There Is Such a Thing as a Free Cup of Coffee

By Beth Davidow, DVM DACVECC

Yesterday, I attended the GoGreen Conference in Seattle (http://www.gogreenconference.net/).  This was a unique meeting where business leaders from Seattle discussed ways in which changes in business practice and culture are having long term effects in helping our environment but simultaneously helping businesses to be successful. Speakers ranged from the Director of Corporate Responsibility for Starbucks to the owner of Alchemy bags, a company that makes messenger and other types of bags out of used bike tires. 

One of the most interesting and relevant speakers to our business was Stephen Grose, the administrative director at Virginia Mason.  In an effort to improve their bottom line, Virginia Mason started looking at ways to be more energy efficient, more water wise, and to create less waste.  https://www.virginiamason.org/body.cfm?id=4917 In their first 2 years of increased efforts at sorting and recycling not only paper but also medical plastics they decreased their waste production by 22%.  Waste out of the operating rooms was decreased by 80%. Health care, because of its need for many single use and sterile products, is the second largest industry producer of waste so these efforts, if duplicated in other hospitals, could have a dramatic impact. This impact is not only on landfills but finding cost savings in health care due to efficiency with no impact on quality is desperately needed.

At ACCES and in veterinary medicine, we have similar issues to Virginia Mason.  We have a busy surgical practice in addition to our ICU and internal medicine services.  We use a large amount of equipment and items that must be sterilized to prevent infections and thus generate a large amount of plastic waste in this process.  We are very concerned about our impact on the environment, built our second facility in Renton using green building techniques and are rated 5 stars by the Envirostar program. Over the last several years, we, like Virginia Mason, have worked on reducing our waste.  About 6 months ago, we introduced the use of single use microfiber cloths to clean kennels and our treatment tables.  This switch has led to a dramatic decrease in our purchase and use of paper towels.  Composting in our staff kitchen and of our reception area coffee supplies has led to further decreases in waste production.  Like Virginia Mason, we have also worked to increase the amount of plastic we recycle.  These changes in practice are better for the environment and make us feel glad we are doing our part but also help free financial resources for new equipment that allows us to better care for pets.

So this Earth Day, think about the small things that you could change that might not only be good for the environment but also good for your wallet.  Bike, walk or take the bus for one errand or one day to work. Compost your food waste and encourage your employer to make this available to you at work.  Recycle paper, aluminum, cardboard, and even your coffee cup. Even better, look at where you can use less:  don’t print that email, pack your lunch in a reusable container, and use your own coffee mug.  On Earth Day, if you do bring your own mug, you will even get that free cup of coffee. http://www.starbucks.com/blog/happy-earth-day/993

           

What's Wrong With Tylenol?

By Beth Guerra, DVM

When your pet is in pain, it seems reasonable to try a painkiller at home, particularly if you aren’t able to see your vet or it’s the middle of the night. You may reach for an over-the-counter medication, such as Tylenol or Advil. Most people don’t realize that cats and dogs are not just small humans; in fact, the way they metabolize certain drugs can be vastly different.

Tylenol, or acetaminophen, comes in a variety of strengths and may also be an additive in other medications such as opioids, commonly used for post-operative pain in humans. A typical Regular Strength Tylenol (325mg) can be enough to cause severe symptoms in an average sized cat. Cats are not able to tolerate acetaminophen and can develop liver or red cell damage. In severe cases, methemoglobinemia can develop, which changes the nature of red blood cells and decrease their oxygen carrying capacity in the blood. A type of anemia, known as Heinz body anemia, can also occur and can lead to the destruction of red blood cells within circulation. As a result, vital organs are deprived of oxygen. Dogs do not seem to develop this symptom, rather, they are at high risk for necrosis, or death, of the liver cells.

Symptoms progress rapidly in cats and death can occur within 36 hours if left untreated. Affected cats may exhibit lethargy or depression, vomiting, abdominal pain, or dark colored urine. The mucus membranes may appear brown or blue in color and there may be respiratory distress. Cats can also develop swelling of the face and paws. Treatment must be aggressive and is best instituted early after suspected ingestion. The prognosis is more guarded in cats due to rapid effects of the toxicity. If your pet was given this medication or inadvertently ingested some, contact your veterinarian immediately. It is best to ALWAYS call a veterinarian before giving any medication.

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.

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. 

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.

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

Brr! Prepare Your Pets for Cold Weather!

By Christina Ryan

Brr.  It’s cold outside this week, and the forecast is calling for a large amount of snow.  Although we have had a relatively mild winter so far this year, the next week or so the temperature outside might drop severely.  Are you ready to care for your outdoor pets?  Below are some quick tips to keep your pet safe and comfortable during inclement weather:

·         First and foremost your pet will need some sort of shelter.  Make sure that it is located in a spot that can shield your pet from rain, wind and snow.  You can add to the shelter by providing extra bedding, straw insulation, or a semi-enclosed area with a trapdoor that shuts behind your pet.  Warning: never use space heaters or electric heat lamps.  These things can be dangerous to your pet by causing burning, overheating, or by catching fire.  If you need an extra heat source, there are heated beds available at some pet stores, but use caution with these items as well.  Read all instructions carefully, only use them as directed, and make sure your pet will not be electrocuted if he chews on the chords.

·         Paws are susceptible to frostbite.  To protect them, you can purchase specially made “boots” at many pet stores.   If you do not cover the paws, just be aware that spending a lot of time in the snow can cause pads to crack or burn.  Keep the area between the toes free of any ice balls that may form there by trimming the hair between the toes and using a warm cloth to gently remove any built-up snow.

·         Always have fresh water available, making sure it doesn’t freeze.  Licking ice or snow is not enough to hydrate your pet, and can cause a drop in overall body temperature.  Heated bowls are available at many pet stores, but use the same caution with these as you would with heated bedding.

·         Watch out for de-icing chemicals and antifreeze.  Salt applied to sidewalks and driveways can be caustic to paws, and if your pet licks these chemicals they could get some GI upset.  Clean paws gently with warm water after coming inside from the snow to avoid this.  Antifreeze tastes sweet to pets but is deadly, and should always be cleaned up immediately if spilled.  If you suspect your pet has ingested antifreeze, call your veterinarian IMMEDIATELY. For more information on antifreeze see, http://www.criticalcarevets.com/antifreeze_20091124124940.pdf

·         Cats like to hide in warm places, including car engines.  Be careful before starting your car, as cats can be injured by the fan belt or other parts of a moving engine.  Knock on the hood or honk your horn before you start your car to flush the cat out of its hiding place.

·         During the cold winter months, many people use space heaters and wood-burning stoves to heat their homes.  Do not allow unsupervised pets in areas with space heaters that could be knocked over by the animal.  Placing “scat mats” on the floor may be helpful in keeping pets away from the stoves and heaters.

·         Electric blankets and heated water bottles are designed for human use only.  Allowing your pet to lie on or near these items could cause burning, so beware and only use those items on yourself.

If possible, providing and indoor shelter for your pet during the worst weather is best.  Also, you may be unable to leave your home for a few days because of the weather and therefore need to have things such as medication and food on hand.   Remember that weather can change rapidly so it is best to be prepared BEFORE things get bad. 

Sources:

http://vetmedicine.about.com/cs/diseasesall/a/coldweatherlist.htm

http://www.aspca.org/pet-care/pet-care-tips/cold-weather-tips.aspx

http://www.peteducation.com/article.cfm?c=2+2098&aid=934