More than Meets the Eye

When I was in ER practice I was often asked about what cases terrified me the most. Most people would imagine things like hit by cars or devastating surgeries or obscure toxicity cases.  Those could be scary but my answer was always the same....dog fights. Big dogs attacking little dogs, big dogs attacking big dogs or the worst of them all.....any size dog attacking a cat. Dog bite wounds still scare me more than anything else. And it isn't because of infection or spread of disease or even the obvious things like bleeding or broken bones. It's because these cases often look very simple. From the outside sometimes you may only see a few small, harmless-looking, wounds to the skin. It's what is happening below the surface that frightens me.

When I was teaching the interns at the ER hospital I always told them to expect the worst when it came to bite wounds. "It's the tip of the iceberg" we would say. That little skin wound is hiding a world of disaster below the surface. The cases that presented with huge open wounds were honestly the easy ones...often the owners could see the damage that was done. It was even better if there was a broken bone because that is easy to understand. But trying to explain to an owner that their dog or cat that appears fine and just has a few small wounds to its neck or abdomen could be in life-threatening danger is tough.

Humans produce about 150 pounds of pressure when we bite down on something - compare that to the average dog who ranges between 235 pounds of pressure (American Pit Bull) and over 300 (Rottweiler). Take that force and add in the length, usually around 2 inches in a large breed dog, of the average canine tooth (the long pointy one that usually does the biting) and you can see the damage that can be inflicted.

When we are examining the skin surface we are merely looking at the entrance wound - we don't know what has happened to the underlying muscle, fat or worse. Wounds present over the chest or abdomen can easily have traveled into the body damaging vital organs or lacerating important blood vessels. I encountered this several times in ER practice after taking a patient to surgery to determine any internal injuries - it still amazes me that a dog can look fairly stable on the surface and have catastrophic injuries internally. I have seen intestines ripped apart by dog bite wounds  and the only thing noted on external exam were 2 small puncture wounds over the abdomen. I once saw a pancreas torn in half - again the external wounds were pretty minimal. This is a perfect example where looks can be deceiving.

Our job as doctors in these cases is to try to uncover as much damage as we can - often this can be difficult especially if owners do not feel that their pets are in trouble or are seriously injured. A dog I recently saw came in for several dog wounds that occurred the day before. On initial exam the wounds were numerous and infected but it wasn't until we anesthetized the patient the next day to explore those wounds that everyone could see the extent of the damage present. If we had not opened the wounds up and removed all the dead and infected muscle and tissue we could have set this dog up for disaster.

So when good dogs turn bad or simple playdates turn ugly and Fluffy ends up with some bite wounds, please take the time to have your veterinarian take a look. They may be very minimal wounds but if we can't tell from the surface, how can you?

Original Presentation

Original Presentation

After wound explore

Thank your Tech today

Thank you to all our hard working Vet Technicians. We could not do our jobs without your hard work. You help keep us sane during the day, keep our patients comfortable, our clients happy and keep our hospitals looking beautiful. Thank you from the bottom of my heart

Something sounds a bit strange

"Something sounded strange when I tried to get a heartbeat", my technician recently told me as she described a  patient in a room waiting to see me. The dog was an older pet, 9 years old, and had come in for not acting right that day. He had been seen a few weeks ago for similar signs but nothing was found that day on his labwork or exam. Today the owner said he didn't really want to get up and was not interested in eating. So when my skilled technician told me her findings, my interest was peeked. As soon as our techs tell us information regarding our patients, we immediately start running a list of possibilities in our minds - its how we are trained to think. We go over abnormalities, symptoms, differentials, possible explanations and so on and so on.

The combination of an older dog who didn't want to get up and eat, along with the strange thing my tech described made my inner ER doctor come to life. I asked her a little more about what she meant - she said it was hard to hear his heart and that his pulses on his back legs felt funny. Small alarm bells start ringing in my head because I immediately know what I need to do for this poor dog and owner. I go in and approach the concerned owner and let him know that based on what he has described at home and what my technician noted on her initial exam I am concerned that his dog may have some fluid developing around his heart - a condition called pericardial effusion. I do my physical exam and notice that this dog's gums do look a little pale and his heart rhythm is abnormal. I tell dad that our next step to confirm things is to do a quick ultrasound to look for fluid around the heart. If we see some I will come back and talk to him about our next steps.

Our ultrasound confirmed what I had suspected - this poor guy did indeed have pericardial effusion - fluid contained within the sac surrounding the heart. Imagine the heart sits inside a thin balloon - usually there is only a small amount of fluid in that balloon but in some instances we get a large amount of fluid there. This fluid fills up the balloon and puts pressure on the heart, preventing the heart from being able to contract and pump normally. This leads to symptoms such as we saw today - lethargy, pale gums, disinterest in food, and difficulty hearing the heart when listening to the dog with a stethoscope. Imagine trying to listen to music through a wall of water - it would all sound muffled right? That's what it sounded like when we listened to this dog - everything was muffled.


We were able to drain the fluid from around the heart using a long needle (a procedure called a pericardiocentesis). We removed almost 1/2 liter of blood from around his heart.

This instantly made him feel better and when his dad picked him up later that day he eagerly walked into the room, tail wagging the whole time.  Often pericardial effusion is due to an underlying cancer somewhere and in this instance, a large tumor on this dog's spleen had metastasized to his heart which was causing the blood to accumulate around it. Unfortunately, the owners had to make the tough choice to say goodbye to their friend a week later.

I credit my great technical staff for noticing such a slight symptom and clinical sign - it was their keen awareness of what is normal and abnormal that tipped me off to know which direction to head in with this patient.  I was glad we were able to provide some relief to this patient, even if only for a short amount of time.

Video Games and Surgery?

I never really played video games growing up - it was never really my thing. I had a Nintendo gaming system (yes I am old) and we would play it but nothing like what some people do nowadays. My husband has a PlayStation 4 or 5 or 20...whatever the latest model is and he does play games from time to time. He invites me to play along with him but I generally decline and go on about my housework, or reading or watching trash TV. Imagine his dismay when I came home a few months ago and said, I am learning how to do 'video game surgery'.

Now it's not really video game surgery - but it feels that way. Minimally invasive surgery is becoming more and more common in veterinary medicine. It already is commonplace in human medicine and often laparoscopic or arthroscopic procedures are done in place of more traditional open surgeries. We know that these surgeries produce less pain, have a quicker recovery and less chance of complications. As with most things, veterinary medicine has lagged behind a little but we are now seeing more and more laparoscopic procedures being performed not only by board-certified surgeons but by general practitioners, like myself.

Why do I call it video-game surgery? Because we do it with a camera placed inside the body through various port sites and use instruments internally to do our work. We do all this while watching a monitor displaying what is happening inside the dog. It feels just like playing a video game or living in virtual reality. Either way...it's super cool!

We all know that elective spay procedures help decrease the incidence of unwanted pregnancies as well as prevent future illness in our female dogs such as pyometra (life threatening uterine infection) and mammary cancer. Most people envision the traditional incision on the belly from a spay as seen here :

What most people may not realize is there is an alternative - laparoscopic ovariectomy. The terminology is a little different in that with this procedure we are only removing the ovaries - we are leaving the uterus. However studies have shown there are no disadvantages to leaving the uterus and removing only the ovaries since it is the ovaries that are producing the hormones and ovulating. Laparoscopic surgery allows us to do our procedures through small incisions that heal quickly and cause less pain. It also gives us the opportunity to evaluate the entire abdomen for any abnormalities and perform additional procedures such as a prophylactic gastropexy in large breed dogs - this is a very important preventative measure wherein we suture the stomach to the muscles of the abdomen to prevent bloating from occurring in the future. If done traditionally, a gastropexy would necessitate an incision from the breastbone all the way to the pelvis to allow enough visualization to do our spay and the gastropexy.  Compare this to the incisions below, recently done, to do the procedures listed above. 

Three nice little incisions right? And I can tell you, this dog was up and bouncing around a few hours after surgery - definitely less sore than the traditional route. I'm lucky to work at a hospital that offers this newer procedure as an alternative to the traditional route. It certainly is less painful, quicker recovery and less chance of adverse events such as infection or breakdown of the incision site. For those considering upcoming spay procedures on their dogs I encourage you to talk with your veterinarian about this option. If you live in the Charlotte area check out our hospital and see if this procedure is right for your dog. Plus, it's pretty cool to say your dog had video game surgery, right?!?

An Open Letter to My City

My eyes filled with tears this morning at the events that are going on in my city the past few days. I am filled with an overwhelming sense of worry, of concern and of sadness for the people of Charlotte. I remember a few short months ago when our city was filled with a sense of pride and camaraderie over our beloved Panthers and their success. We joined in arms as we celebrated this great city we live in. People came together to be joyous. Charlotte...where is that feeling now?

I love this city.....yes I am a transplant and people may criticize me for that saying I am not a true Charlottean but I have been here since 2007. I consider this city my home. It is where I have chosen to set down roots, to get married, to raise a family, to conduct my business. It's where I want to see my daughter go to school, make friends, take part in city celebrations, and learn to love others. But the last 48 hours this city is not the same place I know and love.

No one but the people involved know the true story of what happened a few nights ago when that unfortunate incident set off a whirlwind of emotions. I do not claim to know whether it was right or wrong. I do know that what has happened since that day is just wrong. We cannot attempt to combat hurt and hatred with more violence, more hatred, more destruction. Attacking innocent businesses or innocent people does not justify the hurt that people are feeling. Have any of these protesters stopped to think that the businesses they are looting or destroying may be owned by people who share their same mind frame? That these businesses were not the ones to offset this sequence of events? How does punishing innocent people make any of this better?

My husband and I choose to raise our daughter with a sense of acceptance and love. It is how I was raised and I am proud of it. My daughter has respect for authority and knows that if she does something wrong there are consequences...a concept that seems to be lost these days. This overwhelming sense of entitlement and that we are all 'owed something' has to stop.  The American dream has always been that if you work hard you reap benefits....when did that morph into "I am owed benefits without hard work?" When did we all stop respecting others?

As I look at the images of Charlotte this morning and the destruction that has occurred I wonder when we will feel safe in our city again? I wonder how the police officers must feel as they go home to rest knowing that tonight may bring more hatred, more protests, more destruction, I say a prayer and ask for help. Help to know how to explain these events to my daughter, and how to make sense of them myself. I pray that as my husband ventures into uptown Charlotte today that he will be safe. I pray that as the police report to work today and tonight that they are safe. I pray that the people who feel injustice today find the peace they are looking for. I pray for the families of those that have been lost in the last several days. I pray......

Charlotte.....you are the city I live in and love. I know that deep down we are the city that came together 9 months ago to celebrate success. I pray that my few words reach someone who can make a difference today. I hope that my prayers and the prayers of so many others are heard today and our city finds peace. I pray that people remember how to love. I leave you with that word...LOVE

I'm back

I recently took a little hiatus from blogging to give myself a break. There has been a lot of talk about work/life balance lately especially in veterinary medicine. I returned from my vacation to see posts about yet another veterinarian taking their life due to the demands this career puts on us. I recently shared a video from Dr Andy Roark on my facebook page regarding this topic. And I knew I wanted to comment on what is happening in our field but I needed time to think about what I wanted to say.

It makes me incredibly sad that this career that I dreamt of  having since I was 5 years old is not quite what I had envisioned. There have been many, many times in my life that I thought I should have made a different career choice. I know that sounds terrible so please forgive me and let me explain.  It isn't because I don't love my clients or my patients. It's because the part about loving animals and being a doctor is the easy part of this career. Sure there are days when the  medicine doesn't go my way, or a patient doesn't survive despite my best efforts, or a patient presents to me and I just don't know what is wrong with it. Those days are tough and challenging. As Dr Roark said in his video, veterinarians are type A individuals and often perfectionists. We like to be right. When things don't go our way it is easy for us to blame ourselves and often we are our own worst enemies. We can often beat ourselves up for something that truly was not our fault.

What most people don't take into account is all the other stresses and pressures and challenges we face. We are often not very good at separating home life and work life. Take myself for example, it is not uncommon for my husband and daughter to find me at the kitchen table doing work on my days off or in the evenings. It may be simple things like returning an email question from a client, or updating the monthly schedule for our 11 doctors, or following up on some lab work I did on a patient. There are a lot of people who are able to leave their work at work......unfortunately I have never been very good at that. And even more unfortunate, I think many of our clients have come to expect us to be available at all times. There is a connotation that if we create boundaries from clients or limit our interactions with them when we are not in the office, that it means we don't care. It is a common belief that what you do for a living is who you are.

The problem lies in that I am more than just a vet - I am a wife and a mother, a daughter and a sister, a friend and a colleague. And unfortunately as we all find out at some point, I feel like I am sucking at all those roles. When I am at work I feel guilty for not being home with my family and when I am home I feel guilty for not keeping in touch with my clients. My workdays expand well beyond the 10 hours I am scheduled on the calendar (which is much longer than I would like as it is). I spend 2 hours a day commuting to/from work and then once I am home I am busy cleaning, cooking, doing laundry and spending time with my family. Beyond that I am also available to my clients if they need me - whether it be via text, phone or email.

I'm not saying all this to make anyone feel bad for asking my advice, or contacting me after hours.  I want everyone to be able to understand that often veterinarians are stretched so thin and we feel that no matter how good of a job we did that day, that it is never enough. We want to be the best doctor, wife/husband, mother/father, brother/sister, friend, etc that we can be. And yes....often our expectations are too high. Our goals are unattainable. We know that - it's that drive and determination that got us to where we are in our careers. But that drive can damage us more than we realize.

It's necessary to take a break every so often. Turn off our laptops and our phones. Ignore the facebook messages for advice. Sit in silence with a glass of wine or cup of coffee and just remember to breathe. Maybe lie on the floor and have a tickle-fest with your 2 year old daughter. Force ourselves to remember what is really important and realize that our clients will be there when we return to our 'regular lives'. If we don't take care of ourselves, we can't take care of anyone's furry friends. We owe this to ourselves.....

Would you like Bacon with that?

A few months ago I was greeted on my way to work with the following text message "Penny keeps vomiting and it contains gravel..........do you think I should take an xray?" Penny is an energetic Chocolate Lab owned by one of the technicians at work. As all labs do, Penny likes to get into trouble and on this particular day got herself into a LOT of trouble. I chuckled a little to myself before responding and letting my technician know to go ahead and get some xrays and I was on my way in.

I don't think either myself or my technician expected to see that on the xrays. That is a perfectly sculpted stomach full of gravel. I mean FULL. No room for anything else. Nothing was getting into that thing - nothing, nada, zilch. Do not pass go...do not collect $200. We put poor Penny on some fluids to see if we could make any headway on things ( I have seen gravel move through with just some IV fluids to help) but after a few hours nothing had changed. Poor Penny was destined to have a zipper installed on her belly (ie surgery time).

When it was all said and done I think we removed around 4 lbs of pea gravel from Penny's stomach (including the amounts she vomited before surgery and passed in her stool later on that day). Penny continued to pass some small amounts of gravel for a few days but by the next week was back to her normal labrador self.

I'm sure you are wondering why this sweet girl decided to take part in an all-you-can-eat gravel fest? A poor innocent family member who shall remain nameless emptied a container of bacon grease out the back door onto the pea gravel earlier that fateful day. Without thinking about it a few hours later, Penny was allowed to go out in the yard to do her thing. When she remained out there for a while, no one really thought much of it until.....well you know the rest. No dog can turn down bacon flavored gravel.  I think Penny learned her lesson and will stick to plain bacon from now on.