Medicine

Dr. Sheila Robertson is board certified in anesthesia and in animal welfare in the USA and Europe and serves as the senior medical director at Lap of Love Pet Hospice. Today, she joins Dr. Andy Roark to discuss a recent research publication on which she is an author: the 2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats. This is a great episode for anyone interested in getting our feline patients better pain control and generally better experiences in the veterinary clinic.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Soundcloud, YouTube, or wherever you get your podcasts!

LINKS

2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats:

Feline Grimace Scale (Website & App):
https://www.felinegrimacescale.com/

AAFP Feline Friendly Handling Guidelines:
https://catvets.com/guidelines/practice-guidelines/handling-guidelines

Retain Your Team – Speak the Languages of Appreciation in Your Workplace: https://unchartedvet.com/product/appreciation-languages-101/

Creating Content Clients Crave: https://unchartedvet.com/product/creating-content-that-clients-crave/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Sheila Robertson graduated from the University of Glasgow in Scotland in 1980. After some time in mixed animal practice, she spent a year as a surgery intern followed by specialized training in anesthesia and analgesia at Bristol University (United Kingdom). While at Bristol she also completed her PhD investigating the physiologic effects of different anesthetic protocols in horses. She is board certified in anesthesia and in animal welfare in the USA and Europe and holds a certificate in small animal acupuncture. She has been a faculty member at the University of Saskatchewan, Michigan State University, and the University of Florida. Her research interests have focused on the recognition and alleviation of acute pain in cats, horses and even iguanas, topics she has published widely on.

She spent 2 years as an assistant director in the division of Animal Welfare at the American Veterinary Medical Association. In 2014 she completed her graduate certificate in Shelter Medicine at the University of Florida. In 2019 she received her certification as a Traditional Chinese Veterinary Medicine Palliative and End-of-Life practitioner by the Chi Institute of Chinese Medicine. Currently she is the senior medical director of Lap of Love Veterinary Hospice, a large network of veterinarians dedicated to end-of-life care and in-home euthanasia throughout the USA. Dr Robertson is also a courtesy Professor in the Department of Small Animal Clinical Sciences, University of Florida, Gainesville, Florida. She continues to volunteer at community cat clinics and High-Volume High Quality Spay and Neuter Programs.

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:

Welcome everybody to the Cone of Shame Veterinary podcast. I am your host, Dr. Andrew Roark.

Dr. Andy Roark:

Guys, I am here today with the one and only Dr. Sheila Robertson. She was on the faculty at the University of Florida when I was there. She is board certified in anesthesia and animal welfare in both the USA and in Europe. She is absolutely brilliant and amazing. And she has got some new research out. She is an author on the 2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats. And I wanted to talk to her about acute pain and pain management in cats. And man, we get into it.

Dr. Andy Roark:

She’s super excited about the Feline Grimace Scale and the Feline Grimace Scale app, which I was unaware of. And so man, new tool in my toolbox.

Dr. Andy Roark:

Guys, this is a great episode. We really get into it later on talking about, the back half of the podcast, we get a lot into action steps and what we can be doing in the practices. That makes me super happy. Anyway, all-around great conversation. I hope you enjoy it. Let’s get into this episode.

Kelsey Beth Carpenter:

(singing) This is your show, we’re glad you’re here, we want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the podcast Dr. Sheila Robertson. Thanks for being here.

Dr. Shelia Robertson:

Oh, thanks for inviting me. I listen in a lot. Never thought I’d be a guest.

Dr. Andy Roark:

Right. I have known you for some time now. You were on the faculty at the University of Florida when I was there. You were running my anesthesia rotation when I went through. And that was the first time I got to spend time with you. I’ve seen you lecture dozens of times since then all over the world.

Dr. Andy Roark:

You are the senior medical director at Lap of Love Pet Hospice, which is a group that was founded by some of my classmates and dear friends and they’re a great group. And gosh, you’re just everywhere. You work with the global pain council for WSAVA, which is the World Small Animal Veterinary Association. And you publish all over the place. And that’s honestly what I wanted to talk to you about today is a study that you have put out with a group of collaborators, it’s the 2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats.

Dr. Andy Roark:

And so this just came out in January. I think you were doing some speaking about it at the VMX Conference in Orlando. And I saw, I think you were on the agenda there talking about it, and I am a huge advocate for better care for cats and I think pain management in cats is something that we have not traditionally done as well as we should as a profession. And so I look at this and I say, “This is something that I would like to understand more.” And I’m always checking myself and trying to make sure that I’m practicing good medicine that I’m up to the current standards and things like that. So that is how I know you and kind of what I wanted to talk to you about today.

Dr. Shelia Robertson:

Yeah. Just so everybody knows what these are consensus guidelines.

Dr. Andy Roark:

Okay.

Dr. Shelia Robertson:

And ISFM stands for the International Society of Feline Medicine. So these are global. We wanted them to be able to be used around the world. Where access to different drugs and different types of therapy can be very different. So we wanted to make them global. And the group that put them together is Paulo Stegall originally from Brazil now working in Hong Kong. Myself, Brad Simon, who’s at Texas A & M, and then we have Leon Warren from Australia, was on them. And then Yael Shilo-Benjamini. She is actually based in Israel, did her training here in the US, and then Sam Taylor, who is a specialist, internal medicine and feline person in the UK.

Dr. Shelia Robertson:

So we got that group together and decided that it was time to really focus on cats and give them an entire paper to themselves, not kind of tagged onto the back of a dog paper. So these are completely feline only acute pain management guidelines.

Dr. Andy Roark:

So, let’s start at a high level. What are the objectives of the guidelines when you set out? So what were you trying to accomplish when you guys went to work on this?

Dr. Shelia Robertson:

Yeah. Well, so it almost like I can tell that you might have read them because one of the opening statements says, “Pain has traditionally been under recognized in cats.” And obviously if you under recognize it, that by default, means it’s undertreated, right? And we also know that pain assessment tools aren’t widely implemented. And so cats are very different from dogs.

Dr. Shelia Robertson:

I mean, cats are so good at hiding everything from people. And they’re not as demonstrative when they’re in trouble and we know that from other diseases. And so we wanted to raise awareness of the fact that they will be as painful as dogs after the same types of procedures or trauma, but there are lots of data to show that they’re not treated as well. People are, “Oh, I’m afraid to give a cat this,” because they have unique metabolism compared to dogs as well.

Dr. Shelia Robertson:

So the object was to really let people know that there are some very easy-to-use pain recognition tools out there that are now apps that you can put on a smartphone. And what does pain look like? And once you know what it looks like, you can actually score it. Because my philosophy is that we have an outcome measure for just about everything we do, right?

Dr. Shelia Robertson:

Say a cat comes in with a fever, like a very high temperature. So you can try and figure out was causing it. You treat it, but your resolution is, the temperature comes down, right.

Dr. Andy Roark:

Right.

Dr. Shelia Robertson:

If they’re diabetic, we follow their blood glucose. If have renal disease, we follow their blood work or SDMA. So what are people using as an outcome measure to say that they treated in pain effectively?

Dr. Andy Roark:

Yeah. It’s very little.

Dr. Shelia Robertson:

Other than I just think the cat looks better?

Dr. Andy Roark:

Right. Or, the cat seems more fractious and anxious next time it comes in and you think, “Oh, well maybe we didn’t do as good a job last time as we could have.”

Dr. Shelia Robertson:

Yeah. Yeah. And so we spent quite a bit of time putting in really nice real life images that each of us had of what feline pain looks like and how to examine a cat and recognize pain. And we did quite a lot on talking about the Feline Grimace Scale.

Dr. Andy Roark:

Yeah.

Dr. Shelia Robertson:

Which I like for a lot of quick assessments because it’s basically, you look at the face and they’re scored from zero to 10. Now that is now an app that can be downloaded on a smartphone. And yeah, it’s at the app store and everybody in the world has a smartphone. So you can download that app and use it cage-side to start scoring. You look at the pictures and you score their facial expression and it can tell you. And then if you instigate treatment, if you chose the right drug and did the right thing and things are better, the score goes down, right?

Dr. Andy Roark:

Yeah. I’ll put links to the app and also to the paper in the show notes so people can grab it.

Dr. Andy Roark:

So how widespread do you think that monitoring of pain in feline patients is in vet practices? Do you see practices that are doing good monitoring sort of patient care? And, I think a lot of us do a good job of recording hydration status, recording temperatures. Coming through and just checking on general wellbeing. Do our patients have food? Do they have water? Things like that.

Dr. Andy Roark:

Do you see a lot of practices that are doing an adequate, I’m just going to set the bar at adequate, do you see practices that are doing an adequate job of pain monitoring?

Dr. Shelia Robertson:

So I would say a lot of people using good protocols, but they’re not actually assessing how effective their protocols are. There was a paper just published very recently from a large number of veterinarians. And it was based in Australia and only 15% actually use a validated pain tool to assess pain in their patient population.

Dr. Andy Roark:

Right.

Dr. Shelia Robertson:

So they’re just doing it based on, well, I know if the cat is okay or not, right? It’s almost like you look at the cat and you guess that it’s temperature’s okay, but you don’t actually take the temperature.

Dr. Andy Roark:

Right? No, that definitely makes sense. Do you see good systems that people put in place? In your mind, when you see this, is this something that is hospital-wide, is this support staff technicians that are going by and sort of checking on this? Is it doctors? How sort of frequent in your mind does a monitoring system like this check-in on the patient? Is this an hourly check postsurgery? Help me dig into the specifics a little bit. I guess what I’m trying to do is really imagine this in my practice and what it could look like?

Dr. Shelia Robertson:

So when I was working in referral practice, so university practices, so we were getting pretty complex cases. And basically, my wing men and women are the anesthesia technicians, right? And I think that we need to empower technicians a lot more than we do, because if you think of yourself every day, Andy, you are probably in the surgery room or your surgeons are in the surgery room, doing surgery. The anesthesia techs admit the cat. It has an exam by a doctor and they often examine it. You check it over, you decide on a protocol, and they get it ready. So they’ve spent more time with the cat than you. So they know its personality, how it reacted to things. And then they take it to recovery. And they are really the advocate for that cat because they know how it was behaving before.

Dr. Shelia Robertson:

And obviously, if it’s now still nice and friendly and wants to play, everything went well. But if it’s not, they could come to you and say, “I don’t think this cat is doing very well.” And you might say, “Well, that’s your opinion. Let me look.” And so if you have a validated pain scoring tool, it’s no longer someone’s opinion, right? It’s well, here’s the temperature and here is its blood glucose level, here’s its pain score. So it gives them a lot more to advocate with and for everyone to focus on trying to get that score down.

Dr. Shelia Robertson:

And I think that is important because it empowers them. And there is a lot of what I know. I have pictures that I sometimes show when I go and visit hospitals, I’ll see notices on the front of a cat cage and it says, “Will bite,” and I’m like, “Why?” Does it bite because it’s painful. And if I ask, they go, “No, it’s just a evil cat.” And I’m like, “Well maybe it’s very anxious. Maybe it’s very afraid. Maybe it’s very painful.” So there is a lot of labeling and bias goes on and then people call it the diva cat, it’ll flinch if you just touch it. But to the cat, that pain is real and it will escalate with each visit if we don’t do the right things. And then we can talk later about the connection between fear and anxiety and pain because that’s more of a connection than we ever thought.

Dr. Andy Roark:

Yeah. So let’s go ahead and start to unpack that a little bit. So I, 100% resonate with what you’re saying about, “Oh, will bite. It’s a bad cat. She’s she’s evil.” Diagnosis, evil.

Dr. Andy Roark:

Why do you think that we don’t commonly make that distinction? Is it a lack of knowledge on our part? Is it a lack of understanding of anxiety, behavior, stress, or things like that? Why don’t we do a better job of understanding sort of why we get the reactions that we do from cats?

Dr. Shelia Robertson:

I mean, I think we’re all we’re moving in the right direction. And of course, there’s been a huge initiative for feeling friendly, cat-friendly practices. Lots of people understand how difficult it is to get a cat and a carrier and then drive it. A lot of them are motion sick and people don’t realize that, yet there are drugs we could give them to make them feel better. They could be dispensed with antiemetics before their next visit. And then a lot of people are using Gabapentin to sedate them. But remember that’s an anti-anxiety drug as well. And I think cats are, they don’t like change, but the biggest thing is they get very, very stressed when they don’t have control over their environment.

Dr. Shelia Robertson:

And they don’t get the same, I think, reassurance from having the owner there. A dog is with its owner and it obeys commands. I know we have difficult dogs to deal with but I think it’s more common in the cat. The cat really does not like a new environment and that new environment is extremely threatening to them when they don’t have control. And the control they have, in most threatening environments, is escape, right? And they don’t have that at your clinic. And then if they don’t live or haven’t been exposed to dogs and there are dogs barking and dogs smell, that’s very distressing to them.

Dr. Shelia Robertson:

So certainly understanding what an anxious, fearful cat looks like and what a painful cat looks like is important. But often they’re both. They can be painful and anxious and fearful and all of that is subversive and unpleasant. So we need to deal with all of it.

Dr. Andy Roark:

Yeah. So it sounds more like a holistic kind of generalized approach as far as low-stress handling. How we’re housing cats, things like that.

Dr. Andy Roark:

All right guys. This is when I jump in here with a couple of quick updates. First of all, the Uncharted Veterinary Vonference was last week in Greenville, South Carolina. It was amazing. We will have a virtual conference in the back half of this year. It’ll be in October. It is our GSD for Get Stuff Done Shorthanded.

Dr. Andy Roark:

That’s right. Get stuff Done shorthanded is going to be a virtual conference, which means you can join it anywhere. It will be in October more details coming soon. Registration is not yet open, but go ahead and get fired up. This is a great way to see what Unchartered is all about. See is it really different from everything else? Like people say it is, yeah. You can come and see just how that works online.

Dr. Andy Roark:

And then, if you love it, we’ll see you in person April next year in Greenville, South Carolina. Or, if you’re a practice owner, we’ll see you in person in December for our Practice Owner Summit.

Dr. Andy Roark:

Gang, if you can’t wait that long, and you know you can’t wait that long. We have a couple of workshops coming up. We have Retain Your Team. Speak the languages of appreciation in your workplace that is with Dr. Tracy Sands. It is on May 21st. It is all about showing your team appreciation. You know, they’re tired, you know they’re overwhelmed. You know that they want to feel appreciated for their work. Are you doing it right? Are you showing them appreciation? There are simple things that you can do that really make a difference. Guys, this is, as I said, May 21st 2:00 PM, Eastern, 11:00 AM Pacific time. It is $99 to the public. It is free for Uncharted members. Jump on, get registered, come and be there. This one is actually already filling up. It’s a month away and the spots are largely taken. So jump in there and grab a spot while you can.

Dr. Andy Roark:

On June the eighth, my friend, Bill Schroeder, founder and CEO of InTouch Veterinary Communications is doing his workshop, Creating Content that Clients Crave. This is all about making information in a way that clients will want to consume it. If you are tired of trying to educate in the exam room, if you want some backup, if you want some help, if you’re like, “I don’t have enough time to communicate everything, I need to communicate,” jump in on this webinar or, it’s a workshop, you’re actually going to work on the thing. That’s the difference in a workshop in a webinar, we do the thing, in Uncharted. June the eighth 7:00 PM, Eastern, 4:00 PM Pacific time. This is $99 to the public. Free for Uncharted members. You can hit the link in the show notes and get registered for that as well.

Dr. Andy Roark:

Guys, that’s enough for me. Let’s get back into this episode.

Dr. Andy Roark:

What do you think are the keys for sort of implementing this in practices? From the things that you see, what are the most important changes that sort of make you try to get practices up to speed? Are there approaches that seem to be particularly successful in getting the team on board and actually making changes?

Dr. Shelia Robertson:

Well, I think the AAFP has some very, very good courses that anyone can take. I mean, from veterinarians, technicians, and nurses, all the way down to anybody that even works in your clinic, and at very reasonable cost, can get certified or take a training course in how to handle cats and recognize, what they’re likely to do.

Dr. Shelia Robertson:

So I think the feline-friendly practice program is phenomenal and it’s coming up on its 10-year anniversary this year. And I think that’s made a huge difference to how we understand cats and allows people to work through learning about those things.

Dr. Shelia Robertson:

I think we all understand the exam room should be a little bit different. Using pheromones to calm animals or cats down. Owners can have a Feliway wipe in the carrier before they even come. And again, doing a cat exam, you can do a little bit, you can’t force it, right. You’ve just got to take your time. And I think the pre-visit Gabapentin, which is what most people use, some use Trazodone, but I think the pre-visit Gabapentin has been very, very successful for a lot of people.

Dr. Andy Roark:

Yeah. That’s a trend I definitely would like to see continue to spread. I’m amazed at how many practices do not have pre-visit Gabapentin or another sedative, anti-anxiety medicine pickup. It’s such an easy trick and pet owners appreciate it and it makes such a difference when people come in.

Dr. Shelia Robertson:

Yeah. And the stress itself can actually make you make a wrong diagnosis, right? They’re hypertensive, but they’re not really, it’s white coat hypertension, their blood glucose through the roof, because they’re so stressed out, and yet that could lead you down the wrong path with a diagnosis.

Dr. Andy Roark:

Yeah. What do you see as the biggest pushback that people run into as they start to improve their feline patient monitoring, things like that? Where, where are the pain points? Say that I wanted to advance this in my own practice as a veterinarian, where do people run into roadblocks?

Dr. Shelia Robertson:

I’ll be honest. I think a lot of people say, “Well, we know what a comfortable cat looks like.” And I thought I did until, I mean years and years ago started creating the Glasgow Acute Pain and validating that scale, which is more than just the face. The face is included, but it’s also palpation and so on. And I think what has been overlooked if a cat is sitting at the back of the cage, quiet and not moving, people have assumed it’s okay. And that’s actually the cat that I would now look at.

Dr. Shelia Robertson:

That would be a red flag because they’re at the back of the cage because they’re trying to hide and they haven’t been given a safe place to hide. Because that’s one of their coping mechanisms, right? They don’t have a box to hide in and they’re not moving because they’re painful and they’re not doing normal behaviors like getting up and having a nice stretch because their incision on their abdomen really hurts or they’re not grooming themselves because they hurt.

Dr. Shelia Robertson:

And then pain can make them nauseous as well and then they don’t want to eat in your clinic. I mean, a lot of them are just very suspicious of everything at the clinic. But use pheromones in their cage. And we do what’s called spot cleaning, which I learned from doing shelter work. Is that if it’s their own cage they will have taken the time to mark it and put their cheek pheromones on it.

Dr. Shelia Robertson:

All you need to do when you tidy up is just take anything that’s soiled, leave everything else because they’ve marked it and they’ve said, “This is my safe place.” So all I ever do now is clean up totally soiled articles in a cat cage and then give them a new towel that has been sprayed and left to air for 15 minutes with Feliway to put it in for security.

Dr. Shelia Robertson:

And again, noise, and partially covering the cage, and having the staff all know how to approach a cat, that not every interaction with the clinic should be for something to be done. I actually advise people when a cat is staying for several days that you should prescribe non-medical treatment. So the cat doesn’t anticipate that every time someone’s at the front of the cage, it’s going to be a pill. It’s going to be they’re going to do something to you. And we have good data, from again, from shelter medicine, showing that if you come up to the cage and just stroke the cat, pet the cat, and just have a safe interaction with it that doesn’t involve anything unpleasant, then everything’s much, much better.

Dr. Shelia Robertson:

It would take five minutes extra each day, or you could have volunteers obviously, that know that they’re going to not get hurt, open up and just speak to the cat and stroke it or get out a brush and brush it to help it because even that in itself releases endorphins and it is a good thing to do. But every single interaction usually is a medical interaction and they anticipate it, right?

Dr. Andy Roark:

Yeah.

Dr. Shelia Robertson:

I would too.

Dr. Andy Roark:

That makes perfect… Oh, absolutely. Sure, every time the door opens something bad happens and I get poked with a needle or grabbed by my neck or whatever, exactly. That doesn’t take long to leave a lasting impression about what’s going to happen.

Dr. Shelia Robertson:

So this not this like positive reinforcement that nothing bad’s going to happen. I’m going to groom you or I’m going to give you just a little bit of really super nutritious food, like a little piece of the tubes of Churu, which all the cats love. And they’re like, “Oh, okay. That was okay.” And then it was a predictable, positive interaction and I think they need, they need more of that. And I know everybody is busy. And then to have the time to do that before a treatment and then immediately after their treatment as well, if they’re getting an injection or something’s being done, would, I think, help lot.

Dr. Andy Roark:

Yeah. That makes a lot of sense. I mean, everybody’s busy at the same time. I mean what are the benefits to patient care? What are the benefits to reducing risk of cat bites and things like that by creating a better experience?

Dr. Shelia Robertson:

Well, yeah, I mean, there is good data to show that feline-friendly, trained practices have lower incidents of bite. Well, fewer people in the practice have a cat bite, and you know that can take someone out for days, right?

Dr. Andy Roark:

Yeah.

Dr. Shelia Robertson:

If they’re a surgeon they’re out for days. All has to be reported to HR and it’s horrible. So we know that cat bites can be reduced when people understand cats. And the other thing is a cat that is being totally defensive. You can’t nurse it, right? So the actual care of the cat is suboptimal. But if they’re very relaxed and feel secure, you can actually nurse them and take care of them.

Dr. Shelia Robertson:

They will want to eat, they won’t have GI stasis because they’re so fearful, which then in itself leads to all sorts of other problems. Hypertension, right? Is it real or is it that they’re terrified of being in their cage? So there’s just so much to understanding normal cat behavior and how to make it a better or experience.

Dr. Andy Roark:

No, that’s actually, that’s really great. That’s actually really useful. I’m going to sit with that. I like this a lot. Prescription snuggles, I think that’s fantastic. That makes me happy.

Dr. Shelia Robertson:

Yeah.

Dr. Andy Roark:

Let’s jump back for one second. So let’s say that I have that cat that’s just sitting at the back of the cage. So, I’ve got a patient, they had a fairly routine surgical procedure we’re going to say. Now they’re just sitting at the back of the cage and I’m hearing your voice in my mind saying, “You know, that cat at the back of the cage, that may be your painful patient.”

Dr. Andy Roark:

Can you walk me through just step-by-step? How would you assess pain in this cat. You talked about patient and things like that, but just run me through kind of what is your thought process as you are looking through the front of the cage and you see this cat looking back at you from the back?

Dr. Shelia Robertson:

Yep. So when we assess pain, we have two parts. We observe them only and we try and do that without them sort of knowing we’re there. So not right in their face, but just kind of have a look at them in the cage. So that’s going to let us see what their spontaneous pain behaviors are.

Dr. Shelia Robertson:

Now a spontaneous pain behavior in a cat is sitting still doing nothing but hunched up. That’s a pain behavior, but because it’s not throwing themselves around and wailing like a dog. It’s often ignored as an actual pain behavior.

Dr. Shelia Robertson:

And then we have what we call evoked pain behavior. So that’s when we have done the observation and then we actually interact and touch the wound. Sometimes that’s possible. Sometimes it’s not.

Dr. Shelia Robertson:

So for the cat, that’s sitting at the back of the cage, I would be, if I’ve downloaded, which probably everyone hopefully will do after this podcast, download the Feline Grimace Scale onto my iPhone. I’m going to pull it up. And I’m going to look at the cat’s face and start scoring it.

Dr. Shelia Robertson:

So we look at their ears, we look at their eye position, we look at their whiskers, we look at their muzzle, because it’s called the Grimace Scale for a reason, right?

Dr. Shelia Robertson:

When you’re painful, you kind of go, eh, and when you are a cat that makes your whiskers move, right? And your whole jaw and muzzle changes.

Dr. Shelia Robertson:

And then the other thing, which isn’t actually the face, but it’s the position of the head in relation to the cat shoulders.

Dr. Shelia Robertson:

So cats that are painful will just kind of drop their head down like this. But when they’re happy, their head is up, above their shoulders.

Dr. Shelia Robertson:

So those are the five things that you look at, and each is scored zero, one, or two. So you can have zero for the happiest, I’m doing great cat, and 10, yikes. Something’s really wrong. And round about four or five, we would say this cat needs rescue or needs to be looked at. What’s wrong?

Dr. Shelia Robertson:

Now the ear positions for pain and stress and fear are similar, right? So a cat that’s very fearful. Their ears go kind of flat. And so does a cat in pain. So we need to kind of figure out, and that’s why your nurses and technicians know when they come in for an elective procedure, they’re very unlikely to be painful, right?

Dr. Shelia Robertson:

So you do a baseline score. Now a baseline cat could score two for flat ears because is afraid. So what we’re looking at is differences in that score after the only thing you did before and after is do the surgery, right? So you’re looking for the pain scale or their score not to go up. You’re looking for it to the same. Maybe the flat ears. I’m still a little anxious, but not to go up.

Dr. Shelia Robertson:

And if you take care of anxiety, it’ll go down, right. It’ll be even better.

Dr. Andy Roark:

Yeah.

Dr. Shelia Robertson:

Right. If you take care of that. So that would be the first thing is look at their face. And then we look at posture. But I think people are finding the Feline Grimace Scale does correlate well with the Glasgow Acute Scale, which takes a little longer to do because then you interact with the cat. You touch it and stroke. Does it do the usual greet you? Does it not want to let you near it? Because that’s a bad sign. Do you hold their head, you should be able to touch around and palpate a wound gently if your pain management is adequate or good.

Dr. Andy Roark:

Okay.

Dr. Shelia Robertson:

Without them trying to turn around and nail you, they may flinch a little bit. And it also helps you look and see if your protocols are working most of the time and what I can do, even at feral cat clinics. I can go into one of those clinics, do the facial scale and show that their protocol works for most cats, like 96%. But there’ll always be a few that fall between the cracks, even with the same protocol. And that’s genetics, every cat’s different. It may have had previous pain. So it may already have come in with chronic pain that we don’t know about and we’ve added acute pain because we neutered it. But if I went into clinic and we’re rescuing, 50% of the time your protocol needs to be reworked, right?

Dr. Andy Roark:

Yeah. No, that totally makes sense. All that makes sense. I love the idea of a baseline score and it’s so simple it makes a ton of sense and it simply didn’t occur to me to do a baseline pain score on a cat. You go, “Well, you just came from home, the baseline score’s going to be 0. Well, no, we need to start looking at signs of stress.

Dr. Shelia Robertson:

And, the great thing about if you want to talk about continuing continuity of care when they go home before the owner leaves, they can download the Feline Grimace Scale app onto their phone, right? Or you can give them as part of their, like here. They could even do it at home before they leave to come in. Score their cat and then they can be monitoring the cat at home after a surgical procedure. And you know, you can say, “Well, if you score them with this app and their score goes back up to seven, you need to call us.” And it could be that the cat is getting more painful. Often it’s like, “Well you gave me those meds, but I can’t get her to take them,” right? And that’s why she’s painful. So it helps with the continuation of care at home.

Dr. Andy Roark:

Yeah. And so the app is approachable for vet owners.

Dr. Shelia Robertson:

Yeah. It’s free. It’s one of the number one medical download apps at the moment and it’s for Apple and for the other.

Dr. Andy Roark:

For Android, yeah.

Dr. Shelia Robertson:

It’s IOS and Android and Android. Yep. And it’s free. Yep.

Dr. Andy Roark:

Perfect.

Dr. Andy Roark:

Well, that’s awesome. I’m going to put a link down in the show notes. I’m going to link to the study so that people can download and have that as well. I’ll put a link to the AAFP courses for feline handling.

Dr. Shelia Robertson:

Yep.

Dr. Andy Roark:

Are there any other resources that you would recommend for my cat warriors who want to make sure they’re doing good pain control and learning what they can to be the best advocate for our feline patients?

Dr. Shelia Robertson:

Yeah. Well the good thing about the Feline Grimace Score, other than the app, they have their own website. And it’s now, the actual tool is in multiple different languages. So it’s in Spanish, it’s in lots of different languages because a lot of us have clients or people in our practice that English isn’t their first language. So that’s very positive.

Dr. Shelia Robertson:

And then the other thing, in there, they’re upgrading it more and more. So the really good thing about the Feline Grimace Scale, or tool, is that there is the app, but there’s their own website. And if you go to their website, it’s felinegrimacescale.com. You can get it in multiple different languages, the scale. It’s in Spanish, it’s in Portuguese, it’s in French, and so on. And on that website, they’re updating it all the time. What you can do, or your staff can do, is you can go in and score a cat and see how you compare to an expert that has scored that.

Dr. Andy Roark:

That’s cool.

Dr. Shelia Robertson:

So they’re doing it as a training center, right? You can go in, test yourself. Can I actually score a cat? And the answer is after a few minutes of training, owners can score a cat’s facial expression, whether it’s painful or not.

Dr. Andy Roark:

That’s awesome. That sounds like such a fun thing to do with the team. To say, “We’re going to do this together and everybody gets to do their scores and then we’re going to see what the experts come back at.” That’s really cool.

Dr. Shelia Robertson:

Yep. And then what I would remind people is, if you have a clipboard or you have an electronic, whatever you do for your postop monitoring, you’re probably going to put how much fluid they’ve had or are still having. If they ate. What their temperature is. What their pulse respiration is. Just add a line and put Feline Grimace Score. What was it?

Dr. Andy Roark:

Yeah, that’s awesome. I really appreciate it. That this has been wonderful. Thanks so much for… Thanks for all that you do for our patients. Thanks for taking time to be with us. Thanks for all the research resources. Like I said, I’ll link those down the show notes. I really appreciate you. Thank you for doing this.

Dr. Shelia Robertson:

Well, and I’m going to thank you for getting it out to the masses because that’s what we need. It’s the getting it out there and getting people just to say, “Yeah, wow, this is kind of cool.” And like I always have said, empowering our technicians and nurses that work with us, our support staff, because they’re with the patient more than we are usually.

Dr. Andy Roark:

Yeah. I completely agree. Awesome. Well thank you so much guys. Take care everybody.

Dr. Shelia Robertson:

Thank you.

Dr. Andy Roark:

And that is our episode guys. That’s what I got for you. I hope you did enjoy it. I hope you got something out of it. If you did, the kindest thing you can do for me is go in, leave an honest review wherever you get your podcast. If you didn’t enjoy it, then the kindest thing you can do is just not leave a review until next week when we have a whole new episode that you might like, and then if you do like it, then you can go leave an honest review. And that would be great as well.

Dr. Andy Roark:

So guys, that’s all I got take care of yourselves. Be well, I’ll talk to you soon.

This episode is made possible ad-free with the support of the Purina Institute!

Charlie, the 2 year-old labrador has crept from 76 lbs to 84 lbs over the last 6 months. We need to do something about this, and Charlie’s owners don’t seem super motivated to intervene. They’re good people, and they will listen if we can just communicate the right message in the right way.

Dr. Shelly Adrian, US Ambassador for the Purina Institute, joins Dr. Andy Roark to discuss this oh-so-common case and some resources that veterinary teams can use to have these conversations more effectively. Let’s get into this episode!

This podcast was brought to you ad-free by the Purina Institute.

LINKS

Purina Institute CentreSquare: www.purinainstitute.com/centresquare

Purina Institute: www.purinainstitute.com/

What’s on my Scrubs?! Card Game: drandyroark.com/product/card-game/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr Shelly Adrian received her DVM from Kansas State University College of Veterinary Medicine in 2007. She went on to a rigorous one-year private practice internship, mainly focused on Emergency Medicine, at the Pet Emergency & Specialty Center in San Diego, CA.

Dr Adrian remained with that clinic for an additional 2 years as an emergency veterinarian. In 2010, she entered general practice in San Diego, and continues to practice in coastal San Diego. Shelly’s areas of interest include nutrition, internal medicine, and emergency medicine. In 2015, Shelly joined Nestle Purina Pet Care as a Veterinary Communications Manager and was named a Senior Veterinary Communications Manager in 2019. Her current responsibilities include supporting several veterinary schools as well as providing education on behalf of the veterinary sales team. Shelly also took on the role of US Ambassador for the Purina Institute in 2021 and works to further communication to the veterinary community regarding the science behind nutrition.

Shelly resides with her physicist husband in San Diego and has three dogs: a 77-pound “greyhound-lookin’ thing” named Nutmeg, a young “Monkey” golden retriever mix, who she found on Petfinder.com, and their newest puppy “Walnut”.

EPISODE TRANSCRIPT

Dr. Andy Roark:

Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a good one for you today. I am here with my friend, Dr. Shelly Adrian. She is a veterinarian, a member of Uncharted, which is how I got to know her. She is also the U.S. Ambassador for the Purina Institute and I am talking to her about a case that you have seen, yes, you have.

Dr. Andy Roark:

It’s the young Labrador who is not wildly overweight yet, but we’re seeing it creep up. In this case, we’re talking about Charlie, the two-year-old Labrador retriever whose weight has crept from 76 to 84 pounds. And whose owners don’t seem super motivated to get involved with it. They’re like, “Oh, Charlie loves food.”

Dr. Andy Roark:

Listen, this is about team training is what it is. It’s about communicating effectively, it is about supporting our team as they have these conversations, it’s about veterinarians getting the same story and resources to back that story up from multiple team members. And so guys, Shelly is amazing at this really good conversation about how to approach this super common case. And let’s be honest, super important, right? We know that we expand pet’s lifespans when we manage their weight.

Dr. Andy Roark:

How do we do it? And the resources that Shelly brings to the table really fantastic. If you want your team to do better jobs, talking about nutrition, this is a great episode to get into and to share with them. Guys without further ado, we’re going to jump into this episode, which has been brought to you ad free by the Purina Institute. Let’s get into it.

Kelsey Beth Carpenter:

(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the podcast, Dr. Shelly Adrian. Thank you so much for being here.

Dr. Shelly Adrian:

Thanks for having me, Andy.

Dr. Andy Roark:

It’s my pleasure. You and I have known each other for years. You are an Uncharted member and so that’s where we met back in the day, hanging out at those conferences and I’ve always enjoyed you very much. And I love to see you at our gatherings and our get together. You are a practicing vet in San Diego, and you are also the U.S. Ambassador for the Purina Institute. And I bring that up because it’s central to the conversation that I want to have with you today.

Dr. Andy Roark:

When we last spoke, you were telling me about one of your cases and we were talking about the hard conversation of getting pets to actually lose weight. I had a case yesterday and it was a 10 year old Yorkshire Terrier with collapsing trachea. And it came in and the owners were super nice. They were really great people, but they came in and they’re like the medications aren’t working anymore.

Dr. Andy Roark:

“I’ve been trying to medically manage this case and the medications aren’t working anymore.” And he’s just coughing all the time and whatever. And that little booger had gained a pound since the last time I saw him. And he’s only 10 pounds now. So even from nine to 10 pounds and they’re like, “He’s coughing all the time.” And I’m like, “Yeah, I suspect.”

Dr. Andy Roark:

And I know I talked with them about weight management and stuff before, and I went through like, “What are you feeding?” And it was this again, they’re wonderful people. And they clearly love this dog, but the list of things that they feed to this dog just kept going and it kept going. And there were pates and there were extra things that they were cooking and there were just these things.

Dr. Andy Roark:

And I’m like, this is a hard conversation. And it was a hard conversation, even though I’m like, here’s this glaring medical issue, right? It’s not like, Hey, it would be good if he lost weight. He’s like, no, you came here because he’s coughing and this is getting worse. And I’m like, we’ve got a pressing medical reason for him to lose weight and that’s still a hard conversation. And so that was just yesterday that I had that happen.

Dr. Andy Roark:

And then I step back and I really look at what we do for pets and what matters for pets. And when we think about the things that really affect the life of our patients, the two biggest ones in my mind are weight management, nutrition, and dental health, right? If you think about the goal for me is to increase the life span of the patients that I see, those are the ones I want to get right.

Dr. Andy Roark:

And then the last thing I’ll pull into this is the classic golden retriever study of dogs that are of an ideal body weight, or slightly thinner, live on average two years longer than those that are even slightly overweight. And so we know the importance of this conversation, but it is really hard to get traction on this conversation.

Dr. Andy Roark:

I know that people have a lot of frustration with this. So anyway, go back to our conversation and you and I were talking and you brought up, you were talking about resources that were there and then you had a case of how you would put those resources into use. And I want to unpack that with you today, if you’re okay with that.

Dr. Shelly Adrian:

Yeah, absolutely. And that nutrition conversation is vital, right? Nutrition is considered the fifth vital assessment. We know we have to have that conversation. We know our owners want to have that conversation with us, but…

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

Regardless of whether it’s a weight topic or what they’re currently feeding topic, it can feel very difficult and delicate and uncomfortable for us to have that conversation.

Dr. Andy Roark:

Well, there’s a couple pieces to it, right? There’s the denial piece when they… I never forget. I saw the most morbidly obese pet I’ve ever seen in my entire career. And I showed the pet owners, the body condition score chart, and I was like, which one do you think your dog is? And they pointed right at five out of nine. And I was like, which dog are you looking at?

Dr. Shelly Adrian:

I would say it by nine plus.

Dr. Andy Roark:

Yeah. But it was just like, there is that denial part of it and then there’s the food is love part of it. They have to believe that this is worth it, or it’s just so easy to fall off the wagon so it’s such a struggle.

Dr. Andy Roark:

But let me go ahead and open this up for you a little bit. Why don’t you just tell the story? Why don’t you tell the story that you were telling me before about the two-year-old Labrador?

Dr. Shelly Adrian:

Luckily, I saw this patient before it was in the situation that your York, he was in the other day, but…

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

Very classic patient that we see, I saw her in June 2021, for the one moment we were allowing clients in the exam rooms, Charlie, two-year-old female sped, Labrador was just there for healthy pet, no concerns, vaccines, except I had a concern when she came in, she weighed 84 pounds and previously she had weighed 76 pounds and the owner again, the denial part, right? The owner didn’t realize that those extra pounds can slip on you over six months. I think you’ve all experienced that. So I had to bring up a topic that the owner wasn’t prepared to talk about and draw her attention to a problem that she wasn’t aware Charlie had.

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

So I was able to use this new resource, this online toolkit that’s available to us from the Purina Institute and I had some secret knowledge of this toolkit. And what I was able to do was pull up a video for the owner on how to conduct a body condition assessment on your own pet.

Dr. Shelly Adrian:

And while I went to go get Charlie’s vaccines and vaccinate her, I was able to play that video in the exam room for Charlie’s owner to watch. And then when I came back, we talked about, what did she think Charlie’s body condition score was now being a typical owner after watching the video, she thought Charlie was a five out of nine.

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

Difficult. Right?

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

But on that same website, instead of having to open up a completely new tab and go to a new resource, I was able to pull up the body condition, score chart, and talk with her about what I was looking at when I’m judging Charlie’s body condition and showed her why instead of a five, I would actually grade Charlie at a six. And you’re right, I was able then very quickly to link to a resource that talks about that retriever study.

Dr. Shelly Adrian:

And it was perfect because Charlie is a retriever. And what they found was that paired litter mates who were just slightly heavier, typically those dogs were six and a half out of nine versus four and a half out of nine lived two years shorter than they’re lean lit made. So we have that conversation, we talked about Charlie’s ideal body, weight and body condition.

Dr. Shelly Adrian:

And I was able to print out a body condition score chart to send home with Charlie’s mom was able to print out a brief, or actually I emailed it to her after the exam. And it went through those key bullet points of why it’s important to have my pet at an ideal body condition. And most importantly, to help me feel comfortable having this conversation, it links published data.

Dr. Shelly Adrian:

So this is not just Dr. Shelly Adrian saying this isn’t just random veterinarian saying this. This is based on scientific data, not mentioning any type of specific product or biased in any way. It’s just based on scientific data. And then the cool part is, I just saw Charlie again, six months later, and guess who’s back down to her original body weight. So, how often does it happen and where that weight conversation works the first time?

Dr. Andy Roark:

Yeah. You won. You actually did the thing and got the pounds back off, as opposed to, all the other cases where you see the two-year-old and they’ve gained six pounds, and then next time you see them, they’ve gained another pound and then three more pounds. And now they’re 93 pounds and that’s where they’re just going to live for a while. You actually move the needle.

Dr. Andy Roark:

I want to unpack with you a little bit workflow, right? And one of the things that I think a lot about these days is how we do education in a way that actually reaches people. Some of the pushback that I get because I teach a lot about exam room communication, how we build relationship and how we build trust.

Dr. Andy Roark:

And people are always talking to me about time. Andy, we’re super busy, we’ve got people waiting, we’ve got all of these things and it’s so easy to push nutrition off of your plate and just say, this is not the most pressing thing. They didn’t ask me about nutrition. We can talk about it next time because the dog is still going to be a little bit heavy then and we can do it then.

Dr. Andy Roark:

And I want to be gentle and kind to my colleagues and stand in the exam room. I run behind schedule as well. I know how it goes at the same time when people press me on it and say, well, what do we do?

Dr. Andy Roark:

I really love the idea of using videos and using resources and things that we have in the clinic to let clients work or educate or to support the things that we’re saying when we’re not in the exam room. And so as you say, Hey, I ducked off to do these other things and I showed them this video, and when I came back, we talked more.

Dr. Andy Roark:

That is multitasking, right? That’s an efficient use of time. I’m going to hand you this while I go get these other things going and you’re going to stay engaged and we’re going to advance conversation while I’m in the back, drawing up, setting up [inaudible 00:11:20] getting my next appointment, ready, whatever the things that I’m doing, walk me through that workflow.

Dr. Andy Roark:

Like what exactly does that look like? Are you using tablet computers? I just want to start at the base level. I think I know other people really just want to visualize what this system looks like to get this education into the sessions.

Dr. Shelly Adrian:

That’s a great question and I’m just like you, I’m almost always running behind in the clinic. There’s so much information I want to convey to the owners and we have such a short period of time with them and it’s all critical, right? And I would argue you’re absolutely right that some of the most overlooked conversations are some of the most important and dental disease and nutrition are the top two because all of our patients have to eat.

Dr. Shelly Adrian:

And all of our patients at one time had teeth. So it’s really important that we never leave those pieces out. As far as workflow goes, it can vary from clinic to clinic the way my clinic works, we do have computers in the exam room that I can use. We could use a tablet if we chose to on that same resource, that online toolkit, I can email things.

Dr. Shelly Adrian:

And I did email something after the fact, it was really easy to just click a link and send that email to the owner. There are even additional resources that I could use to train my staff with videos or with reading. So the workflow, again, idea to save us time, to get us quick information, when we’re in the exam room too, what I find is a big area sometimes with nutrition conversations is when we look up good science backed conversation, we pull up some 12 page document that might take us an hour to read, right? And sometimes I just need the quick key messages.

Dr. Shelly Adrian:

I just want the bullet points. What do I need to say? What is the most important information to convey in less than five minutes? And so the nice addition to this tool is every piece of content has a reader watch time, so I can even filter. If I’ve got less than five minutes, what can I use to convey this information and go.

Dr. Andy Roark:

That’s super cool. Yeah. We need to be realistic about what people are going to actually do. Like sending them home with a multi chapter reading assignment is wishful thinking. And it’s just… I liken what we do to auto mechanic sometimes. And not in all cases I know people don’t like that, but for me, it’s the easiest thing that I can imagine that is expensive. It can get expensive real fast.

Dr. Andy Roark:

And personally, I’m not a car guy. I don’t know all that much. I want to be a good car owner. Obviously I want to have a car that works and have a nice long life from a car and I don’t know what I need and I don’t know what I don’t know.

Dr. Andy Roark:

And so when I think about education, I think a lot about my experience with an auto mechanic and stuff like that. And if I go to the auto mechanic and they give me a 10 page document to read with the specs of engine care, it’s not going to happen and you know what’s not going to happen. You and I were talking before, as we were making this COVID pandemic spike, my kids have been doing virtual school for a while.

Dr. Andy Roark:

Everybody around me is sick. Yeah. And it’s like, we are all busy and we’re all stressed. And so just meeting people where they are and being realistic and just giving them the actual information that they’re going to use to make a decision and then giving the pathway to where they can go deeper if they want, right?

Dr. Andy Roark:

I think that’s probably the key with a lot of the clients and trying to educate us. We all have those clients who are sponges. They want to read all the things, they want the 12 page document, and they want to see the original sources. It’s a beautiful thing to be able to give people the executive summary and then have it link deeper, have the ability to go deeper to what they want.

Dr. Andy Roark:

But I think a lot of times we jump to the full Monty and people are not ready for that. And it just goes into their email and it just sits in their inbox for a long time because they didn’t delete it because they mean to read it. They just never do.

Dr. Andy Roark:

And so that’s super interest to me just short my time and have stuff that’s top level. And what… Can I ask you some more questions about the training stuff because that’s really intriguing. I’m a super big advocate for tech training for helping people grow and develop inside the practices.

Dr. Andy Roark:

I like people to be learning new things. I want to learn new things and so I’m always interested in what training resources and stuff are there, can you lay out what’s there and what might be beneficial to practices?

Dr. Shelly Adrian:

I thought that might pique your interest. Yeah.

Dr. Andy Roark:

Yeah. I love it.

Dr. Shelly Adrian:

And that’s the neat thing like you said, some folks want those key bullet points, those key messages and that’s all they need to know. I don’t know what a carburetor is. I’m never going to read further about what a carburetor is, I just hope that it works. Sometimes I really do want to read deeper into what makes a large breed puppy food different than a regular puppy food, right?

Dr. Shelly Adrian:

And so do my technicians because let’s be honest, they might be the ones having the conversation about large breed puppy food versus regular puppy food. So what we can utilize on that center square toolkit, there are videos, there are right ups again with those key bullet points, but then linking to deeper, more science getting into that nitty gritty, that nerdy part.

Dr. Shelly Adrian:

And again, always based on published data, the videos are really cool though and I pull those up frequently just for myself. If I have a few minutes to inhale my lunch, most of the videos are less than five minutes long and they’re recorded by board certified veterinary nutritionists. These are nutritionist that do not work for Purina.

Dr. Shelly Adrian:

So this is not Purina centric at all, and they have really helpful videos about how to fit that nutrition conversation into a short exam. How to have a conversation with an owner who comes in with recommendations for foods, perhaps from a breeder or a shelter that maybe we don’t agree with those recommendations for that pet, the importance of a nutrition conversation.

Dr. Shelly Adrian:

They hit all of those difficult topics and give their pearls and their best practices because they’re having those conversations too, right? So listening to their perspective on it just while I’m inhaling my food, watching that quick video is not only helpful for me, but for my staff as well. And then if they want to dig deeper, they can look below the video and it will link them to some of the deeper information on that same topic.

Dr. Andy Roark:

That’s awesome. I really like it a lot. Can you help me with… So the last part of this for me, that I find is a hurdle to really leveraging resources effectively is what I say in the exam room. Can you help me with some conversation stuff just to set this up to then refer them to some resources and things like that?

Dr. Andy Roark:

You have a lot of experience with this. How do you broach the conversation of either, Hey, I’m going to leave you with this video or I want to send you with more information and I’m going to send this as a link or I’m going to print this off.

Dr. Andy Roark:

What strategically do you do to set up the conversation so it doesn’t sound like, Hey, I know we didn’t talk about this, but here’s bunch of links because that’s not going to go anywhere either way, so you’re naturally a very warm and charismatic person.

Dr. Andy Roark:

How do you lead into this conversation to get people to actually click the links and to feel like, yes, this is not homework for me, this is a value add to my exam.

Dr. Shelly Adrian:

That’s a good question and you’re right. We don’t want to information dump or sometimes we do want information dump, but we know that’s not effective.

Dr. Andy Roark:

Right. Always want to information dump.

Dr. Shelly Adrian:

But yeah. So, I think a part of it is going back to the idea that we’re on the same team.

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

We both want what’s best for their pets health and going back to the idea that food is love, I almost by nutrition to be a topic that usually does peak owner’s interests and as opposed to my car’s carburetor…

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

That the nutrition piece is something they want to eat. So, when I bring up the nutrition conversation, which I always at least mention a piece of nutrition in the exam room, we always talk about what food they’re currently eating the body condition score. So as I go back to that, Hey, remember we talked about, your dog is eating X, Y, Z. The reason I like X, Y, Z food for fluffy is, and then if you want to read more up on that, say, for example, I’m seeing a geriatric cat, this is another true life example, geriatric cat named Angelina 17 years old.

Dr. Shelly Adrian:

It was healthy but she was getting to that where she’s getting leaner and thinner and losing that lean body mass. So we talked about the food she was eating, which was good. But what I said for her is, Hey, I want to focus a little bit more on getting more water into her, help with her kidney function and just for geriatric cat in general, and getting some extra protein into her for that lean body mass.

Dr. Shelly Adrian:

So, if you want to read further on why I’m making that recommendation, I have this link for you. In the meantime, here are some solutions as far as getting more water into her and getting more protein into her. Does that make sense?

Dr. Andy Roark:

Yeah, I like that a lot of, Hey, if you want to get deeper into why I’m making this recommendation, that’s the words that I like, I’m going to put that into my little quiver of arrows for the exam room, because that makes sense for me as well.

Dr. Andy Roark:

So no, I like that a lot. That really makes sense. One of the things I think is true with nutrition, right? I think it is true of people in general, but I think it’s also especially true of people with pets. I think we also want to have control in our lives. I think we all want to believe that we have some control and we want believe that we can keep ourselves.

Dr. Andy Roark:

And I think this is obviously COVID thoughts with Andy. We all want to believe that we can keep ourselves and our family safe, including our pets and nutrition is a thing that we have great control over for our pets. It is a thing where we can make this purchase and we can decide what they get. And this is an aspect of their life that we can control, which is why people talk to us about their pets stool all the time.

Dr. Andy Roark:

Because they’re like, they can see it and it’s there and I can adjust what’s going in, the front side and effect what’s going on the backside and this is control I definitely have. And so I do think that in that mindset, nutrition is really easy to talk about and I do find that pet owners are generally psyched to get a recommendation, to start to Wade into it.

Dr. Andy Roark:

There’s also some research that came out and I’m not going to try to quote the staff because they’ll be off, but I was actually surprised by the high percentage of pet owners who say that they want nutritional recommendations from the doctors and they want to talk about nutrition. I think a lot of us go, they made a choice and this is bringing up old stuff but the research doesn’t, that’s not true.

Dr. Shelly Adrian:

You’re right. And I’m super nerd. I actually do know this stuff.

Dr. Andy Roark:

So I thought, I’m going to toss this out there at half date and I’m going to let Shelly just finish cooking it for me.

Dr. Shelly Adrian:

And I think it’s really important for us to keep this in mind because again, I’m in San Diego. I have had the challenging nutrition conversations and I know what it’s like…

Dr. Andy Roark:

Oh, I’m sure yeah.

Dr. Shelly Adrian:

Talking and you feel like you’re talking to Rick wall, but they hear you. 83% of owners trust their veterinary professional when it comes to nutrition advice, however, less than 25% perceive that they’re getting that nutrition conversation when they go to the vet.

Dr. Shelly Adrian:

So it’s a real… That’s why I think it’s important to have those additional resources say, Hey, if you want to read more, because if they have those, whether it’s an email or a video, we showed them or a printout that we leave them going home with, now they know they’ve had that nutrition conversation, right?

Dr. Shelly Adrian:

So now they’re going to see, yes, I got this recommendation from my vet, whether it was about body condition, score, specific diet, hydration, and whatever, the aspect of nutrition that conversation you’ve had, they know they had that conversation with you and that just builds to a better relationship overall, right?

Dr. Andy Roark:

Yeah. I agree. I want to leave you with a bonus round here and you can take either of these two questions. You can either leave me with your favorite Pearl for getting nutritional compliance, getting people on board, getting people to make changes that you think that most GPS or technicians miss, or you can give me the biggest pitfall that you see in these conversations that most of us fall into. Which one do you want to do? You can take either one yeah, I know.

Dr. Shelly Adrian:

I think the biggest pitfall that I see from my colleagues is shying away from the nutrition conversation. And there are lots of reasons why we might not feel comfortable having it. We might not be fully up on the science ourselves, right? So if we get questioned, we’re not sure that we can justify the recommendation we’re giving, or we don’t know how to have that conversation.

Dr. Shelly Adrian:

But I challenge you to take the conversation back because as we already discussed, the owners want it. If they don’t get the information from their vet professional, they’re going to get it from somewhere. And we have tools available to us that are backed by science. So if you take a step back and you just approach it as a teammate with the owner, right, we’re part of a team to keep this pet healthy.

Dr. Shelly Adrian:

And what does the published data say about this pet’s nutrition? And if we just go back to what our resources and our published data give us, it can take some of the emotion out of it and it makes it less difficult. So I challenge you, especially those times where you really don’t want to have the conversation, do it.

Dr. Shelly Adrian:

Have the conversation backed by science, give a specific diet recommendation every time whether it’s stay on this food, it’s great, I love it. Or I recommend X diet because this is Y.

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

And back up, site your source back up your reasoning.

Dr. Andy Roark:

Yeah. What’s the easiest way or the best way for people to engage with Purina Institute and Center Square? I’m going to put links in the show notes for everybody who wants to click through. But yeah, if people are out there and they’re listen to, as they drive in and they’re like, Hey, I want to look around, I want to see this thing. How would you advise them to get started?

Dr. Shelly Adrian:

Perfect. Yeah. The Purina Institute is the scientific arm of Purina, and the goal of the Purina Institute is twofold. In general, is to generate and communicate scientific content on companion animal nutrition, but also to help us take that conversation back to help us have these difficult nutrition conversations. So if you just go to the website, Purina institute.com, there’s a wealth of information there.

Dr. Shelly Adrian:

If you want to get real nerdy on it, you can, whatever the topic may be. The nerdy shell, you had to come out but there’s a label at the top called Center Square and if you just tap on that, you can search the wealth of resources. I encourage you to play with it, whether it’s veterinarian, technician, receptionist, there’s content there that can help you have those nutrition conversations because we all do.

Dr. Andy Roark:

Yeah. Awesome. Thanks so much for being here. I really appreciate you. Appreciate your time.

Dr. Shelly Adrian:

Thanks for the Sandy.

Dr. Andy Roark:

And that is our episode. Thanks again to the Purina Institute for making this possible guys, thank you for tuning in and checking it out as always, if you like the episode and you feel like leaving us an honest review, wherever you get your podcast, that means the world to me.

Dr. Andy Roark:

I really do appreciate it. Also, remember that we are now on YouTube. So if you like watching podcasts or watching the conversation, check us out there. Anyway, gang take care of yourselves. Be well, talk to you later. Bye.

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram

A 6 month-old bearded dragon presents for shaking and not eating. Dr. Doug Mader walks us through the best way to approach this case and discusses why Metabolic Bone Disease (MBD) is a term we should think twice about using.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Soundcloud, YouTube, or wherever you get your podcasts!

LINKS

Dr. Mader’s Website: https://www.dougmader.com/

Follow Dr. Mader on Facebook: https://www.facebook.com/douglas.mader.9

Retain Your Team – Speak the Languages of Appreciation in Your Workplace: https://unchartedvet.com/product/appreciation-languages-101/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Douglas R. Mader, MS, DVM, Diplomate ABVP (Canine/Feline), Diplomate, ABVP (Reptile/Amphibian), Diplomate, ECZM (Herpetology), Fellow, Royal Society of Medicine

Dr. Mader received his DVM from the University of California, Davis in 1986. In addition, he completed a Residency in Primate and Zoo animal medicine. He is the consulting veterinarian for the Monroe County Sheriff’s Zoo, the Key West Aquarium, Dynasty Marine, the Sea Turtle Hospital, the Everglades Alligator Farm and the Theater of the Sea. Previously Dr. Mader owned the Marathon Veterinary Hospital, a double AAHA accredited 24 hr emergency/referral hospital. Dr. Mader is an internationally acclaimed lecturer and is on the review boards of several scientific journals. He has published numerous articles in scientific and veterinary journals, national magazines, and, is the author/editor and co-editor of three textbooks on Reptile Medicine and Surgery.­­ Dr. Mader’s latest project is his new book “The Vet at Noah’s Ark – Stories of Survival from an Inner-city Animal Hospital.”

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:

Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here today with a legend. The one and only Dr. Doug Mader. If you don’t know Dr. Mader, he wrote the book on exotic animal medicine.

Dr. Andy Roark:

The guy has been elected the Speaker of the Year for Exotics at the VMX Conference, which is one of the largest conferences in the world, something like seven times. It’s incredible. When you listen to this interview, you’re going to find out why. Because he knows his stuff and he breaks it down in a super useful, tangible way.

Dr. Andy Roark:

I’m not a big exotics vet. It’s a weakness of mine. I’m very upfront about that. And so, whether you do exotics all day every day and you’re just looking for pearls from the master. Or whether you are not real comfortable with exotics and you want to get the basics and understand the fundamentals.

Dr. Andy Roark:

Gosh, this is a great episode. Thank you to Dr. Mader for being here. Guys, let’s get into this episode.

Kelsey Beth Carpenter:

(Singing) This is your show. We’re glad you’re here. We want to help you and your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the podcast, Dr. Doug Mader. Thanks for being here.

Dr. Doug Mader:

Dr. Roark, thank you so much for the invitation. I really appreciate it. It’s quite an honor.

Dr. Andy Roark:

Well, call me Andy. I’ve been a fan of yours for about 15, almost 20 years now. I was aware of you in vet school, because I went to Florida. Your practice was in … Was it Marathon, Florida?

Dr. Doug Mader:

Yeah.

Dr. Andy Roark:

You would take externs down there, and the people who went got to do these incredible things. You worked on alligators and sea turtles and just amazing stuff.

Dr. Andy Roark:

And then, I’ve seen you lecture a number of times. You have been the Speaker of the Year at VMX, which is one of the biggest vet conferences in the world, seven times for exotics. You’ve got a book coming out in June.

Dr. Andy Roark:

First of all, you have an amazing career, and you are also an excellent teacher. Thank you for taking time to be here. I really appreciate it.

Dr. Doug Mader:

It’s quite an honor to be invited. Thank you.

Dr. Andy Roark:

Well, I’ve got a case for you. And so, I have to start with full disclosure. Exotics are a weakness of mine. I am a general practice doctor. And so, they come across my desk and I want to be competent. At least get people started and do help where I can do help.

Dr. Andy Roark:

And so, it’s in that. Just know that’s my background. But I am coming to you with a case that I am looking at. I was wondering if I could walk you through it?

Dr. Doug Mader:

All right.

Dr. Andy Roark:

All right. I have got a bearded dragon. This pet was purchased from a pet store. It’s about six months old. The owners have brought it in and they’re not sure what’s going on with it.

Dr. Andy Roark:

It’s shaking and it can’t walk. I’m not … They’re telling me that it’s also not eating. I’ve taken some radiographs. I don’t really know what I’m looking at. To be honest, I don’t see anything obvious. It seems, to me, to be relatively decent.

Dr. Andy Roark:

It doesn’t look like an emaciated lizard that hasn’t eaten in an extended amount of time to me. But that’s what I’m looking at. Can you help me get started in this case and at least take it in a useful direction?

Dr. Doug Mader:

All right. That’s good to know. There are a lot of, especially with bearded dragons, there are some diseases of high concern. Such as adenovirus. That hits them when they’re about four months of age. Anywhere between four and 11 months of age. It shows up as kind of a chronic wasting.

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

Oftentimes, they develop some neurologic symptoms. They can’t walk and of course they don’t eat. But usually, these animals are emaciated when they’re advanced. What you’re describing sounds almost acute, in terms of the anorexia or the hyporexia.

Dr. Doug Mader:

Young, growing animals, especially insectivores and herbivores like Iguanas … Insectivores, of course, like the bearded dragons. Of course, keep in mind, beardies also eat a lot of vegetation. And then, insectivores like chameleons, for instance. We see this frequently in those.

Dr. Doug Mader:

You have to worry about something called nutritional metabolic bone disease. Or the proper term, the veterinary term, is nutritional secondary hyperparathyroidism. If I can jump on my high horse here for a minute. That is … You hear veterinarians talk about MBD. Metabolic bone disease.

Dr. Andy Roark:

All right.

Dr. Doug Mader:

There is no such thing as MBD. MBD is a category. Metabolic bone disease, for instance, covers a whole variety of different metabolic pathologies of the bones. Osteoporosis, osteomalacia, panosteitis, hypertrophic osteodystrophy. A whole litany of them.

Dr. Doug Mader:

The two main ones that we deal with, especially with reptiles, is nutritional secondary hyperparathyroidism, which I coined the term, “NMBD,” years ago. And then, the other one is in adult animals. And that’s renal secondary hyperparathyroidism or RMBD. Based on what you told me, we have to look at the obvious.

Dr. Doug Mader:

If it’s got hoof beats, you think horse first. A young, growing insectivore, less than a year of age. They’re in a rapid growth phase. They’re having difficulty ambulating. They’re not eating well. We have to assume … You’re in South Carolina, right?

Dr. Andy Roark:

Correct.

Dr. Doug Mader:

I’d imagine in the winter, it gets cool?

Dr. Andy Roark:

Yeah.

Dr. Doug Mader:

Not like where I live here, where it’s 85 degrees in the winter. All right. We have sunshine year round. We’re probably looking at nutritional secondary hyperparathyroidism, which is NMBD. And that’s by far the most common cause.

Dr. Doug Mader:

How does that fit your patient? NMBD. It’s a triad of vitamin D3 from the sun, calcium in the diet, and temperature. One of the big things that a lot of people tend to neglect is temperature. And I’m going to use the iguana as an example. Because we have wild iguanas in my yard where I live on the island.

Dr. Doug Mader:

You’ll not uncommonly see them out basking. And it can be 95 degrees outside. If you go and catch that animal and you take a core body temperature … Just take a thermometer, dog and cat thermometer, and slide it in the cloaca carefully. The body temperature going to be 105.

Dr. Doug Mader:

Everybody assumes, “Well, these are cold blooded animals. The body temperature is going to be the same as the ambient temperature.” It never is. So if they have proper husbandry, if their cages are set up with focal heat spots and warming areas … I hate to use the term, “hot rock,” because those dangerous.

Dr. Doug Mader:

But if you have a heating area, so they have a thermal gradient in their cage. They, via temperature regulation behavior, will thermoregulate. Typically, their body temperature is much higher than the ambient temperature of the air.

Dr. Doug Mader:

Getting back to that. The iguana’s ambient normal temperature range is 88 to 104 degrees. You live in South Carolina. They have a pet iguana or they have a pet bearded dragon. They let it run around the house. Well, what’s the temperature in your house?

Dr. Andy Roark:

70.

Dr. Doug Mader:

Room temperature when we have the heater on. It’s 68 degrees. The 88 degrees is the low end for the iguana. Guess what, Andy? That vitamin D pathway. Reptiles need vitamin D3. And if you remember your physiochemistry, there’s that whole cycle where sunshine heats the skin.

Dr. Doug Mader:

It changes ergocalciferol into cholecalciferol. It goes to the liver, where it becomes hydroxycholecalciferol. And then, it goes to the kidney where it becomes dihydroxycholecalciferol. Those reactions … They’re enzymatic reactions and they have a temperature peak.

Dr. Doug Mader:

The temperature at which it gets the second hydroxylation is 88 degrees. So if you’re keeping that iguana or you’re keeping that bearded dragon in your house at 72 degrees or 68 degrees or wherever you sit your thermometer … Even if you give them proper lighting, even if you give them proper calcium in the diet, they’re too cold.

Dr. Andy Roark:

Right.

Dr. Doug Mader:

They can’t metabolize the vitamin D. If they can’t have metabolize the vitamin D to the active form of D3, they’re not going to absorb the calcium from the GI tract. People forget how complicated it is.

Dr. Doug Mader:

It’s really, really basic. But it’s really important. All of the DVM degrees that we have aren’t going to help if the owner doesn’t meet husbandry. Getting back to your question. You need to talk to the client. Find out, “How do you house this animal?”

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

First off, you need to know what the normal temperature range is for a bearded dragon. It should be somewhere between 80 and 90. They’re not nearly as hot as an iguana. If they’re keeping it in their house and it’s not 80 degrees, it’s not going to grow properly because it can’t process.

Dr. Doug Mader:

All right. What are you feeding it? “We’re feeding it crickets.” That’s not their natural diet. In the wild, these guys are heavy herbivores. They eat a lot of vegetables. They do eat some crickets. You’ll find a lot of the pet stores will just sell crickets.

Dr. Doug Mader:

You say, “Okay. Well, crickets are in a balanced diet.” And then, the client will tell you, “Okay. Well, we got loads of crickets.” Well, again, that’s a contrived diet. There’s a lot of different insects available and I don’t have the time on this podcast. Maybe I can come back and we can talk about nutrition.

Dr. Doug Mader:

But the bottom line is they need to be feeding a balanced diet. Let’s just encapsulate that for now. They have to have the right temperature, the right diet. Then, they have to have the proper lighting. And the UVB lights are extremely important. The UVB range is about 290 to 320.

Dr. Doug Mader:

All of these reptile bulbs that are on the market … They have UVA, UVB, and UVC in it. Interestingly enough, if you can see my hands … Let’s say this is a light. The amount of UVB that’s produced by a bulb this big is only in the center about 2%.

Dr. Andy Roark:

Got you.

Dr. Doug Mader:

That’s it. And that only travels about 18 inches. So if they’ve got a light on the ceiling or it’s an old light? The phosphorus will wear out on the inside. It doesn’t produce any UVB.

Dr. Andy Roark:

Got you.

Dr. Doug Mader:

Again, everything interacts with itself. A big part of what you do as the doctor, when you talk to this client, is you got to play detective. You got to get all these facts. Because you can give them all the right medicine.

Dr. Doug Mader:

I can tell you what dose and what milligram to give, but if they don’t do their homework, everything you do is not going to work. And then, they get upset with you as the vet. Because, “I spent all this money and it’s still not getting better.” Well, you did everything right. But it’s the teamwork.

Dr. Doug Mader:

X-rays. Sometimes it’s hard to tell. You take an X-ray and some of these reptiles, especially the bearded dragons, they’ve got all those spikes and thorns and everything. It’s hard to see what’s on the inside. It really is. So if you can’t tell, don’t feel bad. Because a lot of us can’t tell.

Dr. Doug Mader:

Especially, in the young, growing animals. They don’t have fully calcified bones anyway. Because they’re still young and growing. But then, if you add in, on top of that, an animal that’s got nutritional metabolic bone disease … The bones are softer and they’re not as radiodense, so it’s hard to assess.

Dr. Andy Roark:

Got you.

Dr. Doug Mader:

Things like pathological spinal fractures, which may be why it’s not walking. You may not see it just because it’s really hard. Don’t feel bad about that. I’m glad you took the radiographs. Because oftentimes, if they’ve got really good bones, that’s important. But oftentimes, it’s iffy. It can be a challenge.

Dr. Doug Mader:

Other things that you can do. I hear about veterinarians, “Well, let’s take some blood and do an ionized calcium.” You can do that. I’m a pet owner too. I’m actually a retired veterinarian now. When my pets get sick, I got to go to the doctor.

Dr. Doug Mader:

And I do look at the cost. All right. Do we need to run an ionized calcium? That’s an expensive test. Or do we say, “Young, growing herbivore in South Carolina that’s housed inappropriately …” Come on. If you hear the hoof beats, it’s going to be nutritional metabolic bone disease.

Dr. Doug Mader:

We can run ionize calcium, so that we can go, “I’m a good exotic vet, because I ran ionized calcium.” You don’t need to do that. Respect your client’s wallet. They’ll respect you for that too. It’s not going to change how you’re going to treat this.

Dr. Andy Roark:

That was my question. Am I getting information there that’s going to change how I treat it?

Dr. Doug Mader:

No. Not at all.

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

You’re going to go, “It’s slow. It’s slow. I’m so brilliant.” Come on. Yeah, you can do it. If you’ve got the Titanium American Express card and the client says, “Do everything.” Do it. Do you need to do it? No.

Dr. Andy Roark:

Got you. Okay.

Dr. Doug Mader:

I wouldn’t do it. Blood work … Usually, you can run a CBC/chem. And that’s nice. I don’t think you need to. Again, look at what’s in front of you. Use your experience or rely on what you learned from other people.

Dr. Doug Mader:

If you suspect this animal is ill, that’s different. If you think he might be septic, let’s run blood work. Let’s look at the leukocyte morphology. Let’s go and get a PCV.

Dr. Doug Mader:

Make sure that he’s not anemic. Blood’s a nice backup. I do like to do blood work. I think it’s important. Can you still treat this animal without it? Yes. If the client is financially restricted, you can treat it without it.

Dr. Andy Roark:

Hey, guys. I got to jump in here real quick with just a couple of quick updates. First, I got to give some love to Banfield Pet Hospital. Guys, they’ve been making possible transcripts for this podcast for a while. They’re doing it for the whole year.

Dr. Andy Roark:

It is something that I really wanted to have happen. And it’s something they stepped up in the name of increasing accessibility and inclusion in our profession. Providing information so that everybody can have access to it. Anyway, it was a wonderful thing that they did not have to do, that they said was their mission.

Dr. Andy Roark:

And then, they followed through and really made this thing possible. Anyway, spread the word for anyone who would take advantage of transcripts of the episodes. We are so happy to offer them. You can find them at drandyroark.com. There’s links in the show notes below down to that.

Dr. Andy Roark:

Guys, let’s see. What else have we got going on? We have got, over on the Uncharted Veterinary podcast … If you’re a podcast listener, you might be interested in the other podcast that I host with my friend, Stephanie Goss.

Dr. Andy Roark:

Last week, we did an episode on, “What happens when your direct boss’s style is the polar opposite of yours?” How do you survive? How do you bridge the gap? How do you work effectively? If that’s of interest to you, check out the Uncharted Veterinary podcast. The link is in the show notes.

Dr. Andy Roark:

This week, it came out yesterday, we’re talking about, “Do you really need an online pharmacy? How do you make it worth your while?” Anyway, guys, those are some episodes over at Uncharted Veterinary Podcast. Take a listen. See if they’re for you. With that, let’s get back into this episode.

Dr. Doug Mader:

All right. Where are we going to go with this? Number one. This is where your technicians are really important.

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

Make sure your technicians are well-versed with this. You said you’re not 100% comfortable with exotics. Well, when you start getting into exotics, it’s a good idea to get a good technician that’s got a good background in it. Understands the biology and the husbandry.

Dr. Doug Mader:

Pay them really well. They’re going to save you a ton of money and make you a ton of money. The clients are going to love it, because they’re a source of information. They’re great support for veterinarians. We all need really good technicians.

Dr. Andy Roark:

Agreed.

Dr. Doug Mader:

You get the technician in there to talk to them and educate them. And then, you can go off and see your next client. They’re going to discuss the husbandry. We already talked about that. Temperature, diet, and light. Those are extremely important.

Dr. Doug Mader:

What can we do, medically? If the animal has pathological fractures, which oftentimes they do, because they have soft bones. Because of the calcium deficiencies. Analgesics. We tend to forget that animals hurt. If we see an animal that, let’s say, has a broken limb. And that’s not uncommon.

Dr. Doug Mader:

Even a broken back … I’m going to circle back to that in a second. But analgesics and NSAIDs. There’s nothing wrong with giving NSAIDs. I like Ketofen, personally. I know a lot of people use Meloxicam. I don’t know that you need to jump into the opioids, but I certainly use a lot of NSAIDs for these guys.

Dr. Doug Mader:

Supplements. Make sure they get calories. There’s a lot of good commercial herbivore and insectivore diets on the market. I don’t need to mention names, but we all know who the big players are. They’re excellent. They’re great diets. Vitamin D3 supplements. There are some very good commercial reptile vitamin supplements. But when you get them, make sure you get one that has D3 in it.

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

You also want to give an oral calcium supplement. There are multiple different types and the best ones are the liquid ones. Unfortunately, they stopped making them. They pretty much all come as a tablet now, which you can have compounded through any of the compounding pharmacies into a liquid.

Dr. Doug Mader:

The only reason I say that is because, A, they’re easier to give. You can flavor them like a banana or something like that. B, the liquid forms tend to be more bioavailable. For instance, calcium glubionate. If you give it in the liquid form, it’s about 60% bioavailable.

Dr. Doug Mader:

Whereas calcium gluconate is only around 10% to 20% bioavailable. Give a good calcium supplement that the owner can give. If they try and give the calcium supplement and the patient fights it, we both know the owner’s not going to give it.

Dr. Andy Roark:

Yep.

Dr. Doug Mader:

Okay. Analgesics, if needed. Calcium supplements, absolutely necessary. Vitamin D3 supplement, absolutely necessary. If the animal has some pathology … Let’s say, it’s got a long bone fracture. Like a femur or humorous. Put a splint on it.

Dr. Doug Mader:

A wiggling bone is very painful. And these splints shouldn’t be big and bulky. A simple paper tape splint around the humorous or the femur or the distal limb really makes that animal comfortable by immobilizing the fracture. And it can take them six to eight weeks or more to heal.

Dr. Doug Mader:

One of the other things that works really well too, is you take them out of the cage or get a smaller cage and limit their mobility. In other words, you don’t want that bearded dragon feeling better, and then crawl up a rock, and then slip and fall down and re-injure itself. Limit their mobility.

Dr. Doug Mader:

Oftentimes, they’ll put them in a smaller terrain until they’re healed. Now, I just want to bring up the chronic case. You’re going to have some of these, where you have got the gold star client that does everything Dr. Andy tells them to do. They worship you. Everything you say, they write it down. They go home and they do it and that animal is still not getting better.

Dr. Doug Mader:

Chronic nutritional secondary hyperparathyroidism results because when the calcium levels drop … I won’t go too deep into physiology. The parathormone level, PTH, increases. That’s an emergency response by the body to make sure that there’s enough circulating calcium in the blood.

Dr. Doug Mader:

Because you need that for nerve conduction. Things like heartbeat, which is important. And so, the body will sacrifice the calcium in the bone, mobilize it so that it’s circulating and ionized. To keep the nerves moving, the brain functioning, the heart functioning and things like that.

Dr. Doug Mader:

But what happens is parathyroid hormone is extremely powerful. And the only thing that can turn it off is elevated calcium levels or elevated calcitonin levels. Calcitonin will shut off the parathyroid. Completely cut off parathyroid production from the brain.

Dr. Doug Mader:

In human medicine, they use something called salmon calcitonin. Miacalcin is the trade name. In these chronic cases, where you do everything right and the client does everything right. The animals are still … Their bones are staying like Gumby. They’re not getting better.

Dr. Doug Mader:

You need to break the parathyroid hormone influence. Salmon calcitonin does two things. Number one, it’s a powerful bone analgesic. It’s used a lot in women with osteoporosis that get lordosis and spinal fractures and they’re an intense pain. Salmon calcitonin takes that pain away. Number two, and this is the biggie, is that salmon calcitonin is a PTH antagonist.

Dr. Doug Mader:

And so, you can give all the vitamin D, all the supplements of calcium you want. That PTH is still being produced, because the body thinks it’s in crisis until you give the salmon calcitonin. And then, all of a sudden, it shuts off. Just like that. Literally, you will see a difference in a week or two.

Dr. Andy Roark:

Wow.

Dr. Doug Mader:

The only downside of it is it’s very expensive, because it’s a human drug. But if you get those chronic cases, where the client wants to do everything?

Dr. Doug Mader:

Salmon calcitonin is going to be the savior. The doses are in Carpenter’s book and you can find it in my book. It’s everywhere. But anyway, that’s the last therapeutic I’d recommend.

Dr. Andy Roark:

Right.

Dr. Doug Mader:

Let’s just talk about a couple other things. Did you have a question?

Dr. Andy Roark:

No, I was going to ask … Generally, we talked about if you’ve got a long bone fracture. Six to eight weeks in healing. We talked about these chronic cases. How long should I … I like to set realistic expectations for the pet owners as well.

Dr. Andy Roark:

When are they going to start to notice improvement in the symptoms in their bearded dragon? For example, if we can correct the temperature problems. And I’m making sure that we are controlling pain, and that we’re getting good calories.

Dr. Andy Roark:

We’ve got some D3 supplementation. Some calcium supplementation. We’re doing all of the things. How quickly do we expect for pet owners to see significant improvement? I don’t want them to have wildly out of whack expectations.

Dr. Doug Mader:

I’m glad you asked that. I was going to get to it, but I’m glad you brought it up. Because I’m sure others are thinking the same thing. Remember, these are reptiles. They do everything slow.

Dr. Andy Roark:

Right.

Dr. Doug Mader:

You might treat a dog or a cat or a bird and you’ll see some improvement in a couple or three days. It’s not going to happen that fast in a reptile. You got to give it at least four weeks.

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

I tell clients, “Four weeks and you’re going to start seeing a turnaround. Don’t get frustrated a week and a half, two weeks down the road and think nothing’s working. It probably is. You’re just not seeing it. Please, trust me. Follow the instructions. In a month, we’re going to be doing a happy dance.”

Dr. Doug Mader:

Full healing? Depending on how bad it is and depending on how advanced it is when you catch it … Three, maybe six months. But most of these animals come completely back to normal. Some of them will have some deformities. They may have some angular limb deformities from their long bones.

Dr. Doug Mader:

Sometimes they get that bowing in the jaw. They call it rubber jaws. That’s the term that came from primate medicine years ago. But they’re fine. They have a quirky look to them, but they’re still great pets. They’re fully functional. Excuse me. I do want to mention a couple other things too.

Dr. Andy Roark:

Sure.

Dr. Doug Mader:

And that is one of the knee-jerk responses that a lot of veterinarians give. This goes, in the literature, back literally to the 70s. You know how it is.

Dr. Doug Mader:

When something’s in the literature that’s correct, it’s really hard to get people to buy into it. You put something in the literature that’s wrong? Everybody believes.

Dr. Andy Roark:

That grabs them.

Dr. Doug Mader:

It’s like wildfire. Back in the 70s, it was published that, when these animals come in, you can put them on injectable calcium. Because it increases their calcium quicker.

Dr. Doug Mader:

Absolutely, positively not. Think back when you were a kid and you fell off the bike and broke your arm. Did the doctor give you injectable calcium?

Dr. Andy Roark:

No.

Dr. Doug Mader:

No. They sent you home on a quality diet, a cast, and some good vitamins and you’d get better. Same thing. You don’t use injectable calcium unless you have a pregnant bitch in tetany, a cow with milk fever. Or if the bearded dragon comes in, and it is in fact in tetany, where the whole thing is twitching like this … You might want to put him on a very controlled dose.

Dr. Doug Mader:

Seven units per kilogram per hour of calcium until the tetany resolves. And then, you switch to oral. Injectable calcium is emergency, life-saving only. It is not for treating broken bones or chronic osteomalacia. I wanted to make sure. That’s important. Because people still do it.

Dr. Doug Mader:

The other thing too is don’t throw Baytril at them. They come in and they’re not eating. “Let’s put them on Baytril. Just in case.” No. Antibiotic stewardship. We don’t want to be just throwing antibiotics out there. Unless you can see that this animal has some evident infection, don’t just give them antibiotics. They don’t need it. This is a husbandry issue. It’s a supplement issue.

Dr. Doug Mader:

Just to wrap this up. Again, most of these cases in the signalment that you presented are going to be nutritional or they’re going to be husbandry. 90% of the homework is going to be the owners following your instructions and correcting the problems on their end. You’re just helping them along.

Dr. Doug Mader:

They will do really well. Even some of these lizards that come in with pathological spinal fractures. Reptiles are neat. That’s why they’ve been around for so many millions of years. They have spinal ganglia. You can take the lizards back and cut it right in half and the spinal ganglia will allow them to walk.

Dr. Doug Mader:

Their front feet do this. The back feet may do this. In other words, the back feet and the front feet don’t talk to each other. But they still manage to get around. Because of the spinal ganglia, where they’re located, they can still defecate and urinate.

Dr. Doug Mader:

Just because it has a broken back, don’t say, “This animal is going to have to be euthanized.” If the owner wants to keep trying … Man. As a veterinarian, we owe it to them to hold their hand and get them through this. Because a lot of these reptiles will get through it. You just have to be patient.

Dr. Doug Mader:

That’s what a lot of people … They don’t have the experience enough to know that, “Hey. Let’s hang in there for three or four months. This animal will probably turn around.” I want to end with that on the happy note. The majority of these animals will do well, if you identify and correct the problems.

Dr. Andy Roark:

That’s amazing. Thank you so much for that. Let me ask you one more quick question when we talk about pain control. I thought that was really a great point. Things that people may not think about that are truly important.

Dr. Andy Roark:

If we’re going to see slow resolution of symptoms, we’re looking at four weeks. Things like that. How long do you manage pain control? Is that also a four-week process? Things like that? Walk me through some analgesia during this process. Because I don’t want to overdo it, but I also don’t want to under-serve them.

Dr. Doug Mader:

That’s a super good question. Because anything you give an animal, there’s a potential side effect. In long-term use of NSAIDs, you worry about liver disease, kidney disease, potential GI ulcers. That’s a good question.

Dr. Doug Mader:

That’s where I think you, as the eyes on the ground, when that animal starts looking more BAR. The owner’s going to be able to tell that, because they see that animal every day. And you’ll check it on re-checks. And then, I usually say eating.

Dr. Doug Mader:

When they start eating again, oftentimes, they’re feeling good enough that they can stop the analgesics. But clearly, if they start eating … You stop the analgesics and eating stops? You may want to put them back on it. But I oftentimes use appetite as one of my gold standards. That’s a great question. Thank you.

Dr. Andy Roark:

No, I appreciate it. Doug, where can people find you online?

Dr. Doug Mader:

Well, I have a website. It’s dougmader.com. I have a public Facebook page. It’s Douglas Mader on Facebook. From there, you can reach out. If you have questions, you can email me. And I’m pretty good about getting back to people. Feel free to reach out, if you need some help.

Dr. Doug Mader:

You know what? Andy, I just want to say thanks again for having me on. I think we have one of the greatest professions in the world. I hear a lot of people say, “I would never do this again.” I’ll tell you what. I’ve been doing it for nearly four decades. I would do it all over again. Starting tomorrow.

Dr. Andy Roark:

I love it.

Dr. Doug Mader:

I love what we do. That human-animal bond is so special. Anything we can do to keep that thing going, and your podcast and helping educate veterinarians, technicians, and then the pet owners is the way we do this. Thank you.

Dr. Andy Roark:

Thank you, my friend. And that is our episode. Guys, that’s what I got for you. I hope you enjoyed it. I hope you got a lot out of it. I got a lot out of it. I don’t remember the last time I took as many notes as I took on this episode.

Dr. Andy Roark:

Anyway, thanks again to Dr. Mader for being here. Man, that guy is incredible. Anyway, that’s enough of me fanboying over Doug Mader. You guys take care of yourself. Have a wonderful week and I’ll talk to you later.

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram

Tasha McNerney CTV VTS CVPP joins us to discuss the case of Hercules Mulligan. a 4 yo MN Domestic Shorthair who cannot urinate. That’s right… This poor guy has a urethral obstruction and will need anesthesia and pain control STAT! What are the top tips and tricks for handling these cases? What mistakes do doctors and technicians want to make sure to avoid? Let’s find out!

You can also listen to this episode on Apple Podcasts, Google Podcasts, Soundcloud, YouTube, or wherever you get your podcasts!

LINKS

Sacrococcygeal Block Demo: https://www.youtube.com/watch?v=KhAN4SavVzg

Think Anesthesia: https://www.thinkanesthesia.education/

Retain Your Team – Speak the Languages of Appreciation in Your Workplace: https://unchartedvet.com/product/appreciation-languages-101/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Tasha McNerney obtained her CVT in 2005 and has worked clinically in the areas of anesthesia and surgery ever since. Tasha obtained her CVPP (certified veterinary pain practitioner) designation in 2013 and became a veterinary technician specialist in anesthesia in 2015.

Tasha has been a featured speaker on various anesthesia and pain management topics at several international veterinary conferences. Tasha is the author of many articles and blogs on anesthesia and pain management related topics.

In 2013 Tasha created the Facebook group Veterinary Anesthesia Nerds, which has over 65,000 members taking part in education and exchange of ideas from all over the world!

Tasha is crazy and bought a 1920’s fixer upper and is now obsessed with home improvement tutorials on YouTube. She lives in Philadelphia with her husband, son, one perfect cat, and one jerk cat. Trust me that cat is a jerk.

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:

Welcome, everybody, to The Cone of Shame veterinary podcast. I’m your host, Dr. Andy Roark. Guys, I am here today with the original anesthesia nerd, the one and only, Tasha McNerney, and she is fantastic as usual. We are talking about the blocked cat and running effective anesthesia and pain control in those emergency cases. Guys, we see a lot of these in the vet clinic. They are an emergency, and we want to do right by our patients as far as making them as comfortable as possible, while we do uncomfortable things to save their life. Gang, let’s get into this episode.

Kelsey Beth Carpenter:

(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the podcast, the one and only, Tasha McNerney. How are you?

Tasha McNerney:

I’m good. How are you? How is everything?

Dr. Andy Roark:

Things are good. Rolling into the spring. Yeah, exciting times around here. Getting close to the summer break. The kids are starting to make plans for what they’re going to do this summer. I got a load of mulch from my garden and that makes me happy. So, that’s-

Tasha McNerney:

You know-

Dr. Andy Roark:

[crosstalk 00:01:29].

Tasha McNerney:

You’re an adult when you’re excited about mulch, right?

Dr. Andy Roark:

Oh, yeah.

Tasha McNerney:

And then, you’re like, “What type of mulch? Are you a red mulch person? Are you a brown mulch person?”

Dr. Andy Roark:

Oh, it’s-

Tasha McNerney:

“Are you a black mulch person?”

Dr. Andy Roark:

It’s brown mulch, yeah.

Tasha McNerney:

Okay, yeah. So…

Dr. Andy Roark:

It’s the double brown mulch. Yeah, it is. Yeah, the hummingbirds will be back soon. And that is where I am in my life.

Tasha McNerney:

I mean, listen, my husband is out there feeding the birds every morning and he is very concerned about the birds. He likes to watch the birds. He likes to tell me how many birds are in the backyard, whether or not there’s a chipmunk with the birds, if he saw a rabbit outside. These are the things that we get excited about now, right? Yeah.

Dr. Andy Roark:

Yeah. You married-

Tasha McNerney:

[crosstalk 00:02:09].

Dr. Andy Roark:

The cat.

Tasha McNerney:

Yeah, I did. I did marry a crazy cat lady and that’s totally fine.

Dr. Andy Roark:

Oh, god.

Tasha McNerney:

I love him. But yeah, he’s excited about birds, and choosing a high quality bird seed is very important. And we used to be cool. We used to go out on Saturday nights. And now, we’re like, “Um, so Righteous Gemstones and researching bird feeder option?” “Yes.” That’s a Saturday night.

Dr. Andy Roark:

Yeah. Okay, we need to spend more time together because one, Righteous Gemstones for the win. I love that-

Tasha McNerney:

Oh, 100%.

Dr. Andy Roark:

It’s a guilty pleasure show. I love that show. And then number two, this was the first time in my life I have ever walked into a Lowe’s and looked at the different bird seeds and thought, “Ugh, who would feed that?” I never had a thought like that in my life. I’m like, “What has the pandemic done to me? It has made me…” I’m like, “Ooh, this is the cheap stuff. I’m not feeding this.” What have I become? Good God. All right, let’s ride this show. Let’s talk about other things besides bird seed and Righteous Gemstone. Let’s talk about blocked cats.

Tasha McNerney:

Yeah.

Dr. Andy Roark:

The other part of the trifecta of things that are super cool. All right. I have a case. Tasha, first of all, for those of you who don’t know, you are the founder of Veterinary Anesthesia Nerds, which is a Facebook group and also a conference now and so many things. For anyone who’s interested in anesthesia, you should really check out Veterinary Anesthesia Nerds. What is the best place for people to find information on that group?

Tasha McNerney:

So our Facebook group is probably where we are the most active, where we talk about cases every day and run through cases, equipment, et cetera. We also have a website that you guys can check out. And then, we have since partnered with dvm360. So a lot of our content and articles from the administrators, myself, Stephen Cital, Darci Palmer, all VTS in anesthesia, we have a lot of articles on dvm360 that you can find there as well for different anesthesia topics.

Dr. Andy Roark:

That’s awesome. All right, cool. I’m going to toss you a softball today because I just-

Tasha McNerney:

Oh, great.

Dr. Andy Roark:

Want to make sure that I am up on my game. Yeah. I just want to make sure that I’m doing all right. It’s one of those questions just [inaudible 00:04:18] make sure that nothing has changed in how I’m doing this. Make sure that I’ve got all the pearls that I need to do a really good job. I have a four year old male, neutered, domestic short hair named Hercules Mulligan and he is obstructed. He’s come in, he was straining in the litter box. His owners who are huge Hamilton fans brought him in and they were like… He’s crying. He’s in the litter box.

Dr. Andy Roark:

I feel his belly. I know immediately what’s going on. This guy is obstructed. I’ve pulled some blood on him. I’m checking my electrolyte levels, making sure that nothing is super wonky there, and he seems to be okay. Aside from starting IV fluids, things like that, I need to go ahead and get this cat unblocked, and I don’t want this to hurt. And I also want to get him pliable and easy to work with. And so again, he is an otherwise healthy, young to middle aged male cat. Help me with my anesthesia, analgesia protocol here, so that he is comfortable and I can do what I need to do as quickly as possible.

Tasha McNerney:

Sure. So first of all, anesthesia, I mean, it’s definitely about drugs, but it’s not all about drugs. And we know with some of the more kind of progressive ways, at least in the last 10 years and what I have seen and probably you’ve seen in practice as well, is that we don’t just go into drugs. We want to take stock of kind of where the patient is at, kind of where with their own fear and anxiety. So how scared is the cat, right? So, how upset is he with being at the vet? How fearful is he? How reactive is he? And that is really going to play a lot into what I do next. If he is very fearful-

Dr. Andy Roark:

Okay, I like this a lot.

Tasha McNerney:

If he is very fearful and painful, then I’m probably going to go with some IM sedation. I don’t want to take this cat that is potentially again, very fearful, very painful obviously… If anyone here has ever went on a very long car ride and had just an overextended bladder that’s getting very uncomfortable, if you think about that times 10, this is what our patients are experiencing. So, very uncomfortable. I don’t want to take that patient and then have to have our support staff kind of sit on or muzzle or wrestle with this cat to try to get an IV catheter into them.

Dr. Andy Roark:

Right.

Tasha McNerney:

Stress is going to be the enemy for these patients. I mean, any cat that potentially has any underlying cardiac issue, with potentially a hyperkalemic patient as this, we don’t want to stress them. So, stress is our enemy. So, let’s take stock. If he is a super love bug cat, and he is going to let me put an IV catheter in and facilitate that without an IM injection or IM sedation, great. And then, we can follow up with some IV analgesics, anesthetics, et cetera. But if he is saying, “No, you guys. I’ve had enough. I’ve already had a crap day. I don’t feel good. You’re not going to twist my arm to put an IV catheter in. No,” then-

Dr. Andy Roark:

Right.

Tasha McNerney:

I’m probably going to sedate. And I love this option because just sedate the cat, right? Just give them drugs. We have lots of great drug options that we can give them. And first off, we want to look at our analgesics. Certainly, if you have a pure mu-opioid in your practice, my favorite is methadone. But if you guys have hydro, you could consider hydro. Now, just remember, you might see some vomiting with the hydro, but if that’s your heaviest hitter, go with that. I like a methadone combination. Again, if you don’t have methadone and you’re like, “Oh man, I only have butorphanol,” okay. Even though that’s more of a sedative than an analgesic, go with that. So, we want to combine an analgesic with a sedative.

Tasha McNerney:

Now sometimes, as people know and if they’ve ever listened to me talk, they know that one of my favorite sedative analgesic combinations is opioid plus dexmedetomidine. This is not the patient I would probably choose for dexmedetomidine because again, we don’t know exactly… Unless you’ve taken blood and evaluated his potassium levels, we don’t know where that’s at. I don’t know if he’s hyperkalemic and bradycardic and potentially already having some arrhythmias because of the urethra obstruction.

Dr. Andy Roark:

Got it.

Tasha McNerney:

So, let’s just assume maybe he is and I just want to be very careful. So I’m going to take dexmedetomidine off the table. In a younger animal, a lot of times, especially if they’re already stressed, I might… Or sometimes, I might combine midazolam or benzodiazepine. But in a younger animal that is already stressed, fearful, aggressive, et cetera, I’m probably not going to utilize midazolam because our benzodiazepines can kind of give them that excitatory reaction. And it’s even more pronounced in younger patients. That’s why for a lot of the anesthesiologists that I work with, if an animal is under three years old, we’re usually not hitting them with a benzodiazepine because it’s going to ramp up that excitatory phase.

Dr. Andy Roark:

Got it.

Tasha McNerney:

Especially if you have a stressed cat, nothing’s going to take them through the roof like a benzodiazepine. So, I’m taking that off the table too. So, what I’m left with is a huge [crosstalk 00:09:08]-

Dr. Andy Roark:

Got it. You’re taking away all of my favorite things.

Tasha McNerney:

I’m sorry. Listen, don’t worry. We have other options.

Dr. Andy Roark:

I’m like, “Oh, I’m running out of…” Yeah, my medicine cabinet’s looking kind of thin at this point, Tasha. Where we going?

Tasha McNerney:

So, we have other options and the opioid is going to be kind of your heavy hitter. And if you want to, whatever opioid you decide to use, I would just go a little higher on your dosing. And then, if you have alphaxalone in your practice, this is where alphaxalone can really shine because alphaxalone can be utilized IV or IM. We will usually combine the alphaxalone together with an opioid and then give that IM. So if this is a spicy kitty who we want to be very cardiac friendly to, we usually combine opioid plus alphaxalone IM, let them sit in a nice, calm, quiet environment. And that means don’t put them next to a dog that’s recovering from surgery and potentially-

Dr. Andy Roark:

Right.

Tasha McNerney:

Howling. Don’t put them next to other cats that could stress them out. If you can, put them as isolated and as quiet an environment as possible while they kind of calm down, let those drugs start simmering and working. Now, once those drugs have taken effect or while the drugs are taking effect, I should say, that’s the time that your staff should be gathering the supplies that are needed to unblock this cat.

Dr. Andy Roark:

Right.

Tasha McNerney:

Now, whether or not you guys like a red rubber, or you like a Foley, or you like a Tomcat, personal preference, just have a list of things together so that your staff can work quickly. I always advise that I’m a big fan of checklist. I love an anesthesia checklist, I love a surgical checklist. So if you have a little page in your nursing binder that would just say, “Hey, for urethral obstruction, this is what I want you guys to get out and ready.”

Tasha McNerney:

So that way, while that cat is simmering on its drugs, you know “Hey, I’m going to go pull the fluids. I’m going to go pull out the supplies I need for a sacrococcygeal block. I’m going to go pull out everything the doctor might need to facilitate this unblocking, make it go as smooth as possible.” So, use that time while the cat is simmering on its drugs and its analgesics to gather everything. So that way, you’re not running around and kind of… With a spicy cat and a painful cat, it’s always kind of a race against time with them, right? How much can I get done before their stress catecholamines override the drugs I’ve given them? And then now, I have to add in more.

Dr. Andy Roark:

Hey guys, we’re going to jump in with a couple of quick announcements. First off, if you have not head over to drandyroark.com recently and signed up for the Dr. Andy Roark newsletter, you’re missing out. What’s on the podcast is in our new newsletters. I like to write letters in our newsletters. We’ve got some great article stuff that comes out there. It is all really good stuff, and it’s totally free, right in your inbox. So, drandyroark.com. Sign up for the newsletter. Also, on May 21st, we have a fan-freaking-tastic workshop over at Uncharted Veterinary Conference. It is a virtual workshop. It is called, Retain Your Team : Speak The Languages of Appreciation in Your Workplace, with the one and only, Dr. Tracy Sands. Guys, this is at 2:00 PM Eastern time, 11:00 AM Pacific. It’s a two hour work shop on May 21st. It is free to Uncharted members. It is $99 to the public.

Dr. Andy Roark:

If you are trying to get your staff to stick around, if you’re trying to get your staff to be engaged, if you’re trying to get your staff to feel like their work matters, and you keep buying donuts, but it’s just not having the same effect that it used to, it’s time to do something different. It’s time to learn about the languages of appreciation. We have a self-assessment, so you can look and see how you’re doing and how you can make changes going forward. Guys, that’s how we roll. May 21st, 2:00 PM Eastern, 11:00 AM Pacific time. Head over to unchartedvet.com and click on Upcoming Events and you’ll get all taken care of, okay? Now, let’s get back into this. Talk to me a little bit about alphaxalone IM. That’s not a route that I’ve used a whole lot. So, give me just a general idea of what are common side effects? What amount of time are we talking about? Just help me feel out what to expect when I go this route with say, a methadone or a hydromorphone mixed with some alphaxalone.

Tasha McNerney:

Sure. So alphaxalone is a pretty great drug, and then we know that we use it as an induction agent. Anesthesia people like to call it propofol 2.0, because it gives you the same effects of propofol. And when I say same effects, we are… It’s great induction agent. Alphaxalone in itself is a neuro steroid molecule, works in the GABA pathways, and it is going to function similarly to propofol. And when I say that, you also are going to get hypotension the way you would with propofol if you give it in a big bolus. You also can see apnea the way you do with propofol if you give it in a big bolus. But if we’re talking about via the IM route, I like to think of it just kind of as the cream in that Oreo cookie, bringing the opioid, smoothing everything out together. Yes, I do use a lot of food references in a lot of my lectures. So, [crosstalk 00:14:03]-

Dr. Andy Roark:

No, I love it.

Tasha McNerney:

And your alphaxalone with the opioid together kind of makes this nice combination for the patient, because if we just kept relying on all opioid, we know that opioids by themselves are not usually sedating. And the amount of volume or migs per kig we’d have to give to really sedate a cat that’s already painful and spicy is a lot of opioid. And then, we could be seeing opioid side effects, right? Bradycardia, et cetera, which we don’t want. So if we combine our opioid with an alphaxalone IM, alphaxalone’s water soluble. So a much better option than something like diazepam, which hopefully people are not giving diazepam IM anymore. But you can combine these two things in the same syringe, opioid plus alphaxalone, and give that. Usually for cats, we are doing one mig per kig, right?

Tasha McNerney:

Sometimes two, but usually, one mig per kig of alphaxalone IM together with your opioid of choice. And you give them about 10 to 15 minutes. And I’m not saying that they are all the way out in the same way that they would be maybe with a dexmedetomidine or ketamine combination. But again, we’re trying to avoid those cardioactive drugs in this patient. So, they might be out enough that you can facilitate smooth IV catheter placement. And then, once you have a IV catheter placed, you can top off with more alphaxalone, give them flow by oxygen, put all your monitors on, and then release the sacrococcygeal block and get ready to go.

Dr. Andy Roark:

Yeah, cool. Talk to me a little bit about the sacrococcygeal block. Just give me some best practices tips. How do I want to set myself up for success with this?

Tasha McNerney:

Oh man, this is one of my favorite blocks to talk about. I like to talk about a lot of blocks, but if anything, the reason I really love sacrococcygeal blocks is that it doesn’t have to… You don’t have to work in a specialty practice or university. This is something that every general practice, you already have the supplies on your shelf to do this block. And it is going to be a game changer when it comes to urethra obstruction cats. So the nice thing about the sacrococcygeal block is it is just 25 gauge, 5/8 inch needle, a 1cc syringe. You want to keep this clean as possible. So if you can utilize sterile gloves, that is great. And just stuff to scrub up the area. And it’s kind of, again, dealer’s choice with the drugs. Some people like to use lidocaine. Some people like to use bupivacaine. I personally, in this patient in particular, will utilize lidocaine. Little more cost effective. And for this particular patient, lidocaine is going to last for a couple of hours.

Tasha McNerney:

I could utilize bupivacaine and desensitize that area for the six hours that bupivacaine could. But for most of these patients, once we relieve the obstruction, a lot of the pain will go away. And the nice thing about utilizing a lidocaine or a sacrococcygeal block is it is one of the very few drugs or route of drug administration that’s going to completely cut off those signals going to the brain, right? So we know, if you guys have ever had local anesthetic at the dentist or et cetera, if you’ve ever… Childbirth and had an epidural, you know that it cuts off those signals going to the brain. So that way, when your doctor lifts the cat over or puts the cat’s feet forward, or however their technique is, once they start trying to extrude that penis… With a sacrococcygeal block on board, it’s desensitized and the penis will often just come out of the [inaudible 00:17:35]. There’s no fiddling with it. There’s no kind of pulling on it, which causes a lot of irritation and inflammation.

Dr. Andy Roark:

Right.

Tasha McNerney:

So we see a huge reduction in irritation and inflammation, a much faster speed of unblocking, and overall less anesthetic time for the patient. So for us, a sacrococcygeal block is very cost effective and very effective when it comes to pain management.

Dr. Andy Roark:

All right, that makes total sense. All right, good. I feel like I’m really set up well for success here. What pitfalls do I need to look out for? Are there things that you see people get wrong? Are there mistakes that people make any? Any common trips or traps that I should look out for?

Tasha McNerney:

So for block cats, sure. Right? I think everybody’s terrified of tearing the urethra or something worse which certainly can happen. So, I would say that if you are going to do anything… I’ve seen a couple not great things happen. And usually, it’s when people are over aggressive or utilizing… The one I have seen is utilizing a stylet, kind of a metal stylet to go inside the red rubber-

Dr. Andy Roark:

Oh, yeah.

Tasha McNerney:

To give it a little more oomph. But the problem is you give it too much oomph and it goes in and I have seen urethral-

Dr. Andy Roark:

Ew.

Tasha McNerney:

Tear that way. So, just be careful if you’re utilizing anything like that. And these cases can be really frustrating. If you feel like you are trying and you’re not getting anywhere, and the patient’s tissue is just getting more inflamed, take a step back, ask a colleague if they want to step in. I think that has been really the biggest thing for me as a technician. Since I’m usually monitoring the anesthesia and I’m watching the clinicians do this, if they’re getting more frustrated, they’re going to put more pressure on that tissue. It’s not a great experience for anybody. So if you have a colleague, you just say, “Hey, I’m not having any luck with this. Do you think there is a technique?” Because again, everybody goes to vet school in different places and learns from different people. So, I have one doctor who really likes the Tomcat catheters. I have one doctor who really likes the olive tip catheters. So, there might be a technique that you haven’t learned or you haven’t thought of. So instead of keep messing with that tissue, phone a friend. Ask somebody to help.

Dr. Andy Roark:

Yeah. A lot of us not even… When you went to vet school, a lot of it was just, what kind of day are you having?

Tasha McNerney:

Oh, yeah.

Dr. Andy Roark:

That’s the classes. Some days, it’s like, “I just don’t have it some days,” and some days I can throw it across the room and hit exactly where it needs to go. But yeah, I don’t even think it’s often your training or your style. Just some days, it’s just not your day. And it’s better just accept it and phone a friend before you end up in a hole. Awesome. Any final pearls? Anything like that? Yeah, any last words of advice?

Tasha McNerney:

No. I love these cases and I think a lot of clinicians really love these cases as well, because you can see an immediate-

Dr. Andy Roark:

Oh, yeah.

Tasha McNerney:

You can see such a difference in 24 hours-

Dr. Andy Roark:

Super.

Tasha McNerney:

With these patients.

Dr. Andy Roark:

Super rewarding, yeah.

Tasha McNerney:

But for technicians, what I tell technicians is, “Use the time that the animal is simmering on its drugs to really get everything together. And don’t forget about your calcium, [glutamine 00:20:48] and your insulin. Just always have that ready and available, so when you run that blood work, if you happen to see a potassium of, I don’t know, 10, you’re ready to go with some intervention.”

Dr. Andy Roark:

Good, that’s so awesome. We talked at the very beginning about Anesthesia Nerds. Tasha, do you have favorite anesthesia resources online, outside of Anesthesia Nerds?

Tasha McNerney:

Oh, yeah. So I think that, pun intended, the Think Anesthesia website is actually a really great website and it offers a lot of free resources. So if you’re thinking about getting some CE and you don’t have it in your CE budget to actually go to a conference or even sign up for a webinar that may cost money, Think Anesthesia, which was brought about by some of the anesthesiologists at [Durox 00:21:32], is a really fantastic website. They have webinars and articles on anesthesia recovery, anesthesia induction, anesthesia for rabbits, all kinds of stuff. So, that’s a really nice resource that I like.

Dr. Andy Roark:

That’s awesome. I’ll put a link to that in the show notes. Thank you so much for being here. I always appreciate your time.

Tasha McNerney:

No problem. Thanks for having me.

Dr. Andy Roark:

And that is our episode guys. I hope you enjoyed it. I hope you got something out of it. If you are on the Facebook, consider checking out the Veterinary Anesthesia Nerd group. Those guys are so great. It is awesome to see people who are passionate about a thing, sharing their passion. And that is that group. Gang, take care of yourselves, be well. I’ll talk to you soon.

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram

Dr. Jason Gagné, a Board-Certified Veterinary Nutritionist and Purina’s Director of Veterinary Technical Communications, is on to help Dr. Andy Roark sort out a tough case. Budrow is a 3 year-old mix breed dog with waxing-and-waning bouts of diarrhea and vomiting, and year-round allergies. His owners have tried all sorts of drugs and diets on this poor dog, and now we’re right back where we started. Let’s unpack what’s going on and get to the bottom of this!

This podcast was brought to you ad-free by Purina ProPlan Veterinary Diets.

LINKS

Purina ProPlan Veterinary Diets – www.purinaproplanvets.com/

What’s on my Scrubs?! Card Game: drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Jason Gagné is a Board-Certified Veterinary Nutritionist and is Purina’s Director of Veterinary Technical Communications where he leads scientific innovation and product development for the Purina Pro Plan Veterinary Diets Brand. Jason works closely with innovation and renovation of dietary formulations, developing clinical trials, and Sales and Marketing. Prior to, and throughout his residency at Cornell, he served as an Associate Veterinarian in a small animal practice in Syracuse, New York. Jason has authored several publications in veterinary journals and textbooks, given scientific presentations at the regional and national level, taught a series of courses at Cornell, and serves as a scientific reviewer for leading journals and the American Kennel Club Canine Health Foundation.

EPISODE TRANSCRIPT

Dr. Andy Roark:

Welcome everybody to The Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark. Guys, I’ve got a good one today. I have got an itchy, soft-stomached young dog. This dog has bouts of soft stools and a little bit of vomiting. Just a little bit.

Dr. Andy Roark:

He also gets ear infections and some slightly itchy skin. I’m sure you’ve never seen anything like this. Not super common at all. Guys, I want to unpack this. I want to get up-to-date. I want to give the tips, the tricks, and the pearls that I need to do a really good job with this case.

Dr. Andy Roark:

And so, I have brought in my friend, Dr. Jason Gagne. Dr. Gagne is a board certified veterinary nutritionist and he is Purina’s Director of Veterinary Technical Communications. He is a super smart guy and a pleasure to talk to.

Dr. Andy Roark:

Gang, this episode is … Man, I’m so happy. I’m so pleased. This episode is made possible ad-free by Purina Pro Plan Veterinary Diets. Let’s get into this episode.

Kelsey Beth Carpenter:

(Singing) This is your show, we’re glad you’re here, we want to you help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the podcast, Dr. Jason Gagne. Thanks for being here.

Dr. Jason Gagne:

Yes. Thanks so much for the opportunity. It’s really nice to get together with you today.

Dr. Andy Roark:

Oh, man. My pleasure to have you here. You are a board certified veterinary nutritionist. You do a lot of different things. I have a case for you that I think is going to be right up your alley. I was wondering if I could run it past you?

Dr. Jason Gagne:

Yes. Let’s do it.

Dr. Andy Roark:

All right. Cool. I have Budrow. Budrow is a three-year-old … We call him a Carolina Yellow Dog. Some people call them Heinz 57. He is no kind of pure breed I’ve ever seen. He is a mixture. He is a shelter dog and he’s a super nice guy. A sweetie.

Dr. Andy Roark:

He’s probably about 35, 40 pounds. Brown, black checkerboard kind of dog. Just a happy three-year-old guy. The problem I’m having with Budrow is that he is three years old, and he has had intermittent vomiting and soft stools for a year and a half.

Dr. Andy Roark:

Just off and on. Often times, it’ll be his wellness check-up and they’ll just bring it up. Sometimes he comes in and they say, “This is getting kind of bad.”

Dr. Jason Gagne:

Yep.

Dr. Andy Roark:

It’s never awful, like an emergency. But it’s always, “Hey, doc, I don’t think this is normal.” They call it a soft-stomach. Budrow’s soft stomach is bothering him.

Dr. Jason Gagne:

Soft stomach, sensitive stomach?

Dr. Andy Roark:

Yeah. At the same time, the reason that I ended up talking about his stomach is he’s in for ear infections.

Dr. Jason Gagne:

Wow.

Dr. Andy Roark:

Every three to six months he comes in for … He’s sort of shaking his head or he’s got some allergy flare ups. Again, he’s not an awful dog.

Dr. Andy Roark:

Don’t think about … He’s not a bald dog. He’s not a beet-red dog. These are just mild, nagging symptoms. And so, I wanted to ask you about this, because I’m not fixing Budrow. And it’s bothering me.

Dr. Jason Gagne:

And it’s just been occurring off and on for a year and a half?

Dr. Andy Roark:

Yes, but he’s only three. And so, it’s fairly early on. Anyways, I’ve been talking to the owners about this and going back and forth. They want me to fix the problem.

Dr. Andy Roark:

I’ve talked to them a little bit about diet and things like that. And I’ve gotten them to … They’ll try some different things. They’re doing some over the counter, limited ingredient diets. Stuff like that.

Dr. Jason Gagne:

Sure.

Dr. Andy Roark:

Mostly, they’re like, “No, no. I think he needs an allergy medicine,” or things like that. I’m having a hard time just unpacking this. There seems to be a lot going on. I know I just sort of gave you a hot mess. Help me break this case up.

Dr. Jason Gagne:

Sounds like a great case. I may have heard this story once or twice.

Dr. Andy Roark:

There’s a lot going on with Budrow.

Dr. Jason Gagne:

It sure sounds …

Dr. Andy Roark:

Help me to break this apart into bite-sized pieces. How do I work this case up, first of all? And then, how do I get these people on-board with where we need to go?

Dr. Jason Gagne:

Yes. Have you done any treatments in the past with him before? Antibiotics or antihistamines? Something like that?

Dr. Andy Roark:

You mean for … Treating ear infections, he’ll scratch around his neck and everything. Get a skin infection. He’ll end up on some Cefpoderm and things like that.

Dr. Jason Gagne:

Okay.

Dr. Andy Roark:

And then, just basic … Cycling onto bland diets. Cycling onto high-fiber diets. I thought maybe increasing fiber earlier on might be helpful. He cycles onto short-term therapeutic diets and then back off again, to get back onto whatever his owners are excited about.

Dr. Jason Gagne:

Well, I think you raised a really good point there in the beginning … When you were telling me about how long this has been going on and taking your history of this dog.

Dr. Jason Gagne:

A three-year-old dog, a year and a half? It’s a pretty significant amount of time. And the itch [crosstalk 00:05:22].

Dr. Andy Roark:

It’s always one of those things where he comes in and they’re like, “This time, it’s his skin. It’s not his ears. It’s different.”

Dr. Andy Roark:

And I go, “I feel like these things are all tied together.” At some point, we keep having general skin and general stomach problems.

Dr. Jason Gagne:

Well, obviously, it could occur separately or it’s occurring together. The GI and the skins signs as well as the ears. Well, it’s called derm happening there.

Dr. Andy Roark:

Yep.

Dr. Jason Gagne:

You said they tried other diets? Limited ingredients, over the counter things?

Dr. Andy Roark:

Just over the counter stuff. Not therapeutic diets necessarily.

Dr. Jason Gagne:

Okay.

Dr. Andy Roark:

They get excited, like many pet owners do. There was some grain-free stuff they were really excited about. There was a bison diet that they found, that was very affordable that they liked. Again, stuff that they find a Tractor Supply, Costco, things like that.

Dr. Andy Roark:

Not any specific place, but they sort of light on things and they get these recommendations. They get excited about them. I haven’t been able to guide them away from that.

Dr. Jason Gagne:

Right. Right. No. First of all, I think one of the most important points to bring up is that in your history-taking of this dog … Just sitting back, listening to the owner, and the observation that this has been going on for a year and a half.

Dr. Jason Gagne:

The fact that some medications have been tried. The fact that what’s called limited ingredient, over the counter foods have been tried to no avail. I think there’s a little bit to unpack there, because of something like a non-seasonal pruritus … The off and on GI signs with a loose stool. Maybe a little vomiting.

Dr. Jason Gagne:

I think we have to start to rearrange our differentials there. I think we need to start thinking about adverse food reactions, actually. And I think it’s really interesting for me as a nutritionist to look at that problem.

Dr. Jason Gagne:

It’s where food could be your friend, but it could also be your enemy at the same time. And then, it could be the solution to the problem. Let me ask you this. Is the dog in a good body condition score? Good muscle condition? Good appetite?

Dr. Andy Roark:

Yeah. Exactly. He seems to be … It’s one of the confounding parts of the case. He seems to be a pretty much super happy guy. I think if he was less happy, his owners would be more motivated to weight into this. He seems to hold his weight well. He seems to be energetic, playful. A playful, goofy guy.

Dr. Jason Gagne:

Really, a good place to start would be maybe an elimination diet trial. Having that conversation with the owner that, again, food may be something where … It doesn’t seem natural, but sometimes the immune system starts to recognize certain ingredients, certain foods as an enemy.

Dr. Jason Gagne:

How do we work with that dog and understand that nutrition can be a therapy rather than hopping around from medication to medication? At the same time, doing good profession of antibiotic stewardship too.

Dr. Andy Roark:

No, I agree with that. And that makes sense. Let me get into the nuts and bolts of what I need your insight on.

Dr. Jason Gagne:

Sure.

Dr. Andy Roark:

I’ve got this dog. I’ve got Budrow and he’s having this upset stomach. He’s having some soft stool and he’s having intermittent vomiting. Everything. That’s what they were in for most recently.

Dr. Andy Roark:

I’m 100% on-board with the diet trial and I think that I can make this case of, “Hey. It’s been a year and a half. It’s time to do this.” How do I actually implement and carry out the food trial while treating the condition that he has?

Dr. Andy Roark:

Do I want to get him stabilized and then start this food trial? Am I changing his diet while he’s having this soft stool and GI general upset? Help me figure out how to … What does this look like to implement that food trial, while I have a dog that is symptomatic and itchy?

Dr. Jason Gagne:

In my experience, communication is of utmost importance with these owners. It truly is. Because you have to get them to buy into it, in order to do good by the dog like you want to.

Dr. Andy Roark:

Right.

Dr. Jason Gagne:

What we need to do here is inform the owners and discuss with them what an adverse food reaction is. The immune system may be recognizing food as a foe. At that point, we need to take a complete dietary history.

Dr. Jason Gagne:

We need to see what this dog’s been eating. You mentioned that the dog has been eating some of the limited ingredient, over the counter foods. Right?

Dr. Andy Roark:

Yeah.

Dr. Jason Gagne:

Explain to them that, while they are good foods, complete and balanced, et cetera … They may not be taking into account, “limited ingredients.” That’s what they are.

Dr. Jason Gagne:

There may be a little bit of cross-contamination of proteins within the manufacturing environment. We need to move away from those over the counter foods. The reason I bring up the protein is, as we know, it’s an intact protein that is usually the cause of the adverse food reaction.

Dr. Andy Roark:

Let’s unpack that a little bit. Spell that out for me a little bit more. When they say, “Hey. I’ve got this diet. It says it’s limited ingredient.”

Dr. Andy Roark:

You say there may be cross-contamination and things like that … Lay out what you mean when you say that. Help me understand how to explain that to clients.

Dr. Jason Gagne:

There are many companies out there that sell foods over the counter.

Dr. Andy Roark:

Sure.

Dr. Jason Gagne:

They may want to make a bison food or a venison food. And that’s wonderful, as they should … That may be something that a dog has not consumed before and is on the side. We may think, “Hey. You know what? Go to the pet store. Get that bison food. Try that out.”

Dr. Jason Gagne:

However, in that manufacturing environment of that manufacturer, it’s possible that they have run their chicken and rice food, let’s say, first. And then, they run their bison and rice food. Or bison and potato food. Whatever that may be.

Dr. Jason Gagne:

There could be a little cross-contamination of that chicken in the bison food. And then, if the dog has an adverse reaction to the chicken, they are still consuming some amount of chicken within their bison food.

Dr. Andy Roark:

Right.

Dr. Jason Gagne:

That’s what I’m saying. That’s why I err to the side of therapeutic food. Because you have those … What should we call them? Best practices.

Dr. Jason Gagne:

The standard operating procedures in the manufacturing environment. Cleaning those lines. Cleaning those conveyors, so that you don’t have that confounding factor, potentially. Does that make sense?

Dr. Andy Roark:

It definitely makes sense. Give me the basics just real fast of a food trial. What notes do I want to make sure that I hit when I do this? I know we’re going to get serious about it.

Dr. Andy Roark:

I’m going to have to get utmost compliance from the client. I want to do it right the first time. What notes do I need to make sure I hit to run a good food trial?

Dr. Jason Gagne:

I think you need to be upfront that therapeutic diets are more costly. I do think that, at the same time, you need to mention that the alternative here is some medications, which … Depending on the severity of the GI signs or the derm signs, you may have to get some medications at first.

Dr. Jason Gagne:

But you could err away from medications. You could err away from those side effects subsequently. And that food could actually be the solve here. The important thing here is that, in that dietary history, you’re saying, “Hey. What supplements are you taking? What treats are you feeding? Any table scraps?”

Dr. Jason Gagne:

That really starts to come out in that conversation. You’d be surprised how many obesity cases I’ve solved with just asking those questions. The wife looks at the husband or the husband looks at the wife and says, “You’re feeding the dog in the morning too?” And then, they wonder why they were overweight.

Dr. Jason Gagne:

But getting back to this case here. We need to really tell them, “Okay. I understand you’re feeding them this. You’re supplementing that.” We need to get away from anything flavored. We need to be pulling away those table scraps. We need to be pulling away those excess treats. So on and so forth.

Dr. Jason Gagne:

So that the only thing the dog is consuming for this elimination diet trial is the food. That therapeutic food that you’re recommending.

Dr. Andy Roark:

Sure.

Dr. Jason Gagne:

If it’s derm signs, it’s typically eight to twelve weeks in time. If it’s GI signs only, usually you see a fix within two to four weeks.

Dr. Andy Roark:

Okay. That makes sense.

Dr. Jason Gagne:

Some of them. Because so many dogs have GI and derm signs together. It’s going to be the eight to twelve weeks, because the derm is going to trump the GI there.

Dr. Andy Roark:

Right. Got you. That totally makes sense. What are the keys in selecting my therapeutic diet?

Dr. Jason Gagne:

Well, again, taking that dietary history. Asking the foods that the dog has been on previously. It really helps there choosing. If you want to go to a novel protein diet, that is a therapeutic diet.

Dr. Jason Gagne:

I do find that has been a little less efficacious over time. That really is what gave rise to the hydrolyzed diets back in the late 90s, early 2000s. Hydrolyzed diets have been great. They still continue to be great.

Dr. Jason Gagne:

But if you’re not familiar with that concept, it’s basically … You take a parent protein and you break it into smaller pieces, so that the immune system doesn’t recognize the small pieces. It’s highly digestible as well. Oddly enough, some dogs do fail a hydrolyzed diet.

Dr. Andy Roark:

I’ve seen that. And so, I wanted to ask you a little bit about that. I have seen some breakthroughs and failures on hydrolyzed diets. They actually tend to do better on a novel protein diet. Something like that. I’ve found those cases.

Dr. Jason Gagne:

It does happen occasionally and you scratch your head at it … In theory, if this does happen, it’s possible that you break the parent protein into a smaller piece, and then that smaller piece refolds. And it can act as an epitope. The immune system flares anyway is the gist.

Dr. Andy Roark:

I always question adherence at home. Even if they’re like, “No, doctor. I don’t give them anything else.” I always struggle. I may have been unfair to those people.

Dr. Jason Gagne:

No.

Dr. Andy Roark:

I didn’t say anything, but …

Dr. Jason Gagne:

No, no, no. That brings back to my earlier comment about really clear communication of saying, “I’ve taken this dietary history. I know what your dog has consumed. Now, this is all we’re going to consume for eight to twelve weeks.”

Dr. Jason Gagne:

On this therapeutic diet only. Because, I too, have made this mistake in the past, where I’ve had people fail an elimination diet trial. As I scratch my head and wonder why at times … I come back and say, “All right. What are we feeding? Tell me what’s going on here.”

Dr. Jason Gagne:

I have had the owner who goes through the Wendy’s drive-thru and get a Frosty. Not really conducive to the trial at that point.

Dr. Andy Roark:

Right.

Dr. Jason Gagne:

I blame myself there and I’ve really learned to hone my communication skills with these owners. Something else that’s also truly important is that … As we tell these owners to transition their dogs over the course of a week onto that diet, we follow-up with them at the end of the week.

Dr. Jason Gagne:

Someone should call them and ask them how it’s going. “How did that transition go?” And then, continue to encourage them to move along for the remainder of the trial.

Dr. Andy Roark:

Well, what am I looking for at Week One when I say, “How did it go?” What type of …

Dr. Jason Gagne:

A successful transition, Andy.

Dr. Andy Roark:

What is that? What is a successful transition?

Dr. Jason Gagne:

They’re feeding some diet, as they come into you. You want to tell them to wean down on that diet over the course of a week. And then, what would be the term there? Waning?

Dr. Andy Roark:

Waxing? Waxing.

Dr. Jason Gagne:

Waxing and waning here. We’re going to wane down on the old food, we’re going to wax onto the new food. Over that course of a week, you’re slowly decreasing the old and slowly increasing the new.

Dr. Andy Roark:

Success is just doing the thing?

Dr. Jason Gagne:

Yes. Success is just [crosstalk 00:17:30].

Dr. Andy Roark:

Okay. Just giving it to them.

Dr. Jason Gagne:

But it’s that waxing and waning.

Dr. Andy Roark:

I got you. I wanted to know if there was a clinical sign that you’re looking for, Week One, if we’re talking about a six-day … Or I think you said … How many days was it for GI signs to resolve? Six to eight weeks?

Dr. Jason Gagne:

Usually, two to four. Two weeks or four.

Dr. Andy Roark:

Two to four weeks. Okay. Even then, we’re not there yet. That’s why I was pushing back on that.

Dr. Jason Gagne:

No. Success at the end of Week One is that you have transitioned.

Dr. Andy Roark:

Got it.

Dr. Jason Gagne:

If you see improvement at the end of Week One, that’s great. But don’t necessarily expect it.

Dr. Andy Roark:

Right. That makes sense. Set that expectation so that they’re not like, “I’ve been doing this for a week and I don’t see any difference.”

Dr. Jason Gagne:

Absolutely. Absolutely.

Dr. Andy Roark:

Given what we have in modern therapeutic diets, is there a time that you’re going to not reach for a hydrolyzed diet to do this diet trial?

Dr. Jason Gagne:

I would say that what I really like to do at this point is … Considering some of the novel protein diets are not as relevant anymore, unfortunately. And that’s not because of them. That’s just because many of those over the counter foods have started using those proteins.

Dr. Andy Roark:

Sure. It’s gotten bougie … Bison sells. People go, “Oh. I want that.” You see it everywhere.

Dr. Jason Gagne:

It’s novel to owners, but not really novel to your dog per se. I’ve moved away from those. I still do go for hydrolyzed diets as well. But now, there are elemental. There’s an elemental diet out there as well, which is basically an amino acid based diet.

Dr. Andy Roark:

Talk to me a little bit about that. How that differentiates from your hydrolyzed diets.

Dr. Jason Gagne:

Instead of a hydrolyzed protein diet, where you’re talking about a parent protein being broken down into smaller pieces, and then that really odd potential to refold and still stimulate the immune system … In an elemental diet, you’re dealing with amino acids only.

Dr. Jason Gagne:

You’re working from that foundation up, rather than top-down. The immune system isn’t going to recognize amino acids. You look to amino acid base diets in the past. Really great success with pediatric Crohn’s patients for decades on these.

Dr. Jason Gagne:

They’re highly digestible and obviously they really hit the mark for novel as well. Very successful there and have been to shown to be excellent at malnutrition and GI disease. I will back up for one second.

Dr. Jason Gagne:

We talked about a dog here that’s in good body condition, good muscle condition, great appetite. Those dogs, at least in a textbook … I’m not saying this happens, because it doesn’t happen for me very often.

Dr. Jason Gagne:

But when you’re done with that eight to twelve week trial, if you’ve got derm and/or GI and derm? Theoretically, you’re supposed to ask the owner to re-feed the old food.

Dr. Andy Roark:

The re-test.

Dr. Jason Gagne:

Yeah. I may be a specialist, but I’m not sure I have any better luck than you, Andy, at getting people to do this. They may look at you like you’ve got three heads.

Dr. Jason Gagne:

I ask the question. I communicate this with them if we want a definitive diagnosis, because it does help our profession to advance as vets. But that owner has every right to say, “I’m not doing that.” And that’s fair at that point.

Dr. Andy Roark:

I’ve had those conversations. It’s very much in my category of, “Look, it’s my job to tell you this.”

Dr. Jason Gagne:

Occasionally, you get that curious owner and they want to do it. What’s really cool though is that, sometimes they flare, and then you go back onto the food you were feeding and it works. That’s the therapeutic food. And then, they stay on that for life. That’s great.

Dr. Andy Roark:

Sure.

Dr. Jason Gagne:

Occasionally, they re-challenge. And the dog actually can go back to their old food.

Dr. Andy Roark:

Why is that?

Dr. Jason Gagne:

Now, I may not have said that. But it speaks to nutrition probably giving a rest to the epithelium or the mucosal epithelium.

Dr. Andy Roark:

Interesting.

Dr. Jason Gagne:

Nutrition being the cure in that case.

Dr. Andy Roark:

That’s fascinating.

Dr. Jason Gagne:

It’s weird. I know.

Dr. Andy Roark:

But it validates some of the things that we’ve seen. Where you say, a lot of times if I can get this calmed down, sometimes I can get at least a long break from …

Dr. Jason Gagne:

It’s almost like a reset button.

Dr. Andy Roark:

Exactly. Right. That’s a great way to put it.

Dr. Jason Gagne:

For those owners that, there may be a little bit of sticker shock at the therapeutic diet. Saying, “This is a lot of money.” Maybe they actually do want to do that re-challenge and go back to the old food and see what happens?

Dr. Andy Roark:

That makes sense.

Dr. Jason Gagne:

The only time you would not deviate from it and say, “No, you’re on this food for life,” is when you have the severe GI disease. The protein-losing enteropathies, the lymphangiectasias, et cetera. Because you know that you have to stay therapeutic for that.

Dr. Andy Roark:

And that does make sense. That’s super helpful. And then, also I’ve talked to clients and I’ve said, “Hey. Look, this is the diet that we need to use.” They look at me and they’re like, “We can’t afford this. This is a three-year-old dog, but we hope Budrow’s going to be around for another 10 years.”

Dr. Andy Roark:

And I go, “This is 10 years of an expense.” It’s nice to at least say, “Well, let’s try this and let’s get him straightened out. See if we can hit the reset button at least, and see what we’ve got.”

Dr. Andy Roark:

Sometimes, they do. They hit the reset button and they re-challenge. And then, he starts to itch again or he starts to have soft stools. But they’re a believer in the diet. They say, “Okay, well, we’ve seen this work.”

Dr. Jason Gagne:

Absolutely.

Dr. Andy Roark:

A lot of times, people are looking at it and they go, “I don’t know if this is going to work. I don’t even know if this is really a problem that can be addressed with nutrition.

Dr. Andy Roark:

They may not have totally bought into that, “Budrow’s ears comes from his diet,” idea. And so, if I can just get them past that and get them to see some results. A lot of times, I have a lot more credibility with them.

Dr. Jason Gagne:

You know what? When you talk about the derm aspect of adverse food reactions and that true food allergy … Otitis externa. Those ear infections may be the only derm sign.

Dr. Andy Roark:

I believe that.

Dr. Jason Gagne:

It’s actually quite common. That is the number one sign for derm in food allergies, is the otitis externa. In addition to really stressing to owners and saying, “This is the only food to feed.”

Dr. Jason Gagne:

Taking that dietary history first and really actively listening to how long this has been going on, the signs, the off and on. I think what’s a really, really important point is to stress that the alternative here is continued medications.

Dr. Andy Roark:

Right.

Dr. Jason Gagne:

You’ve already been doing that. And it doesn’t seem to be working. The problems keep recurring. You think about it as we brought up the antibiotics. Those antibiotics are really disturbing that GI microbiome.

Dr. Jason Gagne:

What does that mean in the long run? What happens there? The Prednisone. The dampening of the immune system at the same time, systemically. What are the side effects long-term of that? Probably, not good. Probably, worth an eight to twelve week trial for the food.

Dr. Andy Roark:

That makes sense. I did a presentation in Orlando at the VMX conference, and I was talking about the psychology of making recommendations. There’s this idea of reframing. And it’s how we present concepts to pet owners.

Dr. Andy Roark:

If I take them to the therapeutic diet, and I put it down and I talk to them about the price … If they compare that price to over the counter dog food that they get at the grocery store, it looks really expensive.

Dr. Andy Roark:

If I compare it to the drugs and the medications and the examinations and the re-checks and the pain of dealing with infected ears … It looks like a much more reasonable cost. But it really is, how do you frame it?

Dr. Andy Roark:

Are you comparing the therapeutic diet to the thing that they buy at the grocery store? Or are you comparing it to the repeated visits to the veterinarian? The medications. The drug refills. Things like that.

Dr. Jason Gagne:

It absolutely is. It’s a whole slew of other things. And then, lastly, the long term side effects of the meds too.

Dr. Andy Roark:

That’s a really good point. Jason, do you have any final pearls, words of advice for me? Or pitfalls that I should look out for when I go and have this conversation?

Dr. Jason Gagne:

I’m just going to … I think we’ve done quite a bit of talking here about it and the importance of the communication. Just following up with these owners. Particularly, after that first week to make sure that they’re continuing to be compliant.

Dr. Jason Gagne:

And then, maybe some re-checks along the way there during that elimination diet trial. Touching base with them after two to four weeks to make sure about the GI. And then, definitely as we get out to the eight to twelve week period too.

Dr. Andy Roark:

This is fantastic. Thank you so much for your time. Thanks for helping me with this. Where can people get more information if they want to learn more about therapeutic diets? You mentioned the new elemental diet. Where can people learn more about this?

Dr. Jason Gagne:

Well, if you’re interested in that elemental diet that I was talking about earlier on, I’d say a great website to look up there would be purinaproplanvets.com. Or, of course, like any company, reach out to your sales representative.

Dr. Andy Roark:

Good. Sounds great to me. I’ll put a link down in the show notes for people to get that. Thanks a lot for being here. I appreciate your time.

Dr. Jason Gagne:

It’s been excellent. I appreciate the conversation. Good luck with Budrow.

Dr. Andy Roark:

Thanks, buddy. I’ll need it bye. That is our episode. That’s what I got for you. Guys, I hope you enjoyed it. I hope you got something out of this. Some tips, some tricks, some pearls. Some new ways of thinking or just a refresher on how to handle these uber common cases.

Dr. Andy Roark:

Gang, take care of yourselves. Be well. Enjoy your practice. Enjoy doing good things. Enjoy helping people and vets. And I will see you next time.

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram

Professor Biscuit has been having some blood in his urine, and Dr. Roark is seeing something that doesn’t look right in the poor guy’s bladder. Today we talk with Veterinary Oncologist Dr. Sandra Bechtel about Transitional Cell Carcinoma and how we can best approach it. Let’s get into it!

This episode has been sponsored by KRUUSE.

LINKS

KRUUSE – Preferred partner to the Veterinary Industry since 1896: kruuse.com/

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All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Sandra (Axiak) Bechtel is a Veterinary Medical Oncologist and Associate Professor at the University of Florida in Gainesville, FL. She graduated from Michigan State University’s College of Veterinary Medicine in 2004 followed by an internship at Mississippi State University and Medical Oncology residency at Gulf Coast Veterinary Specialists. She achieved board certification in Medical Oncology in 2008 and practiced as an Associate Oncologist at Veterinary Specialists of North Texas in Dallas and Assistant/Associate Professor at the University of Missouri prior to joining the University of Florida in 2017. She loves teaching veterinary students how to apply their didactic education to patient care and to understand the goals of cancer therapy in dogs and cats. Her research focuses on improving the lives of companion animals with naturally occurring cancer and providing translational models for research in cancer causation, progression, and treatment. Particular areas of interest include novel diagnostics and treatments in cancer therapy and immune system dysfunction and modulation in cancer. This focus provides advanced cancer treatment for companion animals and essential information for translation of novel treatments into people. She has lectured and published extensively on her research in translational oncology. She relishes outdoor activities with her husband Scott and daughter Ainsley, and enjoys taking her boisterous Cavalier King Charles Spaniel, Watson for long walks.

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:

Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one today. I am here with my friend veterinary medical oncologist and associate professor at the University of Florida College of Vet Medicine, Dr. Sandra Bechtel. We are talking about a poor little dog straining to pee, and we get into transitional cell carcinoma and what you need to know, guys, this episode is brought to you ad free by my friends at cruise. Learn more at cruise.com. Now let’s get into this episode.

Kelsey Beth Carpenter:

(Singing) This is your show, we’re glad you’re here, we want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the podcast Dr. Sandra Bechtel. Thanks for being here.

Dr. Sandra Bechtel:

Thanks for having me. I’m excited.

Dr. Andy Roark:

Oh, it’s my, all my pleasure. I love getting to work with you. Thanks for doing this. I appreciate you taking time out of your day as a veterinary medical oncologist at the university of Florida to take my question, because I got a case for you. You ready?

Dr. Sandra Bechtel:

I’m ready.

Dr. Andy Roark:

Sweet. I have a seven year old male castrated West Highland Terrier named Professor Biscuit and Professor Biscuit is…he’s got blood in his urine and the presenting complaint about this was…mom and dad come in and they, he had never had any problems like this before. He was not a urinary track guy. You know, any of that sort of stuff had some allergy stuff early on in his life that they got pretty well managed, but he started having blood in his urine. So he went to another veterinarian and they empirically treated with some antibiotics. So they were like, it’s probably a urinary tract infection. I wasn’t there. I don’t know. I don’t know why they jumped straight to empiric treatment or if they did diagnostics that I’m not getting access to. I don’t know. But the take home from mom and dad is that Professor Biscuit was having some blood in his pee and he got antibiotics and it got better.

Dr. Andy Roark:

And now he’s off antibiotics and its come right back and they’re like, can I have some more antibiotics? And I’m like, I don’t think so. I have concerns. And so I am worried about this. And as I think about getting a ultrasound guided cysto, I’m seeing some things in this bladder that I don’t like that would make me reach out to my friend, who’s an oncologist. And so I am worried about transitional cell carcinoma in this case. I want to make sure I get it right. I don’t want to, I don’t want to make it worse. And I also want to set realistic expectations. Can you just real quick, can you run me through, how do you treat that?

Dr. Sandra Bechtel:

Absolutely. I think that’s really reasonable when you have a dog and sometimes you may end up treating what could be a urinary tract empirically because clients might decline and-

Dr. Andy Roark:

Sure. Of course, Yeah [crosstalk 03:11:00]

Dr. Andy Roark:

I won’t throw anybody under the bus like 100% [crosstalk 03:13:00].

Dr. Sandra Bechtel:

Sure. And you treat it that first time and then it comes back and you’re correct, that’s just not right. And so to keep throwing antibiotics at the situation is just a little bit, it doesn’t feel quite right. And you’re worried, is this the same infection that came back? Was it just not treated long enough? Is it so is it refractory or recurrent? I mean, or is it refractory? Do we have a different bug in there? Is it a different infection, it a resistant infection or is there something underlying that is actually causing us to be more susceptible to a urinary tract infection? So when you take a look at that bladder and you see something in there and you think, huh, I don’t like the way this looks, that’s a really good place to go. Those things that you’re going to be looking for would be things like bladder mass. Of course, we’re always worried about transitional cell carcinoma being the most common or there may be even bladder stones.

Dr. Sandra Bechtel:

Those are something to look for as well. And when we, I don’t often as an oncologist get dogs that early in the initial workup, but when I do, I do let them know that we’re not always looking for cancer and that there are other things on our differential list that we need to make sure are or aren’t there before we start talking and jumping into treatment.

Dr. Sandra Bechtel:

But if you know, you do your bladder ultrasound and you see what looks like it might be a mass and that’s something where before you do that cysto, which is, I know exactly where you’re going with that you might want to take a step back and think, huh, there could be a bladder mass there, maybe a cysto isn’t our next best step, at least at this point in time. And that’s because with transitional cell carcinomas, we know that there’s that risk of seeding of tumor cells through the bladder wall and the published risk of that seeding through cystocentesis is fairly low.

Dr. Sandra Bechtel:

It’s less than 10%. It’s closer to 4% in the published literature. And, but if it happens, it’s pretty bad for that dog. So at least for us is, if it’s something we can avoid, we will try our very best to avoid that. hen we know we have that infection that is occurring, the clinical signs of that potential infection are occurring again after antibiotics, we want to get the urinalysis and urine culture. Is there a safer way for us to go ahead and collect urine and get good culture results? And in particular with male dogs, it’s at least quite a bit easier. I think anyway,there’s lots of people who are very skilled at catheterizing female dogs, but urinary catheters in male dogs are quite easy to place. So this is a situation in which urinary catheter can be placed sterilely and help us collect that sterile sample for both urinalysis and urine culture and also be quite safe.

Dr. Andy Roark:

OK. What are you looking for in a…and this sounds like maybe a bit of odd question, but what are you looking for in a catheter? Like how does, I mean, is it this classic red rubbers? Are there, is there, I don’t know any just general guidelines for what I’m picking out, that’s going to get me the best sample, that’s maybe not going to be traumatic or anything like that.

Dr. Sandra Bechtel:

Sure. So in addition to the general length and size of the catheter itself, and we want it to be stiff enough so that we can place it easily, but not so stiff that it’s going to be uncomfortable. And if I’m just collecting just a quick urine sample for urinalysis or culture in a dog with a suspected bladder tumor, and that’s super worried about using something like a balloon or Foley catheter that I need to stay in place.

Dr. Andy Roark:

Gotcha.

Dr. Sandra Bechtel:

Now I will be using those if I have a confirmed bladder tumor dog and I’m using ultrasound to subsequently look at bladder mass size, we often will place a catheter with each ultrasound during the bladder and then put in the same amount of saline each time we do the ultrasound, just so that the bladder itself is the same size. So that way, ideally we’re getting the, at least as close as we can in the same measure with each abdominal ultrasound, but on the initial collection, it’s usually just a quick, you know, what’s the quickest, easiest and most comfortable for the pet.

Dr. Andy Roark:

That’s what I needed.

Dr. Sandra Bechtel:

And so I think that’s a great place to start. And sometimes if there is not a lot of inflammation in the bladder, you can sometimes even get some cells on the urinalysis and on the urine sediment that might help clue you in as to whether or not you might be dealing with the cancer. If there is a lot of inflammation, so if you have a secondary urinary tract infection, what you might see on that urine sediment, those cells may look pretty scary, but inflammation can actually make the cells look cancerous and they may just be reactive. So, you may not be able to get that definitive answer if there’s a lot of inflammation in the background.

Dr. Andy Roark:

Okay. So, beyond catheterization, urinalysis, cytology, things like that. What…are there other diagnostics that I want to get pretty early on? I mean, chest radiographs, things like that, looking for spread, what’s the likelihood that those are going to be valuable?

Dr. Sandra Bechtel:

So early on in the diagnostic process, and it depends on how my clients feel, there’s a lot that we can do, but I like to see where my clients are both emotionally and financially in the process. So if I have more of a thickened and inflamed bladder wall, but not really a distinctive mass yet, I may focus more on trying to get the cystitis under control before getting to too heavy on the staging tools, unless I have a confirmed cancer present. If I have clients who are like, yes, let’s do everything. Then I would love to do full staging. That would be three-view chest x-rays and a full abdominal ultrasound to look for any evidence of cancer movement. Transitional cell carcinoma being the most common of the bladder tumors does like to go through lymph nodes, liver, spleen lungs, and sometimes even to bone later in the stage of disease.

Dr. Sandra Bechtel:

Yeah. But initially before I have a diagnosis, we could do things like, look at that urine sediment to look at…and if, again as long as there’s not a whole lot of inflammation, sometimes we can get an answer there. We can do the BRAF test and that’s a urine test. Does have to be done on free catch urine. Can’t actually be done on cystocentesis or urinary catheter collected samples, just because it tends not to get as many cells as a free catch. And you, need a lot of urine for it, so Professor Biscuit, who is a Westie, you need probably 30 to 40 milliliters of urine. So we actually send it home with the owners to collect in one container and put into the collection cup. Because it has a preservative in it. So owners get to chase around their dogs with the collection cup in the yard.

Dr. Andy Roark:

Talk to me a little bit more about the BRAF test. So, it’s not one that I’ve used.

Dr. Sandra Bechtel:

So it is not invasive, which is what makes it really quite nice, and the publications out there show that it’s both sensitive and specific. And it’s actually looking for, in the cells of the lining of the bladder that are shed into the urine, it’s looking for a specific genetic mutation that is found in transitional cell carcinomas. When those…that mutation is actually found it, in almost all cases, can confirm the presence of transitional cell carcinomas. We’re pretty confident when there’s a bladder mass and the presence of the BRAF mutation, we’re pretty confident in a diagnosis of transitional cell carcinoma. If there is a bladder mass and there is not the BRAF mutation, then we need to do other diagnostics to see what is there, because we can get some false negatives.

Dr. Andy Roark:

Okay. So, other diagnostics just being cytology, biopsy, in some cases, things like that.

Dr. Sandra Bechtel:

Yes. So we may need to do things like a diagnostic catheterization, or we may need to do cystoscopy with biopsies or other things to get a better idea of what’s going on in the bladder.

Dr. Andy Roark:

When, unfortunately, this comes back as transitional cell carcinoma, so say we get a positive result and we can confirm the diagnosis. How do you approach this conversation with the pet owners? Like what just going in, aside from some breaking the news, what expectations do you try to set just as you open this conversation and try to get them to see what a post diagnosis life is going to be like?

Dr. Sandra Bechtel:

So, it is a hard conversation to have because it’s not a cancer that we can cure. And I think that is probably one of the most important expectations to set up from the beginning. And we tend to, and I think this is probably an oncologist view, but we tend to think of cancer as more of a chronic disease process. And I think cancer is a very scary word. So when you hear heart disease or kidney disease, it’s maybe not as scary to hear as cancer. So, we try to think of it more as a chronic disease management. And we just have different tools to manage cancer than we would for kidney disease or heart disease. And in a similar way, transitional cell carcinoma is a disease that we try to manage with a real focus on quality of life. Because certainly if your bladder is inflamed and very thick, it seems like it would be very uncomfortable for pets.

Dr. Sandra Bechtel:

And so that first focus is what can we do to make our pets more comfortable and what options do we have to provide that comfort for as long as we can. So one of the things that we need to focus on is, is there a secondary urinary tract infection? And if there is what is the correct antibiotic to who have this pet on and for how long? And so with these bladder tumors, by definition, they’re complicated infections. So we’re looking at culture based treatment for four to six weeks and checking that culture seven to 10 days after starting antibiotics and about a week after completing antibiotics to try and avoid an antibiotic resistant infection. Which can be life limiting.

Dr. Andy Roark:

OK. Yeah. No, that makes sense.

Dr. Sandra Bechtel:

Yeah. So those can be life limiting in some patients that have been on multiple empirical short courses of antibiotics. The second thing we want to focus on is, if safe, we want to use a nonsteroidal anti-inflammatory. Ideally Piroxicam, that’s been shown to be very effective in a lot of cases, not in just decreasing inflammation and providing comfort, but in some cases can even shrink down the size of the tumor itself. So that by itself can be an effective treatment for transitional cell carcinomas and it’s pretty affordable too.

Dr. Andy Roark:

What’s the difference between, whenever you and I have talked about this in the past, and there’s always been people around who have asked, what about this other non-steroidal? How much is the difference between [Inaudible 13:19:00] Piroxicam is the gold standard so I’ve heard, how is it, I guess what I’m saying is when my colleague says, “Oh, can we use Carprofen. Can we use something else?” What is the difference between the two? Is it…I don’t know. I guess what I’m saying, is it worth saying this is the one or are there instances where we’ll choose alternatives?

Dr. Sandra Bechtel:

That is a great question and I don’t know the answer to it because we have not had any studies comparing the different nonsteroidals side by side. We do tend to try and stick with the ones that have been looked at and shown to be effective in transitional cell carcinomas. Piroxicam has been used the most often and I think we really like that one, because we’ve seen that work so often, but there are times where it does tend to be the least well tolerated. So if we can’t tolerate Piroxicam, Firocoxib and Deracoxib have also been studied as a single agent for transitional cell carcinoma. Then for other nonsteroidals the answer is we just don’t know because they haven’t been looked at, but certainly if that’s what is tolerated then, and if it seems to be working for that particular patient, then that is what we will use. Then of course we can run into the issue with patients that have underlying renal disease that may not tolerate the nonsteroidal and we’ll have to work with that patient, with that drug and how often to give it, and if we can safely give it and try to balance as best we can, the different diseases.

Dr. Andy Roark:

Okay. So, start first line…probably nonsteroidal, things like that. Is there a place or so what makes a chemotherapy candidate? Other modalities that we look at it, I know just, I see some of these dogs that end up on chemotherapy drugs, things like that, is that common? What is the dividing line between patients that we kind of direct in that direction and those that we don’t.

Dr. Sandra Bechtel:

When I have clients present for other options, I always give them different options. I feel like I have that easy job and that I can give them what’s available, what I think would be appropriate options for their pet. But also as a pet owner, I know that the hard job is to actually sit on their side and then actually decide based on a lot of different factors.

Dr. Sandra Bechtel:

Sometimes it’s finances, but sometimes it’s…their pet. Will my dog tolerate coming in every three weeks for chemotherapy or is my dog super frightened or do we have to sedate my cat so heavily every time that we bring my cat in that it’s just not a very good quality of life. Can I actually take off work to bring my pet in for treatment every two to three weeks when it’s recommended? Is that right for my family and other emotional decisions and certainly cancer and chemotherapy that experiences that the family may have had with themselves or close family members or friends. So many different factors go in concurrent diseases, their pet might have. So many different things may go into the decision as to whether or not they would like to pursue chemotherapy that we always discuss it as an option if they would like to be a bit more aggressive.

Dr. Sandra Bechtel:

If their pet is a good candidate based on concurrent disease status, it is something that we recommend because we know that it can, in some cases, help shrink down the primary mass and also delay metastatic disease onset. But we know that it’s not right for every patient or every family. We don’t know which chemotherapy is best to start first. I wish I had an answer on that too. But more recent studies by Debbie Knapp out of Purdue seems to not so much matter, which when we start with, but if we keep switching to different protocols, when they become resistant to different drugs, that those are the pets that seem to do well for the longest. Unlike, lymphoma, when we talk about, once you become resistant to one drug, it seems like every drug we try has less of an effect and the duration is shorter. It seems like transitional cell Carcinoma is not one of those drugs. You still have a pretty good chance of responding to the next drug and responding for quite a while. Each time we try a new one.

Dr. Andy Roark:

Gotcha. That makes sense.

Dr. Sandra Bechtel:

Yeah. And then we also have radiation therapy as an option, and I think we’re returning to that more frequently as well, to try and get a little bit more local disease control to the bladder. As we’re getting better at localizing the radiation to the bladder and reducing side effects to the area, to the normal tissues in the area, we’re seeing better local disease control with the use of radiation therapy as well, but certainly the timing of treatment, the expense of treatment and the time commitment on the part of the owner are going to all be factors and to whether or not they elect to add in radiation therapy as well.

Dr. Andy Roark:

What do you say when clients ask if surgery is an option? When they say can you not, can you just take it out? How do you sort of walk through that with them?

Dr. Sandra Bechtel:

So a lot of it actually depends on the size of the tumor and also where it’s located. Unfortunately most of them are in the trigone or kind of the neck of the bladder area, so it’s not in a place where we can strategically excise it. There are some that are in what we call the apex or kind of that rounded part of the bladder, so it looks like we would be to take it out. Certainly there’s some, actually some papers out there that suggest those patients, where we are able to take it out, that they actually live a little bit longer. Those patients tend to have smaller tumors.

Dr. Sandra Bechtel:

We don’t know if it’s because they have surgery or because they started out with smaller tumors. But we do know, for sure, that those patients are not cured when we take them to surgery and that in the bladder, there’s…this concept of what we call field carcinogenesis. What that means is whatever that one part of the bladder that was exposed to that allowed that tumor to form, the entire bladder was exposed to. So even if we are able to completely surgically resect, the little mass that we can see, we will see other areas of tumor pop up within that bladder.

Dr. Sandra Bechtel:

So we know that surgery is not curative and there are select patients where we might discuss it with them as an option. And they may or may not pursue to elect to pursue surgery. But the majority of patients that we see to be completely honest are not surgical candidates based on the size and number of masses that we see in the bladder.

Dr. Andy Roark:

Yeah. What’s the prognosis that you communicate to the bad owner? As far as the expected amount of time that we can have where we still have quality of life?

Dr. Sandra Bechtel:

So to be completely honest, it depends on the response to treatment. And what we see is across the board. What’s published, if we use a nonsteroidal chemotherapy, can range anywhere from a median says where 50% of dogs are alive and 50% of dogs are, have died due to their cancer can range from about nine ish months to tenish months. But we do see dogs in a large range where we see some dogs that really just don’t respond to treatment at all and have a rapidly progressive disease course. We have some dogs that are one, two, and three years down the road that may have had a little bit of shrinkage, but then sit with stable disease for quite a long time. And because they don’t really have clinical signs, a bladder mass is there and we’re keeping it stable and they feel really good and have an excellent quality of life and it doesn’t bother them. We consider that stable disease a treatment success.

Dr. Andy Roark:

Gotcha. Are there sort of prognostic flags that you look for? When the pet owners come in and they’ve been doing this for, I don’t know, a week or a month and they say, do you think that she’s going to do well? Are there things that you have spotted that you think may indicate patients who are going to respond well to treatment versus those that are not, or monitoring steps where you say, really, this is, this is a monitoring way that we can kind of look and get an idea of the speed of progression in individual cases? Or is it just a crap shoot and you’re like, sometimes it looks bad and then it looks okay and sometimes it looks great at the beginning and then all of a sudden it looks bad?

Dr. Sandra Bechtel:

And cancer does do whatever [crosstalk 21:18:00]

Dr. Andy Roark:

I’m trying to put control where there is no control, but pet owners always look at me and they say, well, how do you think this is going? And I guess I was trying to put that to you and be like, is there any way to tell how this is going once treatment is rolling along

Dr. Sandra Bechtel:

There is and you know, some of it is honest to goodness where the tumor actually is, and if we have the tumor that’s in the urethra, if it blocks off the dog’s ability to urinate, those tend to do poorly just because of the functionality of where it is and our ability to control it. Or if we have one that’s growing near the ureter, so a tube that connects the kidney to the bladder, that can actually cause secondary damage to the kidneys. That tends to be problem just because of where it’s located. So even if I can stop it from growing for a little while, it’s still in a problematic place. Those are the ones that tend to go poorly because it’s harder for me to manage, even if I can stabilize it, if that makes sense.

Dr. Sandra Bechtel:

So those that are in bad places tend to do worse just because they’re harder to manage. Whereas those that are in less bad places, if I can have them stabilize or even shrink a little bit, then I can provide that good quality of life for the patient. Then I can do what I want to do and give them a really good quality of life. Whereas that tumor that blocks the urethra, even if I make it shrink a little bit, that dog is still very uncomfortable and I’m not providing the quality of life that I want to provide. Then we start talking about things like urethral stents, which are then quite expensive and cause incontinence, and there’s a whole nother realm of possibilities and things that we need to discuss.

Dr. Andy Roark:

When do you start get into that conversation of urethral stents? Because we’re going way down the rabbit hole at this point, but do you offer that to every client or is it a certain type of owner that you feel like is the ones who are up for this? I can’t imagine it’s something that most pet would be excited about. How do you make that distinction?

Dr. Sandra Bechtel:

It’s not something we actually do that often. That’s because it does have its own set of side effects and it is quite expensive and we only would use it in the face of a urethral obstruction. If the bladder mass is in the trigone, or in the bladder neck, and it’s causing an obstruction, then an urethral stent is not necessarily going to be helpful. But if it’s in the urethra and causing an obstruction, we may not have a choice other than to offer a stent just to relieve that obstruction. We may be at a decision making point where we say you know what, we can offer a stent to relieve the obstruction, or we may be at a point where we need to consider euthanasia because chemotherapy is just not going to work fast enough to provide your dog comfort. If we do a stent, it comes with its own set of complications.

Dr. Sandra Bechtel:

Unfortunately it can cause incontinence in quite a few dogs. And it also, because you’re opening up that urethra, makes them more susceptible to urinary tract infections in a dog with a bladder tumor that’s already a little bit more susceptible to urinary tract infections. It’s not right for a lot of families. It’s not the right answer and that’s okay because we’re not talking about something we’re going to cure. I’m not going to say we’re going to place this stent and your dog is going to go home and be happy for five years. It’s a short term solution. It’s a short term bandaid. We’re talking maybe weeks to months with that bandaid, so to speak. It’s important that if we are going to go that route, that we are all on the same page with what we expect the results to be.

Dr. Andy Roark:

Yeah. No, that setting of expectations is important. That all makes sense. I think I’m ready to have this conversation. I think I have what I need. Are there any last pearls of wisdom or pitfalls to avoid that you would remind me of?

Dr. Sandra Bechtel:

I think the biggest things are I generally, to be completely honest, don’t put a whole lot of stock into minimizing breed predispositions for cancers, except for transitional stock carcinomas because that’s one that you can’t really see. You can’t palpate it but it’s one where I think we should become suspicious of it with those signs of a urinary tract infection in an older dog of this specific breed that hasn’t had these issues before. Chances are if you have a Scottish Terrier owner whose dog comes in with a urinary tract infection, you’re going to mention transitional cell carcinoma and they’re probably going to get annoyed because they already know.

Dr. Andy Roark:

Yeah. They’ve been told since that thing was a puppy. Someone looked at their beautiful nine-week old puppy was like, you know they get transitional cell carcinoma. I don’t know why people do that, but they totally do.

Dr. Sandra Bechtel:

They do. So this is one of the few types of cancers where I think being aware of the breed predisposition is helpful because you can’t really see or palpate it. It’s like the lymphoma breeds. You’re going to palpate and you’re going to work it up regardless of what breed the dog is. A dog is limping, you’re going to work up that dog for limping, regardless of what breed it is and whether or not it gets osteosarcoma. For a bladder, it could be a little bit trickier. I think this is one of those cancers where its worthwhile just to kind of have it in the back of your head. This is a Sheltie, I treated a urinary tract infection, but it came back right away. Maybe I should think about imaging the bladder a little bit earlier than I would in maybe a mixed breed dog. I think that’s a good pearl of wisdom.

Dr. Sandra Bechtel:

The BRAF test is a nice non-invasive test for confirming a transitional cell carcinoma. I’ve done a lot less diagnostic catheterizations since that’s come onboard and that’s nice. I do like to use urinary catheterizations for collecting urine on these guys for cultures and analysis when it’s feasible and to avoid cystos when possible.

Dr. Andy Roark:

Gotcha. That totally makes sense. Well thank you so much for being here. I really appreciate your time.

Dr. Sandra Bechtel:

Thank you for having me. I love coming and speaking with you.

Dr. Andy Roark:

Guys, that’s it. That’s my episode. That’s what I got for you. I hope you enjoyed it. I hope you got something out of it. I love talking to Dr. Bechtel, she’s brilliant and go Gators and all those sorts of things. Thanks again to cruise for making this episode possible. You guys are wonderful to work with, and I really appreciate your support so that we can do these podcasts. They are great guys. Anyway, gang, let’s meet up again and do this soon. All right. Take care of yourselves. Be well, bye.

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram