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

Anesthesia Fears

      When we recommend a surgical or dental procedure that will require general anesthesia, fear of anesthesia is frequently paramount in the owner’s mind.  Fear of anesthesia is universal.  In people, patients often fear anesthesia more than the procedure itself.  This is true even though patients often are at a greater risk of dying from the procedure than from the anesthesia.   For example, women have about the same risk of dying from an uncomplicated pregnancy as they do from having anesthesia.  The fear of anesthesia is much greater than the real risk.  Though we can’t ever take the risk of anesthesia to zero, the risks are very minimal in animals and people.

     The first anesthesia was used by a doctor at Massachusetts General Hospital in 1846.  Ether was the first agent used; later chloroform was introduced.  In the 168 years since the beginnings of anesthesia, veterinary and human medicine have worked and struggled to improve safety.  We long ago stopped using drugs that were explosive. Current agents also do a much better job of protecting vital functions.  New drugs are constantly on the horizon and we are always fine tuning monitoring parameters and techniques.

       During anesthesia in our hospital, veterinary surgical staff monitors blood pressure, oxygen content of the blood, ECG and blood carbon dioxide levels, among other parameters.  In addition to mechanical monitors, we know, and have always believed, that the best monitor is well-trained staff. At the Lien Animal Clinic, every patient is assigned a licensed veterinary technician who is with that patient from the time they are prepped for surgery until they wake up. The technician administers drugs that relax the patient and provide pain relief, induces the patient and places an endotracheal tube, enabling the patient to breathe oxygen as well as the anesthetic gas. The same technician monitors anesthesia throughout the surgical procedure and is with the patient until it is fully awake following surgery. Our belief is that the technician should act as an advocate for the patient, including requesting additional pain control or other techniques to provide patient comfort and safety.

      Most patients have a blood test before anesthesia ensuring that they are normal metabolically.  All patients have intravenous catheters that supply vital fluids throughout surgery and give us constant access to their blood stream.   All patients are intubated so they can breathe oxygen along with anesthesia gas. This provides additional safety in cases where it becomes necessary to offer respiratory support. 

       We hear quite often that certain breeds are sensitive to anesthesia or specific medications.  This is rarely true. Each patient is unique and our drug and anesthesia protocols are based on what is best for that patient, not on their breed.  A multi-drug approach is the most effective and safest approach.  We add the benefits of certain medications while decreasing the negatives by using anesthesia cocktails with lower doses of individual medications.  Typically, animals receive pain medications with sedative medications prior to anesthesia.  This relaxes them, pre-treats for pain and removes the stress from their experience.  Then, an IV catheter is placed and the patient receives anesthesia-inducing medications.  The endotracheal tube is then placed enabling them to breathe anesthesia gas and oxygen.  Following the procedure, the patient is given oxygen until they eliminate the anesthetic gas from their body.  If appropriate, pain medication is repeated on recovery.

This scenario is exceptionally safe and is our standard protocol.  Know that the care-giving team providing your pet’s anesthesia is skilled and focused on your pet for the duration of its procedure and attentive to its needs through discharge from the hospital.

      Always feel free to discuss any concerns with us about any care your animal may need, including anesthesia or other procedures.

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

Outreach Chairman, American Board of VeterinaryPractitioners

Family Medicine

     The blog I re-posted last week was by Dr. Brita Kiffney.  Brita is veterinarian in Bellingham and is my cousin.  I have always been very proud that we are both veterinarians.  In all the interactions we had as kids I don't ever remember talking about both of us wanting to be veterinarians. We just looked up when we were in college and saw we were following the same path.  I graduated from vet school in 1989 and Brita in 1995. We had this happen again a few years ago when we realized we were both pursuing board certification with the American Board of Veterinary Practitioners (ABVP). We are now both Diplomates of the American Board of Veterinary Practitioners, specialty Canine and Feline Practice, and certified just a year apart.

   
Brita's dad, Paul, is my dad's little brother.  Their dad, Don, was a physician as was his brother, Austin.  Don and Austin practiced together in the Kraabel Clinic near Woodland Park Zoo.   Grandpa and his brother were in practice when penicillin was discovered.  My Uncle Paul tells stories about how magical his Dad's little black bag that he carried on house calls seemed.  He learned later that mostly he could only dispense hope.  Grandpa used to talk about the advent of penicillin ushering in the era where doctors could finally do something.  Our Uncle Al is also a physician and orthopedic surgeon, though he hasn't practiced since the early 90's.
   
Brita and I grew up with our family taking care of us.  I remember going to the Kraabel Clinic. There was a messy doctors' office with shag carpeting and dark paneling and a spot in reception where lollipops were kept.  Helen, the great nurse who seemed larger than life, would always let me have as many as I wanted. My memories are sketchy since I was young when they both stopped practicing and they were both gone by the time I was in middle school.  Our Uncle Al was a great role model.  I spent a lot of time at his office with various orthopedic/sports injuries over the years.
   
Brita and I took the medical legacy in our family into veterinary medicine.  I have always felt medicine was in my blood, even if I didn't chose to direct that towards human patients.   Early in my career, I would see the occasional client that had been a patient of my grandpa or Uncle Austin.  It always made me feel connected across decades to a set of brothers that I only really knew for a short time.  I recognize their contribution to my life in veterinary medicine.

Life has interfered many times and Brita and I have had times we haven't kept in great contact.  But between social media and ABVP that has changed.  We initially reconnected over the ABVP certification process and have stayed in better contact since.  We just got back from the annual ABVP continuing education conference.  It was great to spend time with Brita and our extended group of friends in the organization.
 
Significantly, Dr. Fritzler and I are proud that the family legacy may move into the next generation.  I wrote in a blog before that our sons both want to be veterinarians.  We just found out this week that our oldest son Geoffrey got through the initial application process to vet school and has an interview in January for a spot in the WSU College of Veterinary Medicine Class of 2019.

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

Outreach Chairman, American Board of VeterinaryPractitioners