Man and Man's Best Friend - Remembering Jeff and Partner

            Partner died a number of years ago.  If you asked me when, I would have said it was a few years ago.  I looked it up; he died in 2004.  It seems like I was just in an exam room with him.  I think of Partner often.  He was one of the good dogs.  I see many wonderful patients and wonderful owners and Partner was one of the former.  His dad, Jeff, was one of the latter.  I took care of Partner for the majority of his life.  He was a big German Shepherd that was both serious and silly.  He never enjoyed coming to the vet as much as we enjoyed seeing him.

            We saw Partner a lot during the later three quarters of his life that we knew him.  He was prone to skin infections and allergies.  His skin maladies are common to Shepherds and he took frequent antibiotics to control Staph infections in his skin.  He was also very arthritic in his later years.  We saw him often for Adequan injections for his joints and he took medication for arthritis and pain.  All of this meant that Jeff and Partner knew their veterinarian well.

            Jeff’s daughter called the other day to let me know that Jeff had died.  Jeff was an older man when I met him 17 years ago so I know he had a long life.  To his vet, it certainly seemed to be a happy life as well.  When I met Jeff in the 1990’s, I noticed his address was familiar.  His house was 5 houses from the one I grew up in.  I had been the paper boy for our block when I was a kid.  I remember riding by his house on my bike.  He, however, didn't subscribe to the paper.  I did, eventually, try to forgive him for the slight.  Jeff and I used to talk about “the hood” all the time.   He would tell me the latest.  I would ask about the cast of characters from my time there.  We would reminisce about the old lady that still had her picture window boarded across with plywood and the people that had moved away.  He was bright and funny and had a joyful way about him.  He and Partner were indeed partners in life.  They had one of those special bonds that are a pleasure to watch and fulfilling to experience.  They are what makes veterinary medicine the grand profession it is and the two of them were the type of creatures that motivated James Herriot to put pen to paper. 

I had seen Jeff many times in the years since he lost Partner.  He also had a cat.  It was never as often but when he was in we spoke frequently of Partner.  I think he was the one Jeff never really got over.  I saw Jeff’s own deterioration over the years and watched his memory lapse.  In recent years, his daughter would bring him to the clinic.          

          So long guys.  I said goodbye to Partner years ago but now it is goodbye to Jeff as well.  I trust you are walking together again.  I’m sure Partner's skin is healed and his hips move freely.  I trust also that Jeff is no longer forgetful nor lonely for his friend.  Thanks for stepping into my exam room.  The planet is a better place because you walked on it.

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

Outreach Chairman, American Board of VeterinaryPractitioners

The Controversial Non-Anesthetic Dental Cleaning

Dental care is a complex issue in veterinary medicine.  Perfect dental care for pets is rare.  Complete homecare can be difficult and more extensive dental care has traditionally always required anesthesia. We provide non-anesthetic dental procedures and we believe these cleanings are an invaluable part of a complete dental program.  At our hospital, non-anesthetic dental cleanings are performed by technicians from Animal Dental Care. They are a company of highly trained veterinary dental technicians that come to our practice.

The non-anesthetic dental (NAD) is an oral assessment and charting, teeth cleaning and polishing done with gentle restraint.  The NAD should be used only with patients that have minimal, early (stage 1) dental disease who are easy to handle.  Because the patient is not asleep, it is not possible to mirror all that can be done in an anesthetic dental procedure.  Deeper disease may be missed in non anesthetic procedures.  Behavior issues and patient compliance can interfere.  Dental radiographs, extractions, and some level of assessment simply is not possible awake.  The NAD and the anesthetic dental should be considered as two distinct procedures.  You and your veterinarian need to determine, often along with the trained dental technician, if a NAD is appropriate.  As noted, we have to consider how much dental disease is present and your pet’s temperament.  During preventive cleanings, Animal Dental Care technicians also may find disease that requires further care under anesthesia.

“Dental” procedures are also often done at pet shops and groomers without anesthesia and without the supervision of a veterinarian.  This easily may lead to pets with too high a degree of dental disease receiving incomplete and inappropriate dental care.  There is no benefit to simple removal of the tartar if deeper issues are present.     

Non-anesthetic dentistry is a controversial topic in veterinary medicine.  There are those that believe dental procedures should never be performed without anesthesia.  They believe that it is not possible to accomplish significant dental cleaning and assessment awake.  We disagree with this.  The technicians with Animal Dental Care have demonstrated over many years and hundreds of patients that they can effectively treat early dental disease.  As long as we select the right patients, good can be done with the NAD.  The best times for us to recommend a non-anesthetic procedure are early in life when there is minimal tartar and in between anesthetic dental cleanings when the tartar build up is low.

We believe providing non-anesthetic dentistry for the right patients in the right circumstances is the best dental care for our patients.  Feel free ask us for more information.

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

Outreach Chairman, American Board of VeterinaryPractitioners

Summer Baseball

My first writings were about family and veterinary medicine.  The next most important topic is baseball.  This is because baseball is the perfect game.  The preceding statement is something I no more need to defend than one would need to explain their religious leanings or their belief that their mother makes the best chocolate chip cookies.
              This Saturday was a baseball marathon.  It was all baseball, all day.  Nick, my twelve-year-old, was playing in a tournament.  I spent the day in a comfy fold-up chair with a friend watching our boys play and elusively chasing shade.  We chatted crossword puzzles and baseball.  After the last game, he and I took our boys to the Mariners game.  

The boys played two games in the grueling heat.  I’m from Seattle so “grueling” is anything above 75 degrees.  Though, to be fair, it was 90+ degrees on Saturday.  You could have fried an egg on the pitcher's mound.  Their first game had several good innings but the defense was colander-like and the other team hit too many balls hard.  They lost by a lot.  The second game was worse.  There were moments though.  My son caught two outfield fly balls.  The catcher played well and hit a double.  The pitchers threw strikes and bravely carried on.  They lost by more.  Even from the losing side of the diamond, a day watching baseball is a good day.  We scurried out quickly and headed to Safeco.  Iwakuma was slated to pitch.

We sat in seats close to the field that my family has had since the first season the Mariners played.  I grew up, and my kids have grown-up, in seats behind the plate.  We watch pitches break and hitters buckle to curve balls.  We call pitches with the umpires and question their strike zones.  We watched Ichiro do his on deck routine for many years.  We saw Felix Hernandez break in to the majors and learn to dance his pitches around the strike zone.  I saw Ken Griffey Junior explode on to the scene and I watched Randy Johnson learn to throw “Mr. Snappy”.  I was there for every game of the 1995 division series when Edgar Martinez took out the Yankees and Seattle became a baseball town.  And it is a baseball town.  We may mock the Mariners in their drought of prominence but it is different now.  The discussion goes on today, win or lose.  Pre-1995 was another era.  The Mariners were irrelevant except to the faithful.  The Kingdome echoed.  We could hear the pitchers grunt and the ball hit the catcher's mitt.
              Iwakuma was masterful Saturday.  Kyle Seager and Robinson Cano hit homers.  The team played stellar defense.  The Mariners won and took the second game in a row from Oakland, the best team in baseball at the moment.  It is July and the Mariners are in the conversation.  If the playoffs were tomorrow, they would be the second wild card team.  I spent the game talking baseball with my friend.  The boys were having a great time between embracing the many food choices and being riveted to the game.
           As I looked at the boys and as I watched the game, I was struck by the similarities between the games I had watched.  The later game had more talent to be sure, this game was a touch crisper and the participants made more money doing it.  There is certainly more pressure and greater expectations up here but, at the core, it was still just a bunch of boys playing ball on a summer day.  All the players are thrilled when they get hits and dejected when they don't.  All the pitchers try and outsmart the hitters.  All the boys laugh and congratulate each other for good plays and bask in the camaraderie of the dugout.  When looking around the stands at either game, it is a bunch of people wishing they could play.  If not literally, then at least figuratively.  In our own ways, many of us want to be part of it.  We want to make the pivot at second and throw on to first to complete the double play.  We dream of connecting with an elevated fastball and driving it over the left center fence.  All baseball fields are fields of dreams.

Within those dreams are so many good parts of life and so many of life's lessons.  Things are more fun with friends.  Hard work is rewarded, except when it isn’t.  Failure is inevitable in the pursuit of success. Overnight success takes a long time and an immense amount of background sweat.  You’ll pay more for food if someone carries it to you.  Wear sunblock.  Don’t argue with authority.  Over half the battle is believing in yourself.  Sun, grass and play are the leisure trifecta.  Hope runs eternal in spring.  Tomorrow is a new game. 

Play ball.

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

Outreach Chairman, American Board of VeterinaryPractitioners

Chemotherapy in Pets

            I heard it said once at a lecture by a veterinary oncologist that “cancer” was the scariest word in our language and that “chemotherapy” was the second scariest.  From many discussions over the years, I know that he was right. 

            Technically speaking, the term “chemo” means simply chemicals or chemistry.  Taking an aspirin is “chemo”.  Cancer chemotherapy may involve many different drugs, in an endless mix of protocols, to treat an array of different cancers.  It is just too broad a term to consider by itself.   The details of diagnosis and drugs dictate what the experience may be like and what we can expect as an outcome.  Of course, there are also many individual variations in response and how different creatures handle the medications.  The potential benefits can be profound.  The potential side effects vary widely. 

            We hope for ourselves, our families and pets to never hear either word and to never deal with a diagnosis of cancer.  The medical reality of course is that we do see cancer in pets and it is imperative that we know how to help these animals.  We have seen several cases of lymphoma, one of the most common cancers in dogs and cats, at our clinic in the past several weeks.  The diagnosis is devastating.  But, despite the aggressive nature of the disease, there is room for hope.  Chemotherapy can extend the quality and quantity of life significantly for most patients.  Toxicity and feeling sick on the chemotherapy drugs are a real concern and an important consideration.  But the vast majority of patients brave through therapy with few to no side effects.  A typical chemotherapy protocol for lymphoma involves 5 drugs used in 16 treatments given on a schedule over 24 weeks.  Two of the drugs are pills given at home and three of them require brief time at the clinic to administer.  Frequent blood tests are used to monitor patients.  We try to minimize the time animals are with us at the clinic.  

People commonly worry that their pet will feel sick for the whole time they are being treated.  We just would not tolerate that.  The animals can feel lethargic and even have some diarrhea or vomiting after some of the treatments but side effects are usually mild and transient.  Dogs and cats rarely lose hair.  If significant side effects occur, we may delay subsequent therapy or skip those specific medications when they come up again.  If necessary, we may even decide to forgo further chemotherapy.  Each successive treatment is an active choice based on the response to the preceding one.   It is a mantra of therapy, and cancer care in general, that we won't allow vomiting or diarrhea and we will alleviate pain.   Lymphoma is a disease we most often make a positive difference in the lives of our patients and owners.  There are many other cancers that we have effective treatments for as well.

I am also a strong advocate for complimentary medicine and alternative care.  My patients that receive acupuncture and herbal medicine from Dr. LenaMcCullough, along with chemotherapy, do the best.  In my experience, they have the longest survival, the fewest side effects and the best overall experience trying to combat their disease.  Visit her website, www.kingdomofbasil.com, for more information.

Should you ever face a cancer diagnosis for your pet, remember that there is hope and there are options.  I often say and truly believe that our pets have an enormous advantage over us.  They will never stop and ponder their diagnosis or prognosis.  They never look at the dog next to them and compare their good or bad fortune for the future.  They just take the next moment as it flows by and the tomorrows as they become known. 

May you never need any of this information.

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

Outreach Chairman, American Board of VeterinaryPractitioners

Drug Sensitivity Testing in Dogs (MDR1)

  Many dogs, especially herding dogs and herding cross breeds, carry an abnormality in the multidrug resistance gene (MDR1).  This makes them very sensitive and reactive to certain drugs.  Such drug reactions can cause serious neurologic disease and even death.

 
Collies and Australian shepherds are very commonly affected but English Shepherds, herding cross breeds, German Shepherds, Long-Haired Whippets, Shelties, McNabs, Old English Sheepdogs, Border Collies, Silken Windhounds, and mixed breed dogs may also be affected.  Since herding breeds and their crosses are so over-represented with this problem, and commonly have white feet, you can remember it as “white feet, don’t treat”.
P-glycoprotein 1 (permeability glycoprotein) is the multidrug resistance protein.  It sits in membranes in many areas of the body, like the intestinal tract, kidneys, liver, adrenal glands, and nervous system.  MDR1’s job is to pump things out of the cells and regulate what things get into the brain and nervous system.  When animals have a mutation of the MDR1 gene, drugs and toxins can accumulate in unexpected and dangerous levels.  Dogs can have 0, 1 or 2 copies of the gene.  One copy of the gene may result in sensitivity and mild reactions to a given drug; two copies would lead to more severe reactions.

The drugs implicated include a broad range of medications.  The antidiarrheal medication imodium, the antibiotic erythromycin, and antiparasitic drugs such as ivermectin, milbemycin, selamectin, moxidectin, and emodepside [Profender] may cause neurologic toxicity.  Some medications will have an increased sensitivity.   These drugs include the sedative acepromazine, the pain medication butorphanol, and the chemotherapy agents doxorubicin, vincristine, and vinblastine.

The signs of toxicities may vary and will have an onset of 24-48 hours post administration.  Animals most commonly show excessive sedation, salivation, vomiting, and a slow heart rate.  They may also have dilated pupils, tremors, a wobbly gait, and disorientation.  There is no antidote or specific treatment.  Patients have to be supported until the medications can completely wear off.  This may involve many days, or even weeks, of hospitalization including fluids, nutritional support and sometimes a ventilator.  The diagnosis is based on medication exposure and suspicion.

Thanks to the discovery of the mutation of the multidrug resistant gene and the establishment of testing by the Washington State University College of Veterinary Medicine (my school), we can predict these drug sensitivities.  The American Animal Hospital Association and the American Veterinary Medical Association together offer a set of Canine and Feline Preventive Healthcare Guidelines. They recommend that dog owners use genetic testing—like the MDR1 test —as part of an overall healthcare plan for their pets.  The Lien Animal Clinic recommends testing all dogs with potential herding ancestry and considers testing mixed breed dogs. Testing at our clinic involves taking a cheek swab or a blood sample and submitting it to the WSU laboratory.  

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

Outreach Chairman, American Board of VeterinaryPractitioners

Spay and Neuter Project in Costa Rica

Veterinary Medicine On Location

  Welcome to my first blog post!  I have intended to start a blog for some time.  I love to write and there is so much medicine to discuss and many stories to tell in veterinary medicine.

Dr. Fritzler and I love to travel.  We have long thought we could combine travel with providing veterinary care in under-served areas of the world.  Such an opportunity presented itself this spring and our family went to Costa Rica with Critter Care International on a spay and neuter project.  Our friends and colleagues, Dr. Stan Diment and Susan Savage from Orlando, Florida, have been traveling to Arenal, Costa Rica with this group since 2011.  They asked us to join them on this trip and it was a worthy journey. 

Several days of the trip were spent at a local Arenal home providing low cost spays and neuters.  The home had an outdoor area made up into a surgery ward and there were many willing volunteers and lots of animals.  We felt a bit like rock stars pulling up in our van full of the veterinary health care team.  Dr. Diment, Dr. Mario (a local veterinarian), Dr. Fritzler and myself performed the spays and neuters.  Our kids, Geoffrey, Aubrey and Nicholas, were along as assistants along with Keri, a volunteer who came with Dr. Diment and Susan.  We treated a few sick animals as well and repaired a wound on a dog that showed up.  A bunny also came in for me that needed extensive dental work.  Susan Savage is a licensed technician and handled all the anesthesia.  The group of volunteers handled everything else including admissions and manning the recovery ward in the homeowner’s bedroom.  It was certainly different than what we are used to in the United States but we provided good care and helped a lot of animals.  Dr. Diment and Susan have seen the pet overpopulation in the town of Arenal drop significantly over the years they have been visiting.

Costa Rica is a beautiful country.  We stayed in a small bed and breakfast with an innkeeper from New York named John.  He had 3 wonderful great Danes and a lovely house with a view of Lake Arenal.  We took a few days off and went on a river cruise near the Nicaraguan border.  We saw Caiman and monkeys and tons of birds and had a relaxing day on the river.  We also spent a day zip lining, which was very cool, but not relaxing.  We loved the local cuisine and the people were welcoming and gracious.  The people of Arenal in particular were thankful for our help.  A husband and wife team, Balo and Emily, were our drivers and we loved and bonded with them immediately.  We spent the last two days in the town of La Fortuna before flying home.

The experience was life changing.  It was difficult to do surgery outside of our comfort zone, but we adjusted to the conditions and everyone did well.  Our kids, at least two of whom want to be veterinarians, got exposure to lots of surgery.  We all saw another unique and beautiful part of the world while feeling like the place was a bit better off for our visit.

 

 

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

Outreach Chairman, American Board of VeterinaryPractitioners