients together.  She is an integral part of the care we provide.  From my recommendation letter to the WSU Veterinary school, “Sarah is skilled and excited about veterinary medicine.  She is adept at problem solving and is interested in applying clinical data for the benefit of active cases.  I am ever more committed that she is headed down the correct career path.  I expect her to excel in clinical medicine.  She has the interpersonal skills, compassion, competence, and drive necessary to succeed in school and practice.”  Sarah will be an excellent veterinarian.  The clinic and I will miss her but are so proud of her accomplishment.

Congratulations Sarah!  

I have long told her that she belonged in the doctor inner circle.  Time moves on quickly.  She will go off to vet school in August but it won’t be that long until you may see Dr. Kwon back at Lien.

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

Vice President, American Board of Veterinary Practitioners

Canine Flu Update

There has been recent concern about whether the canine flu is a problem in the Northwest.  We discuss this issue frequently during appointments.  At this time, it doesn’t appear to be a major threat. 
Canine influenza viruses (CIV H3N8 and CIV H3N2) cause a respiratory infection in dogs that is often referred to as 'Canine Flu'. Canine influenza virus (CIV) is one of the causes of CIRDC (Canine Infectious Respiratory Disease Complex) - also called “Canine Cough” or “Kennel Cough”.  The clinical signs of CIRDC include coughing, sneezing, nasal discharge, eye discharge and fever.  Pneumonia may occur as a complication.   

Influenza A, or Canine Influenza Virus (CIV H3N8), was first identified in racing greyhounds in Florida in 2004.  Genetic analysis shows that the original canine influenza virus is closely related to equine influenza virus, suggesting that it evolved from equine influenza virus and jumped species.  The virus has a high rate of causing sickness but a low rate of serious complications.  It is passed directly, aerosolized and can be transmitted on inanimate objects (fomites).  It is easily killed with bleach and other disinfectants and is not known to infect people.  Virtually all dogs are susceptible.  The disease is more likely in populations such as animal shelters, boarding facilities, dog parks, dog shows, or day care settings.

CIV H3N2 emerged in the Chicago outbreak of 2015. This virus is of avian origin and not related to the earlier CIV H3N8 virus.  Recently, two dogs associated with a respiratory illness outbreak in a King County boarding and dog daycare facility had laboratory results indicating H3N2 positive infection through PCR testing.  Since that time, no other cases have been reported and we have not experienced a rise in kennel cough cases.  We did recently test a patient at Lien Animal Clinic suspected to have influenza but the test came back negative.

We do have H3N2 influenza vaccine for use in high risk dogs who frequent shelters, boarding facilities, dog parks, or dog shows. We have not been recommending it routinely.  This certainly may change if more cases emerge.

For more information and ongoing updates, visit the Seattle and King County public health website -  http://publichealthinsider.com/2016/01/12/dog-owners-beware-canine-influenza-may-be-on-the-rise-in-king-county/

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

Outreach Chairman, American Board of Veterinary Practitioners

Medicine From the Other Side of the Exam Table

        I haven’t blogged for a while.  Many reasons.  Certainly when I started to write blogs I intended to produce them uninterrupted until the end of time and maybe a little bit beyond.  But there were the holidays, my many tasks, the kids, etc.  Those things are my responsibilities, joys or distractions, depending on the moment.  The real emotional drain and time sink of late has been the medical issues with my aging parents.  Both parents are in their 80’s and time stops for no one.  The sand runs down the hourglass and time’s conveyor belt moves along its circuit with no pause button.  My mom had complications from a heart surgery that have left her in skilled nursing care and I recently returned from Tucson where my dad had an abdominal aneurysm repaired.  Dad came through surgery and my mom is stable and trying to recover.  It is very different for me being on the sidelines while medical care is provided.  I spend my days presenting options and being in charge of making things happen.  As my wife likes to point out, I don’t like it when I’m not in charge.  The veterinary and human worlds of medicine are not so different.  And, they are worlds apart.  Some things in human medicine are better.   Some aren’t.  The truths and our needs are the same.  We need to understand and participate in decisions.  Patients need to have advocates.  We need hope.  When we can’t have hope, we need honesty.  When we need honesty because we can’t have hope, we need empathy and support.

                In watching my parents care, I saw skill, talent, empathy, genuine concern, innovation, and efficiency.  I also saw indifference, rampant inefficiency, unnecessary roadblocks, resistance to patient advocacy, narrow thinking, and system failure.  Mom’s heart surgeon is the best.  He is an older guy who worked under the original guy who developed some of the first heart valve techniques in the ‘60’s.  I think he did Moses’ pacemaker.  As talented as he is, I’m not sure his team tried to see how prone mom was going to be to complications.  When things went south, the family was really out of the equation.  There was no one specifically in charge.  She was under anesthesia/heavy sedation for more than a week with only a vague plan.  Medicine was in charge of this.  Surgery was in charge of that.  As good as everyone was at their parts, they were individually reluctant to drive the bus.  Without central responsibility, it was hard to decide who to be mad at.  Or, who to direct the advocacy towards.  Her nursing staff was mostly fantastic and was the best at centralizing her decisions and care. 

                My brothers and I flew to Tucson several days before my father’s procedure to spend time with him.  We randomly cleaned his garage.  This had been his wife’s idea so we would throw away, or give away, anything that could be used in a task she considered dangerous.  All plumbing supplies, ladders and power saws needed to go.  Had I known I would’ve brought a bigger suitcase.  When he looks for these things later, everyone can share the blame for their absence or claim it was someone else.  I plan on phrases like, “Terry must have given away your conduit”, “I think Tom put your outlets somewhere”, and “Hmmm.  I don’t remember seeing a circular saw.”  We also organized his shop area, likely ensuring that he never finds anything again.  This was not intentional.  The morning of the procedure my two brothers, dad’s wife, and I waited in surgical waiting.  The chairs were right out of the inquisition on the comfort scale.  The surgery went well.  The doctor came out and updated us.  And then we waited.  Six hours later he final was transferred to an actual room and out of the recovery area.  This was at least 5 hours later than we were told.  It was not anything to do with his recovery, they just didn’t have a room and family can’t come into recovery.  My brothers had to leave for the airport and didn’t see him.  Surgical reception stonewalled them and still said they couldn’t see him.  Dad’s recovery nurse eventually came out and took his wife back to see him and I got to go back a few hours later.  His surgery was a success and we all agree that that was the most paramount issue.  But we have lives as well and need to be kept in the loop.  Either make sure there are enough rooms for the day’s patients or open up recovery to the family.  The family wasn’t an important part of the plan.  There was little consideration within the system for us.  I can empathize with this professionally.  We never get too busy for patient care but we can get busy enough to drop communication and for things to be delayed.  We all do our best but this struck me as a system failure beyond just a busy day. 

                In looking for the silver linings, watching medicine makes me reflect.  Human medicine can do miraculous things and has treatment modalities that we haven’t developed or we under-utilize.  Directed specialization creates healers that are exceptionally skilled and this allows so much care that wasn’t possible not very long ago.  But, it is too big sometimes.  There is disconnect and things get moving at a pace where they don’t stop and check in with the family and patient advocates.  We can do everything; we need to ask ourselves if we want everything.  As veterinary medicine advances and we have more equipment and more options, we need to keep to the things that got us here.  The needs of the patient, not their disease, should drive medical decisions.  The information needed to make those decisions should come through a doctor and staff that know their patient with full participation of a patient’s advocate.  The doctor-client/patient relationship is integral to medicine.  Veterinary medicine is far from perfect but I feel like as a clinic and as a profession we strive to protect this connection.  May we never lose that.

I missed seeing such a relationship at work with my mom and dad.

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

Outreach Chairman, American Board of Veterinary Practitioners

   

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