ACCES

ACCES

Thursday, March 31, 2011

Saying Goodbye

By Beth Guerra, DVM

I wanted to take some time to address euthanasia and its place in the veterinary setting. Although veterinarians take an oath to preserve animal health, we also take an oath to end animal suffering. The choice to euthanize a pet can be made for many reasons; terminal illness, chronic pain, severe behavior problems, and occasionally financial limitations. As veterinarians, it is our duty to help animals pass in a dignified manner, but also to provide guidance to grieving pet owners to help them make a decision.
As an emergency doctor, euthanasia is performed more than any of us would like. Sometimes it is planned, and the entire family is present. In other cases, the decision to euthanize is made because the pet has a life threatening illness or has sustained massive trauma. I do my best to provide a prognosis and plan so the owner is able to make an informed decision. Unfortunately, despite medical credit options and our willingness to discuss options A, B and C, cost sometimes drives the decision.
I always ask owners whether they wish to be present for the euthanasia. This requires a delicate approach, as some owners feel strongly that they wish to be with their pet, but others don’t think they can witness the event. I reassure my clients that there is no right or wrong decision in these cases, that whatever makes them comfortable is what they should choose. We place an IV catheter so that we have access to a vein as this facilitates the process. Some owners ask for sedation prior to the euthanasia. Some say goodbye at the door, others hold their pet during the euthanasia. Some leave the room immediately, some stay for hours in the exam room, grieving for their lost friend.
While the injection is essentially an overdose of an anesthetic and can be very quick and peaceful, the body can react during and after the injection in ways that can be unexpected. I warn owners that pets usually don’t close their eyes, as many people are upset when they see the eyes are still open. Cats often stick out their tongues. Rarely, pets vocalize, usually from dysphoria, during the beginning of the injection. After they have passed, they may take some gasping, or agonal, breaths, which is purely a reflex. Sometimes they lose control of their bladder or bowels. Slight muscle twitching may be observed as well. These reactions can be alarming to owners, and often I have had people ask if their pet had really passed away because these reflexes are lifelike. They are just reflexes, and occur often after the heart and breathing have stopped.
We have a very respectable company that provides cremation services for our clinic. Clients can choose to have their pet cremated privately and the ashes returned to them in an urn. We make paw prints in circles of clay for the owner to keep. Some clients take their pet home for burial.
Euthanasia is a difficult decision. The process is never easy but can be easier to face with more information.  Never hesitate to ask your veterinarian about your options and about the process itself.

Tuesday, March 15, 2011

What's With All the Questions?

By Beth Guerra, DVM

It seems at times when patients come in on emergency that we have a thousand questions, ask the same question in multiple ways, repeat the same questions, or ask clients to repeat the same history over and over.  Why is this?
Number one, our patients can’t talk to us.  Symptoms can often be very vague or subtle.  Or, the causes to a particular symptom may have a 4 page long list and we are trying to pare down the possibilities.  An example would be a patient presenting for vomiting.  Common questions may be; does he have previous medical problems, taking any medications, recent vaccinations, eaten anything abnormal, coughing, diarrhea, blood in the vomit or stools?  Has the patient been anywhere new in the last 5-7 days, travelled outside the area, weight loss, increased thirst or urinations, type of food they eat, etc?  Our goal is to create a concise record in order to determine what tests are optimal to yield the most results for a given situation.  Does it make sense to run $500 worth of tests or not?  Do we need to recommend hospitalization?  How aggressive do we need to be, or is symptomatic care reasonable?
Another reason for repeated questioning is it sometimes sparks your memory.  I recall occasions in which a client’s answers changed after thinking more about some of the questions they had already answered.  Sometimes an answer might be different if is is asked a different way.  A thorough history can keep us from performing unnecessary tests.
Then there are the times that the barrage of questions reveals that the symptoms are misinterpreted.  For example, it is very important to determine whether a patient with bowel problems has symptoms consistent with the small intestine, large intestine or both.   Owners may think their pet is vomiting, but it may actually be coughing or gagging.  What may appear to be straining to defecate may actually be difficulty urinating.  What looks like a seizure is actually fainting from a heart problem.
Our veterinary patients also lack discretion, in particular when eating things they shouldn’t.  Animals are similar to infants in the sense they don’t realize that what they just ate may cause problems.  It is important to know if a dog is the type who gets into things, got into the trash 3-4 days ago, or likes to chew on rocks. 
Then there are the instances that a patient comes in for a procedure that may require anesthesia.   It is very important to know if the patient has had problems with anesthesia, or if they are already on medications, have heart problems, etc.  These questions help us to determine risk and to prepare for possible complications.
In essence, what may seem like an interrogation can be vitally important to the direction we go with a particular patient. 

Thursday, March 3, 2011

Rats! My Pet Ate Rodenticide!

By Dr. Beth Guerra
Rodenticides are tasty, and not just for rodents. Whether accidental or deliberate, rat bait poisoning in dogs is quite frequent. Even the most well hidden baits can often be ferreted out by curious pets. There are three main types of rodenticides on the market and they have vastly different effects.
Usually ingestion is not witnessed; this can be problematic with anti-coagulant rodenticides as they have delayed onset of action. The most common brands are D-Con, Rodex, and Contrac and they usually come as green pellets or blocks. The active ingredient is Coumadin (brodifacoum or bromadiolone), which directly interferes with vitamin K dependent elements in the clotting pathway. Depending on the type (generation) of this ingredient, symptoms can develop anywhere from 4-7 days after exposure. If ingestion is witnessed, vomiting should be induced by a veterinarian as soon as possible. The pet will be sent home with oral vitamin K, which is the antidote, for several weeks. For cases where ingestion of a toxic dose has occurred several days prior, the affected animal will exhibit hemorrhaging, which can manifest as nosebleeds, gingival bleeding, bloody urine, joint swelling, or respiratory difficulty from bleeding into the lungs or chest cavity. Weakness or collapse can occur from severe anemia. Depending on the location and severity of the bleeding, death can occur. Diagnosis is based on history, physical exam, blood work and clotting times. Treatment is supportive and involves vitamin K, fluid and oxygen support. Transfusions of whole blood or fresh frozen plasma are required in cases of life-threatening hemorrhage. If caught early and treated, prognosis is favorable.
Another other type of rodenticide is bromethalin, which is a neurotoxin and does not affect clotting ability. The most common brands are Assault and Vengence and they can also be green pellets. Symptoms occur within several hours of ingestion and include depression, paralysis, tremors, or seizures. Decontamination with vomiting or gastric lavage should occur if ingestion is witnessed. Supportive care and control of neurological symptoms is key. Death usually occurs from respiratory failure secondary to paralysis. Prognosis is very guarded as only a small amount of bait is needed to cause symptoms.
A third type involves cholecalciferol, or vitamin D. This can lead to elevated levels of calcium in the blood, leading to arrhythmmias, seizures, and kidney failure. Onset of symptoms, including vomiting, diarrhea, and lethargy, is within 18-36 hours. Treatment includes decontamination where applicable, aggressive IV fluid therapy, and monitoring of kidneys and heart. A drug called pamidronate can be used to try and lower calcium levels in the blood.
If you suspect your pet has gotten into any type of rodenticide, contact your vet or Poison Control immediately. If possible, have the packaging on hand because the active ingredient is important in guiding treatment.