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When the News is Given…

Vinnie

One of the most heartbreaking and gut-wrenching verbal communications that we experience is hearing that our family member and pet has a terminal/fatal disease or injury. What are some of our first responses as we receive this news? Is it anger, disbelief, anguish, despair, or denial? If you are any part human, you probably experience a mixture of these emotions. How do you deal with and sort out these feelings? Do you internalize these feelings (like me), do you lash out at an unexpecting party, or do you logically discuss these emotions? Also, does the delivery of this news matter? We have all had interactions with doctors (veterinarians and human physicians) that communicate very well, displaying compassion and empathy, as well as, those with the personality that rivals a brick in the pavement. Unfortunately, I have been on both the receiving end and the giving end of various levels of unwanted news and know that while bad news is bad news, compassion and tact in delivery does help in accepting the news and aids us in beginning the steps of acceptance and sorting our feelings.

While illness and death are topics that are not often discussed, they are topics that are unfortunately, a part of life that creep up from time to time. My goal of this small series is to look at emotions and feelings that are associated with these unavoidable topics. My point of view is from one delivering the negative news and the emotions that I see exhibited. Giving good news and success stories are easy, it is how you deliver negative news that define you as a clinician and fellow human. My hope is that this discussion can be enlightening and possibly help someone that may be going through a difficult time in their life.

While we all can recall bad experiences, what are some of the good communication skills that you have encountered? Remember that words and body language used can impact others more than we may ever know. Please share on either this page or the Facebook page (Kevin Benjamino DVM, DACVS). Also, what were some of the initial emotions that you experienced?

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GDV

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Gastric Dilatation and Volvulus (GDV)

Gastric dilatation and volvulus is commonly called GDV and even more commonly referred to as bloat. The term bloat is somewhat of a misnomer because that really only describes half of the issue. This condition occurs when the stomach both dilates (fills with gas and/or fluid) and rotates on its axis. Unfortunately, we never know which happens first the rotation or the dilation. Regardless, surgery is necessary in order to correct the issue and prevent recurrence, we will describe the procedure below.

This condition most commonly occurs in the large/giant breed dogs and deep chested breeds. It is rarely seen in small and medium size breed dogs. The most common breeds are the Great Dane, Mastiff, etc – you get the picture. Surprisingly, in addition to the larger breed dogs, we also see it in Standard Poodles more frequently. There are a lot of theories out there as to why this may occurs. Some common thoughts range from frequency and size of meals, exercising after meals, elevation and height of bowls, etc. We also see an increase in GDV incidence in dogs that have other types of gastrointestinal disease, such as inflammatory bowel disease.  Stressful environments such as pets being hospitalized, boarding, storms, etc. can increase the risk of this issue too. As a practicing surgeon, I can’t tell you how many times, dogs that present with a GDV are coming from a referring veterinary hospital, boarding facility, the pet-sitter, etc; so it is a real problem. A lot is done to avoid some of these situations to try to prevent this from occurring, the most definitive way to avoid this is to have a prophylactic gastropexy performed either by your veterinary or veterinary surgeon. I will address these techniques later on in the series, and we will spend some time on it, because this can be performed very easily by minimally invasive techniques.

Clinical Signs

Some of the most common signs an owner will see include the attempt to vomit, which is termed non-productive retching. This occurs due to the junction of the lower esophagus and stomach being rotated >180 degrees in effect kinking this area. Other signs are signs of discomfort such as listlessness and the inability to get comfortable. Also, many times you will notice enlargement of the abdomen. In cases that have been going on for some time (even a few hours) you can see dogs that are unable to get up and/or not responsive to stimuli.

As described above, this condition can progress rapidly and be fatal, so immediate veterinary care is a must. This condition not only directly affects the stomach and gastrointestinal system, but also affects the cardiovascular system (compression of the vena cava and return flow to the heart) which places these patients in shock and can propagate various inflammation and coagulation cascades that can also cause death. The spleen can also become affected due to its close proximity ad shared blood supply from the stomach. As the stomach rotates these splenic vessels can become torn.

Diagnosis

An experienced veterinarian will be able to quickly diagnose this condition, based on signalment (breed), clinical signs, and physical examination. Radiographs (X-rays) generally leave little doubt, as there are “tell-tale” signs seen on x-rays. Blood work will also be performed to assess values such as red blood cell concentration, electrolyte abnormalities, lactate, etc all factors that will be used to guide initial stabilization and treatment prior to surgery. Once diagnosed, surgery is required. If surgery is not feasible (patient is not able to be stabilized, owner unable to move forward with surgery, etc), humane euthanasia will be likely recommended.

This is a right lateral abdominal x-ray. Note the large, dilated stomach and evidence of the duodenum (intestine) just above the stomach and below the spinal column.

This is a right lateral abdominal x-ray. Note the large, dilated stomach and evidence of the duodenum (intestine) just above the stomach and below the spinal column.

Treatment

As one may assume anesthesia is more risky in a sick animal, but is needed for this problem. Unfortunately, there is no conservative/ non-surgical approach that has been shown to work. After immediate stabilization of the patient, surgery is indicated.

The surgical goals are to decompress the stomach, place the stomach in the correct position, and attach the stomach to the body wall – to drastically decrease the chance of this happening again. The last part of the procedure is called a gastropexy, dogs that do not have this performed, are at high risk for this to happen in the future.

Other things that need to be evaluated while in the abdomen are the stomach – there are times where necrotic (dying) segments of the stomach must be removed. Unfortunately, there are times where gastric (stomach) necrosis is so profound or is affecting a non-resectable location of the stomach when humane euthanasia may be recommended. Thorough evaluation of the spleen is necessary and a splenectomy may need to be performed. After these organs are evaluated, the rest of the abdomen is evaluated.

Post-operative care is also very important, since many cases are not completely straight forward. Close monitoring, aggressive fluid therapy and appropriate management is necessary for a successful outcome. More recent reports show an 80-85% survival rate (with straight forward cases), which is much higher than previously thought. The more damage done (gastric death, spleen involvement, etc), the worse the outlook. Again, a quick response and aggressive management is what is needed.

Prevention

While there are many different views about how to decrease the chance of a GDV occurring, the most successful way is to have a prophylactic gastropexy performed. A gastropexy is a procedure that attaches the pyloric antrum segment of the stomach to the body wall. While this does not prevent dilation of the stomach, it does prevent the deadly rotation of the stomach.

When is the best time to have this performed? I recommend this procedure be performed at 6 months or older. This timing of the procedure coincides with spaying and neutering of your pet, both procedures can be performed at the same sitting. This procedure is especially easy in female dogs that are being spayed, since the abdomen is already open.

Recently, we have the advantage of doing this procedure and the spay procedure via laparoscopy. Laparoscopy is a minimally invasive procedure in which small incisions (0.5-1.0 cm) are made in the abdomen and the organs are visualized on a screen with cameras and surgery is done with small instruments through these incisions. The laparoscopic gastropexy is typically a very fast and effective procedure and is commonly combined with a laparoscopic ovariohysterectomy (spay). Contact your veterinarian for details about this procedure or a referral to a veterinary surgeon who can perform this procedure.

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New Horizons!!!

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Under Construction!!!

There will be some changes made to this website in the near future in both content added and in format. You can still access all the previous posts and pages during this time. Please excuse the appearance of this site as we renovate!

New Total Hip Replacement Video
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New Total Hip Replacement Video

Take a look at our new Total Hip Replacement (THR) video. This happy dog is a recent (last fall) recipient of a total hip replacement at AVS Orange Park. As you can see, he is a very happy boy and much happier now that he is feeling better!! Please contact us with questions or if you feel that your dog may benefit from a THR.

Total Hip Replacement video

February 2016 – Case of the Month.
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February 2016 – Case of the Month.

I am getting this in by the “skin of my teeth” before February ends, no pun intended since it is Pet Dental Health Month! In the spirit of dental health – this case will revolve around a common oral tumor that we see in dogs. This stresses the importance of having your pet’s teeth fully evaluated which is part of the routine dental cleanings that your veterinarian can perform, especially as your furry friend ages. Countless times (including the following case), I am referred cases of oral tumors that were noted and biopsied by the family veterinarian.

There are many types of oral tumors and they can range in both their local aggressiveness and there ability to spread to other areas and significantly shorten your pets life and diminish their quality of life. The overall prevailing thought is that early detection of an oral tumor can increase the odds of a successful outcome in many cases. Any new nodules/bumps noted in the mouth or along the jaw line or nose should be brought to your veterinarians attention for further investigation.

The case for this month, involves a German Shepherd mix that presented to me for a mass that was noted in the front of the mouth – incisor 1-3 on the right side of the maxilla (upper jaw). This was noted on a routine dental examination and was biopsied before seeing me. (I love it when patients come with the oral mass already biopsied – it removes that first step for me). It is very important that oral tumors are biopsied prior to developing the final surgical plan. The size/extent of the surgery is very dependent on the tumor type – some are less aggressive and require less of an extensive surgery than others. Also, knowing what we are dealing with can help us predict the course of the disease and survival times.

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Figue 1: Picture of the oral mass on the upper jaw.

The tumor’s biopsy results revealed that it was an acanthotamous epulis/ameloblastoma. The epulid tumors come in three varieties with this type being the most common. These types of tumors can behave locally aggressive (invading into the local soft tissue and destruction of the underlying bone), however they tend to not metastasize (spread to other organs). With this type of tumor, because it doesn’t have a tendency to spread elsewhere, the next step is to perform a CT scan of the head to evaluate the extent of the tumor, which guides us in the surgical planning for tumor removal. If the patient has other concerns, a more thorough work-up may be needed (chest evaluation and abdominal ultrasound). A Complete Blood Count/Chemistry profile/Urinalysis is performed prior to an aggressive surgery and anesthetic event.

With these types of tumors, local excision is generally necessary along with removal of the underlying and surrounding bone. This is why it is so important to catch oral tumors early. I have certainly seen these tumors (among others), where they are too big to safely remove, that will still allow the pet to be comfortable and function normally. Luckily for this dog, she was able to do without the front portion of teeth and bone (incisive bone) and this left her with no visual abnormality, once her fur grew back! The last thing that we look at following surgery is our margin assessment, which tells us whether we removed it all and by how much. For this lucky girl, no further treatment was needed!

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Figure 2: Immediately following removal of mass and affected bone/teeth.

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Figure 3: Patient is visually normal following surgery.

 

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7 Things You Need To Know About Pet Health Insurance

This is a very well written, to-the-point article about pet insurance, which is becoming more and more commonplace in veterinary medicine. Give it a read!

 

Chances are, you love your pet as a family member and you would do anything for them. If they get sick, the vet bills can climb quickly. In some cases, a single illness or injury could amount to ov…

Source: 7 Things You Need To Know About Pet Health Insurance

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Welcome

Welcome to “A Veterinarian’s Perspective”. Thank you for taking the time to visit this site. One of the many goals is to give accurate and useful information about a wide array of veterinary medicine topics. There are many places online one can obtain information; some “good” and some “not so good”. This site is geared to both the veterinary professional and the non-veterinary trained. Another passion and new facet to this website/blog is in the realm of business management as it pertains to the practice of veterinary medicine.  Look for some fresh, useful topics in the near future. By all means, feel free to give suggestions for topics!

What’s Your New Year’s Resolve??
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What’s Your New Year’s Resolve??

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Ah New Year’s day! The day the gyms are packed with high aspirations, the day that we “turn over a new leaf”, start dieting, develop new relationships, try to find love, etc. We have been at this juncture last year and every January 1st before; many times we were met with the same outcome – disappointment. Not that our “resolutions” weren’t admirable, but we were never quite able to carry them out for a week, month, or let alone a whole year.

I hope this is not the normal New Year’s Day post. As we embark on a new year, we do have a clean slate and can start fresh. While we can restart on any day of the year, January 1st has become the day to reset. I hope everyone can do things differently and better in 2016. This can range from improvement to our health, personal relationships, business relationships, and more. Let’s make our New Year’s resolution one in which we follow out our new found goals! While a common definition of a New Year’s resolution is “a tradition in which a person makes a promise to do an act of self-improvement or something nice”. Wouldn’t it be better if we took a different approach and made goals for the new year and use our “resolve” to accomplish the goal.

A recent definition of the word resolve is “firm determination to do something”. Wow that is powerful, it almost sounds like we WILL accomplish that goal if we show resolve! When making goals we not only need to define what it is we want to achieve, but we need to define the “why we want to achieve it” and the “how we are going to achieve our goal”. The why and the how will fuel and power our resolve. If we never define these important components of our goals, they become mere resolutions and dreams – they are admirable and lofty, but there is no power behind them!

When choosing goals for the new year (or at any part of the year), remember to chose goals that are reachable, defined, and are dependent on you and your actions. I also want world peace, but I also realize there are many factors that go into that dream. Another thought is to WRITE down your goal(s)! Unfortunately, this is a lost art – writing in a journal or notebook. This can be one of the most inexpensive tools, yet one of the most effective tools we can employ. The ability to see our goals in writing can make an immense impact on us and be a constant reminder. Lastly, share your goals with someone you trust and someone that can provide encouragement. Accountability is an essential tool that can power your resolve. For some this may be a spouse, significant other, employer, colleague, parent, etc., whomever this is for you, this can make or break success. You may be thinking that this is a lot of work and you would be correct, reaching goals requires dedication and discipline.

Throughout this new year, let’s continue to make new goals and power them with resolve to follow them out to completion. Remember as we enter a new year, we can put last year behind us, with all the doubts, concerns, and failures – DON’T dwell on the past! Make goals that will better your life and the lives of those around you, both on a personal level and in your business life!

Remember these 4 points:

  1. Write down your goal
  2. Define your why
  3. Define your how
  4. Tell someone

Happy New Year and attack this year with RESOLVE!!!

  • Kevin Benjamino DVM, DACVS
    • Copyright January 1, 2016
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2015 in review

Happy New Year!!! Thank you to all the followers of this page. It has been quite a year of ups and downs. While there are some parts of 2015 that we are sad to see leave, we are excited for what 2016 will bring! We are sure that 2016 will have a lot of surprises. Let’s make 2016 a banner year!

  • Kevin Benjamino DVM, DACVS

 

The WordPress.com stats helper monkeys prepared a 2015 annual report for this blog.

Here’s an excerpt:

A New York City subway train holds 1,200 people. This blog was viewed about 6,500 times in 2015. If it were a NYC subway train, it would take about 5 trips to carry that many people.

Click here to see the complete report.