“I thought it was just a little limp.” When a diagnosis of lameness leads to something more concerning…

Duffy’s owners noted he was limping on his right front leg a few weeks ago. They didn’t give it much consideration at the time. It wasn’t unusual for this handsome and active 9 year-old Golden retriever to tweak a muscle once in a while, and after a few days of rest and prescription anti-inflammatory medication, Duffy was feeling much better.

 

The lameness returned about 10 days later, and this time they noticed a swelling above Duffy’s carpus (wrist) on the same limb. They recognized this wasn’t just a sore muscle and they made an appointment with his primary veterinarian the next day.

 

Duffy’s vet performed radiographs (x-rays) of the swelling over his carpus. The images revealed near complete destruction of the distal (lowest) part of the radius (weight-bearing bone of the forelimb) with a significant amount of swelling and also some new bone formation. All of these signs unfortunately pointed towards the high likelihood Duffy had bone cancer. Duffy’s doctor recommended they come talk to me about different options available for obtaining a definitive diagnosis and also to learn about some potential treatment options.

 

I met Duffy and his worried owners soon after. I agreed with Duffy’s vet, and discussed most likely he had a specific type of bone cancer called osteosarcoma. This very aggressive tumor causes significant pain for affected dogs, and is also highly metastatic, meaning there was a high chance tumor cells had already spread to distant sites in Duffy’s body. The most common sites of spread would be the lungs and other bones.

 

I talked with Duffy’s owners about tests we could perform to be certain of my concern and also how we could look for any spread of his cancer. The “gold-standard” test for diagnosing bone cancer in dogs is a biopsy, where small pieces of the affected bone are removed with a surgical procedure under general anesthesia.

 

Although a biopsy is likely to provide an accurate diagnosis, there are some downsides to the procedure. The turn around time for biopsy samples can be as long as week or more, and during that time pets are still painful, and there is a risk (albeit low) for causing a fracture of an already weakened bone. There is also a small risk of infection and bleeding, and if not planned correctly, seeding tumor cells into the surrounding connective tissue.

 

For dogs with suspected bone cancer, I typically recommend we start with an ultrasound guided fine needle aspirate of the lesion itself. This is a relatively straightforward procedure that is performed under light sedation. A medium-sized needle is inserted into the affected bone and cells can be extracted and evaluated under a microscope by a trained cytopathologist.   The major pro of this test is the rapid turn around time (within 24-48 hours in most cases), and the risk of inducing a fracture is minimal.

 

The fine needle aspirate test is very good for obtaining a diagnosis of “cancer vs. not cancer.” Results typically indicate either sarcoma (cancer) or reactive bone (no obvious cancer). Sarcomas are tumors of connective tissue, and bone is an example of one of many types of connective tissue in the body.

 

When it comes to bone sarcomas, there are several types we commonly see within bones. As stated above, osteosarcoma would be the most common type, followed by chondrosarcoma, fibrosarcoma, and hemangiosarcoma. Other primary bone tumors include histiocytic sarcoma and multilobular osteochondrosarcoma.

 

The reason an aspirate lacks the specificity to determine the subtype of sarcoma is because with this procedure we are just extracting individual cells, whereas a biopsy sample will obtain not only tumor cells, but other elements of the bone itself that help a pathologist determine the exact nature of the tumor.

 

If an aspirate sample returns positive for sarcoma, an additional test (alkaline phosphatase stain) can be performed to rule in or rule out osteosarcoma. I urge owners to start with an aspirate first as I find it the most rapid way to obtain a diagnosis with minimal risk to the patient.

 

I discussed this with Duffy’s owners and they elected to move forward with the radiographs of his lungs and the fine needle aspirate procedure. As expected Duffy handled the procedure perfectly, with no complications. We added some stronger pain medications to his at home anti-inflammatory treatment and he left that day still limping, but carefree and happy, not understanding his owner’s worry at all.

 

Two days later, late in the evening after finishing my appointments, I sat down to call Duffy’s owners. On a conference call with both owners eagerly awaiting my words, I sadly relayed the test results confirmed our suspicions: Duffy had osteosarcoma.

 

I’m not often the one breaking the news of a diagnosis of cancer to owners, but when I do I’ve noticed there are several typical reactions. Some owners will become angry and lash out while others are too upset to speak.   Duffy’s owners fell into the “strong but silent” type, not really showing much emotion, stoically listening to my words with a bit of detachment and hint of skepticism. They asked what the next step would be, and I told them I recommended they schedule an amputation of Duffy’s affected limb as soon as possible.

 

The subtle short intake of breath by both owners was barely audible through the phone, yet I immediately knew its significance. In it, I detected the fear of the prospect of surgery and what it would mean for Duffy to live the remainder of his life as a three-legged dog. I’ve had this discussion with owners numerous times before, and I knew I was about to embark on a lengthy and emotionally driven conversation.

 

I literally kicked off my heels and put my feet up on my desk and stated, “Try not to panic. Let me tell you what you can expect…”

 

Stay tuned to learn about what Duffy’s owners decided and learn more about therapeutic options and the prognosis dog with osteosarcoma.

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And now for something entirely different!

I was invited to write an article for Next Avenue, a national organization that provides news, information and advice for America’s over-50 population through the power of media outlets such as their website and a national network of media partners and government and nonprofit allies.

The suggested topic was advice on how to spend your money wisely at the veterinarian’s office, a topic that transcends general veterinary medicine and specialty medicine alike.

Owners have varying abilities to pay for their pet’s care, and it’s something I always need to be cognizant of and be prepared for – there’s never only one option for treating a pet’s cancer and I work with owners to come up with what works best for their situation.

Talking about money isn’t easy when it comes to medicine, but it’s a part of our career as veterinarians.

Click here to read the article!

Why does my veterinarian want to run blood work when it “doesn’t tell them anything?”

We’ve all been there.

Staring in anticipation at the sharp and shiny needle, poised above our arm, ready to pierce tender skin and withdraw a sample of our blood for some purpose related to our well being.

Bloodwork is a fairly routine diagnostic test prescribed by doctors. It’s performed to ensure we’re as healthy on the inside as we appear on the outside, or to monitor previously diagnosed medical conditions. The same is true for companion animals, and veterinarians utilize the same tests that are used in people to help us better assess our patients’ physical status.

The most common blood tests I recommend are a complete blood count (CBC) and a serum chemistry panel. Each test provides me with very different but remarkably complementary information.

A CBC measures a patient’s white blood cell count, red blood cell count, platelet count, and usually provides some information regarding the size and/or shape of the red and white blood cells.

A chemistry panel provides values related to organ function (e.g., liver and kidney), as well as electrolyte levels and other important enzymes that can be measured in the bloodstream.
I am fortunate to have the option of having lab work performed directly in the hospital where I work. This means results are usually available within a few short minutes of a pet arriving for an appointment, and I can make important decisions regarding their treatment plan right away.

In less urgent situations, I can send blood samples to a larger laboratory located off-site and the results are typically available later that same day or the following day.

There are actually a “variety” of CBC and chemistry panels I can order, each offering slightly different information depending on what I am looking to measure and what information I am hoping to learn.

For example, I can send blood out for a “routine CBC,” or I can order a “CBC with a pathology review.”

The former provides strictly numerical values related to the counts of cells in the sample obtained by a diagnostic machine.

For the latter, a clinical pathologist will actually evaluate a sample of the blood under a microscope to confirm that the counts provided by the machine are accurate and to also determine if there are any abnormal cells present, damage to the cells consistent with certain toxins or poisons, or even evidence of parasites that can live in the blood stream.

I can order a full chemistry panel, which will give me over 25 different values, or I can just order a “renal panel” to tell me information about a pet’s kidneys.

Despite the wealth of information bloodwork can tell me, rarely do the results provide information about whether a patient has cancer or if their cancer has spread in their body. This is a difficult point for many owners, who wonder why I want to have bloodwork performed so often when it “doesn’t really tell [me] anything.”

I explain to owners that CBC and chemistry panels assure me that my patient’s body is handling the prescribed treatment plan without complication. I would much rather pick up on a mild anemia (lowered red blood cell count) or slightly elevated kidney value that occurs secondary to chemotherapy prior to a pet vomiting uncontrollably from organ failure or collapsing from weakness related to blood loss.

Each parameter measured on bloodwork is associated with a particular reference range, which encompasses a series of values between a specified low-end measurement and a high-end measurement. The specifics will vary, but in general, the reference range of any particular value encompasses the average of values obtained from apparently healthy animals, plus or minus some predetermined number of standard deviations.

Veterinarians are taught how to interpret lab work very early on in their curriculum. We learn what each of the dozens of abbreviations stand for, which body system or systems they are associated with, and what things we should be thinking about when the values are outside of the “normal” reference range.
What we also learn, in a surprising number of cases, is how to dismiss a value that falls either too low or too high on the scale as something we shouldn’t be concerned about.

Is the patient’s albumin level too high? Don’t fret, it just means they are dehydrated.

The lipase is low? Meh — that means nothing.

Say the cholesterol is 100 units over the high end of normal. Despite how hard your own MD probably comes down on you about trying to keep your own blood cholesterol levels below a certain value, veterinarians don’t pay too much attention to it in an otherwise happy pet. It probably just means they weren’t fasted before the sample was taken.

When I talk to an owner about lab work results, some are happy to hear that my interpretation of things is “normal.” Others pore over each and every detail with the diagnostic acumen of a forensic investigator. They focus so much on the numbers that they miss the bigger picture of what is truly going on with their pet’s health.

Labwork is a very important part of my patient’s medical record and I’m happy to spend time explaining this to owners so they feel empowered about their pet’s care. I also want them to understand the limitations of what these tests tell us so that everyone’s expectations are the same. The amount of information garnered from that simple syringe and needle is truly remarkable.

In a future article, I will discuss the pros and cons of several commercially available blood tests designed to aid in the diagnosis and treatment of cancer in animals.

“What would you do if you could have any job in the world?”

I contemplated the words in my head before uttering them out loud, as I hungrily scooped a large spoonful of homemade chocolate peanut butter ice cream into my mouth.

The question was posed on a small plastic card, sticky with the fingerprints of dozens of other ice cream aficionados of years past. Just one of a larger set of equally provocative printed questions piled on the rustic wood tabletop of the quiet but quaint sweet shop.

A simple party game designed to stimulate meaningful conversation amongst friends instilled an immediate sense of curiosity in my mind. Without missing a beat, I offered up my answer: “I would be a writer.”

Many of my colleagues will tell you that, for as long as they’ve understood what the job entailed, they’ve always known they wanted to be a veterinarian. I’m not sure why the innate compulsion is so prevalent in our profession, but you’ll find it’s a common theme if you start asking around.

I suspect it has something to do with being gently encouraged by adults who are less familiar with the specifics of the job, but who find it “adorable” or “noble” that a little person could be motivated to work in such an honorable field.

Likewise, with only a few exceptions, people really respond positively when I tell them I am a vet. People who love animals are certainly the most receptive, but even non-pet owners show excitement over me being an animal doctor. There is a near inexplicable fascination with the job. Unfortunately, there is a great deal of romanticism regarding the actualities.

As long as I’ve known I wanted to be a veterinarian, and as much as I was always encouraged to do so, I’ve known the path to success would be exceptionally difficult. The same people who cultivated my dreams would be the first to tell me how I would need to study constantly, work endlessly, possess the highest grades, and have the most varied experience, and even then, I would not be guaranteed the chance to prove my intentions.

I knew more about the low acceptance rates, challenging curriculum, and general “scariness” of the idea of putting all my professional eggs in the vet med basket at a time when I should have been encouraged to pursue my aspiration with random abandonment. The pressure was palpable long before I even truly understood what the pressure was really all about.

Writing was something I always enjoyed, but never pursued for anything more than hobby. Instead, I toiled away, earning degrees in the sciences, working in veterinary hospitals, performing research, and teaching courses in basic biology; all things I needed to do to make myself an ideal candidate for gaining acceptance to vet school. The time and energy required to complete these tasks came at the expense of my ability to cultivate my creative endeavors.

What I find so interesting is that the concept of pursuing a career in writing, like veterinary medicine, is full of an inordinate amount of obstacles. As many times as I was told how difficult my life would be trying to become a vet, it seems, a career as a writer was given even less consideration and presented in an even more negative light.

Furthermore, those of us who write are often intensely self-deprecating, lacking the confidence in the strength of our written words. We are often our own worst enemies when it comes to sabotaging our own success. We all may write, but we rarely feel comfortable enough to call ourselves writers.

A major difference between veterinary medicine and writing is that achieving a degree and license to practice medicine is a quantitative endeavor, and a person can become a doctor on calculable characteristics alone. It really was true that if I put the hard work in I would achieve what I set out for in a very measurable sense. Yet, I would be hard pressed to define how it is that someone truly “becomes” a writer, as there are no specific defining characteristics of the job.

I supposed it wasn’t truly surprising that my knee jerk answer to my adult-life dream job was “writer.” This doesn’t mean I’m not fulfilled working as a veterinary oncologist. It simply means I still possess a restless sense of my own capabilities, especially with regard to what will bring me happiness in the long run.

My story also emphasizes how important it is to encourage a dream rather than discourage it. Or maybe even to just let the dream exist without judgment, at least for a little while, in the mind of a child.

And that you are “never too old to become what you might have been.”

As I placed the card back on top of the pile, I knew in my heart that I am as much a writer as I am a veterinarian. Possibly even more than I have ever given myself credit for in my entire life.

I couldn’t do my job without them…

Behind every good veterinarian, there’s an even better veterinary technician.

Few veterinarians would disagree with this statement. We know firsthand how hard technicians work and we only barely attempt to understand the struggles they endure on a daily basis.

We appreciate how indispensable these individuals are to ensuring that we can do our jobs as efficiently as possible and that our patients receive the maximal standard of care.

However, public awareness surrounding the role of a veterinary technician is surprisingly poor. The amount of work they perform is severely underestimated and they are given little respect for their remarkable efforts.

Most laypeople understand what a veterinarian does. They know vets are doctors trained in the prevention, diagnosis, and treatment of diseases related to animals.

Though not everyone understands the educational process behind the degree or the specifics of my job, generally speaking, I don’t have to do too much explaining once I tell people I’m a veterinarian.

When discussing the role of veterinary technicians, the remarkable individuals who back me up and work so hard to make my day flow smoothly and efficiently, I find people are much more likely to tilt their head in confusion and misunderstanding.

Veterinary technicians are typically likened to registered nurses. Though the comparison isn’t entirely correct, it does provide a partially accurate description of their role in veterinary medicine.

Like nurses, veterinary technicians assist doctors in their daily tasks, in order to streamline their schedules and maintain an excellent standard of patient care.

Veterinary technicians are trained professional staff members who provide patient monitoring, restraint, surgical and dental anesthetic assistance, perform laboratory analyses, and administer medications and treatments.

Veterinary technicians are graduates of specific programs that offer either 2 or 4 year degree granting curriculums in veterinary technology. Upon completion of a formal academic program and/or by taking state-administered certification tests, one can become credentialed as a veterinary technician.
Credentialed veterinary technicians are known by one of three different acronyms, depending on the state where they obtained their licensure:

Registered veterinary technician (RVT)

Certified veterinary technician (CVT)

Licensed veterinary technician (LVT)

The exact qualifications and requirements for obtaining the specific certification is designated by the state the technician is licensed in.

Further complicating the issue is that some states do not require individuals working in the role of a “veterinary technician” to hold any formal training or advanced degree, while in other states, it is a mandatory process. The lack of consistency in nomenclature certainly doesn’t aid in clarifying the already confusing situation.

Credentialed veterinary technicians can find themselves legally capable of performing a specific task or tasks in one state, which would be considered illegal for them to perform in another state.

Such blurry lines further perpetuate the confusion about the role of the veterinary technician and make describing their specific job requirements and responsibilities difficult.

Outlining the expectations and role of a veterinary technician is quite challenging as their day-to-day responsibilities are nothing short of variable and unpredictable.

Technicians are the first people who greet our patients when they arrive for their appointments. They obtain the initial history and take the pet’s vital signs. They are responsible for obtaining all lab samples and presenting the results to me before a scheduled treatment.

Techs restrain the pets while I perform exams and double-check my dosages and prescription plans. They draw up and administer chemotherapy with confidence and expertise to keep themselves and our patients safe. They also are often the ones to discharge the patient following the appointment.

Technicians are the frontline for questions from nervous owners, who are often too intimidated to ask me directly. The technicians who work with oncology patients are most often the reassuring face to owners who are in desperate need for consistency.

A very exciting aspect of veterinary technology that is becoming increasingly popular is obtaining certification in specific areas, including anesthesia, dentistry, emergency and critical care, internal medicine, cardiology, neurology, oncology, behavior, zoo medicine, equine, surgery, general practice, nutrition, and clinical pathology.

To be certified in a specific area of expertise, technicians complete an exceedingly rigorous process of formal education, intense training, hands-on experience, writing case reports, and testing. This is above and beyond the requirements they face in obtaining their general licensure to practice veterinary technology.

My job would be impossible without the assistance of the capable and talented veterinary technicians I work with each day. I rely on their ability to communicate with owners, run lab samples, administer chemotherapy treatments, and often to spend the extra time and effort keeping my patients feeling comfortable and loved. Even just attempting to enumerate the daily “tasks” of the technicians I work with is exhausting.

Veterinary technology is a physically and technically demanding field that is emotionally charged and poorly financially rewarded. It’s rare to see veterinary technicians who still work the “trenches” over the age of 35. Pay rates are low, and hours are long and often entail nights, weekends, and holidays. Those who do the work are certainly not in it for the money or the glamour.

I’m grateful to have worked alongside some of the most talented and compassionate veterinary technicians in the field. From my early days of assisting in a veterinary hospital during my undergraduate years to the technicians who shaped me during veterinary school, internship, and residency, and to those who have toiled away with me during my professional career. I’ve been privileged to know and learn from the best.

If you are considering a career in veterinary technology and live in the United States, the National Association of Veterinary Technicians in America provides an excellent resource of information regarding educational requirements and opportunities.

ACVIM Forum 2015

Coming to you straight from Indianapolis, where I’m attending the 2015 ACVIM Forum.

 

I’ll be giving a technician lecture later on this afternoon on “Making Sense of Lymphoma Diagnostics!”

 

Hope to see you there!