For the blood is the life... Part one

Watch out, haemophobes! This one is about blood - specifically, blood transfusions in dogs and cats. For the first of this two-parter, we're going to have a look at how you might end up wanting to give a transfusion in the first place, before we get down to the meaty stuff in part two. Before we get too carried away learning about motion lotion, though, here's a quote from one of the true horror greats to get us in the mood:

'Something was pouring from his mouth. He examined his sleeve. Blood!? Blood. Crimson copper-smelling blood, his blood. Blood. Blood. Blood. And bits of sick.' 

Garth Marenghi, Slicer

Thank you, Garth. Blood. We all have it (unless you're a 13th generation cyber-mind reading this in the thirty-fifth century, but I can only cover so many angles with my writing) and we all have an idea of what it's for: to take oxygen out of your lungs and transport it to all your other bits to prevent them from being dead. It has other uses too, but this is the one you will be most concerned about if you start to run out.

Let's do a bit of jargon de-tangling here - us medical types love our jargon (see this post on the subject). The medical prefix for blood is 'haem' (or heme if you prefer; you know who you are. Go on then, just this once, I will do you a favor and leave the 'u' out of that favour. Happy now?). So: haemophobia - fear of blood; haemorrhage - blood loss; haematuria - bloody pee - and so on. Lack of blood - specially red blood cells, the Werther's original-shaped cells packed with the oxygen-loving haemoglobin that do the donkey work of moving oxygen around - is known as anaemia (presumably because anhaemia is awkward to say), and in its severe forms is what is going to make us reach for the blood bags.

Anaemia (and, so y'know, there's a lot more to know about anaemia, but let's keep it simple) is the most likely reason that you're going to find yourself at the business end of a blood giving set, and my extensive study of human literature has revealed that commonest form of human blood loss is, of course, vampiric attack. For dogs and cats it's a little different. We are not, at least in general practice, ER (my close resemblance to George Clooney to the contrary). If an animal has suffered such severe blood loss in an accident that it is in immediate need of a blood transfusion, then I'm afraid it is very unlikely to survive - principally because in general practice we are not allowed to store animal blood products, and so the dog or cat is going to have to wait for us to find a donor animal and drain it before it gets a snifter of the good red stuff, by which time it is highly likely to have given up waiting in a terminal fashion.

So, for vets in general practice at least, the most likely reason we are going to want to give a blood transfusion is either due to a slow semi-controlled bleed (like a ruptured splenic tumour) or expected blood loss (which reminds me of one of my lecturers telling us about attempted surgery to remove a tumour from a dog's aorta - the main artery from the left side of the heart; the vessel ruptured and our lecturer, a master of understatement, told us that the dog 'experienced brisk haemorrhage' which later had to be scrubbed off the ceiling of the op theatre), or because of IMHA.

IMHA

IMHA stands for 'Immune-mediated haemolytic anaemia' - please don't switch off, we can get through this, don't worry. Haemolytic anaemia we can already work out - lysis is the medical term for cells breaking down, so 'haemolytic anaemia' just means 'red blood cells breaking down, leading to a lack of blood cells'. I think HA is punchier, though.

As for Immune-mediated - well, as it sounds, this just means the disease is mediated by (i.e. caused by) the immune system going a bit tits up. Lots and lots of diseases are immune-mediated - all allergies, for instance. Just like The Force, the immune system is a powerful tool, but it can be used for evil as well as good. In IMHA, the immune system has decided that red blood cells are invaders and must be destroyed without mercy. Anything that stimulates the immune system - infections, drugs, and yes, sadly even vaccinations can trigger the immune system off in the wrong direction. Regardless of the In a grim parody of the Russian Revolution, all throughout the blood vessels, red cells square off against white. And red always loses.

The treatment for IMHA, like many of the immune mediated diseases, will be familiar to IT professionals. Switch the immune system off as quickly as possible, then let it come back online slowly and hope it's calmed down a bit. Steroids are the cheapest and most-frequently used drugs to do this, though there are a number of others. The problem is, it takes time for the immune system to stop popping the red-blood cells like an overactive needle-armed toddler in a balloon shop, and during that time the anaemia can reach severely (and frequently fatally) low levels.

PCV

Another definition for you (sorry) -Anaemia is - or at least can be - measured by the Packed Cell Volume - or PCV. If you spin down blood in a centrifuge, all the red cells will squish up together at the bottom of the tube, and the PCV is just the percentage of tube that is filled by these red cells - the lower the PCV, the fewer red blood cells you have. Dogs and cats normally have a PCV in the 30-40% range. Unless they're planning to run a marathon any time soon, they're going to be fine until it drops below 20%, where they're going to start looking a little tired. By the time it drops below 12% they're heading into trouble and are probably going to need a transfusion very soon. For dogs, if it drops much below, say, seven or eight percent, they are in serious danger of death. Cats seem to tolerate very low PCVs a little better, and I've know a few survive even with PCVs of five or six - but it's still brown-trousers territory for the clinician involved.


So, for whatever reason, we have a dog or cat with a worryingly pale gum colour and a PCV that is making us sweat. What now?

Let's talk about that in part two (although - spoilers - it involves sticking more blood into the animal).

Lingua Medica - medical terminology deciphered

It has, of course, been literally the worst week for the English language ever. A bad week for me, certainly; how am I supposed to snigger in a superior and condescending fashion when one of our nurses tells me that 'When the phone rang, I literally turned round and shit myself.'? Sigh.

All is not lost for me, however. Fortunately for me, I have a whole language that was pretty much custom-designed to make me feel superior to normal mortals: medical terminology.

You see (and this may come as a surprise to you, so I'll whisper it) - many years ago, doctors didn't actually know very much. Sure, they could prod you, and prescribe leeches to suck blood out of you, but it couldn't really escape the notice of the general population that your chances of getting better with the treatment weren't dramatically better than the chances of getting better without. A poser. How could one make a living as a quack when it was patently obvious that you didn't know what you were talking about?

The solution: make it sound like you know what you're talking about. Language is, and always has been, a useful tool for those in power to keep the masses subjugated; Orwell's Big Brother understood this, with his doubleplus sinister idea, NewSpeak, and the founders of the Christian religion understood it too. Latin survived as a language largely because it wasn't understood by the poorly educated masses. The bible was always written in Latin so that churchmen (who had a similar credibility problem to the proto-medics) would be able to interpret it for the poor - and thus control the poor. If you know your history, you'll know the violence and consternation that surrounded the eventual translation of the bible into languages that everyone could read, and if you don't - go and read about it! Fascinating stuff.

In a similar spirit, early practitioners of the medical arts realised that suggesting to a prospective patient that 'I'm going to suck out a lot of your blood and hope that you feel better,' tended to garner a less-than-enthusiastic response. However, if you told them 'I'm going to perform a phlebotomy in order to balance the humours within your body,' people tended to nod, smile hopefully, and (crucially) hand over their coins.

And so medical terminology developed largely as a way of keeping knowledge (or lack of it) from the masses. As medical arts slowly transformed into medical science, it became more than that, however; much of medical language has a very specific and precise literal meaning (unlike, ironically, 'literally', any more - in fact, my money is on 'ironic' to be the next one on the list) which can get across a lot of information very quickly, and nowadays it's an invaluable tool to precisely explain your thoughts on a case in terms that, in theory, mean exactly the same thing to any medically trained personnel who reads or hears them.

I've been told a number of times that learning the medical lexicon is like learning another language. I'm suspicious of this claim...

(certainly there's nothing in medical terminology to compare to my excruciating 2nd year French classes, where Mrs McKee used to point at random suspects in the class room and utter the dread nonsensical phrase 'Eresbotty' in a low growl (everyone else in the room seemed to know what she meant, and after a few lessons I was afraid to ask; fortunately, fate never selected me for such punishment and it was only several weeks into term that I realised she was saying 'Error Spotting,' meaning they had to comment on the next pupil's French skills. I'm not sure why I was considered a bright child, to be honest)

... but I can't deny that I get a certain thrill from being able to say that I'm suffering from post-prandial narcolepsy, rather than 'I'm feeling dozy after eating'. However, I am, as you may be aware, a writer as well as a veterinarian, and as a writer it's my job to attempt to make my thoughts as clear as possible. In the spirit of this, I'd like to offer you up a number of medical terms, and explain to you what they mean, how they're useful (and, hopefully, regain some of my sense of patronising superiority that has been cruelly snatched from me by the opening up of the word literally).

1. Shock

I know, I know, it doesn't have ology at the end, or sound particularly clever - but it's a word that arises often in emergency situations - 'Is he in shock, doctor?' (I do get embarrassed when clients call me doctor, but I'm far too polite to correct them. Okay, okay, I get a thrill out of it too).

I chose this one because it's a good demonstration of the preciseness of medical terms - shock, in medical language, does not mean 'surprised' or 'pissed off that a car has just hit them' but that the patient's tissues are starting to run dangerously low on oxygen, because there isn't enough blood getting to them. Shock is further divided into several categories which more precisely define why the blood isn't getting where it needs to be, such as: cardiogenic (the heart isn't pumping the blood around the body properly), hypovolaemic (literally 'low volume' - you've lost a lot of blood), endotoxic (the blood vessels have become leaky due to infection; you've still got all your blood, but it's leaked out of the blood vessels). It's a useful and descriptive word, and nothing at all to do with the emotional shock experienced when, say, discovering that your evil twin brother has been performing an elaborate decade-long revenge against you culminating in them stealing your job and knocking off your wife. For instance.

2. Cranial/caudal/medial/lateral/dorsal/ventral/left/right

These are among the first medical terms I learned; they're all terms used orientate yourself anatomically so that you can describe exactly where on the body you have encountered a lesion or abnormality. Fans of Jaws (and this will, presumably, include all my readers, as it is literally the greatest film ever) may be familiar with 'dorsal', due to the terrifying image of that grey triangle slicing silently through the water, signifying the arrival of Bruce the Shark. The triangle is Bruce's dorsal fin, named because 'dorsal' means 'on the same side of the body as the spine'. Ventral means the opposite - the side of the body opposite to the spine, so that your belly button is on your ventral abdomen (and if it isn't, a trip to the doctor's may be in order, if you haven't been already).
'Cranial' means, perhaps unsurprisingly, 'towards the head', whereas 'caudal' means towards the tail - so your stomach is cranial to your colon, but caudal to your lungs (unless you really are in trouble) - and you'll see that these terms can refer to internal as well as external anatomy.
'Medial' means towards the midline (i.e. towards the spine) and 'lateral' means away from the midline - so your thumb is (usually) medial to your little finger, and both your eyes are lateral to your nose.
I include left and right as an anatomical point of order - such terms are always from the patient's point of view, so 'left eye' means 'the patient's left eye'.

There's a whole load more of these, for more precise localisation - 'buccal' and 'lingual' for 'on the same side as the cheek' and 'on the same side as the tongue', for instance. Hopefully you can see these terms are very useful for medics, and this help you to understand such gobbledygook as '3mm ulcerated lesion approx 2cm caudal and 3cm medial to most cranial nipple right hand side'

3. Acute and Chronic

A little like shock, these terms are occasionally used correctly, but more frequently abused, by the general public. Taking a history, I often see acute and chronic used as descriptive terms for how severe a condition is, so let's be specific - from a medical point of view, these words say nothing about a condition's severity - all they tell us is about is how long you've had the condition.
'Acute' means the condition appeared suddenly, and has tended to change rapidly - this means, of course, that acute conditions also tend to be more severe when we see them, and more likely to be a crisis - but the term in itself merely means sudden onset, rapid change.
'Chronic' conditions are the opposite - slow to develop and cause symptoms. There can be mixing of the terms; often a chronic disease will arrive in our practice in an acute crisis, because that tends to be when you notice something going wrong.


4. ...otomy/...ectomy/ ...ostomy


Ahh, now we're getting to the good stuff - the Greek. The above are suffixes that we apply to parts of the body to explain what we've done to them, only to do it in such a way that makes us sound clever.

'...otomy' means to cut a hole in something. So, instead of saying 'I have cut a hole in your dog's stomach', we can instead gravely pronounce the far sexier 'I have performed a gastrotomy.' It works with anything you can cut a hole in - bladder (cystotomy), small intestine (enterotomy), large intestine (colotomy), chest (thoracotomy) and so on. To perform a phlebotomy, as mentioned above, you make a hole in your patient's vein so the blood can leak out - usually done nowadays with a collection tube to send the blood for analysis.

'...ectomy' - remove entirely. So, no languishing in the 'I cut your cat's kidney out' for us - nope. We performed a nephrectomy. Works for anything you can chop out, so enterectomy (section of intestine), hysterectomy (uterus), orchiectomy (testicles). The ancient Incas were, of course, skilled practitioners of cardiectomy, although this is generally not good news for the patient.

'...ostomy' means to create a permanent hole in something. We don't do this very often in veterinary medicine - possibly the most common operation (and it's not all that common) would be a urethrostomy, a procedure where we permanently open up a male cat's urethra (the tube that runs from the bladder down through the penis) to prevent it getting blocked (stop wincing, men! It's a life saver) although you may be more familiar with a colostomy, performed in humans with damaged or blocked bowels.


5. Hyperplasia/ Metaplasia/ Neoplasia

All to do with tissue growth - or, more to the point, cell growth. If you have hyperplasia, then the organ in question is perfectly normal, but bigger than it should be. This is rarely anything to worry about, but occasionally this can cause trouble if you haven't got a lot of room somewhere. Prostatic hyperplasia - enlargement of your prostate gland - a common ageing change in men - is the reason is gets harder to pee as you get older, owing to the fact that the prostate gland is annoyingly wrapped around your urethra.

Metaplasia is change from one type of cells to another type of cells, usually as a result of some kind of injury or stress. It's reversible (usually if the stress is removed), and benign, and we don't see it all that often - usually because by the time we find out about this, the cells have moved onto the next stage, which is...

Neoplasia. The medical term for cancer. Similar to metaplasia, except that once they get to this stage, the cells aren't going back to their previous state. They're very different cells to the ones that should be there, and unlike normal cells, which know when to stop growing, they just keep dividing. This, as I'm sure you're aware, causes all manner of problems, which I won't go into know. Neoplasia doesn't necessarily mean a malignant tumour - a wart is a form of neoplasia.

For the record, neoplasia, cancer and tumour are all synonyms - none of them mean malignant or benign by themselves, although 'cancer' tends to be used to mean malignant, nowadays (If I'm being pedantic, tumour simply means 'swelling', in the same way that 'rubour' means redness, but almost no-one uses it in this context any more). The difference between a malignant and a benign neoplasm is not clear cut, but it's related to how they behave. Benign tumours tend to stop growing when they reach a natural tissue boundary, and not spread via the lymph tissue or blood. Malignant tumours, unfortunately, are less respectful of tissue boundaries.

6. Idiopathic and ...opathy

And now we really enter the realms of sounding clever, without saying an awful lot. Very, very helpful terms, these. Idiopathic means, effectively, 'we don't know'. More to the point, it means that the consensus of medical opinion is still unsure as to the cause of this problem. So, when I tell you that your dog has 'idiopathic vestibular syndrome', I might be sounding very knowledgeable, but what I'm really saying is that you dog has a condition that no-one in the veterinary world quite understands.

That's not to say this term isn't helpful - just because we don't understand where a condition comes from, doesn't mean we can't treat it, or at least recognise the pattern of the disease - idiopathic vestibular syndrome, for instance, has a well-understood course (i.e. it usually gets a lot better within 24-48 hours) and, if I write it on my notes, other vets who read it will know what I'm thinking. I'm just telling you that it's a shorthand way of us saying 'Oh, it's that thing where their balance centre goes wrong, but usually gets better again'.

...opathy is along the same lines. It's another suffix, and when attached to a particular organ, it means 'something is wrong with it'. Brilliant, eh? Works with anything. Pneumopathy - lung disease. Dermatopathy - dodgy skin. If I tell you that your hamster has an 'acute idiopathic hepatopathy', I'm telling you that your furry friend's liver has gone wrong. I don't know how, or why, but at least I can tell you it happened pretty quickly.

7. Iatrogenic

A classic face-saver. Iatrogenic means caused by medical examination or treatment. In other words - that thing that's wrong with your pet? I did that. So, iatrogenic Cushing's disease is caused by your vet giving your pet too many steroids. In you vet's defence, they may have had no choice, because the disease that they're giving the steroids for is probably more severe than the Cushing's disease they're creating.

Iatrogenic haemorrhage is a euphemism along the lines of a surgeon tell you 'I'm afraid he lost a lot of blood during the surgery'. He didn't lose it - the surgeon did. It's nice that we have a special word for our balls-ups.

8. Borborygmi

Finally, I wanted to make special mention of my favourite word in the whole of veterinary medicine. It's pronounced BOR-BOR-IG-ME. Say it with me, because this word is onomatopoeic - which is to say, it sounds like the thing it's trying to describe.

Borborygmi is the medical term for the sound of stomach gurgles. Say it again out loud, and tell me that isn't the greatest word ever invented. Literally.

The Bluffer's Guide to Neutering

Firstly, congratulations are in order, for today is graduation day for the veterinary students of Nottingham University - well done, new vets! Well-deserved! My lord, you all look so young. I hate you.

Ahem. Apologies. Also, I don't hate you. You have a long and likely happy career ahead of you, but you've got a bit of a learning curve ahead of you now. Well, okay, not so much a curve as an Everest.

Thinking enviously about your cheerful, fresh faces, has got me thinking about being a new graduate myself, you see, and of all the things I started worrying about the moment I realised that bloody hell, I had only bloody qualified as a bloody vet!

I'm good at worrying (and at whinging, as regular blog readers are no doubt aware). After I graduated, I was at the very height of my worrying powers, and could probably have worried for Team GB. Amongst the many, many things that I worried I wouldn't be able to do (blood sampling, consulting, driving the practice car without writing it off (it turns out I was right to worry about this one)) one that loomed very, very large in my mind was surgery - and, particularly, given my woeful experience at the time of graduation (five cat castrates and a half a dog castrate), neutering.

Neutering. The bread and butter of the general practioner's day. If you can't neuter something, you might as well hang up your stethoscope before you've even bothered to (very cooly) drape it around your neck.

I am here to tell you, new graduates, not to worry about it. Well, that's not entirely true. I'm here to tell you why it's totally pointless worrying about it (a subtle distinction), by showing it to you from my perspective as a equally fresh-faced, enthusiastic new graduate; and I'm going to do that (along with telling everyone else what neutering actually entails) that with the aid of my (please insert a fanfare mentally at this point)

BLUFFER'S GUIDE TO NEUTERING! (Or, how I stopped worrying and learned to love the ops)

(You didn't do that fanfare, did you? Tsk)

Neutering is the generic term for removal of an animal’s reproductive ability. For males, it’s castration (removing the testicles. You might think this is rather too obvious to spell out, but I have, in my career, been confronted by a furious owner demanding ‘where the fuck’ her dog’s testicles were after I had castrated him. A few awkward moments passed while I explained the procedure that she had signed for that morning. The owner had been under the impression that castrating her dog merely meant ‘giving it the snip’. She was especially annoyed because now, all the other dogs in the area would pick on him because they would spy his conspicuous lack of love spuds, and realise that he was an easy target. We sorted it all out in the end but it was, as I say, an awkward consultation). For females, it’s speying (or, if you’re American, spaying; all I’ll say on the matter is that you’re wrong about grey, and you’re wrong about this).

Castration is a relatively simple (if eye-watering, for male readers) procedure in both dogs and cats – relatively low risk exercises in ligation (tying off blood vessels) and suturing. As with all surgical procedures, there are a few variations in technique, based on personal preference, but they were good procedures for my new-graduate self to sharpen my surgical teeth on (if you’ll forgive the slightly disturbing mental image that metaphor creates). Speying... speying is a different matter. The medical term is ovariohysterectomy – the surgical removal of both the uterus and the ovaries (As opposed to the human hysterectomy – removal of just the uterus (hystera being the Greek word for uterus, and the same root word from which we derive the word hysteria – which probably tells you all you need to know about the male attitude towards women throughout history)) is much more involved surgery. The ovaries are inside the animal – just below the kidneys, to be precise – and so harder to get to. Ligation is trickier, because the blood vessels supplying the ovaries and the uterus are similarly harder to manhandle into a position where you can tie your knot (incidentally, our domestic pets don’t suffer from hormone deficiency problems in the same way that humans do, on account of having a different reproductive cycle – the oestrus cycle, as opposed to the human (and other primate) menstrual cycle. This explains both why female dogs and cats don’t go through a menopause as they age, and also why humans don’t come on heat – which is why you never see un-neutered male humans leaving their homes searching for other women. Oh, wait...)

With cat speys, the added complication, just to make things interesting, is that in the UK we have decided to make the flank approach to the uterus our approach of choice. Flank means what it sounds like – making an incision in the side of the cat’s abdomen, rather than the midline approach that we choose for every other abdominal surgery we ever do. I’m still not entirely sure of the reasoning behind this; I’ve heard arguments that it’s quicker, that you get less post-operative reactions, or that if you get a hernia it tends to be less serious in the flank – but I’m not convinced by any of them. A well-practised surgeon will be equally speedy with either technique, I’ve see my fair share of post-operative reactions with flank cat speys, and if you get a hernia then you need to surgically repair it whichever hole the internal organs happen to have popped out of. I can just about see the argument that it’s a useful technique for animals that are lactating, because your wound is further away from the teats, and so the mother is less likely to reject the kittens when they come to suckle. You’re less likely to get milk leaking into your wound and causing an infection (because if there’s one thing that bacteria love, it’s a bit of milk) – except that in lactating dogs we still operate midline and don’t seem to see any of the attendant problems.

The main problem with the flank cat spey is that if you make you incision in just the wrong place it is an absolute bugger to find that bloody uterus. In these early months of my career, I spent many, many hours peering into a cat’s abdomen, fruitlessly searching for its reproductive organs like Gollum forlornly searching for his lost ring, only to discover that I had yet again failed to penetrate the peritoneum (a thin membrane coating the abdominal organs, that shrink-wraps them away from hapless surgeons that fail to make their cut deep enough), or that my incision was to dorsal, or too ventral, or (on one occasion) so far back that I had managed to enter the poor cat’s abdomen through the muscles of its hind leg; this last individual seemed fine when it woke up but I made sure it had extra pain-relief at home. Even though my days of elusive uteri are long behind me, I have spent enough hours since helping out stressed and sweary foreign locums attempting this strange technique to wonder why it is we persist in our approach. Tradition, I suppose. I guess it's no weirder than putting trees in our houses at Christmas.

The last, and by no means at all the least of the ‘routine’ neutering procedures is the bitch spey. Ahh, bitch spey, my old nemesis. The bitch spey is the same surgery as a cat spey, in that you’re performing an ovariohysterectomy, but it’s much, much harder. I would contend, in fact, that speying a fat deep-chested dog is about the most difficult surgical procedure you’re likely to encounter before you start entering the realms of certificate-level surgery. There’s a feeling that only surgeons know – a warm, prickly, feeling, experienced during an operation that isn’t going very well; the surgeon’s sweats, we’ll call it: a terrible feeling that you want to escape, you want to be anywhere but standing here in this hot, humid operating theatre wondering what the hell you are going to do to sort this mess out. In my early years, I came to associate bitch speys with the surgeon’s sweats.

Here’s how I saw it: a bitch spey is a no-win procedure. You’re starting with a completely healthy animal who, given the choice, would probably rather not have you ferreting about in its abdomen, and you’re performing major abdominal surgery upon it. Those blood vessels of the ovaries, those difficult to get to ones up by the kidneys, are no small potatoes. If you don’t ligate them properly, the dog could bleed to death. Now, it’s worth pointing out that in my decade (and a bit mumble mumble) as a veterinary surgeon since, I have never once seen or even heard of a bitch spey bleeding to death either during the procedure or afterwards (although I have seen a handful need to be re-operated on to re-tie oozing blood vessels) but the knowledge that it was at least theoretically possible was very much on my mind as I learned my surgical skills. When abdominal fat, which obscures your vision and makes everything – including your suture material - as greasy and slippery as a bacon sandwich, is added into the mix, then you have a recipe for a young veterinary surgeon such as myself turning the air blue as he attempts to complete a procedure that he wishes he had never started, in the full blush of the surgeon sweats (although, apparently, it's not when I start swearing that my nurses get worried nowadays; it's when I stop swearing and go quiet). As well as that horrible feeling, I discovered to my surprise that during a long, hot and unpleasant surgical procedure is the time that I seem most likely to be afflicted with an ‘earworm’ – the internet term for a song repeatedly playing unasked in your head. There were many times in my younger days when I stood with my hands placed inside a still-living animal, surgical gloves covered with a slippery sheen of fat, feeling hot, stressed, sweaty and miserable, with ‘Memories are made of this’ inexplicably blaring at full volume within my skull. After several of these long, stressful and strangely lonely experiences, I started to develop something of a 'thing' about bitch speys.

Much as I started to do with consultations that I might have to see the next morning, I started to check the ops board the day before my ops day. A board that featured a bitch spey larger that fifteen kilos, or older than a couple of years (and so likely to be fatter) would mean a restless and worried night’s sleep for me. I grew to loathe them. However, I decided that the best way to deal with my ‘thing’ was to confront it full on, and do as many as possible, rather than try to avoid them (which is what I desperately wanted to do). 

I sweated and swore my way through a lot of speys. They got easier, but I never stopped worrying. what if I get a bleeder? What will I do? How will I cope?

Eventually, of course, my worst nightmare – the one that had deprived me of so many hours of sleep worrying about it- came true. During the spey of a particularly chubby Doberman, one of my ligatures slipped off an ovarian stump, and the dog’s abdomen began to fill with blood. I panicked, and called for a colleague, who very calmly scrubbed in with me, helped me find the stump, made me ligate it again, smiled, and walked back out whilst I got on with the rest of the spey. 

This was a surgical epiphany for me, because I realised that all that worry and fear over what would happen if one of my stumps wasn’t ligated properly had been for nothing, because all that actually happened was that the operation took about ten minutes longer that it otherwise would have done. That’s all. Everyone, at some point in their career, has a bleeding stump from a bitch spey, and everyone goes through that same realisation – what was all the worry about? It didn't completely cure my nervousness of bitch speys, but it was the beginning of the end of it. It took a lot more bitch speys before I began to see them in my own mind in the way we describe them - routine - but I did get there eventually.

(Having written that personal odyssey through my earliest surgical steps, it occurs to me that the conclusion that may be drawn from it is that the best way to stop worrying about a surgical procedure is to immediately cause the worst complication that you can imagine on the basis that it will all get better from there. Please don't follow that advice, or crucially, if you do, please don't mention this blog to the Royal College of Veterinary Surgeons)

So, the months passed, and the stresses of surgery began to recede. Neutering, taking bloods, hitting veins, placing catheters (intravenous and urethral), placing ET-tubes and the scores of other practical things that I had lain awake at night wondering whether I would actually be able to do became easier an easier, as things do when you’re doing them all day, every day. All that worrying, for nothing. You see what I hadn’t realised is that, in veterinary medicine, as with every other aspect of life, it’s not generally the things you worry about that end up becoming a problem. 

It’s the things that jump out upon you unexpectedly, like a phone call at three in the morning, that really cause you trouble. Err... have fun with that out of hours work.

Right, well that's all the worries of today's Nottingham graduates (well done again!) eliminated, as well as, I suspect, the worries of all future veterinary graduates from here on in. A good day's blogging, I think. Now, to relax in the sun with a drink. Oh rats, I can't, I'm on call. Can anyone hear the phone ringing?

Halal Slaughter

This isn't a full-blown blog post, but my mother contacted me tonight to ask if I would consider doing a post on Halal slaughter. She's just having a little trouble explaining why Halal meat may have some welfare issues to some friends. In lieu of a blog post, I sent her an email, which I have rather lazily reproduced here in case it's of interest to anyone else.

EDIT *I'd like to make clear something that a commenter reminded me right at the start of this post... over to Josh...


Just wanted to mention that a lot of Halal slaughter now allows stunning before slitting the throat in which case the process seems much more akin to traditional stun and bleeding, providing timings are kept tight. Jewish slaughter however, is still lacking in stunning.

*

And back to the post...

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Hi Mum

This website explains exactly what Halal meat is http://www.halalcateringco.com/halal_meat.asp

However it contains a number of inaccuracies and glosses over the truth a bit. The bit about 'carrion' is crucial - it means that animals cannot be stunned prior to slaughter, as technically stunning (when done properly) stops the heart, and the meat would count as dead. So animals have their throats slit consciously. From this website...

'When carried out correctly the sudden drop in blood pressure to the brain renders the animal brain dead within seconds and many researchers have found Dhabiha to be less stressful and painful to the animal than modern western methods of slaughter.'

Sadly, this sentence does not apply to either cows or goats - they are unlucky enough to have a vertebral blood supply, unlike many other mammals. The details are here... http://www.animalwelfareapproved.org/wp-content/uploads/2012/01/TAFS-18-Why-pre-slaughter-stunning-is-important.pdf

This is an extra blood supply that runs along the spine and supplies the neck. You can research the details if you like, but this quirk of anatomy basically means that if you slit a cow's throat (i.e. sever it's carotid arteries), instead of leading to almost instantaneous unconsciousness (as it would in humans) this extra blood supply enables the cow to remain conscious for anything from 19 seconds to 120 seconds - which I would suggest is unacceptable. Some studies have shown brain activity 680 seconds (11 minutes!) after the throat was cut.

The extreme sharpness of the blade (called a 'shechita' in Jewish ritual slaughter, but is effectively the same blade used in Halal slaughter ) is also a problem - it's so sharp, and produces such a clean cut, that the carotid arteries retract and clot in some cases, preserving blood pressure, and thus consciousness. You'll notice my quote from the first website doesn't reference the 'research' that it mentions.

This 'ballooning' occurs even in animals that don't have the verterbral circulation, such as sheep and chickens, unfortunately allowing them to experience suffering as well - some studies suggest it may happen up up to 62.5% of cases.

The wikipedia page on shecitas outlines these problems http://en.wikipedia.org/wiki/Shechita if you need a reference.

This page http://en.wikipedia.org/wiki/Zabiha explains the minimal differences between Jewish and Islamic slaughter. Both effectively cause the same suffering, except in one case the cow is facing Mecca when it has its throat slit.

I'm hoping that's a fairly unbiased look at ritual slaughter, but I think you can guess which side I come down upon...

Nick




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Not a cheery blog post, but some points worth making, I felt!

Bright Eyes - 3 things to consider before getting a pet rabbit

'A robin redbreast in a cage

puts all heaven in a rage'

William Blake

This is a blog about rabbits. That may be a little hard to decipher from Mr. Blake's quote above, but the sentiment in it gets across my feelings about the all-too-common fate of the pet rabbit, which is to get stuck in a hutch at the bottom of the garden and never given a first, let alone a second, thought. I did try and modify the quote to make it a little bit more relevant, but the best I could come up with was this:

'A rabbit in a hutch at the bottom of the garden

makes God sit up and say 'What? Pardon?'

Nick Marsh

which I can't help but feel loses a little something from Blake's original. Let's leave poetry to the experts, and just get on the with blog, eh?

Now, personally, I'm not a huge rabbit person (that would be a great film, though, eh? Like a cross between King Kong and Watership Down) (and that, incidentally, is the first and last time I'm going to mention Watership Down, title aside, because if I keep thinking about it I'm going to end this blog in a blubbery pile of tears, and I think I've done quite enough blog posts like that recently) in that I haven't ever owned a rabbit. However, they are swarming to the practice in increasing numbers (which is also another idea for a film...along the lines of Dawn of the Dead, with bunnies) and are easily the third most common animal I'm called upon to see, after cats and dogs, which makes it a shame that they suffer from neglect so often.

You see, a rabbit is something of a specialised creature, with some very specific requirements, not a single one of which is served by leaving a rabbit stuck in a small wooden cage at the bottom of the garden as if it was an inmate of some kind of bunny Guantanamo bay. Just getting their diet right is about as much fun as trying to cater for a group of wheat-intolerant vegans. Now, a lot of the clients who bring rabbits in to me nowadays are smart, savvy owners who know what they are doing, so it would be easy for me to think that things have changed. Unfortunately, I also see a fair proportion of owners who aren't quite so savvy, and real suffering is caused as a result - and these are the people who think enough of their rabbits to bring them to the vets when they're sick.

So, here's my effort to try to alleviate and prevent some of that unnecessary suffering. If you're thinking about getting a pet, and thinking that a rabbit is sounding like a funky idea, please just have a quick read over some of the points below first.

1. A rabbit is really, really NOT a child's pet

I'm not sure how rabbits got a reputation for being a great 'first' pet, sort of a starter before you move on to something else, but there's a number of reasons why I don't think a rabbit should be the sole responsibility of a kid.

For starters, rabbits live a long time - six to eight years. (in fact, there's some evidence to suggest that they have the potential to live a lot longer than this, but as pets they generally don't). Six to eight years. That's, like, long enough for George R. R. Martin to write a book! And it is, sorry to say, easily long enough to for a child to get bored with their pet. It might sound cruel for me to say it, but believe me, it happens a lot, so as a parent you've got to be ready to take over when that happens.

Secondly, rabbits are prey species. As Watership Down teaches us (oops, damn it), that means that the world and his mother wants to eat them dead. As a vet, this makes rabbit diseases more challenging to diagnose than cats and dogs, because if a rabbit shows weakness in the wild, likely as not someone will come and eat it. As a pet, this means that rabbits, as a general rule, do not like all the cuddling, tickling and squeezing that usually is part of the job description of a child's pet. Don't get me wrong, some rabbits adore it, especially those that have been brought up to expect it, but a lot of them find it extremely stressful, and will attempt to escape from it or just suffer in silence, all of which adds to the risk of the child getting bored.

Thirdly, rabbits are just not as easy to look after as dogs or cats, or, for that matter, hamsters, gerbils, rats or mice, and the next section will go some way to explaining why.

2. Rabbits like fast food just as much as the rest of us

Earlier in the post, I alluded to the fact that it's fiddly to give a rabbit the correct diet. It's a pain. So, I'm about to give you a quick rundown of all the things you need to feed your rabbit to keep it healthy. Brace yourselves.

Braced? Ooookay, here we go.

1. Grass.

That's it. That's as complicated as a rabbit's diet needs to get. Grass has everything in it that a rabbit needs to live, thrive and survive. A few other plants for variety and vitamins will help, but in the main, let your rabbit eat plenty of grass, and get lots of exercise while it grazes, and you won't be going far wrong.

So why do I keep suggesting that it's hard to get a rabbit's diet right? Because a lot of rabbit owners have a yearning, aching need to feed their bunny all manner of other junk, the vast majority of which will shorten their rabbit's life.

Let's go back to basics a little bit. Grass, it turns out, is a real pain to digest. You'll know this if you have a dog which is an enthusiastic grazer, because you'll often have to help to grass out when it pokes out, completely intact, at the other end of the dog (I suppose you'll also know this if you, yourself, are an enthusiastic grazer, but that brings to mind all manner of mental images that I'd rather not dwell upon). Grass is full of cellulose, and it takes a real effort to get anything useful out of it at all. It needs to be fermented, and getting grass to ferment takes a lot of digestive effort. Cows, and other ruminants, deal with it by having a ridiculous number of stomachs (well, okay, four), and repeatedly regurgitating the semi-digested gunk for another chew (cudding).

Rabbits, like horses, take a different pathway - they ferment with their hindgut, not their stomachs, which leads to a very complicated and specific bowel set-up. I don't want to get into the complexity of it too much here (not least because I don't quite understand it myself. Ahem) but bear in mind that although it looks like a simple process for a rabbit to chew on a bit of grass and then pop out a pellet, there really is a wondrous and complicated alchemy going on inside that compact little belly (assuming that alchemy was concerned wasn't concerned so much with converting lead into gold as converting grass into rabbit poo). Here's a nice simple, and better discussion than mine on rabbit digestion for those who are interested.

This means that rabbits have a digestive system wonderfully evolved to deal with grass, and really not great at dealing with just about anything else.

The problem is, nobody seems to have mentioned this to rabbits. See, eating grass looks like hard work to me. There's an awful lot of chewing involved, it tastes like...well, like grass, and you have to be outside to do it, which is this country means getting rained on. Rabbits seem to feel much the same about this state of affairs as we would, and so, given the choice, they would rather eat pretty much anything else. So, if you give them a tray full of rabbit food that is, basically, the rabbit equivalent of a KFC party bucket, and they'll forget all about that grass.

Okay, let's take a slightly more serious look at what you should be feeding your pet rabbit.

1. Grass/Hay. 

I was a little facetious about this above, but not very. Grass or hay needs to be about 90% or your rabbits diet, and they'll get along for a very long time eating just this and nothing else. Grass (or the dried version, hay) is full of dietary fibre, and it's fibre that drives the rabbit's digestive tract. Not only that, because grass is such a pain in the arse to chew, and is gritty, it actually wears the teeth down. This is fine for rabbits - in fact, it's not just fine, it's necessary.

Rabbit's teeth, just like horses, grow continually throughout their lives, and if they aren't continually worn down by eating grass, they end up with a mouthful of teeth. Dental problems caused by a lack of grass or hay in the diet are the number one problem I see rabbits for. It's completely preventable. Feed your rabbit grass or hay. Please.

2. Other plants/fruit/vegetables.

Yes, okay. If you must. But not too much! Definitely not more than 10% of the diet. The point of this is just to add a little variety to the diet, and a few extra vitamins and minerals that aren't found so much in grass. 

To be honest, if you let your rabbit just free range around the garden, it'll get everything it needs from nibbling at other plants as it grazes. So, feel free to give a small amount of a fruit or veg as a treat. But really, not a lot.

3. 'Rabbit food'

Harrumph. Really? I know it's tempting. I know it says 'rabbit food' on the packet, probably next to a piccie of a rabbit looking extremely pleased, but really, you almost certainly don't need to feed any of this at all if you've got the first two right. Maybe if your rabbit is too thin, and you need to bulk it up, but I can't think of many other circumstances where rabbits need to eat this stuff.

If you really, really must, here's a few tips. Firstly, get pellets, like Burgess Supa Rabbit. Yes, they're boring, and look not unlike rabbit poo, but it prevents the rabbit from picking out all the really tasty bits, and leaving all the vitamins and minerals that they're supposed to be getting. Rabbits are just as bad as us as voluntarily missing out the important bits of the diet, so try not to give them too much opportunity to do it.

Secondly, this food should make up a tiny portion of your rabbits diet, unless you want a fat, unwell rabbit. My advice would be that if it's taking your rabbit more than ten minutes to eat it's pellets, then you're giving too many pellets.

Hopefully I've got my message across there. FEED GRASS! Ahem. I have been subtle, I think.

I have gone on about it at length because, as I hope you can see, although a rabbit's digestive system is complicated, it's diet really doesn't need to be. If I could forcibly restrain all rabbit owners from feeding cheap crappy rabbit food, and just get them to feed even cheaper grass instead, I would see far fewer rabbits in the practice. Yes, they can have the odd treat, just like horses - but bear in mind a horses weighs roughly two- to three-hundred times what a rabbit weighs, and so can cope with a lot more treats than a rabbit can.

3. Rabbits make great house pets

No, really, they do!

My first two points were rather negative, and coupled with me saying that I'm not a big rabbit person myself, I'm worried that I've left you with the impression that I don't think rabbits should be kept as pets at all. Not true! They can be wonderful pets, and, perhaps unexpectedly, make wonderful companions in the home. 

A couple of vets in our practice have rabbits living with them, and they are evangelical about them - they love them to bits (not literally). Yes, you need to have a think about where they can get to and what they can chew (rabbit-proofing electrical cables and such) but it's far less work than worrying about what a toddler might get up to in your house. They're very easy to house train, and (generally) get on pretty well with dogs and cats. 

So why stick them in a hutch in the garden instead? Have them in the home, like you would with your other pets (with the possible exception of horses). Yes, they need to go out to graze in the garden, but that doesn't mean they have to live their whole lives out there.

So, let's summarize, shall we? Summarizing's always fun.

1. A rabbit doesn't make a good child's pet. Parents need to pitch in and help with rabbit care too.

2. Feed grass or hay and not much else.

3. Rabbits are much more pleasurable pets when they're house pets.

There we are. I hope that's helpful if you're thinking about getting a rabbit. Feel free to send me any questions (and I'll rather lazily pass them on to my rabbit-oriented colleagues).

Now, I'd better get back to practising some poetry...

Mistakes

Regular readers of my blog will probably be aware by now that the tone of my posts tends to vary wildly between flippant and maudlin - sometimes even within the same post. I'm going to be honest; this isn't one of the flippant ones. Consider yourself warned.

'Experience is the name everyone gives to their mistakes' - Oscar Wilde

There's a nice little word that you can use in medical terminology - you may have heard it before. I may even have mentioned it in the blog before. That word is 'iatrogenic'. It's especially useful for those of us in the field because it sounds nice and official, slightly intimidating, and mysterious. Here's what it means - the doctor did it. Your physician ballsed up in some way, and now you're ill because of it. If you've got iatrogenic Cushing's disease, it's because the doc gave you too many steriods. If you've got iatrogenic aural trauma, then it's likely he was a little overenthusiastic with his otoscope. If you're iatrogenically monorchid...well, you get the idea.

There's a reason that this word was created, and that reason, of course, is that doctors (or in the case of this blog, vets) make mistakes. You may be getting an inkling of where you think this blog is going, now, but you may be wrong. I'm afraid this isn't going to be an 'Alright on the Night' style list of amusing veterinary cock-ups, where the poor James-Herriot-alike accidentally drills through their own finger whilst attempting to pin a fracture (though, I must admit, I have known that happen). No, this is really a confessional blog, a penance for me for a mistake I made. I did warn you at the start.

You see, I've been reading through my blog posts recently, and much as I like them, I do rather give the impression that I never make any mistakes myself, and that the hard positions I've found myself in have been due outside influences. This is, I will admit now, not the case. I have - in common with most of humanity, I suspect - made many mistakes, both in and out of my career. It's possible that this blog post is one of them. But I am so weary of politicians and others in the public eye avoiding even talking about, let alone admitting to, errors they have made on the basis that they may - horror of horrors - actually be called to account for them, that I wanted to make my own claim to honesty here.

I've been a vet for a long time now - ten years - and it has been quite some time since I felt that awful 'out of my depth' feeling that lived with me as a new graduate. Considering how much I've learned since then (and see Oscar Wilde's quote above for the true meaning of 'learning'), I'm a little surprised, when I think back on it, how few serious problems I got in to. Most of them were learning how to communicate with clients effectively and fairly, or easily corrected surgical mistakes, but here is something that has stayed with me down through the years :

I was a new graduate - maybe three or four months into the job, and it was one of those evening surgeries - the kind where all your old cases come back to haunt you. Nothing has got better, some things have got worse, and even the vaccinations have got heart murmurs, or sinister-feeling lumps that the owner has never noticed. I've had many, many of them since, and have discovered that really all you can do is take things one at a time, and remain calm. Back then, watching with alarm the list of people waiting grow whilst I was trying to think about a Chinese water dragon that had just been presented to me 'off-colour' (as I recall, it turned out to have been dead for a few days), panic was setting in. It was the first time I had experienced anything like it.

I was on my own - my colleague (a keen surgeon - a classic of the breed, very interested in the technicalities of the work. The animals, not so much) had left me to take one of his spinal cases to...well, I remember it as MRI, but I wonder now if, all those years ago, it would have been far more likely to be a C-T scan. Doesn't matter) and no cavalry  was coming to save me. The 'complaints' list on the computer, a brief description of what was wrong with each animal, read like a thesaurus - 'worse','no better','no improvement'','poorly' etc - and I had just run out the back with my immobile water dragon to try and get a better look, when I got the phone call.

I forget the name of the breeder, and I wouldn't put it here even if I could remember, but she had phoned the practice to speak to my boss, and was upset that he wasn't around. She was even more upset to discover that the only vet she could talk to was the new graduate - and if she'd realised my state of mind at the time, she probably wouldn't have spoken to me at all. She had a reputation at the practice for being incredibly demanding - and any vets reading this will have a picture in their minds right away of exactly the sort of client I'm talking about. Flustered, with one eye on the water dragon (about which I was starting to suspect the truth - it's not quite as easy as you might think to immediately diagnose death in a reptile. Well...not if you've never seen one before. Anyway, that's not the mistake. I got that one right, in the end, it just took me a while) and another on the ever-growing waiting room list, I took the receiver from my nurse.

The situation explained to me was this : one of the breeder's bitches has just finished whelping. The births had gone fine, but one of the puppies had been born with a severe umbilical hernia - it's intestines had prolapsed through the large hole and the pup was not looking at all well. The breeder wanted me to go straight out to her and put the puppy to sleep.

This (like most things in those days) was not a situation I had been in before - I had never seen, or even heard of a puppy with such a severe problem. The breeder was adamant that the problem could not be fixed, and it certainly sounded serious enough to me. This is painful to write - but that's the whole point of this blog, isn't it? - but I agreed the puppy needed to be euthanased. 

That's painful to write, because it's wrong. It's a treatable condition with immediate surgery, and I have fixed a number of puppies in a similar situations since. I was wrong, but that wasn't the worst of it.

I couldn't get out on a visit; I knew that. I had a waiting room full of people and no back-up. I asked her to bring the pup in, and she absolutely refused - she couldn't (she said) leave her bitch, and all the other puppies, just to bring this one in.

I wince to think of it. Older now, and wiser, I would have told her to bring the whole lot in right away. I also would have told her the pup could have been saved. I didn't. I merely feebly protested that I couldn't make it out.

'That's okay,' the breeder said. 'I'll deal with it myself.' She wasn't rude, or annoyed. She had really just wanted to check whether I thought the puppy should be put to sleep or not. She put the phone down. I didn't ring her straight back. Instead, I got on with my evening surgery.

Twenty minutes later my boss phoned me. He had a number of missed calls on his mobile phone from the breeder in question. When he got back to her, he found out what had happened. It was here that I discovered that the condition could have been surgically corrected. My boss had also discovered what had happened to the puppy.

She had drowned it.

I cannot tell you, dear reader, the number of times I have played that phone conversation over in my mind, wishing I had handled things differently. I can't count the number of nights I have lain in bed, staring at the ceiling and thinking of the pup, struggling against calloused hands, bubbles escaping from its mouth. That one mistake, based on a lack of veterinary knowledge and poor client handling, has haunted me for years. Its taken me ten years to write it down.

I don't even know, at this stage, how bad that seems to someone else. Its grown to be so large in my mind that I find it hard to think and write about, even now. I've made mistakes since then, of course - some worse that this one. But it was my first one, my first realisation of what can go wrong in just a few seconds of thoughtlessness. The drowning puppy lives in my mind (and only in my mind - it's painful to think that it could still be alive even now, all these days, weeks and years later, if I had acted differently) as a symbol of failure, and mistakes. Whenever things go wrong - which thankfully is not so often, these days - I think of that pup.

So, my confession is done. Don't think for a moment that this is my only error in ten years. As you may have suspected, this blog was prompted by a mistake as well, and of a similar kind. A few moments thoughtlessness, forgetting what really is at stake if I don't try my hardest, may have cost another animal its life. I ignored my instincts and took an easier path, and I was wrong. Likely it would have made no difference - in fact, I'm almost certain that in my recent error of judgement, acting different would have merely meant that the animal ended its struggle in the practice, rather than at home. Almost certain. But I'll never know now.

I suppose the hallmark of a mistake, as opposed to simple bad luck, is that if you think back over the situation - like I have, many times, thought over my phone call to the breeder - and you wish you had done something other than what you did, then you made a mistake. And that's how I feel today about this new mistake. I could have acted differently, and I wish that I had.

I'm not perfect. I wonder, if any vets are reading this, how many of them have their own version of the drowning pup, that swims into their mind when things go wrong? More than a few, I suspect. I'm so sorry that I failed then, and I'm saddened to realise that the lesson, hard and painful though it was, still needs reinforcing to me from time to time. This post is a way of doing that.

Thanks for reading.

Toxic Shock - 3 pet poisons to be aware of

There's a little bit of background to this blog before we get to the actual poisons, so if you're in impatient type, or are desperate for the loo and don't want to risk carrying your laptop/smartphone/desktop along with you (and I really wouldn't advise trying the latter) then you can scroll down quickly to have a peek at them to save time.

I had already decided to write a post about common pet poisons before this weekend, mainly motivated by a site that a friend of mine shared on Facebook, discussing the most common toxic materials that pets ingested. Reading through the article, it seemed to bear very little resemblance to my experience of dealing with poisoned animals.

The number one for pet poisons on the list was, as I remember, onions. Now, to be fair, this was a US-centric site, and it's just possible that animal companions in the States have a far more rapacious appetite for eye-wateringly bitter bulbs than those on this side of the Atlantic (or, and maybe just as likely I suppose, it's also possible that I have misdiagnosed a vast number of cases of onion toxicity in my career), but it struck that that almost none of the poisons mentioned were ones that I had seen cause a clinical problem in practice. Rather rudely, I hijacked my friend's thread to point out the substances which I saw regularly in practice. Afterwards, I decided probably the best thing to have done was just to blog about it myself.

I also wanted to blog about something that might actually prove useful to people - I know this in itself is stepping far beyond the normal boundaries of my blog, but what the hell, sometimes I just like to give something back :). A less altruistic reason is that blogs with a 'Top 3' in the title tend be more widely read than those with a crappy pun for a title - I know it's depressing, but don't tell me you haven't occasionally been lured by the promise of the 'Top 5 Celebrity Hair-Related Injuries' or similar - so I decided to have a go at one myself for a change.

My plan was to start relatively light-hearted, and not make it too heavy. Poisoning is a strange one - it seems far easier for people to believe that their evil neighbour has poisoned their companion than something has gone wrong with their metabolism, and their immune system. I often get clients leaning over and whispering to me conspiratorially, 'Well, the man over the road has never liked him. Do you think he might have given him something?'. Ninety nine times out of a hundred, of course, the answer is no. Despite all the things I have seen, and despite the fact that I always think of myself as something of a cynic, I often find it hard to genuinely believe that there are many people out there prepared to maliciously cause harm to animals. That doesn't mean it doesn't happen, it's just that I find it hard to believe. Hopefully, I always will! I might well write something at some point on humanity's schizophrenic relationship with other members of the animal Kingdom.

Anyway, I'm sorry to say the light-hearted approach has somewhat gone for a Burton, because that was before I went to work on Saturday. This weekend I put four cats to sleep because they had been poisoned with antifreeze, all of whom lived in the same street. It's possible (maybe even likely) that this was a deliberate case of poisoning. I mention this not because I want talk about it especially (because it really was very depressing. Incidentally, if you're the type of person who might think 'Well, they're only cats - we poison plenty of rats to death, don't we?' - firstly, I do have some sympathy with that view. Humanity is very good at setting up strange double standards for animals. I may have mentioned in another blog treating a cat that was on a rabbit & chicken diet only, to then have as my next two consultations- you guessed it - a rabbit and a chicken. Secondly, whatever your position on how much animals can suffer (and trust me, they can suffer, terribly) please bear in mind there was quite a lot of human suffering and misery that accompanied these four deaths, too) but to drive home the point that we genuinely do see cases of these poisonings. They're still comparitively uncommon, but they can, and sadly do, happen.

So, that's the background. Below we're going to talk about the three poisons that I and my colleagues see most frequently in practice, with a few honourable mentions. The eagle-eyed amongst you will probably spot this is a fairly cat-heavy blog. At first glance this is unusual, because cats are generally a little more discriminating about what passes their lips compared to their canine brethren. There's a couple of reasons felines are over-represented on the poisoning front, though. Firstly, they are (usually) physically smaller than dogs, and so generally need a much smaller dose of whatever the substance is to cause harm. Secondly, cat's livers aren't really as robust - perhaps versatile may be a better word - as dogs, or ours, and they tend to struggle with a number of substances that we can manage quite readily. It's probably a function of the fact that they're obligate carnivores (they have  to eat meat) as opposed to us, and so their diet tends to be a little less varied.

1 - Ethylene Glycol - Antifreeze

Perhaps unsurprisingly, antifreeze is on my mind at the moment. I mentioned earlier that I wondered if I was naive about people - but perhaps not, because there's a part of me that worries even mentioning how toxic this substance can be to cats might encourage more poisoning. Still, everything is available on the 'net, nowadays, so hopefully this will help more cats than it harms.

The Stuff

Ethylene glycol is a nasty substance - it is toxic to us, and to dogs, but sadly it is especially poisonous to cats - mainly because of their smaller size than anything else.

Ethylene glycol is similar to alcohol, and in the early stages of poisoning, animals (and people) do appear to be drunk. This is rarely the difficult stage, though - the trouble comes when the body metabolises the ethylene glycol to other products. It reacts with calcium on the bloodstream to form calicum oxalate, and it is this that causes the harm, usually in the kidneys. There's an article here that describes the process far better than I can, and has lots more information antifreeze too.

How poisonous is it?


Short answer - very. For cats, the amount they need to take in is tiny - simply licking the outside of a cracked antifreeze bottle would almost certainly be enough to cause irreparable kidney damage. For your average 20kg dog, the lethal dose could be as little as a teaspoonful.

I was always taught that it's doubly dangerous because of it's sweet taste, and that cats would drink it voluntarily quite happily. I'm not at all convinced of that. In my experience, cats aren't especially excited by sugary treats, and antifreeze itself does not take good in my opinion (mind you, I think that about badger faeces too and both my dogs disagree) but it's poisonous enough that simply cleaning it off their fur is likely to give them a fatal dose.

Is there an antidote?

The other thing about poisons - people tend to assume there's an antidote, just like the exciting-looking vial of blue fluid that Indy spends the first act of Temple of Doom trying to grab. Sadly, in real life, it doesn't usually work that way, and the vast majority of poisons have not antidote at all, and you just have to deal with the symptoms.

That said, antifreeze poisoning dose have an antidote of sorts. As I say, the dangerous stuff is really the calcium oxalate that comes from metabolising the stuff. The enzyme in charge of the transformation is alcohol dehydrogenase, the same guy who's mops up all the wine you've got in your system after a crappy day at work. Give him enough alcohol to deal with, and he's so busy with it that most of the antifreeze gets peed out of your system without changing, and you're safe.

Great, in theory. The problem is the speed of ethylene-glycol related kidney damage. If you don't get the alcohol in within twelve hours of ingestion, you're probably too late. All you're likely to have seen by then, if you didn't see them actually drink the stuff, is a bit of wobbliness. The problem, for a clinical perspective, is that an awful lot of conditions cause a bit of wobbliness, and if we admitted them all and gave them intravenous vodka, we'd probably kill more cats than we saved.

The take-home message, then, is that if you know or suspect that your pet has taken in antifreeze, get them to the vets as soon as possible, and let the vet know that's what you're worried about.


Outcome


Pretty bloody awful, I'm sorry to say. The vast majority of cats (and it's usually cats) that present to us with antifreeze poisoning are already in kidney failure, and by then it's too late. Almost all of them end up getting euthanased.

So, if you have antifreeze at home, bear all of this in mind - clean up any spillages on the bottle, or on the drive, and keep pets away!

2 - Lillies

Another one for cats, I'm sorry to say - in fact, in a way this is even worse, because it is quite a common poisoning for kittens. They need an even smaller dose than adult cats, and they tend to be a bit more inquisitive.

The Stuff


Good question! As far as I'm aware, no-one is entirely sure of the mechanism of action for lily poisoning, but there are a number of points about it.

Firstly, it seems to be specific to cats - other animals may vomit or get diarrhoea if they scoff one, but for cats, lily poisoning leads to old enemy, kidney failure.

The second point it - whatever the toxin is, it is in every part of the lily. Secondly, the lethal dose, as with antifreeze, is miniscule. I've known cats that brushed against a lily plant and licked the pollen off their fur to end up with severe kidney damage.

Not every species of lilly is as poisonous as the others - there's a list of the toxic species here - but unless you're a horticulture expert, the best thing to do is just avoid them altogether when cats are involved.

How poisonous is it?


As mentioned above - very. Nibbling a leaf, petal or stamen can all be quite enough to destroy the kidneys.

Is there an antidote?


As no one is sure what the toxic substance is, no one can counter it. The only thing that can be done with lilly poisoning, as with a lot of poisoning, is damage limitation - try and prevent the bloody stuff getting absorbed. To the vet, this means putting the cat on a drip (to 'flush the system through' and support urine flow), making them vomit (if they ate the stuff within 30 mins - 1 hour) and preventing absorption from the stomach by feeding things like charcoal paste.

Outcome


Pretty crappy, I'm afraid. Just as with antifreeze, by the time you work out what's going on, it's often too late. I've had some extremely sad cases where lilies have been around the house due to the funeral of a family member, and as a consequence a few days later the family cat is brought in to us.

The vast majority of these cases get put to sleep too, I'm sorry to say. Take home message - either keep lilies well away from cats, or (my advice) just don't have lilies in a house where you have cats. It's too risky.

As with antifreeze, if you know or suspect your cat has been in contact with a lily, get it to your vets as soon as possible to try and limit absorption.

3. Rat-bait poisoning - Warfarin and the Coumarins

One of the classics - in that everyone seems to know a little about rat poison, and it's also probably the most suspected poison by clients of the three on this list - but that doesn't mean it never happens. Sadly, it does, relatively frequently. It's also one of those strange 'double-standard' poisons - it's dreadful if pets take it in, but it's fine to kill rats with it. I won't ponder the mysteries of the human mind any further though - I can't pretend I'm not a hypocrite either. I suppose we've all got to draw the line somewhere. Shall we press on?

Rat poison is the first on the list to affect more dogs than cats - largely because most cats have more sense than to tuck into a load of weird-smelling blue pellets.

The Stuff

Warfarin and the Coumarins may sound like a Glam Rock band, but they are actually the active ingredients of rat poison. You're probably already familiar with warfarin. It's mechanism of action is to inhibit an enzyme by the long-winded name of vitamin K epoxide reductase - and it's this enzyme that has the job of recycling used vitamin K in the system. Without it working, you run out of vitamin K very quickly.

Vitamin K is a vital component in the 'coagulation cascade' - a group of proteins which, along with protein, allow your blood to clot and prevent it from all leaking out of you when you are lightly burst. Without vitamin K, a number of these proteins fail to form, and without them you're at risk of bleeding to death.

Warfarin (I'm sure you're aware of this but I'm telling you anyway) is used at low doses in human medicine to 'thin the blood' - what it actually does is reduce your risk of getting a clot within your bloodstream (a thrombus). What you might be less aware of is that it isn't used in rat poison any more, because almost all rats are greatly resistant to now, on account of humanity feeding them lots of it down through the years.

The coumarins (of which warfarin is a so-called '1st generation' one - nothing to do with Captain Kirk) are used instead nowadays - usually 3rd generation ones such as brodaficoum or difenacoum) all work in a similar way to warfarin, the main difference being that the more modern drugs work for much longer, and are far more potent.

The symptoms of this kind of poisoning are the sort of thing you would expect - blood, from anywhere. If a dog is bleeding in two unrelated sites (for instance in the pee and from the mouth) or if there are tell tale signs of bleeding in the gums or the eyes (petechial haemorrage) then rat poison is on our list of diagnoses. Lethargy is another common sign due to the anaemia, as well as blue-coloured vomit or faeces (simply from the blue dye in the pellets - just like slug bait poisoning)

How poisonous is it?

The answer to this very much depends of exactly which coumarin has been eaten, but as most rat poisons are second- or third-generation nowadays I'm going to refer you to my sadly standard answer - very. We can work out the exact doses, but basically if your dog or cat has definitely eaten any amount at all, it could be in trouble.

Is there an antidote?

By now you might well have read how the coumarins work, and you can probably take an educated guess at the antidote if you don't know it already - Vitamin K.

As with all poisons, the best thing you can possibly do it get in early and prevent absorption as soon as possible. If you can't get to it in time, vitamin K will do the job, but it takes 24-48 hours to work, because it needs to get synthesised into the clotting factors, so the dog usually has to stay in the practice on fluids, and occasionally will need a blood or plasma (basically blood minus the red blood cells - easier to store and transport, and gives the dog a whole load more clotting factors to work with) transfusion if the bleeding is too severe.

Coumarin drugs remain in the system for a long time - the dog is likely to have to take vitamin K supplements for 3-4 weeks after the poisoning incident.

Outcome


Refreshingly, the outcome is often better than the other two toxins we've discussed already. Partially because people are well aware of the poisonous nature of the substance (it is called rat poison, after all), and partially because the antidote can work even a few days after exposure, we generally have a good chance of getting animals dosed with rat poison through. Sadly, we still see some cases too late or too far gone to influence the outcome, but fortunately these are the minority rather than the majority (unlike lily and antifreeze poisoning)

So, there we have it...the three (arguably) most common toxins I see in my daily life as a small animal vet in   south west England. For the argumentative amongst you, there's a few honourable mentions for other toxins below - some serious, some less so. Here we go...

Flea products - Permethrin poisoning in cats. First thing to say - NEVER USE A PERMETHRIN-BASED FLEA PRODUCT ON A CAT. There are still some dog flea 'spot ons' that use permethrin - do not be tempted to try a small dog dose on a cat and think you'll get away with it. Permethrin causes severe seizures and death in cats, and I've known it happen from a kitten licking the wet patch on the back of a dogs neck. If in doubt, never use a supermarket or pet shop flea spot on for a cat, get them from your vet instead.
House flea sprays, including those bough from vets, can contain permethrin too, so keep your cats away from sprayed rooms.

Grapes - I was surprised and embarrassed to discover this one a few years ago, because I knew nothing about it. In fact, I've been known to feed the odd grape to my greyhound (thankfully without consequence other than being badgered to give her another one). The reason I've managed to remain ignorant of it is because a dog needs to eat quite a few grapes to get problems, and some dogs seem very resistant to the problem. It causes severe vomiting and diarrhoea, and in extreme cases can cause kidney failure. Remember than raisins are grapes too, and can cause them same problems.

Slug-bait poisoning - metaldehyde. Can be extremely toxic, usually seen in dogs. It can cause severe seizures and death, though for whatever reason I've never come across it in my career. It may just be luck, but I'm hoping that means it isn't all that common nowadays. If it happens, though, you need to be in touch with you vet quickly.

Chocolate - at my practice we're commonly quizzed about this, what with dogs being dogs and chocolate being chocolate. The toxic substance is theobromine - which is actually technically poisonous to us as well, although we'd have to consume a good few kilos of chocolate before it started to have any effect, and by then you may have other more pressing social problems such as being shunned/arrested for eating your way through an entire sweet shop.
Dogs are a little more sensitive to theobromine than we are, but even then the dose required is comparitively large. The other saving grace is that the cheaper and milkier the chocolate, the less theobromine it has in it, so the problems tend to come with small dogs (less body weight) and expensive dark chocolate (more theobromine). Our own greyhound ate her way through an entire tray of Guylian belgain choccies, and although I can't quite say she didn't suffer any ill effects (because my wife was not at all impressed with the theft), she certainly didn't get theobromine toxicity.
If you're in doubt, ring your vet with the chocolate wrapper to hand and, ideally, your dogs weight -we can usually work out how much would be too much from there. And I'm sure you understand why I've mainly talked about dogs, here, but theobromine can also be toxic to cats.
Symptoms are usually vomiting and diarrhoea but can progress to seizures and serious problems with higher doses.

Paracetamol - dogs will tolerate this, and we do occasionally use it in them, although the cut off between 'safe' and 'toxic' doses in dogs is a little narrow for comfort. Cats, however, lack the required liver enzyme to deal with it, and a SINGLE HUMAN DOSE OF PARACETAMOL CAN KILL A CAT. Never be tempted to use human painkillers in cats - not even child doses like Calpol (UK).

Human medications - although animals can often be buggers to take their own tablets, they often find their owner's medications irresistable. Toxicity and problems of these vary wildly, so it's best to ring your vet if you find your dog happily sitting on top of a tablet box with a few scraps of silver foil hanging out of their mouths - but to reassure you, as a general rule anti-depressants and contraceptive drugs are usually pretty safe.

Minoxidil (Regaine or Rogaine) - For gentleman, like me, whose brain is so hot with energy and imagination that their hair starting to fall out due to the intensity of the supercomputer that nestles beneath it, it's worth being aware of this particular product - for those of you who (damn you!) don't know anything about this product( because you've never had to worry about that perfect head of hair you flaunt horribly to us baldies (or in my case, soon to be baldie) Regaine is a sticky ointment that you rub on your bald patches and hope that something starts to happen up there.
Well, you also need to know that it's highly toxic to cats - It's another one for the liver hall of fame, I'm afraid. They (and you can probably say this along with me by now) lack the required enzyme to metabolise it, leading to dangerously low blood pressure, pulmonary oedema and death. It's just about treatable, if caught in the early stages. Thankfully I've never seen this particular poisioning, but I nearly caused it myself in my own cat. Ignoring the old adage that 'you can't polish a turd', I sadly bowed to vanity and got myself some of this stuff - only realising after some internet research quite how poisonous it can be for cats. Now, I wasn't planning to rub it onto my pussy (quiet at the back! Although, sadly, I do believe some people have tried this; don't) but you are supposed to rub it onto thinning patches before you go to bed. Our cat likes to sleep on our pillows. You can probably see where this is going - suffice it to say the drug is potentially toxic enough that if your cat licks your pillow it could end up in serious trouble. I've decided not to use it at all, and to age with whatever dignity I can muster. Just be careful with the stuff.

Okay, well, I think that's enough to be getting on with. I hope that was of some help, and not to depressing!

See you all soonish.

Always two there are...a master, and an apprentice

It's been a pleasant few weeks at the practice.

Actually, now I come to think of it, that's a bit of a fib. It's been a teeny bit horrible, what with the pre-Christmas busyness and the usual set of 'clearout' euthanasias - but one of the things that has made it a little more enjoyable is the presence of a couple of vet students seeing practice with out.

Ah, vet students. They all look so young, fresh and excited. Makes me quite nostalgic for my student days, and all the things that will never come again - pound a pint nights, Oasis versus Blur, my hair...happy days. I can almost smell the formalin from the dissection room (if hte aforementioned formalin hadn't already sizzled most of my sense of smell away)

Vet students are nice to have around for a number of reasons. Firstly, they're a lot more interested than the typical stand in the corner and look bored work-experience types - probably because they're thinking 'Oh my God I actually have to do this job in a year or so and I have absolutely no idea what I'm doing!' (Don't worry, vet students. I've been doing it for ten years and I'm still not entirely sure either).

Secondly, it's nice to have some company in the consulting room, partly to share some of the strange experiences we have in there (see previous blogs for details), and party to be able to talk medically with someone. Maybe this sounds a bit feeble, but nice as it is to talk to clients and try and explain to them what you think is going on in simple terms, it's also nice to be able to talk to someone who can understand medical terminology, and follow your clinical reasoning. Well, if nothing else, it makes me feel clever (unless the student asks me a question that I don't know the answer too, but I usually brazen that out by telling them to clean my table, or put up some drugs, or as a last resort faking a fainting episode)

The enthusiasm they have is a little infectious too, and reminds me why I wanted to do this job in the first place. I genuinely do love animals, but I also love medicine, and am fascinated at what a complex, wonderful machine a living creature is. It's nice to be reminded of that from time to time, and to talk to someone who feels the same way, without the jaded cynicism that comes from ten years in (I suspect) any job.

For every Jedi, though there is a Sith, and the Yang to the Yin of having a vet student watching me consult is that I'm suddenly very aware of my own consulting skills. Fairly soon into the surgery, I hear myself saying for the fourth time in a row 'Now, the reason I gave that cat an injection of steroids is...'

Steroids are powerful anti-inflammatories, which probably relieve more suffering than any other drug I have in my arsenal. They also have many other effects upon the body, and so using them is a bit like the medical equivalent of using a cluster bomb. Lots of things other things will get hit, but you'll probably get the job done. They are regarded with horror, fear and loathing by veterinary colleges, and students (like me) have it drummed into them to avoid falling into the trap of using steroids at every available opportunity. They're a bit like the Dark Side of the force - quicker, easier, more seductive. And very cheap, to boot.

To me, however, and to many vets in practice, steroids' reputation amongst more academic members of our profession as the drugs of Satan himself is somewhat overstated. Yes, you get side-effects, but these effects are predictable and, for the most part, reversible. One of the more serious side effects, particularily in cats, can be diabetes - but this is rather rare, and I always explain the risk of this to clients. I can think of many cases of mine that would have had to have been euthanased years ago if it wasn't for the anti-inflammatory and itch-relieving power of steroids.

All this I can justify to myself...except when I have a vet student with me, who can't help but notice that I keep reaching for the same bottle on the shelf.

It's not just steroids of course. It's all the little things that you find yourself doing 'just to be on the safe side' - the things that you know probably aren't necessary but you just want to be sure. Things like giving antibiotics for diarrhoea in dogs, or for cystitis in cats. You know you probably don't need to, but...you don't want them coming back tomorrow, and another vet doing it, and you looking stupid for not doing it in the first place.

(The antibiotics issue is, actually to me, a more serious point that the steroids. Vets are as guilty as anyone else (well, more so than doctors, less so than farmers) of the overuse of antibiotics. Bacteria are getting wise to our antibiotics pretty fast, so we've got to try and be more responsible over their useage - but perhaps that's a topic for another blog)

So, I raised this as a bad thing about having vet students at the practice - but it isn't, really. It's a little like watching yourself on video - you're suddenly unpleasantly confronted with all the weird things you do that you weren't even aware you were doing.

As you get older as a vet, there's a certain arrogance that creeps over you - you've seen most things that can happen at least a few times before, and you've got a fair idea of what's going on with a patient within the first few minutes of a consultation. It's the common things occur commonly principle - sure, this animal that is presented to you after collapsing out on a walk -might- have myasthenia gravis...but it's probably just sprained its leg - because the leg sprainers will outnumber the myasthenia cases by tens of thousands to one.

The trick, when you reach my level of experience, is knowing when to listen to those little alarm bells ringing at the back of your head that tell you something isn't quite right here - it might appear to be a normal gastroenteritis, but it seems a little too pale, or a little too sore in it's abdomen, or just...just not right. It's the difference between giving a shot of steroids, or admitting immediately for a blood sample, x-ray and intravenous fluids. It's very easy just to slip into the steroids-every-time-because-you'll-be-right-nine-hundred-and-ninety-nine-times-out-of-a-thousand. I can feel myself of the brink of this 'old-vet' approach. teetering on the tightrope, ready to fall from experienced professional to, essentially, a knowledgeable amateur. It's my duty to my clients, and my animals, to avoid that slippery slope! This is part of the reason that I'm studying for my certificate in advanced veterinary practice.

Which is why vet students making me squirm as I reach for the steroid or antibiotic bottle once again is a good thing. It makes me question exactly what and why I am doing what I am doing, and what the consequences could be if I'm wrong. And, If nothing else, my excuses will get more finely honed!

So thank you, Laura and Jess, for making the last few weeks more enjoyable, if slightly harder on the brain!