Irish Wolfhound Presentation

In May I spoke at the Irish Wolfhound Club of America’s 2017 meeting. It was held in Geneva, NY and during the day they had fantastic events of these gentle giants competing in athletic activities.

On Monday evening, I met with this great group, and discussed the vital role of proper spinal health in eventing, and a dog’s health in general.

We reviewed spinal anatomy, a number of spinal diseases (lumbosacral stenosis, spondylosis and degenerative myelopathy to name a few), and some key concepts in improving spinal mobility, as well as preventing certain aspects of disease as well.

I look forward to continuing the conversations with the member sof the group, adn future meetings.

Check out these great photos of the multiple day event.

https://maryo.smugmug.com/Irish-Wolfhounds/Events/IWCA/2017

A Tribute to Milo

For those not familiar with my cat Milo, please check out my prior blog post about him here. https://drbrunke.wordpress.com/2013/07/28/matters-of-the-heart/

Milo turned 14 earlier this year, but had been slowly declining in health over the last few months. I had noticed he was drinking more and urinating more. He began to lose body weight, but was still happy, interactive, and eating. He also would have sneezing fits of 10-50 sneezes at a time.

In the last 4 weeks, he began to have trouble breathing, and would make a sound close to a snore when awake. I debated taking him to work for tests, but he would stress out about it. I also knew that he could not undergo anesthesia for a CT scan or biopsy due to his heart. Additionally, he could not be medicated, since any attempt to do so in the past was too much stress for his heart condition.

Given his signs, I was suspicious of a nasal tumor.

So, I waited. I kept his food bowl full and he would interact happily with Adelaide and Penny.

I was away last week for training, and he stayed at home with my pet sitter. We had previously discussed that if he went into acute crisis that he would be euthanized without me there. I did this for one reason, Milo’s best interest.

Shortly after arriving home Sunday, I found Milo having trouble breathing. I tried to relax him, but he was struggling. I dropped everything and took him to the hospital where I sedated him. Once he relaxed, I could appreciate a mass invading his skull.

I then humanely euthanized him, letting him be at peace.

While letting him go was difficult, it was absolutely the right decision for him and me. Diagnosing or treating his tumor would be near impossible given his heart condition, and it would not be fair to Milo to put him through that.

I am very thankful for all the lessons I learned from him. To take a chance, to give things time, and that not all the patients read the books nor follow rules. Milo lived thirteen years longer than he should have. Those years were full of fun, eating, playing, and hunting. In the end, his heart was still strong and that is the message I appreciate most of all.

Quality over quantity

Last week, I made the final decision to have my own dog humanely put to sleep. Skeeter was 15 years old and had been part of my life since 2001. She was diagnosed with cancer almost 2 years ago. In the end, it wasn’t the cancer but her overall quality of life that was the deciding factor. Let me explain.

Skeeter found her way into my life when I was living on St. Kitts for veterinary school. As a stray dog, she was a little under weight but overall healthy. And throughout the first 12 years of her life, she pretty much stayed out of trouble health-wise.

In December of 2013, I was in Florida taking the final exam for my acupuncture certification. Skeeter was staying at the emergency room where I worked. They were looking to get a new ultrasound machine and had a demonstration model in one day. They used her to check out the machine and accidently found a mass on her spleen. There was no evidence of rupture (many splenic masses, benign or malignant will rupture and bleed internally).

Since she was otherwise in good health, the doctors waited for me to return from my exam to fill me in on their findings. I was concerned but needed to know more information. I ran baseline blood tests (all normal) and took chest x-rays (also normal). This was the week of Christmas and I was uncertain about what to do next. So, I reached out to some friends for help.

Louie-Philippe de Lorimier is one of the world’s leading veterinary oncologists. I am lucky enough to know him as both a colleague and a friend. When I told him what was going on, I took a drive up to his office the next day in Montreal for an ultrasound and consult. We checked out and measured the mass on her spleen. We also found a few small suspicious areas in her liver. The ultrasound images were not conclusive, so we did an aspirate of the questionable areas to find out what cells were inside of them. An ultrasound of her heart didn’t show any masses (some forms of cancer spread here as well).

A few days later I got the results. The spleen samples showed no cancer cells but further testing was recommended. The samples from the liver showed cancer cells of hemangiosarcoma. This means that the mass in the spleen probably was also. Either way, the spleen had to be removed. If the mass (benign or malignant) continued to grow she was at risk for rupture and bleeding internally.

Later that week, I removed Skeeter’s spleen and biopsied her liver. Lucky for me I didn’t see any other masses in her abdomen and there was no evidence of internal bleeding. She did great through anesthesia and recovery. I then sent the liver samples (to confirm) and the spleen (to double check) out to the lab.

About a week later, I got the news. The spleen was also cancerous. This happens on aspirates vs. biopsies. When you get larger amounts of tissue, you get a better chance to know what is going on. Sometimes aspirates don’t get the base of the mass and just the outer shell.

Stage 3 hemangiosarcoma. One of the toughest types of cancer to deal with. It likes to spread from the spleen to places like the liver, lungs, heart and bone marrow. Average survival time with chemotherapy is about 9 months.

Time for a side bar. Cancer in pets. A few things about this. A dog’s life expectancy is much shorter than a person’s. So, if the dog would live to be 13 and got diagnosed with cancer at 11 we would only expect 2 years anyway. That influences how we treat cancer in veterinary medicine. Most importantly, we always aim for quality over quantity. We want whatever time for our patients and their families to be positive. In human medicine, they aim as best they can to cure you, or to get you 10, 20, 30 years or more from the time of cancer diagnosis. This means using much different doses of chemotherapy and other treatments. And when we talk about average survival time, it’s just that, an average of all the patients we have records on. It’s our best guess. Some live less, some more.

Most veterinary chemotherapy patients don’t lose their fur. Most don’t even know they are sick. Even fewer have vomiting or diarrhea from their treatment. And if they do, they usually respond well to supportive care and we can adjust doses of chemo. Again, always for quality over quantity.

Back to Skeeter. Having Dr. de Lorimier in our corner was a huge help. I had access to all the latest research, journals and studies. If I did nothing, I would have on average 3-6 months; with chemo, 9-12 months. Chemo would be one different medication each week for 3 weeks, (this would be one cycle) we would aim for 3-6 cycles. That means 9-18 weeks (3-4 months) of chemotherapy to get maybe another 4-6 months past that.

It took me a week to make my decision. I went back and forth. Read articles on low dose oral chemo (less invasive, but also less survival time). I added in acupuncture and Chinese herbal therapy to help support her while I pondered. The benefit of being a veterinarian is not only having access to all this information but also being able to do my own chemo. Some of the medications in her 3week protocol I was comfortable with. One I was not.

Ultimately, I asked Dr. de Lorimier for one more summer with my island dog. We both knew this meant going forward with injectable chemotherapy. In order to give the best chance, we also added in a new option. There is a mushroom derivative that has shown very promising results in hemangiosarcoma treatment. Hemangiosarcoma literally means blood vessel tumor. It likes to “seed” a patient similar to how you lay down grass seed. It then grows tiny tumors of cancerous blood vessels that can grow and grow until they rupture. This mushroom derivative has been shown to slow down the rate of growth of those new blood vessels.

So here is my 13-year-old dog, who had barely been sick a day in her life, now taking a literal pharmacy. She was on acupuncture and Chinese herbal therapy to support her immune system. She took Deramaxx (an arthritis medication) because hemangiosarcoma has been theorized to use the same receptors that joints use for arthritis to grow itself new tumors. To minimize her risk of getting an upset stomach following her chemotherapy, she took an anti-nausea medication the day before and a few days after one of her chemo drugs. She also had to take antibiotics if her white blood cell count was too low. And she was awesome about it. I got lucky. She liked canned dog food, so we just mixed it all together.

Her first drug in chemo was Adriamycin (doxorubicin). This was the one I traveled up to Dr. de Lorimier to have him calculate, adjust and administer for me (with his awesome team of nurses, Nancy and Carol). It is a great medication but I was not comfortable enough with it to give it at home.

A week later, I would check her blood count and if all was okay she got cyclophosphamide. This is an oral medication but it had the potential to irritate her bladder. So with it she got furosemide (Lasix, a diuretic) to help her make urine to flush out her kidneys and bladder. That also went well.

The third week, I gave her Vincristine as an injection into her vein. This she also tolerated very well.

And we repeated this, after 2 cycles her liver lesions (I couldn’t remove all the cancer in her liver at surgery) had shrunk by 50%.

After 4 cycles, the liver lesions were completely gone. We were in remission. This was springtime. There were a few problems along the way. She had some coughing and vomiting occasionally but otherwise was her happy, cheerful self. The coughing and vomiting is a story for another day.

We did 6 total cycles of chemo. After that, most patients still have some visible evidence of cancer in them. Being that she was still in remission, there was no indication to continue chemo or an oral chemo (lots of patients will benefit from low dose oral chemo after injectable chemo to keep the cancer cells from growing).

At this point, I slowly weaned her off the mushroom extract and Chinese herbs. Partly because there was no indication for her to be on them, and partly because her appetite was not that great. After a few months of medications, herbs and such, her body needed a break.

Now, we were into summer and Skeeter had a great time. Fall came, she was still going strong. Got through winter with the help of arthritis medications. The following spring came and we checked for any evidence of re-growth of cancer (we had checked every 3 months since ending chemo) and still she was in remission.

This summer, she was noticeably slower and enjoyed napping more than going for walks. She got to visit some of her favorite places (a beach trip, hiking in the park and a trip to Ithaca, NY).

This fall, I checked again for cancer and still she was in remission. She turned 15 a few weeks ago. For a person, that’s roughly 110 years old. She would get confused about things, get stuck in corners, pace late at night. Tried some simple adjustments and treatments with her, not much improvement. Right along, I had kept her on arthritis medications, a joint supplement and a special food.

Finally the time came where it was a decision of quality over quantity. Sure I could keep her going, but last winter was rough enough on her. A year older would be just as tough, if not worse. In the last months, she stopped being active in the house. She would not greet people; she would not let them pet her. She just lay in her bed.

That was not the quality of life Skeeter had ever led. It was not the dignity she had filled my life with. It was time to change that.

With the help of friends and family near and far, I processed all these thoughts. With the love and support of those people, I came to the decision I had been avoiding since we had started down this road almost two years ago. And on a quiet day, I sat by the water with my dog, my friend and fed her BBQ ribs. I thanked her for the amazing good times and stories. She napped, curled up in a circle around my arm.

Later that afternoon, my friend Dr. Andrea Kitson helped me lay Skeeter to rest. The quality at which Skeeter lived her life is exactly how her life came to a close. Her story though lives on.

I can’t guarantee you an outcome like mine. I am lucky and thankful for all the 22 months I got with Skeeter. Dr. de Lorimier modified the chemo protocol specifically for her. With other patients, we may or may not see similar results. Talk with your veterinarian about options. It’s always best to get a referral to a specialist to find out about what’s available.

Hunting for a reason.

Hunter is a neutered, five-year old male Pembroke Welsh Corgi. He lives with two adults and two other Corgis. I met him after discussing his case with his mother on the phone. She had called looking for an evaluation to see if he was painful. Hunter had become grumpy over the past few months and he had nipped at a few people. His eating habits had also changed.

He had recently been examined by his primary care vet and no problems had been found. A full set of blood tests were also normal. The owner was concerned about his behavioral changes and wanted to be sure she wasn’t missing a painful condition.

Pain comes in many forms. There is bone pain, joint pain, nerve associated pain. Pain from surgery, pain from arthritis. Detecting pain in pets can be very challenging. Hunter had nipped at the staff of his primary care when they were drawing blood. While drawing blood isn’t painful, it can be stressful. It can also be uncomfortable for a pet to have blood drawn if they have a painful elbow or hip joint and have to be in certain positions. I try to keep my mind open to these when I do my evaluations.

Hunter came in and was immediately anxious. Panting, pacing and looking all around the room. He also stuck close to his mom. New hospitals can be stressful for any pet and taking the time to make a good first impression is key. I let Hunter wander around the exam room for about 15 minutes while I went through his history and asked mom questions about him.

For many appointments, I do not wear a white doctors coat. It can be intimidating to some patients, and there is a study that showed it can elevate the pressure within the eyes of patients with glaucoma. In human medicine, some people have elevated heart rates, blood pressure and stress levels from just seeing the doctors white coat. For Hunter, I wanted to minimize his stress. I also sat down and kept my voice soft. Being over six feet tall, male and deep voiced has its drawbacks to some patients.

After letting Hunter check me out and feeding him some treats, I was able to examine him. He let me check out every body part, move his neck, legs, and check all of his organ systems. Never once did he growl or snap. I did my exam on the floor so that he could step away if he got too stressed. I found no obvious sources of pain, atrophy or other complications.

Without a source of physical pain evident, I chatted with mom about other options. A consult with a veterinary behaviorist would be tremendously helpful. They have special training in animal behavior and treating it. Often times we can use Xanax or Prozac to help pets work through their problems.

While the owner agreed with the behavior consult she was not a huge fan of using anti-anxiety meds with him. Changing gears, I started to ask her my common background questions for Traditional Chinese Veterinary Medicine (TCVM). I found that Hunter had once been a confident, friendly and outgoing dog, but parts of his environment had changed lately.

The owners work schedule had changed, two new dogs had come into the house and the owners had been arguing at home. Hunter had been with his mom before the other two dogs and her husband had come into the picture. That is a lot of change.

In TCVM your mind is your Shen. Anxiety is a Shen disturbance. This emotional pain Hunter was carrying around was my suspicion for his behavioral changes. I discussed trying acupuncture and herbal therapy to help with this. I could not guarantee results nor would it be the whole solution, but I felt it would allow Hunter to minimize some of his stress or at least manage it better. I did three acupoints that day as his first treatment and waited to hear back from the owner.

Hunter had a consult with a veterinary behaviorist who diagnosed conflict aggression. She discussed pharmaceutical therapy as well as modifying how the owners introduced Hunter to certain situations and how to react when he was aggressive. The owner took a combination approach and did the exercises and re-training the behaviorist recommended along with acupuncture and herbal therapy.

After one acupuncture treatment, the owner said she had seen a change in him. This often doesn’t happen, but can in some cases.

I saw Hunter once a week over the next six weeks, each time making it a low stress, positive experience. He was my last appointment of the day on Saturdays so there were not many patients around for him to be stressed about. Each week he became easier and easier to treat. Initially he was timid about his needles but we worked slowly with that.

Acupuncture works on a cumulative effect and, over the course of the month, Hunter’s personality changed. He would now come in wagging his tail and jumping up to greet me. He enjoys his treatments and we are trying to see him less often.

The owners have made great strides at home minimizing the stress triggers for him. Taking the time to set the right environment at home and at the hospital helped this case succeed.

As I said before, pain can be very hard to identify in pets. The dog that holds its leg off the ground with a torn ACL is obvious. The subtle changes that arise from stress and emotional pain can be easily overlooked. But with a calm eye and heart, these troubles can be seen and alleviated.