Full Moon and the ER

By Dr. Beth Guerra 

There are nights in the ER where I take a moment to reflect upon the phase of the moon. This usually occurs when I have every exam room full of potential patients and multiple critical animals being carried into the ICU on stretchers hemorrhaging, seizuring, or gasping for breath. Every emergency doctor, human or veterinary, cannot shake the conviction that a full moon coincides with a full, and often crazy, emergency room.

I have several friends that are human ER physicians, and we all swear by this phenomenon. Reflecting back on my years in the ER, I can recall with difficulty the full moon shifts where I wasn’t up to my elbows in critical patients, no matter what clinic I was working at during that time. I even psych myself out driving to work when I happen to glance up and notice the moon is waxing full.

Multiple studies have been done about this correlation, in both human and veterinary medicine, and the bottom line is, there is no correlation. Separate statistical analyses have failed to show any link between a full moon and the caseload in the ER clinic.

One study from the Indian Journal of Medical Science (2004) failed to show any positive relation between full moon days and variables such as number of trauma patients, assaults, or attempted suicides. Another retrospective study in Resuscitation (2003) analyzed ER caseloads for six years and did not find a correlation between the number of ER visits, the phases of the moon, or the signs of the zodiac. A similar study in Journal of Veterinary Emergency and Critical Care (2007) found no correlation between case load and the phase of the moon (or Friday the 13^th), but did note that weekends and holidays were consistently the busiest days of the year.

A literature search revealed that this phenomenon has been studied extensively since the late 1960s and has even delved into variables like number of births, dog bites, drug overdoses, suicide attempts, surgical complications, and cardiac arrest. In each instance, no relationship has been established that can be linked to a full moon.

Even with all this evidence to the contrary, I still approach my full moon shifts with a certain amount of trepidation. I make sure to get as much sleep as possible and eat before I get to work; as every emergency shift worker knows, you may not get another chance. I take a deep breath as I walk in the door and remind myself that it’s just another day, and that no matter how out of control things get, I can’t blame it on the moon.

SEPTEMBER- Healthy Aging Month

By Jennifer Waldrop, DVM DACVECC

What does “healthy aging” mean for your pet? Is it the same as for you? Basically, the answer is yes, with one glaring difference. Your pet cannot be trusted to tell you when something is starting to go wrong. Subtle warning signs of a problem may resemble age-related changes. For example, increased sleeping might be a headache or blurred vision. Difficulty rising could be arthritis, but could also be weakness related to low blood pressure, altered electrolytes, bone pain, or dizziness. We humans also tend to rationalize and “anthropomorphize” our pet’s issues, which can sadly delay diagnosis of many treatable diseases. Then it seems surprising when our pets are really sick and we hear of the degree or chronicity of the problem.

Given the rapidity of animal aging and their short life span, the only way to reliably monitor aging is by frequent visits to the veterinarian with an examination and geriatric lab work including a Complete Blood Count, Chemistry Panel and a Urinalysis. Chronic kidney disease is one of top three diseases of geriatric pets and kidney failure is only reliably diagnosed by checking a urine sample for concentrating ability (urine specific gravity.)  Ideally, this should be every six months for a dog over nine to 10 years (over seven years for Giant Breeds like Great Danes) and every year for cats over 10 years of age. For exotic pets, these recommendations will vary depending on the size and type of pet. This can become expensive and makes a good argument for pet insurance to cover some of the ongoing costs. When choosing a pet insurance, take care to check for geriatric exclusion clauses given that many pet insurance companies are also aware that aging pets require more care.

What else can we do to fend off some of the preventable changes of aging? Just as in humans, a healthy diet and exercise are crucial. Most commercial and many alternative diets are complete, but when in doubt, your veterinarian or a veterinary nutritionist will be able to consult on the appropriateness of the diet. Most “senior” diets do not have significant changes in ingredients or electrolytes that make them better than regular diets. Supplements like fish oil may have a place in treatment of canine osteoarthritis, but their role in prevention of other diseases such as heart disease or dementia is unknown. I still recommend them if there is no fish in the pet’s diet. There are instances when fish oil supplements are discouraged, specifically in some human cancers during chemotherapy.

Exercise of the body and mind are both important to provide your aging pet. Exercising with your dog has been found to improve health for the human in multiple research studies, and the reverse is likely true as well. The cardiovascular and muscular strength that moderate exercise provides is important to keep both healthy, but also serves as a reserve when you are sick. This reserve strength will improve recovery after accidents, surgery or other health issues. Outdoor exercise is also a mental boost for our dogs with input into all their senses. Time spent with their owner is also important for mental health, so part of a moderate exercise program should include an interactive component.

Exercising a cat or exotic pet can be a little more difficult, to say the least, but is extremely important given the high rate of obesity in our pets. Cats may enjoy chasing a toy on a wand or chase toys or balled up socks, but sadly some cats are not interested in chasing. For these cats, a companion cat or dog may provide some impetus for moving around even if it’s just to get away from the other animal. (Conflict can provide good stimulation ;) A younger cat could keep the older cat more active both physically and cognitively. The same is likely true for birds and small mammals.

At home, grooming and petting your cat or dog provides both with the benefits of companionship. Having friends and relationships is as important for our pets as for us. Studies in humans have shown increased longevity and mental health for those people who actively continue human interaction and relationships. Sometimes a pet and their human can become isolated from the rest of the world and this is not healthy for either individual. One of the least judgmental places for dog owners is the dog park where dogs of all sizes, temperaments and interests congregate with their humans of the same variability. For indoor-only cats, frequent household visitors and companionship with other housecats should provide good stimulation.

The best part of living with a pet is having a good friend who lives every day to its fullest. We can follow their example while we age as well and continue to fully enjoy each moment.

Men do not quit playing because they grow old; they grow old because they quit playing.

~Oliver Wendell Holmes  

Rabies in Washington State

By Dr. Beth Guerra

I grew up in the Midwest, where rabies was more prevalent in wildlife such as bats, raccoons, coyotes, and skunks as well as the rare household pet. In Washington state the primary animal that has been identified is the bat. Although the risk is fairly low (less than 1% of bats are infected), the virus is nearly always fatal and care should be taken to avoid exposure.

In 2011, 11 bats in Washington state tested positive for rabies in the following counties: Chelan, Clallam, Island, King, Lewis, Pierce, Snohomish, Walla Walla, and Whatcom. As of July 2012, there have already been three infected bats in similar counties. The most recent case of rabies in a household pet (cat) was in 2002 in Walla Walla county, and the last two human cases were in 1995 and 1997. All of these cases were infected with bat rabies.

Bats that carry rabies are usually clinically ill and cannot fly properly. This makes them more likely to be found by humans or household animals. There have also been reports of bats getting into houses and being found in closets or shoes. The teeth of the bat are very small and a bite may not be easily detected, especially if a person is bitten while sleeping.

Rabies is a virus that affects the central nervous system. The virus is found in saliva and transmitted via bite or scratch wounds. Household pets are exposed through wildlife and are usually the source of exposure for humans. Early symptoms may include headache and fever, but within two to eight weeks can progress to confusion, paralysis, and difficulty swallowing. If exposure is suspected, the exposed person usually begins a regimen of injections, including rabies immunoglobulin as well as the vaccine, over a two week period.  The best treatment is prevention.

As of January 1, 2012, current rabies vaccines are required for all dogs, cats, and ferrets. Rabies vaccines are readily available at veterinary clinics and are inexpensive. If a household pet is exposed to rabies, there is mandatory six month quarantine, so vaccination is best.

The following information was taken from the Washington State Department of Health:

What should I do if an animal bites me?

Clean the site of any animal bite with soap and water. Contact your health care provider and Public Health Communicable Disease and Epidemiology at (206) 296-4774 to determine the potential for rabies exposure, the need for treatment, and to decide whether or not to test the animal for rabies.

What should I do if I find a bat in my living space?

Do not touch the bat. Close the doors and windows to the room. Wait until the bat lands on the floor or a wall. Wearing leather or other thick gloves, capture the bat in a can or box without touching it. Seal the container and call Public Health Communicable Disease and Epidemiology at (206) 296-4774. The health department will help you determine if any people or pets in your home may have been exposed and can arrange to test the bat for rabies, if needed. “Bat proof” your home by making sure open windows have screens and that other small entry points—such as cracks, crevices, or holes—are sealed.

What treatment is available after exposure to rabies occurs?

Safe and effective treatment following potential rabies exposure should begin as soon as possible after the exposure occurs. Treatment is a series of shots. These shots, called post-exposure prophylaxis (PEP), include one dose of human rabies immunoglobulin (HRIG) and four doses of rabies vaccine given on a specific schedule over a 14-day period. People with weak immune systems will also need a fifth dose of vaccine and a blood test to check that the vaccine worked.

Treatment can be arranged through your health care provider and your local health department.

What can I do reduce the risk of rabies exposure for my family and me?

• Do not handle wild animals, especially bats.
• Teach your children never to touch or handle bats, even dead ones. Have your children tell an adult if they find a bat at home, at school, or with a pet.
• If you see a wild animal leave it alone.
• Do not keep wild animals as pets.
• Keep bats out of your living space by “bat proofing” your home.
• Pets may get rabies if bitten by a rabid animal. Protect them and yourself by getting them vaccinated routinely. Dogs, cats, and ferrets are now required to be vaccinated in Washington. Consult your veterinarian for vaccine recommendations.

Sources: Washington State Department of Health

Are these foods REALLY toxic?

By Beth Davidow, DVM DACVECC

There are a number of foods that are now known to be toxic to pets. I tend to wonder each time I hear of a new toxicity, “is that really true?” I often think, “Well, I’ve seen lots of dogs who eat that who haven’t had a problem.” The growing list of toxic foods for pets now includes chocolate, onions, grapes, raisins, and chewing gum containing xylitol (many of the sugar free gums). Although I read these new reports critically, working in emergency, I have now seen all these toxicities first-hand.

Chocolate toxicity has been known to many of us for years. Theobromide, a methylxanthine, is the main toxic component, and causes extremely fast heart rates, tremors, and can lead to seizures. The darker the chocolate, the more theobromide is contained in each ounce and the less the pet has to eat of it to cause problems. White chocolate is actually not toxic at any amount. A 60-pound lab would need to eat 20 ounces of milk chocolate to have moderate to severe signs but only three ounces of dark bakers chocolate. Depending on when the chocolate was ingested, we might recommend inducing vomiting or having us administer activated charcoal. (Activated charcoal binds toxins that are in the stomach or intestinal tract so they can’t be absorbed into the blood stream.) We’ve seen many dogs that presented with agitation and severely elevated heart rates. Most have done well but some needed 24-48 hours in the hospital on IV fluids and medication to decrease the dangerously high heart rates.

Onion toxicity is one I hadn’t seen until a few years ago. Onions and other members of the Allium family (shallots, garlic, and green onions) contain a compound that can weaken red blood cells. The red blood cells break down causing anemia (lack of red blood cells) and hemoglobin (the protein inside red blood cells) to spill into the urine. Dog’s red blood cells have less antioxidants than people’s making their cells more prone to damage. Cats are even more susceptible to red blood cell damage. Ingestion of 5g/kg of onion in cats or 15-30 g/kg in dogs can lead to clinically important hemolysis. Damage consistently happens in dogs who ingest more than 0.5% of their body weight in onions at one time. A few years ago, an English setter was referred to us for inappropriate urination and red colored urine. It turns out he had eaten three cups of onions the day before – 1.5% of his body weight! The red color was hemoglobin in his urine. He became very anemic four days after he ate the onions and needed a transfusion. To complicate matters in his case, he also had a bacterial urinary infection. The combination of the hemoglobin going through his kidneys and the infection, despite antibiotics and IV fluids, led to acute kidney shut down. After 10 days of hospitalization, antibiotics, and IV fluids, he is doing well at home.

Grape and raisin toxicity was first reported by the National Animal Poison Center in 2001. At that time, they knew of 10 reported cases of acute kidney failure with ingestion of quantities varying from 0.2 oz/lb to 4.4 oz/lb. A retrospective study was published in 2005 in the Journal of Veterinary Internal Medicine involving 43 cases. Of the 43 cases, 20 died or were euthanized due to a poor prognosis. Unfortunately, it is still not known why some dogs, but not all dogs, develop acute kidney failure from ingestion of these foods. Pesticides, fungus and heavy metal contamination have been ruled out as causes and it appears that the toxic principle is in the flesh and not in the seed. Last year, we treated a dog who developed acute kidney shutdown after eating grapes off a vine at a friend’s house. The dog survived and is now doing well but was hospitalized for almost two weeks and required subcutaneous fluids for many weeks afterward. We do recommend inducing vomiting, activated charcoal and IV fluid diuresis with any grape ingestion over 0.7 oz/kg or raisin ingestions over 0.1oz/kg. Induction of vomiting is recommended up to eight hours after ingestion in these cases as in many of the cases reported to National Animal Poison Center, raisins were still found in the vomit at this point.

Xylitol is a sugar substitute that is good for people on a low carbohydrate diet, those with diabetes or those watching calories. It is found in sugar free gum, some toothpastes (it can prevent oral bacteria from producing acids that damage tooth surfaces), and can be bought as a powder for cooking. Although the lethal dose is >130 g/day in people and greater than 20g/kg in mice, the metabolism is different in dogs. It appears that doses greater than 0.1g/kg can lead to hypoglycemia 30 minutes to 12 hours after ingestion. This is because in dogs, but not in people, xylitol causes a dose-related rapid, severe insulin release. In addition, acute liver failure and bleeding problems has been reported in eight dogs after eating xylitol containing products. Most of the dogs presented with vomiting and lethargy nine to 72 hours after xylitol exposure. The reason for the liver failure is currently unknown. National Animal Poison Center does recommend vomiting induction, IV fluids, and careful monitoring of blood glucose and liver enzymes.

The NAPCC is a fantastic resource and we recommend that their phone number be easily accessible in your household. The Washington Poison Center now also has a veterinary toxicologist on staff and is also very helpful especially in cases of household chemicals or product exposure. In addition, our emergency doctors are very knowledgeable about toxicities and are always happy to answer questions at any time of day or night. (NAPCC, 888-426-4435 and Washington Poison Center, 800-222-1222)

Bird Emergencies: From Cockatiels to Cuckoos to Chickens

By Jean Maixner, DVM

Did you know that birds are the third most popular companion pet in the United States, behind dogs and cats?  The American Veterinary Society estimates there are over 10 million birds in this country, with the highest concentration of our feathered friends in the Pacific Coast Region.  Some birds are extremely social and bond with their owners; they mimic words and even and actions.  Others are just beautiful to look at.  Some birds are extremely intelligent and have remarkable memories and problem solving abilities.  In fact, some crows have learned how to use tools: “Using their beaks as scissors and snippers, they fashion hooks from twigs and make barbed, serrated rakes or combs from stiff leathery leaves.  And they don’t throw the tools away after one use–they carry them from one foraging place to another.” http://www.pbs.org/lifeofbirds/brain/index.html 

Yes, birds are remarkable and that is why their popularity as companion animals has grown.  Pet birds have brought new and interesting challenges to veterinary medicine; they carry some illness that are similar to their 4 legged counterparts, and some illnesses that they’re uniquely sensitive to.  Did you know the fumes from a heated Teflon pan can cause breathing problems and death to our feathered friends?

ACCES medical director, Dr. Davidow, is an Emergency and Critical Care specialist who has an interest in birds and who has owned birds.  She says, “Emergencies in birds are difficult because these animals often hide illness until they are quite sick.  Often, the first significant sign is that they are on the bottom of the cage, fluffed, or unwilling to perch.  Because birds hide their illnesses, any bird that doesn’t eat for more than 12 hours, is very fluffed in the cage or who is sitting and not moving on the bottom of the cage should be seen right away.”

Some of the most common emergencies include:

1.       Breathing problems from: viruses, bacteria, toxins in the air and seeds caught in the airway.

2.       Some birds even develop heart disease.

3.       Bleeding from injured toenails, beaks and broken feathers.

4.       Difficulty laying eggs or egg binding; this condition can be life threatening because it prevents stool passage and impairs blood flow.

5.       SEIZURES, yes birds can have seizures.  There are many causes of seizures including; toxins, trauma, cancer and more.   Seizures can be life threatening in any animal but birds are especially sensitive as their muscle spasms they use up their glucoses (sugar) stores and oxygen very rapidly. 

Emergency support for your bird will include oxygen, controlled heat support, fluids and often sugar replacement.  In addition, support may include pain medication, antibiotics or other medications.

If your bird needs to see a veterinarian on emergency basis Dr. Davidow has some suggestions:

1.       Call the emergency hospital to let them know you are coming and so they can be prepared.

2.       Transport them in their own cage and cover the cage if it cold outside.  This helps to decrease the birds stress and allows the veterinarian to determine a lot about the bird’s condition by examining the food and droppings that are in the cage.

For more information visit the ACCES website and read Dr. Davidow’s article on Avian Emergencies: http://www.criticalcarevets.com/Avian%20Emergencies.pdf