Look Before You Leap

Notice: This case is a lengthy one. I will try and condense it to the relevant aspects, but the backstory and details help to make it so memorable.

A young couple and their infant daughter were up from Florida to run their family’s summer business a few years ago. They brought with them their 5 year old male Greyhound, Dunkin.

Living in a rural area, they let him out after dusk one night to do his business. He took off, chasing something. A few minutes later they heard a thud, and went to find him. His head was bleeding, and he was very painful.

They took him to the local emergency clinic, and he was treated for a laceration to his forehead. While he was there, they also found that he could not walk, stand, or move his legs on his own. X-rays were taken, and showed no fractures. The owners declined an MRI (due to cost), and he was started on pain relievers and anti-inflammatories.

In the morning, they looked at their pick up truck, and there was a dent in the side of their door panel. The dog was found the night before collapsed by the truck. So, Dunkin had run straight into their parked truck and dented it!

The next day he was transferred to my hospital. He was on a constant infusion of opiods from the emergency clinic, and still could not use his legs. He had a urinary catheter in place so he didn’t soil himself.

My thought process went something like this. Greyhound, young healthy, runs into truck, compresses or bruises his spinal cord. With no fractures, I was hopeful that with time he could recover.

Problems: If the trauma caused him to severely herniate a disc between his vertebrae, medications and time may not work. Also, greyhounds present an interesting challenge, tiny little bits of pain meds will make them loopy, but they also have relative LOW pain tolerances. So trying to figure out if he was more disoriented or painful on his treatment was a challenge.

I had a long discussion with the owners, ideally an MRI would give us a better understanding as to his chances for a recovery, but at 1800 dollars by itself, it was out of their budget. The one owner was pressing for him to be put to sleep, because he wasn’t better already. The other owner wanted to give him more time.

It had been less than 24 hours at this point. I explained that we could take it a few days at a time, try and get him comfortable, wean him off his medications, and see how his body responds. If he gets worse, yes, humane euthanasia may be in his best interest. I also explained that he could make progress, and then may plateau at a certain point, or he may make a full recovery, but that could take weeks, if not months.

Over the next few days, I got to know this dog really well, his likes, his comforts, his concerns. I weaned him off the constant infusion of Fentanyl over 3-4 days. I started him on oral medications instead. We kept him on prednisone to help minimize the swelling of his spinal cord. Every few hours he had to be flipped, have his foley bag emptied, be sat up, have his legs massaged and have repeated neurological exams.

Depending on his mental state, many of these had to be done with a basket muzzle on. This is the type of muzzle you see on greyhounds at the track, or the type from “Lady and the Tramp”. It allows them to open their mouth and breathe easily, but not bite you. Since most greyhounds that are in people’s homes are adopted after a racing career, they are used to them.

Eventually we had to work on getting him to eat, which means no more muzzle. Once I was able to get through to him, he started to understand that we were all there to help. Multiple times a day he had on electrical stimulation pads to mimic muscle contractions in his legs and back. He had laser treatments to help stimulate nerve conduction down to his paralyzed legs. He also received acupuncture treatments to help with pain. This allowed us to have him on less oral medications. And slowly but surely he made some progress.

After about 2 weeks, I was able to remove the urinary catheter. We then worked on starting to express his bladder for him, until his body got the right message that he could do it on his own.

After a month from admission, we had him off all oral medications. We continued to work with him multiple times a day, 7 days a week. He spent time in a lift apparatus to mimic him standing and walking. The owners would come and visit, and sometimes he would show them the little signs we were seeing. A little wag of the tail, a smile when they came in.

Occasionally one of the owners was still impatient and thought that he would not walk again. I had to reassure them that he was making progress. Could I promise him that he would walk again? No. However he was making progress, and therefore we had to give his body time. Time is the greatest healer.

A funny thing happens when you support and do everything for a patient. Sometimes they enjoy it. Sometimes they stop trying because they expect that you will continue to do it for them. That is why you have to condition your help. Challenge them to do something new. If it is the same activity day in and day out, we would all get bored. As the weather got nicer, we worked with him outside. We had other dogs, or cats, come into his area and interact with him, to stimulate his play drive. I had a checklist of tasks that he needed to be able to do every week.

And one day he stood up. His owners came to visit and I was talking with them, and he righted himself and shook on unsteady legs and pushed himself up and walked 4 feet to his dad. We were all happy. We tried to get him to do it again, but it had taken all of his strength. The next day, no walking. But the day after that it was like the lights came back on, and he was ready to get in gear.

It took him another 4 weeks to be able to walk consistently on his own. At that point, I was comfortable sending him home, but the owners did not feel that way. Due to their work commitments, they felt that he would be alone too much during the day. So he stayed until the end of summer.

During that time, he would follow his rehab nurse around the hospital every morning for 30 minutes. He went on walks outside for 20 minutes twice a day. He greeted clients and staff from behind the reception desk. We blocked off a spare exam room and put up baby gates so he could interact with the world. He essentially became our mascot.

When he came in, he initially weighed about 85 pounds. At his lowest during his recovery, he was 70. When he left he was 75 pounds. They went back to Florida and walked and walked and walked him. Dad took up running, and they both got back into shape. I got Christmas cards from them. And the following summer they drove up to visit, and he was 90 pounds, and all of it was muscle.

The owners continued to work on his recovery for that whole year, and if you didn’t read his record, you never would have known that he was inches away from being put to sleep. He had made a full neurological recovery, and all he lost was a summer.

 

Proof that dogs don’t read

A few years ago, an older husky/shepherd dog named, Victory, came in for licking intensely at his back leg. He had what is commonly called a “hot spot”. This is an area of inflammation and infection in the skin. It can be triggered by many things, from fleas to allergies. This area was a bit unusual in that it was over his tibia (shin bone). It was treated with a topical lotion and oral antibiotics and was resolved.

About six weeks later he came back, again with the same problem, but this time he was limping on that leg and the bone itself was painful. I recommended to the owner that we take a radiograph (X-ray) to understand what the bone was doing. The radiograph revealed a large tumor growing in the middle of the bone pushing it outward. It had nearly eaten away 50% of the tibia.

Bone cancer, unfortunately, occurs in dogs and cats. There are a few different types of bone cancer, but osteosarcoma is the most common and aggressive type. I have seen it in animals as young as 6 months old, but more commonly it’s found in older pets. On x-rays, it looks very different from infections or other conditions that could affect the bone.

In hindsight, the hot spot from earlier was his reaction to the growing discomfort in his bone. This was a sign letting us know that his leg hurt. Even before the distortion of the bone, Victory knew something was wrong with his leg.

I went back to the owner to discuss my findings. I recommended that we take radiographs of the chest to look to see if the cancer had spread (metastasized). The owner agreed, and luckily the new rads (X-rays) showed no obvious spread at that time.

Although new research is always being done, the options for treating bone cancer is limited. Survival time is best with surgery followed by chemotherapy. Chemotherapy is used because the cancer often spreads microscopically at the time of diagnosis.

Other non-invasive ways exist, including radiation and drugs. Radiation can help to slow down the tumor if surgery is not an option. There is a combination of pain medications and anti-inflammatory agents that can also help slow it down.

One has to take into account all the circumstances and options for both the pet and the family. Bone cancer is extremely painful, and doing something to address the animal’s needs is the most important. Even with surgery and chemotherapy, survival time is only about 9-12 months on average, as surgery usually requires amputating the entire limb.

There are some limb sparing procedures, and even some work with prosthetic limbs now, but the majority of patients will be moving on three legs after surgery. They actually do extremely well most of the time. However, it is always important to assess the other three limbs to determine if they can support the patient. If there is a lot of arthritis, or other conditions in the remaining legs, the pet may not do as well.

The owners consented to amputating the back leg and would consider chemotherapy. After checking blood work for any other problems (none), I amputated his hind leg above the knee a few days later. He did well through anesthesia and recovery, and was on a constant infusion of morphine and other pain medications for 24 hours.

He went home a few days later, and was walking on his own in 24 hours. I had the lab analyze the bone to determine what type of tumor it was. He had the worst case, an osteosarcoma. I notified the owners, and they were going to meet with our oncologist the same day I took out the sutures.

The owners decided that at 11 years old, they did not want to pursue chemotherapy for him. His survival time, at best, was considered to be 6 months. Eleven is old already for a big dog, and at least his pain from the tumor was gone.

A few days later, I called the owners to check in on him. He was getting around really well, and they were very happy that he was comfortable. I talked with them again about chemotherapy, but I understood it wasn’t an option for them.

They did ask me if there was anything else to do. I focused on making sure he was happy, and keeping him comfortable.  I prescribed a pain medication for him to take on an as needed basis, and then researched an antibiotic that had been shown to have potential anti-angiogenic effects for some types of cancer.

Anti-angiogenic explained: Tumors, like all cells, need the oxygen in blood to grow; slowing access to this source slows the rate of tumor growth. This could perhaps keep Victory alive and comfortable longer. I discussed this with them as an option, it had little chance for side effects, and was cheap. He was started on a once a day dose of this medication.

A few months later, I saw him for a follow-up. I barely recognized him. He was happy, tail wagging and MOBILE! He had lost some weight, and when I asked the owners about it, they said he had been constantly chasing the other dog around outside.

They did not want to take new chest x-rays to see if anything had changed, and I was fine with that. We kept him on his medications, and I told them to keep in touch with me if anything changed. I was glad that he was doing well, but I was concerned for how long.

That was 28 months ago, as of March 2012. I saw him just before Christmas 2011 and he had slowed down some, but was alive to celebrate his 13th birthday. I hope that he continues to do well. He takes his antibiotic every day, along with his pain medications as needed.

His case is definitely not the norm. Most patients, even with aggressive treatment, do not get past 12 months with osteosarcoma. I tell this to remind you that rules are meant to be broken, and to do what you feel is best for your family.

With cancer in veterinary medicine, it is the caregivers and the medical staff that know the big words like metastatic osteosarcoma. We study these diseases and learn the standard diagnoses, treatments, recovery and survival times. I’m just glad that Victory didn’t read the book.

*August 15, 2012 update – I recently heard from Victory’s parents and can happily let everyone know that he is continuing to do well 3 years after surgery. Here is a recent photo.

3 years after his amputation surgery and still doing well.

An Introduction

Greetings All-

Thank you for finding your way to my blog.

I am a veterinarian, originally from Bellerose, NY. From a very young age I knew I wanted to work with animals. I was lucky enough to gain great experience during high school with a veterinary hospital in my neighborhood. From there, I studied Animal Science at Cornell University. During my time there I was able to work in the College of Veterinary Medicine. I also gained great experience working with horses at a friend’s farm. After graduating from Cornell, I attended Ross University School of Veterinary Medicine on the island of St. Kitts in the Caribbean. I then did a clinical year at Purdue University.

After graduation, I took a job at a mixed animal practice in Columbia County, NY. There I predominately worked on small animals (dogs, cats), but also gained great experience with horses, sheep and other animals. This combination of species allowed me to gain a better understanding of sports injuries and lameness problems in both horses, as well as dogs. I practiced there for 3 1/2 years, and then moved to Albany, NY. There I received advanced training in orthopedic surgery, as well as being certified in veterinary rehabilitation.  I continued to do general practice work, and helped the hospital to expand it’s capabilities in emergency medicine and surgery. The majority of my time was spent working in the Rehabilitation Department. There I worked with licensed veterinary technicians who were also certified in rehab. We would work together to diagnosis and treat patients with any multitude of conditions. We worked on patients with bulging discs in their back and neck. Some of these patients were referred for surgery, and then we helped them post-op to learn how to walk again. Others had already had surgery and needed assistance. Many did not have surgery, but still needed appropriate case management in their recovery process. Many of the neurological patients were treated on an outpatient basis, but I also managed many that would stay in the hospital for months at a time, until they were able to be home. I also worked with orthopedic patients, either those that I had done surgery on, or diagnosed their conditions.

Other patients came from neighboring hospitals, either after surgery or for case management. I would also see patients as a second opinion for injuries and conditions that had not yet been diagnosed or treated. I found these cases particularly interesting, a puzzle to be solved. That is one of the many things I enjoy about veterinary medicine, my patients may not be able to tell me what their problem is, but it requires a team effort on the aprt of the owners, technicians and myself to help them. And as you will see, not all patients read the textbooks.

Recently, I have decided to relocate my practice. I am considering my options in the NYC and Long Island area. I hope to bring my experience and skills to a new set of clients and patients, and to continue learning new ways to help them.

This point of this blog is to share some of my experiences in veterinary medicine, to give insight to problems and to let people know that there are sometimes more options than you know about. Please realize that I can not diagnose or prescribe treatment for any condition over the internet. Also, always check in with your veterinarian with regards to your pet’s specific needs.

Thank you,

Matt Brunke, DVM, CCRP