Medicine

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

Gertrude is a 16lb obese cat who simply refuses to lose weight. She will not run, play, or exercise in any way. She refuses to eat anything but the food she wants. Her health is on the line and Dr. Andy Roark is out of ideas. Fortunately, Ingrid Johnson is here to talk about how she handles these cases. Let’s get into it!

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ABOUT OUR GUEST

Ingrid Johnson is a Certified Cat Behavior Consultant (CCBC) through The International Association of Animal Behavior Consultants (IAABC). 

Ingrid owns and operates Fundamentally Feline, providing in home consults for locals and virtual consultations worldwide for clients experiencing behavior challenges with their cat(s). In addition to behavior consults, Ingrid also offers medicating consultations to help clients overcome, or get ahead of, medicating challenges. Prevention and training, the best medicine! She makes her own line of feline foraging toys, scratching posts, vertical space, and litter boxes. She lectures nationwide on cat behavior at veterinary conferences such as AAFP, VMX, ACVC and the like. She is employed at Paws Whiskers and Claws, a feline only veterinary hospital, as a tech, groomer, and office manager and has been working exclusively with cats since 1999.

In the Fall of 2016 a paper she co-authored, Food puzzles for cats: Feeding for physical and emotional well-being, was published in the JFMS (Journal of Feline Medicine and Surgery) and to compliment it she co-developed FoodPuzzlesforCats.com. To date it is the most popular and widely downloaded paper in the history of the journal! Ingrid’s home, cats, and environmental enrichment expertise has been featured on Animal Planet’s Cats101 show and featured in numerous publications including the website WebMD. She has created a series of educational How-To videos of her own, viewable on Fundamentally Feline’s website and YouTube channel. Ingrid regularly interviews and offers her expertise for various media outlets. She is Co-Director of Paw Project-Georgia, working towards ending the cruel practice of de-clawing cats. 

Cat Fancy magazine’s 2008 “Home Issue” showcased her feline friendly accommodations and the aesthetically pleasing ways you can provide for your cats innate basic needs while still having a home the humans can enjoy. Ingrid is a huge advocate for enrichment and is determined to thwart the belief that one’s home will look unsightly in efforts to provide it. 

Ingrid shares her home with husband Jake, five rescue cats, and Sebastian, a rescued Great Pyrenees Dog. Follow Fundamentally Feline on Facebook, Twitter, Instagram and You Tube!

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 my friend, Ingrid Johnson. Ingrid has been on the podcast a number of times before, because I think she’s amazing. I love how matter of factor and straightforward she is. I love her thoughts on feline behavior, I love her thoughts on play and getting cats to play. And so I bring to her a tough case today. I’ve got Gertrude, she’s a 16 pound obese cat who just is not interested in playing, and she only wants to eat what she wants to eat, and she just basically refuses to lose weight, and you guys know what that case is like. And I put it to Ingrid and say, help me buddy. She’s got great advice. I again, I love the way she thinks, I love the work she’s doing at Fundamentally Feline. I’m glad to have her 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 in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome Ingrid Johnson. Thanks for being here.

Ingrid Johnson:

Hey There. Thanks for having me back.

Dr. Andy Roark:

Always, always, always, because this is exactly what I… This is what I most love to talk to you about and I got a case for you about it. Are you ready? You ready for a challenge?

Ingrid Johnson:

Super. I’m totally ready, always ready.

Dr. Andy Roark:

I’m going to see you improvise, adapt and bend like in the matrix here, I think.

Ingrid Johnson:

That is a tall order.

Dr. Andy Roark:

Oh yeah. You know, here is the thing, one of the things that I love the most about you is I love how you get into the mind of a cat and you are so pro-cat and you want cats to have great lives. And at the same time you very much understand the health outcomes that we’re trying to achieve. And you’re really good at presenting solutions to cat behavior problems in a way that I feel like I can get owners excited about.

Ingrid Johnson:

Cool.

Dr. Andy Roark:

And so that’s why I want to do this with you. So this is just going to be… This is such a classic. It’s not a complicated case at all, but I’ve got a cat that I am working with and the owner is super great, she is super enthusiastic, she loves her cat. I think she’s a very compliant owner, I really do. I think that she’s going to be really great to work with. I just want to make sure that I’m working with her the most effective way that I can. She has got a 16 pound obese female cat.

Ingrid Johnson:

Okay.

Dr. Andy Roark:

Gertrude is her name, which I love. Gertrude. Gertrude doesn’t give a flip about what you want or what mom wants. Gertrude is living the easy life. And so she just eats basically dry kibble. And I’ve talked to mom about weight loss food and things like that, but Gertrude just… She just eats her food, she doesn’t want to play. She doesn’t want to chase the thing. She, you know what I mean? She is just content to lay in the sunshine.

Dr. Andy Roark:

In a way, let’s be honest, Gertrude is my spirit animal, I think, in a lot of ways. I get Gertrude at a deep level, I get her. What am I doing with this cat Ingrid? Just seriously, it’s 100% lack of motivation. It’s like trying to do a weight loss plan with a person who has zero interest in a weight loss plan at all.

Ingrid Johnson:

Exercising or eating healthy.

Dr. Andy Roark:

Exactly, like nope, what else you got Andy? I’m like I don’t have any, don’t have anything else.

Ingrid Johnson:

I’m also guessing that Gertrude hasn’t seen her tush in a few years.

Dr. Andy Roark:

Oh no, no. She’s…

Ingrid Johnson:

May I suggest we start with a sanitary shave.

Dr. Andy Roark:

Yeah, she sways when she walks, if you know what I mean?

Ingrid Johnson:

So at our office with these cats, well we do shave their butts. We shave a lot of butts, not going to lie, it’s practically our specialty. But what we do is, because they’re cats, so we carry all the prescription foods. We carry Hills, Royal Canin and Purina. We have more food at our vet clinic than most clinics that actually do dogs. And we send home what we call our high protein, low-carb sample.

Dr. Andy Roark:

Okay.

Ingrid Johnson:

So the cats go home with one of every single can that could possibly be appropriate for weight loss. And then we send home usually one small bag of dry to sell. And then we often have bags that have been returned for palatability, and so we’ll also give a free sample of some other dries, so they’ve got a couple different ones to choose from. But this is the perfect time to implement food puzzles and foraging.

Ingrid Johnson:

So what this would look like is, once we figure out what the kitties enjoy, then we have them feed two to three canned food meals a day, and we put all the new dry in a food puzzle because cats are not going to work for food that’s been easily available. They do not contrafreeload, if the audience is familiar with contrafreeloading. They are one of the only species on earth that has been studied that will not contrafreeload, which means if food is easily available, cats will not work for it. [inaudible 00:05:17].

Dr. Andy Roark:

Gotcha.

Ingrid Johnson:

I don’t think that it’s they’re lazy, I think that they are very intelligent. And why would you put forth effort when it’s free? So they’re probably looking at us and dogs and chimpanzees, like we’re all just nuts.

Dr. Andy Roark:

Yeah.

Ingrid Johnson:

So we put the novel food in the puzzle, we put the canned food out two or three times a day, and we have to start with some basic guidelines, but I think what we have to remember is that the recommendations on the back of these bags of food and the recommendations even in the formularies from Hills, Royal Canin and Purina are simply guidelines. So we start there because we have to start somewhere. But then as we have the kitty come in for rechecks and sanitary shaves to get weighed.

Dr. Andy Roark:

Yeah.

Ingrid Johnson:

We adjust because everyone’s a unique individual and we might still be overfeeding a high protein, low-carb food because it might not be calorie restrictive enough for that particular cat.

Dr. Andy Roark:

Yeah. Okay, let’s unpack this a little bit because I think that’s really important. I think a lot of us struggle with that because pet owners are like, how much do I give? And you kind of go, about half a can give or take. It seems very… It does seem very unscientific, especially when they’re doing some dry and some can together. I think we as vet professionals are all very good at looking at the recommendations on the bag and coming up with an amount saying, okay, well if you do this much dry food and you do this much wet food and this is what we do. And I think that we can all do that.

Dr. Andy Roark:

Walk me through the process. So I’ve got Gertrude and she is 16 pounds, and I figure out she needs this much sort of canned food, and if you’re going to do this much dry food, I’m going to take that amount of dry food. I’m going to put it into forging puzzles so that she’s going to have to work for and then I would give her the canned food. Okay, from there, walk me through the reduction process. Do you give her what you think is indicated based on what’s on the packaging? From our pet food maker friends?

Dr. Andy Roark:

You give them… Just say, this is what we’re going to start with, what we’ve worked out. Do you go ahead and say, we’re going to shoot under this and then I’ll see you back? And how frequently do you see them back? So yeah, walk me through that process please.

Ingrid Johnson:

So typically if we got a 16 pound cat, we’re probably going to feed for 14 pounds, so that’s going to be your first goal. I mean, you can’t be like, well she should be eight pounds and we’re going to feed her for eight pounds. That’s going to create some starvation frustration behavior, like no get out. You got to bring it down slow. So our first goal is 14 pounds. We’ll go with the recommendations on the formulary to start.

Dr. Andy Roark:

Okay.

Ingrid Johnson:

She might come in and not have lost anything, but maybe at least the win here is that we got her transition to high protein, low-carb prescription food. We’ve got her off of whatever she was eating over the counter that maybe was less than ideal. And we’ve taught the cat to forage. So we’ve now increased enrichment and a little bit of activity. So now is the time, about every two months we have them come in for weight checks, by the way.

Dr. Andy Roark:

That’s what I was going to ask. So two months after we’ve put them on this sort of diet amount, we’re going to get them back. Okay, alright, cool, okay.

Ingrid Johnson:

Yeah every two months for a sanitary shave, you see, I keep circling back to the clean tushy. Every two months for that is about practical too, and a nail trim. So once we have that established that we’re like, okay, well she didn’t lose weight, but she does like this food and we’re feeding this way and she’s actively foraging. Now we’re going to go ahead and scale back on the portions of it. And we might actually leave the can alone, but we’ll scale back on how much dry we’re offering because cats are carnivores and they need meat and they’re going to do better with weight loss with more wet food if we can get them to eat it, so we usually start taking down the dry.

Ingrid Johnson:

And then sometimes what we do is we actually just make the dry even harder to acquire. So we start with those easy food puzzles, clear, rolls easily, multiple holes for the food to dispense from. She learns how to play the game. Once she learns how to play the game, the game gets harder. Those easily rolled puzzles now only have one hole of dispense food, or maybe they’re cubes, maybe we’re filling a small food puzzle and putting it inside a big food puzzle so she has to double work a double stuff toy. That’s going to be more time consuming and probably leave her a little frustrated and walking away from the puzzle going, I’m full, I don’t need to do any more of this.

Dr. Andy Roark:

Hey gang, I just want to jump in with a couple of quick updates. The first one is the newsletter, the Dr. Andy Roark newsletter. Guys I’ve been writing a lot recently and I really enjoy it. I’m just writing stuff that makes me happy and stuff that I think is useful and sort of responding to questions that people ask me. And it’s been a great fun exercise and it’s gotten a lot of really positive feedback. If you guys want to see it, it’s 100% free. Just go over to drandyroark.com, sign up for the newsletter and then you’ll get the writings in your inbox. And I’m trying to write about once a week. It may be once every other week, but it’s just kind of, I don’t like to write more than I have to say. And so my promise to you is when I send you something, it’s something I think is good and at least worth looking at and considering. So anyway, head over there, check that out, it’s 100% free.

Dr. Andy Roark:

I have the April Uncharted Conference coming up. It’s the 21st through the 23rd in person in Greenville, South Carolina. Guys, Uncharted is the conference that I founded five years ago, it’s our five year anniversary. It is unlike any other event out there. It is an active learning discussion based conference. We actually make some of the sessions at the event based on what we do our first night, so we have attendees get together and talk about what’s important to them and what they want to do, and then we actually create sessions based on that, so that you have the conference that you want to have.

Dr. Andy Roark:

It is all about discussion. It is all about active workshops where you take away things you can actually use in your practice. It is about making connections. It is about finding out what’s possible. It is super, super inspiring. And man, if you want to have your spark, your passion for medicine, for running your business, for growing your career, for leading teams, re-lift, if you want to develop young leaders who are coming up in your practice, guys, there’s just nothing better than Uncharted. It really is the conference that never ends because our attendees are members in our online community which is vibrant and active and so useful.

Dr. Andy Roark:

I feel like I’m overselling it, but I don’t think that I am. It really is something special. Check it out. April 21st through the 23rd in Greenville, South Carolina.

Dr. Andy Roark:

The last is my friend, the one and only Jamie Holmes is running her workshop called Put on your Pants, it is how to hold meetings that matter. If you are struggling to get on the same page with your team, this is a fan-freaking-tastic, quick to the point workshop to help you build a structure using the pants structure that will help you communicate effectively and run tight, effective meetings. This is bedrock business knowledge that you should have. If you have a growing business, you should know the basics, how to block and tackle and run great meetings, and that’s what this is. So it is free to Uncharted members, it is $99 to the public. I will put a link in the show notes. Guys, that’s enough from me, let’s get back into this episode.

Dr. Andy Roark:

We have an episode together and I have to look back, I think it’s the first time that you were on the podcast. It’s one of my absolutely favorite ones on losing weight for cats and foraging. Why don’t you give us a quick rundown on forging, because I love the way you present this and your insight on it. So let’s talk a little bit about how you do forging and food puzzles? How you, and when you increase in difficulty? Give me a mile high flyby please.

Ingrid Johnson:

Sure, yeah, so we want to start with puzzles that are really easy, that roll easily, have multiple holes for the food to dispense from, are lightweight and clear, so the cats can hear, see and smell the kibble inside. And then as they get better at the game, the number of holes to dispense the food decreases, the toy might become opaque, the toy might not roll so well, the toy might become a cube. And of course we have stationary food puzzles too, of which a lot of those are quite easy. So we have to look long and hard for some stationary puzzles that really present more challenge and problem solving.

Ingrid Johnson:

And then eventually when the cats get really good at foraging, we start either dummy stuffing by taking crinkled up balls of paper and sticking them inside the toys so that the kibble has to work its way around the crinkled up paper to find its way out of the hole. We might put weights in the toy to make it hard to push. We might double stuff the toy by filling up a small food puzzle, like my little foraging ping pong ball and putting it inside a little foraging cube, and now they have to work that cube to get the food out of two objects at once.

Ingrid Johnson:

So I do want to make the point that there was recently a study published, showing that food puzzles did not help with weight loss. However, I don’t think that they’re implementing all of these other suggestions. You know, you’ve got to do the high protein, low-carb food. You’ve got to make the puzzles much more challenging. If you utilize them the way I utilize them, I think the results sometimes are different.

Dr. Andy Roark:

Yeah.

Ingrid Johnson:

And more successful.

Dr. Andy Roark:

Yeah that definitely makes sense. Okay. Alright. Cool. So I like this. I like combining sort of the food puzzles and the forging with a two month check in cycle and sort of cutting down. Yeah, I like it, totally makes sense. What else we got?

Ingrid Johnson:

Well, we also have to remember this cat needs some exercise, so we have to engage this cat in some interactive play. And a lot of people will tell me, well my cat doesn’t play. Well, if we’re overweight and lethargic, we’re probably a little sedentary, so yeah, it’s going to be a little hard to motivate them, right? But we’ve got to find that toy that gets them going, we’ve got to evoke that prey drive, moving the toy appropriately and evoking chase. But then we also might have to spice up life a little bit, maybe we leash and harness train this cat, maybe we get this cat out in the front yard walking around, sniffing the grass and the…

Ingrid Johnson:

You know, just getting a little activity because now we have this novel environment that is evoking more movement and we can get the toy going out there in the grass, which is even more fun. So it really just depends on the individual, the client’s motivation, the cat’s capability level, all of this factors in, but we can click or train these guys. You know, that’s a great activity. Part of the meal and the portioned amount of food could be a treat that’s given during training. And that clicker training could lead us to walking on a cat wheel, which is feline treadmill, great way to get some exercise.

Dr. Andy Roark:

Yeah, this is the matrix bending I was anticipating, okay right here. That’s a lot. There’s a lot going on there. Okay. Let’s… There’s a lot going on.

Ingrid Johnson:

Possible.

Dr. Andy Roark:

It is. No it is, it definitely is. It is. It is. Okay, so there’s a lot there. If you by magic wand went to my client’s house and you were going to live there and just work with this cat, walk me through how you are going to start implementing these things, because it feels like we’re going from lying comatose on the ground under the sun to full on sprinting Usain Bolt style. And so, talk to me a little bit about what is your thought process? And especially if I’m explaining this to the pet owner.

Ingrid Johnson:

Yeah.

Dr. Andy Roark:

I could just see their eyes getting wider and wider and wider as I talk about leash walking and clicker training and, and, and. So start at the beginning. What’s the first thing you do? How do you tie these things together? What would your thoughts be on what’s the most realistic, reasonable approach to start introducing these ideas to the cat?

Ingrid Johnson:

Well I think first we have to remember that an appeal to the natural predatory sequence that is a cat. So everyone tells me their cat won’t play, but everyone tries to play with their cat in the evening, after they’ve sat down, after dinner to sit and watch TV. That’s nap time.

Ingrid Johnson:

The predatory sequence for a cat is to hunt, stalk, chase and kill. Well, let’s back up. They torture it a little bit, rip off a limb, very suffering death, and then they kill it and then they eat and then they groom and they sleep. So we’re going to play, and then we’re going to give that canned food portion, that first wet food meal.

Dr. Andy Roark:

Gotcha.

Ingrid Johnson:

And then for those… Because cats eat nine to 16 meals a day, many small meals a day. If you want to get a cat to lose weight, you can’t starve them into losing weight, that creates frustration behavior, and honestly I think in most cases slows their metabolism down. So no twice a day meals, none of that. So we’re going to have the food puzzles out throughout the day so they’re not frustrated and they can walk up to a puzzle and bat it around and get kibble whenever they want. So now we’re playing before meals, we’re getting wet food meals as the bulk of our diet. Then the dry food is put in the food dispensing toys to lessen frustration and anxiety because they want to make sure they always have access to their main resources. And then if we want to do a little clicker training, we might incorporate a clicker training session maybe before dinner and we teach the cat to target on a mat or touch a click stick. We have to start somewhere, so we might just teach them to target first. That’s a basic foundation behavior.

Ingrid Johnson:

And part of their meal, say they like chunks and gravy, well, they’re going to get a chunk for every click and treat. We can use their diet food as their reward, or maybe we use a high protein reward, like freeze dried chicken, something that’s not super calorie dense. We’re not going to be using temptations for this cat, we’re never going to get the weight off.

Dr. Andy Roark:

Yeah, right.

Ingrid Johnson:

So we have to start with some really basic clicker training foundations. And then of course we can build on that and teach them to hop on a wheel. I mean, I literally have a cat that I can say wheel and he jumps on the wheel and starts running. I realize that’s not every cat, but it is possible, you just have to stick with it.

Dr. Andy Roark:

Yeah. So it sounds like what you’re saying is clicker training is foundational in order to get to these other things. I mean, basically that type of training and interactive work is what is going to let us try things like harness training, leash training, cat wheel, things like that, correct?

Ingrid Johnson:

Absolutely. Yeah, absolutely. I mean, sure you can train your cat to a harness without clicker training, but I think it’s easier for people to have some structure. It helps them teach the cat because we’re very confusing and we’re terrible with our timing. I mean most humans are terrible at training.

Dr. Andy Roark:

I agree. Yeah, no, I completely agree. And I guess that’s sort of part of my concern going into this conversation was sort of like, I’m not even doing the training, I’m coaching another human being to do the training. And so that’s why I wanted to sort of unpack that and try to get down into it. It also seems like if we can get the calorie intake under control and we’ve got… They’re having to do some work for food that will possibly motivate them to engage in training and stuff in a way that right now, when mom’s like, I try to get her to do things and she’s not doing anything.

Ingrid Johnson:

Yeah.

Dr. Andy Roark:

She’s wholly unmotivated. So she’s [crosstalk 00:20:08].

Ingrid Johnson:

She’s [inaudible 00:20:09] from a trough.

Dr. Andy Roark:

Yeah, exactly, right. And so you have no leverage. I guess that’s what I was getting at is you have no leverage and Gertrude has no motivation. If we just start, even by changing our feeding and how we do it, we may be able to create motivation that did not otherwise exist. Talk to me about play a little bit, is it that once we start down this road and we’re doing some training, do you think it’s easier then to start to do some play? Does the cat get more interested in that or is that a whole different ball of wax?

Ingrid Johnson:

I think as the weight starts coming off, they tend to get more interested in the play. So even if we can just get a half a pound off, things start changing. And one of the ways that we can play with them is by tossing kibble on the hardwood floor and they run, they catch that one piece of kibble and they come back for another, and they don’t get another piece of kibble tossed until they walk at least halfway back to you. And that can be a great game. So rather than putting that portion in a food puzzle or just tossing it.

Ingrid Johnson:

And I would like to reiterate or just, I guess, drive that for cats that don’t like wet food, this can totally work for them too. We’re just going to put high protein, low-carb prescription food in puzzles and make sure that we’re controlling to some extent the volume of that they’re eating, but we’re going to appeal to those many, many small meals throughout the day. And I also have a kind of a sneaky trick.

Dr. Andy Roark:

Okay. Tell me.

Ingrid Johnson:

This works really well and seems highly counterintuitive. But a lot of these overweight cats, they’re eating a bowl of Friskies and they’re carbosauruses, and they don’t even want their wet food. And they certainly don’t want to switch to Royal Canine glyco-balance because it’s like one of my favorite foods for these cats. So we will put them on an appetite stimulant to make them hungry enough to accept the therapeutic diet change. And then we slowly wean them off and it works like a dream. And it’s also fantastic for those cats that need prescription urinary food that have struvite crystals and food is their medicine, and if they don’t eat this food we’re going to have a medical emergency. Make them hungry enough to accept the therapeutic diet change and then wean them off.

Dr. Andy Roark:

That’s interesting, I’ve never done that. That makes a ton of sense. That’s awesome. Were you reaching for your version of mirtazapine? Have you got something sexier than that? What do you reach for?

Ingrid Johnson:

Any of the above. Mirtazapine, Cipro, Entyce/Lora? We actually use Entyce more because it’s more concentrated, so you have to give less volume. We don’t understand why the cat version is less concentrated and you have to give more, it seems odd. So we typically work with Entyce, but we put it in a capsule because it tastes horrible. So we [inaudible 00:22:39] the cat with the Entyce in a capsule. And then Mirtazapine, I love that because you’ve got so much flexibility. You’ve got your little 15 milligram tabs, you can cut into eighths. You’ve got dissolvable mini melts from Roadrunner. You’ve got transdermal gel, so many options.

Dr. Andy Roark:

Gotcha. That totally makes sense. This is great. Thank you so much for taking time and doing this with me.

Ingrid Johnson:

Sure.

Dr. Andy Roark:

Tell me a little bit, can people still get foraging toys from Fundamentally Feline?

Ingrid Johnson:

Absolutely they can. I’m making them as fast as my little fingers can be [inaudible 00:23:10]. I hand make all of my foraging toys and they are all available for sale on my website and they’re quite inexpensive really too. So yeah, please feel free.

Dr. Andy Roark:

Awesome. So yeah, I’ll put a link in the show notes. Fundamentally Feline. You are on social media as well under that, and then your websites fundamentallyfeline.com. Ingrid Johnson, thanks for being here.

Ingrid Johnson:

Thanks so much. Appreciate it.

Dr. Andy Roark:

And that is the episode, that’s it. That’s what I got for you guys. I hope you enjoyed it. Hope you got something out of it. As always feel free to leave me an honest review on iTunes or wherever you get your podcast. Just let people know what you think of the podcast and let’s help people find us. Anyway, take care of yourselves. Be well. Talk to you later. Bye.

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

Imagine a CSR working from home, checking a client out and booking appointments from his home, or a technician live-chatting with three different pet owners through the clinic webpage from her apartment, or a doctor doing telemedicine appointments from another state? This isn’t fantasy. There are practices actually making these things happen today. Christina Freeman and Summer Burke-Irmiter join Dr. Andy Roark to talk about how their clinic is breaking the mold to give employees (and clients) flexibility like never before. Let’s get into this episode!

LINKS

Uncharted April Conference: unchartedvet.com/uncharted-april-2022/

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

PICTURES

ABOUT OUR GUESTS

Christina Freeman joined the Adobe family in 2015 and focused her first few years in the Veterinary Marketplace. She was excited to move to the remote team and work with our online chat services and telemedicine and help these new communication tools grow and evolve. Christina is a native of North Carolina where she currently lives with her family and a large collection of animals great and small. Christina has a retail background and degree in Animal Science from North Carolina State University along with a teaching certification in all things science. She spends her spare time chasing children, gardening, doing pottery and oil painting.

Summer Burke-Irmiter, MBA, has worked in veterinary hospitals for over 25 years. At the Uncharted Conferences, you will find her proudly wearing her Founding Member button and excitedly talking about her two amazing hospitals with over 22 doctors, the Open Hospital design which allows clients to go wherever their pets go and pitching her latest outlandish ideas to anybody who will listen. She’s earned the nickname of “Goddess of Innovation” in some circles (along with other nicknames we won’t mention here) by helping to launch remote teams at Adobe over 9 years ago, pushing for video visits a year before the pandemic, and touting the benefits of online chat to her team. The recent development of Video Client Representatives is one of the many creative solutions Summer has to solve common issues in our industry. Summer runs away to the circus every chance she gets and trains in Cirque du Soleil type arts such as lyra, a spinning hoop 6-12 feet in the air.

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 so excited about this episode. I am talking today with my friends, Summer Burke-Irmiter and Christina Freeman from Adobe Animal Hospital. Guys, imagine your vet clinic for a second. Imagine that the technician is in the exam room with a pet owner and he’s going over the medications to go home. And he asks the pet owner if they have any questions and they say no. And he says, “Great.” And he taps the screen on the wall, and one of your CSRs who’s working from home, perhaps this person, son lives in another city or another state appears on the screen.

Dr. Andy Roark:

There’s a credit card reader mounted on the wall, and this person working from home checks out your client, asks any questions, schedules up follow-up visits, all of those sorts of things. And meanwhile, in between appointments, this person is chatting through your website with multiple pet owners at the same time, as opposed to talking just one person on the phone. Guys, that’s life at Adobe Animal Hospital. These guys are doing amazing things. I’ve got pictures that you need to see. I’m going to put them in the blog. I’ll put a link in the show notes so you guys can drop down and see it.

Dr. Andy Roark:

But at their hospital, at the front desk, there are literally screens turned around to face the pet honors and they have CSRs working virtually at their front desk. Gang, we talk and think a lot about what does the work from home revolution look like in that medicine? Guys, the truth is there’s a lot more things than we have thought of in the past. Get ready for a mind-bending episode about what one practice is actually doing in virtual medicine, in work from home in the vet space. I love this conversation so much. Anyway, gang, buckle up. Get ready for a great one. 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, Christina Freeman and Summer Burke-Irmiter. How are you guys?

Christina Freeman:

Good. How are you?

Dr. Andy Roark:

Doing really good. I am super excited for this conversation. For those who don’t know you… Let me just say why I’m excited for the conversation, and then I’ll introduce you guys through that. You guys work at Adobe Animal Hospital, which is out in the San Francisco Bay Area. You guys are part of Uncharted, which is a community that I love and get to run. And you have been for a number of years and you are one of my fanboy hospitals that I crush over because you do these cool, cool things. You were the first hospital that I was aware of that was an open hospital, meaning that people could go basically wherever their pets go.

Dr. Andy Roark:

My head hurt for a week after I first talked to you and really came to understand what you were doing and what that meant. You guys just, you do these things that get me excited and just remind me about what’s possible, and that medicine can be very different from what it has been in the past. And so I am a huge fan of you guys and the work that you do. Summer, you are the hospital administrator and the owner. Christina, you are the remote manager, which is how we come to be here today. Summer shared with me a couple of weeks ago, a new program that you guys were rolling out with what you called video client representatives.

Dr. Andy Roark:

So I’m not talking about CSRs that are answering phones from home. I’m talking about you guys have screens in your lobby that people can see traditionally, a CSR, a customer service rep. That they can see the customer and they can check out with this video screen. And you have people not just answering phone, but actually dealing with clients in the building while they, the employees are at home. And that’s amazing to me. And so I was like, “I want to talk…” First of all, I want to go through the system with you. I just want to unpack it and understand what you guys are doing.

Dr. Andy Roark:

I’m so impressed with just… And let me just say this too. I know this is a new program, you’re only doing it for a while. I love that you are doing this and putting it out, and I just think that so many people, as we’re looking at the great resignation and people changing jobs and also battling burnout and people being able to work from home. That has been shown to decrease levels of burnout, when people get to spend some time and say, “Hey, I’m changing my environment. I’m going to work in a more relaxed place. Even just a limited amount of time.” I am really looking hard at burnout. I’m looking hard at efficiency. I’m looking hard at making the jobs better and more flexible.

Dr. Andy Roark:

And I feel like you guys are actually out there in the wilderness doing the thing. I didn’t say you were lost in the wilderness. I said you are out in the wilderness, more of a Lewis and Clark, like headed westward sort of feel. That’s, how I feel about it.

Summer Burke-Irmiter:

Definitely.

Dr. Andy Roark:

Definitely. Those are the things I’m geeking out about, and so let’s go through. I just want to go ahead and start to walk through the journey that you’ve made so far with you. Go ahead, why don’t you guys tell me just a little bit about Adobe. I mentioned a very high level. Give me a clear picture of what you’re working with as far as the hospital, what makes it special? Just so people can have a mental picture of Adobe and what we’re talking about.

Summer Burke-Irmiter:

I’ll jump in there. Adobe is a really amazing place. We have two hospitals here in the Bay Area, one, which is a 15-exam rooms, three surgical suites, full cat and dog ICU, full lab and pharmacy. And so we’re big and I love it, 15 exam rooms. Overall between our two hospitals, we have 22 doctors and about 145 team members. Yeah, we’re a big guy. We have a second location about 20 minutes away that’s six exam rooms, ultrasound suite. They can still do major surgeries. They’re open six days a week there.

Summer Burke-Irmiter:

You mentioned the thing that I think makes Adobe special and amazing, which is the open hospital. So clients can go with their pet to ultrasound. They can help us set up an x-ray and then step out. We do vaccines and blood draws in front of owners. And because of that, our have a different level of trust with us. And our doctors all practice the medicine, they feel as best. So as a business, we actually don’t have a lot of hard lines with our medicine and what we recommend. We want the doctors to talk with the patients and the clients decide what the [crosstalk 00:07:15]

Dr. Andy Roark:

Talk with the patients too. You never know what you’re going to get.

Summer Burke-Irmiter:

Where are they going, what their risks are. For vaccines, we don’t say you give every puppy these set of vaccines. You talk with the owner and see what’s going to be best for that puppy and for that owner. Those are the two big things that I think make Adobe in general. Christina, what would you add to that?

Christina Freeman:

Truly the open hospital, I think is one of the big things that makes Adobe different and drew me to Adobe. When I first read that applying, I was like, “Oh, that’s awesome.” I had grown up in a little small town hospital where I got to go wherever I wanted to go, but yeah, I saw other people not be able to do that. So it important to me. It honestly gives a huge hospital that small town feel because you’re part of your pet’s care. I think that was definitely one of the things that drew me to Adobe.

Christina Freeman:

I’m not from the Bay Area, I’m from North Carolina, which is where I currently live. Why? I’m the remote manager, but I think what’s kept me with Adobe is just the constant creativity and growth, and the fact that we’re always changing things up to make things a little bit better for namely the pets. That’s always the first and foremost. That’s how we’ve gotten here, is keeping pets first.

Dr. Andy Roark:

Talk to me a little bit about the idea of remote work. When did Adobe start to really look at this as a concept? You guys were way pre pandemic when you started to kick this around. People are like, “Oh my God, look how far they’ve gotten in the last two years.” And I’m like, “No, you guys were way out ahead starting to work on this.” But help me really understand that, when did this idea of remote employees, when did that come together and why did that come together?

Summer Burke-Irmiter:

It’s been some while so I always have to remind myself. I think it’s eight to nine years ago we started.

Christina Freeman:

Yeah.

Summer Burke-Irmiter:

What happened is, here in the Bay Area, the cost of living is very high. A starter home within an hour of Adobe, you’re going to be at least 600,000 plus. And so a lot of our staff already live farther away, and then if you’re going to buy a home and raise a family, oftentimes our staff would move out of the area. And that’s what happened, is we had a staff member who was going to leave the area and we didn’t want to lose them. We all know how hard it is to get really great staff. And when we were faced with one of our staff members moving, we were like, “No, we need to make this happen.” I was like, “I need to make this happen.”

Summer Burke-Irmiter:

We keep good team members. They’re part of our Adobe family, and so how do we do this? And why are we limited by our building? Why can’t we do more? And so there’s so much work to do. There’s always work to do at Adobe, and so we just started figuring it out, really just one step at a time, lots of trials and errors, but it was to keep our team members. And so that original person did start out, I think like many hospitals now have a remote person, which is helping answer phones, helping call back clients for us. So it did start small and it just kept growing.

Dr. Andy Roark:

You guys also started to do remote communications with pet owners. Tell me a little bit about that. That’s different from having people work from home. That’s having pet owners stay home. How does that come into this?

Summer Burke-Irmiter:

One of the areas that I was really excited to explore was getting into chat. I don’t know about you guys, but pre pandemic, I loved chat. I actually had apparel companies that I would chat with all the time back and forth. I was on Zappos once and buying shoes. And I was chatting with this CSR on there with a question about the shoes and we ended up talking her cute pit bull that she just rescued. And so I saw that you could have a connection and get really great, fast help. And so really started looking at different platforms, what could we use? That’s where we initially settled on live chat, and this is where Christina actually comes in and I’ll let you take it from here because you can give all kinds of information.

Christina Freeman:

Yep. That was Summer’s crazy idea. I came to her and needed to move back for my family to North Carolina and she said, “Well, if you’ll stick with me, I’ve got a crazy idea. What do you think?” And I loved it, and so we really started small. It was truly just, we had a couple people trying some things out, but when we first started chat, it was just me for the first couple weeks. And then we grew to a couple people and added one of our doctors who was remote at the time or starting in the remote world. We were shocked at how fast our clients adopted it. Through the live chat platform, we just popped a widget up on our website.

Christina Freeman:

And so whenever someone would come on the website, the way we started originally was very organic. We would ask the client if we could help them with anything. And they would say yes or no, or some were thrilled. We really found… I think at first we were all like a little bit worried it would feel impersonal, so we really tried to give it a good conversational spin and not using forms and things like that. Just really us talking because I really wanted to create the atmosphere that this was real people, real Adobe people who knew what they were talking about and we were not a robot, and it worked. And our clients adopted it and really quickly and started coming repeat back questions day after day after day, short, little questions.

Christina Freeman:

Little questions about the hospital, little questions about their pet. We love it because we can send videos and pictures back and forth. That really helps us triage, especially like a surgical patient. We can look at that incision site without the client having to drive in and we can get really good images too. So we were thrilled at how interactive we could be with the clients. Another thing that I think surprised Dr. Lau and I, when we were first doing this, we would cover a lot of the evening hours. And we had a lot of our senior pets or our hospice pets that would come day after day after day.

Christina Freeman:

We got really invested in these people and their pets and their journey through what they were going through and just really created a nice, comfortable rapport and atmosphere with the clients that you don’t always have time for in the clinic. And so we really found it not only helped clients, but it sometimes enhanced their experience with us. That was really rewarding and kept us pushing. And as time went on, word got out. And so we became pretty overwhelmed pretty quickly with the load. And so we’ve grown our team from one to 24 in the last two years or three years, I guess and we’ve been really pleased at how the clients and the staff members love it.

Christina Freeman:

We have some staff who still work in hospital that help us with chat, some on a part-time basis, so they’re part-time remote, part-time in hospital. And now we have a lot of people who are fully remote. And it’s helped with people whose life has changed or a medical condition has changed. And so we’ve really been able to keep our good people and keep their skills in this field through this.

Dr. Andy Roark:

I have to point out the elephant in the room here, at least what it is for me can. One, help me understand what chat looks like. I guess what I’m saying is, what are the most common things that people ask? And then two, the reason I’m asking this is, when you guys are talking about chat and you’re very excited about it and you seem to really love it. I’m imagining complete pandemonium in chat of like your own social network and people talking about their grandkids and and like a Friendster network on my webpage. Conviince me of the return on an investment of chat.

Dr. Andy Roark:

You have 24 people doing chat. As a business owner, I’m like, that sounds like a nightmare. Convince me of the value of this. I’m trying to get my head around what this really means for the pet owner and what it means for you guys from an efficiency standpoint. It like more, not less and I want to get my head around that.

Summer Burke-Irmiter:

And actually before-

Dr. Andy Roark:

You’re both laughing real hard as I say that. I think I’m probably having all of the anxiety and the nerves and the worries that you had at the beginning. I’m having this now of… But first of all, my first thought would be, what if this fails? And my second fear would be what if this succeeds? And I can panic in both directions. Talk me down off this ledge.

Summer Burke-Irmiter:

Well, actually I’m going to add to that ledge just a little bit.

Dr. Andy Roark:

Holy crap.

Summer Burke-Irmiter:

It’s not to brag and just really show how big this can get. Christina and her remote team, since we started the live chat in 2018 have helped 60,000 clients. They’ve taken 60,000 chats. And now that’s not the back and forth that you can have. That’s not counting each one of those. That’s a single session with a client. I’m going to add that mind-blowing right there.

Dr. Andy Roark:

I feel like you’re helping people in Brazil. That’s what I feel. I feel like there’s people who’ve just found you and they’re like, “These people will talk to me. If you’re lonely and have a pet, they’ll talk to you.” That’s what I feel like. Is that true?

Christina Freeman:

There was a handful. I think the farthest I’ve ever spoken to someone was Singapore when IAMS Pet Food stopped creating their vet diets. It became like this frenzy of finding people with these products. That’s as far as it’s gone. but for the, I would say 97% is our actual clients. We are careful, we don’t, we do. Every time we start a conversation, we get the pet details. We look up their record.

Dr. Andy Roark:

Smart.

Christina Freeman:

If they’re not our clients, we do recommend that they speak to their local hospital, just so that history is with them. We’re not trying to push people off, but we do feel like, don’t talk for me for 30 minutes about diarrhea and then go to your hospital and expect them to know what we talked about. That is one thing that we are pretty careful about. And the great thing about the chat is every single thing we say, every single thing we share, we upload into the medical record, so when that pet does come in a couple days later or later that day, it’s all there, that history’s there. So they don’t have to go back through that again, our medical staff can read through that.

Christina Freeman:

Just a short thing on the ledge, and I know Summer can, can help remove people from the ledge quickly, but what we’ve done with our team is allow the in-hospital team to focus on the pets that are in the building, rather than you’re sitting there helping a pet and you’ve got four people waiting on the phone that have a question for a doctor. We’re able to take that load from them so they can focus. And we can seamlessly help the client. The client has no clue in cases that we’re not actually in the building.

Christina Freeman:

We stay in constant contact with our doctors who are on the floor, they’re feeding us advice. And so we’re able to take that load off of the team in the building who need to focus 100% on the pets.

Dr. Andy Roark:

Okay. No, that makes a ton of sense.

Summer Burke-Irmiter:

And you bring up a good point there, Christina is one of the reasons we started looking at this in 2018 is at that time, if we all can remember past then. I know it’s been eons, seems like a decade, not just three years, we were already experiencing that short staffing with technicians in particular. With the high cost of living in the Bay Area was compounded, and Adobe had always offered medical advice to our clients. We’re probably way more open than most hospitals about that client calls. We will talk to them through, make sure there’s no contraindications. And then if it’s that vomiting lab, we’ll go ahead and give them a bland diet, what to look for and when to call back.

Summer Burke-Irmiter:

And we were looking at losing that. That was something that I felt was really important to Adobe. And by figuring this remote piece out, we were able to keep something that I thought was part of Adobe and part of Adobe soul and just move it out of house. And that worked out really well. And yeah, to talk you off the ledge there, Andy, there are some tips and tricks behind the scenes with these chat systems that really make it helpful. One of which is, and this is good for everybody to know, they can see what you’re typing before you hit enter. Remember that.

Dr. Andy Roark:

Really?

Summer Burke-Irmiter:

So when you’re about to be like [inaudible 00:21:10], and then you erase it, they saw it.

Christina Freeman:

They see all that.

Summer Burke-Irmiter:

You see all that. So when you can already see somebody typing out about the diarrhea, and then what you’re doing is there’s scripts that Adobe did, ourselves, but you can have a diarrhea script. So as soon as that client is done, you press enter on the diarrhea script and it’s got all the questions we always ask. How is their eating? How often? What’s the color? All of that. So then that gives you a minute to either work on another chat. Our chatters who are super experienced can take multiple at a time. You can’t take multiple phone calls at a time per person, but you can with chats.

Summer Burke-Irmiter:

Or it gives you that moment to either take a breath or to do another task, which is a lot of what the remote operators they’re doing. They’re then working on something else while that person fills in their answers with the diarrhea. And you’re already seeing again what they’re doing. So if you’re like, “Ooh, they just said blood.” You’re going to be ready for that and you’re going to get them in the hospital. Or, this is where Christina mentioned Dr. Lau. We have two remote doctors for video visits, which came in 2019. And those doctors also help the remote team with advice, questions of, “Hey, what should I recommend for this?”

Summer Burke-Irmiter:

Or if it’s more specific, “This client is asking a medication question that their dog’s currently on. Can you help us with this?” And so that’s where behind the scenes, they’ll also with that. There’s a lot of tools behind the scenes to help out with those 60,000 chats that they’ve taken.

Dr. Andy Roark:

Okay. I have some questions. Let me start to dig into this. The idea of having some scripts makes total sense, and especially like follow up questions of when they talk about diarrhea, here are the follow-up questions. That makes my innovative efficiency smooth workflow heart so heavy. And so that totally makes sense. Okay. Talk to me a little bit about chats uploading into the medical records. That sounds like it could be a Herculean task. It also sounds like it could be turnkey smooth as silk. Which one is closer.

Christina Freeman:

You’re in the middle. One of the things Summer and I have been talking about recently is there are some pain points in some of this because we’re starting at the very beginning. But the great thing about it is the companies are really listening to us that we’re working with. We are feeding them our problems and they’re helping us solve them. So that has been great. It’s been challenging to be in it, but it also, we are discovering the problems as we go that need fixing. And so the companies are super helpful to help us. We are transitioning with companies major that reason. Right now it is manual, we do copy and paste this into the record, and we’re talking about six key strokes to get it in the record.

Christina Freeman:

But the company that we’re talking with now is going to make that automatic. As soon as we finalize that chat, it’s automatically fed into the record. This has been fun to be on the innovative front of like, “Okay, here’s our problem. Help me solve it.” And so that’s going to speed us up. Summer mentioned, part of the glory of chat is we can do multiple things at the same time and we can help clients at the same time. When you’re speaking medically, and you’re looking for medical records, and you’re having to bring up the pet of, if you’re a seasoned chatter, three is tops because you need to be focused and make sure, like three pets at a time.

Christina Freeman:

But as Summer said, you’re stuck on the phone with one call, where with a chat. And also you don’t get those visuals that we can get via chat. We can say, “Hey, could you go snap a picture of that?” The owner runs away and snaps a picture and comes back while we’re helping another client, or we’re picking up a phone call or we’re answering an email. So there’s a lot of other administrative things that we can do behind the scenes while all this is going on, while we’re also helping pet owners via chat.

Dr. Andy Roark:

Cool. Who are the companies that you’re working with on your chat?

Christina Freeman:

Well, we’ve been using live chat and we’re transitioning to TeleVet. And TeleVet is a more veterinary-centered product that is helping us build the things we need and these automated things.

Dr. Andy Roark:

Hey, everybody, I just want to jump in here with a couple quick updates. If you’re listening to this podcast and you’re like, “Oh my gosh, vet clinics are doing stuff like this. This is amazing.” You should join Uncharted. The Uncharted Veterinary Conference and Community, that’s where I met Summer and Christina, is where we learned about Adobe. This is the type of stuff that we talk about in there. Everything from open hospitals, where pat owners go wherever they want to virtual medicine, to work from home, to the classics about getting the staff to come together as a team.

Dr. Andy Roark:

Building culture, solving problems, growing people as leaders and communicators and visionaries. That’s what we do in Uncharted. If you’re like, “God, I want to live in this world. I want to practice medicine in this other way. I want to be the captain of my own ship.” Check out Uncharted. Guys, our April conference is coming up, April 21st through 23rd. If you’ve not been to an Uncharted conference, I promise you have not been to anything like this. We do choose your own adventure sessions where attendees make sessions on the first night that we then put on during the event, it is all networking focused.

Dr. Andy Roark:

You will make friends. You will talk to people who are doing incredible things. You will get re-inspired, you will get reinvigorated. You will learn techniques and tips and tricks and strategies for running a smoother, more efficient, more rewarding vet practice. That is what this conference is all about. The 21st to the 23rd, is in Greenville, South Carolina. I’ll put a link in the show notes. You can become an Uncharted member. We have a vibrant online community. We talk constantly. It is not a thing where people get in there and it’s a ghost town or where there’s canned content.

Dr. Andy Roark:

We are constantly talking as a community about solving problems, about growing practices, about doing new and different things. About making our lives better and easier, about handling hard problems together as a group. That’s what we do. So anyway, if you’re not familiar, if you haven’t tried out Uncharted and this episode is inspiring you, this is your call to action. This is what you need to do.

Dr. Andy Roark:

Gang, I also have to stop here real quick and just say, thanks again, to Banfield Pet Hospital. Through their help, we’re able to have transcripts for episodes. And this is all about increasing accessibility, inclusivity in vet medicine, and making sure that everyone has access to the materials that we’re putting out. We could not do this without them. They have supported The Cone of Shame and having transcripts and The Uncharted Veterinary Podcast, which is our other podcast. It’s a business management podcast. But thanks to those guys for stepping up and leading the charge to make vet medicine more open and inclusive. They really are doing amazing things. Anyway, guys, that’s all the announcements I got. Let’s get back into this episode.

Dr. Andy Roark:

Talk to me a little bit about how the veterinarians support this. You’ve got veterinarians that do telehealth visits, and I want to put a pin in that and come back to that in a little bit. But let’s just say that you have veterinarian behind the scene that is lending support. How do you back channel that? You’ve got someone and they’re working remotely, I’m assuming, and then they’re doing the chat, and then they’re… How does that person feel supported and not feel like they’re out by themselves? How are you handling that behind the scenes communication?

Christina Freeman:

It’s been interesting. Being remote, we have built some closer relationships than we ever had in the hospital, which we… I’ve been working with Dr. Lau for three solid years all day, every day and I had never actually gotten to hug her until about six months ago. And we actually converged accidentally at the same time on a trip to California. She works and lives in Virginia and I work and live in North Carolina. We’re close, but it just hadn’t happened. But it is remarkable the trust that we’ve all built working together. We are in constant contact via… We use Google Hangouts a lot.

Christina Freeman:

We do a lot of remote training together with each other and with our new team members that we’ve grown so quickly where they are just on video all day with us, and they’re just watching what we’re doing or vice versa. We’re watching what they’re doing. So we are literally, virtually side-by-side all day, every day, which has been really good for team building and bonding and training. We’ve been really surprised at how the efficiency of our training through video. And it’s also grown into like we’re starting to train some in-hospital people through video because it is so efficient and we can be a little bit more open about times and hours and availability.

Dr. Andy Roark:

Let’s let’s follow that thread a little bit. So I said we were going to put a pin in the telemedicine doctor visit stuff. Let’s follow the video path. So we’ve talked a lot about chat and then let’s talk about how do you guys use video… I started off talking about the video client representative but let’s go into the telemedicine part first, just walk me through your approach in video communication.

Christina Freeman:

A lot of our chats do generate into a video visit. So we’re having a conversation with an owner and we’re talking about new puppy owner. They’ve got a lot of puppy questions, but they also have got diarrhea going on at the same time. So pet stable, we’ve answered all the scary questions and everything’s okay. So very natural progression to move into a video visit with one of our doctors. That lets the owner be at home, they don’t have to come in, that lets the pet be at home, be comfortable. And we’ve seamlessly gone from the chat to now a video visit where they meet with the doctor. The doctor’s able to see the pet and evaluate what’s going on. Medication is needed or give a little bit deeper advice on how to get that pet back on track or what that puppy might be experiencing.

Christina Freeman:

Same thing on the senior side where owners contact us and they have a senior pet, got some concerns. We’re able to move that into a video visit pretty seamlessly most of the time, same day. So it’s very convenient for the pet owner, they don’t have to leave the house. Sometimes we can go straight from a chat into a video visit if we have availability. Now that we have two doctors, that’s quite often what we do. So a lot of our more, I don’t want to say simple but more straightforward issues, that’s how are born from chat into a video visit the natural progression.

Dr. Andy Roark:

Good. Talk to me about doctor scheduling for this. So again, I really appreciate you guys just letting me pick through this. So that’s the other thing. People always say, “How do you have doctors…” I think that’s a big hurdle for Telehealth is how do you make the doctor’s schedules work? So do pet owners have the ability to make telehealth visits? And then also we flex chat appointments in to fill that schedule out. Is there a standby vet just support chat? Did that happen at the beginning? Or did you add in some Telehealth visits after you had built the chat up and you were having these conversations and you felt like, “Oh, now we’ve got enough of a caseload that would support this vet.”

Dr. Andy Roark:

Yeah. Share with me your thoughts on that because there’s a lot of people who were like, “Oh man, we’ve been talking about Telehealth visits… I think for me, when I look at Telehealth, it makes sense if you can generate the volume. Because otherwise you’ve got that hanging out, not seeing appointments. And then if they go and start seeing appointments in the physical exam rooms and you say, “Well, how do we get them back out to be on time for these other things?” I think a lot of people are balancing these logistics and you’ve got this really neat outside around the way you have done this. And so yeah. Talk to me a little bit about doctor scheduling for these types of Telehealth appointments.

Summer Burke-Irmiter:

Okay. So yeah, with Dr Lau, who I have to give credit for, for finding our video visit platform. She found TeleVet and we originally thought we would go with a human-based video visit company because they were established, they had worked through the kinks. But it turned out that the human systems were super complicated and really didn’t fit the veterinary world. So with TeleVet, the reason why we originally got excited about them is they had chat on their platform and we’re like, “Okay, if we have chat and they have chat, this might work out well.”

Summer Burke-Irmiter:

And they were super responsive. What we didn’t realize at the time is the reason they were responsive is they were I think a two and a half person company at the time. And it was the big male who was chatting with us. Straight awkward, but. But we loved the response, we loved how engaged they were, the platform fit well, and then as we onboarded and started getting used to it, they would make all these tweaks and changes that really fit us. And again, that’s what called to my heart is we were making this fit for Adobe and that was really fantastic. So I’ll stop there though and let Christina talk a little more about the scheduling and how the juggling that they do over there is amazing.

Christina Freeman:

Well, in the beginning it was just Dr. Lau and I, so we had luxury and the flexibility of being at home and so we worked when the demand was high. And so we were able to monitor the website and know when people came on the website and so when they came on, we made ourselves available and we were there to chat with them and help with them and I’d ping Dr. Lau and be like, “Hey, can you do a video visit?” And she’s like, “Sure.” And scrambling together from whatever else she was doing. So we were very organic in the beginning in the fact that we just saw when our clients were needing us, and so that’s what we did.

Christina Freeman:

As we grew, we needed more structure, we needed a life. We were available 24/7 in the beginning just to get this work in it had figured out. But then we really did discover the peak times that clients wanted and needed us. And so we built a Dr. Lau’s schedule around that. And then as we added Dr. Nakamura as well, he balanced the other parts. So we do have a doctor available to our chatters and for video visits seven days a week between the two. And I guess truly what we did is we looked at the peak request times and managed our time from that. So if you want to get started small, totally able to do that, look at your clientele, look at when they’re asking for things, just very generalizing. It’s going to be early evening hours and sat morning hours when clients first get home from work and they discover there’s a problem.

Christina Freeman:

So you get home from work at 5:30 and you’re like, “Oh, my puppy has diarrhea.” Or you get home from work and you discover your senior has had some changes during the day that you need some advice. And so running some hours in the evening, two or three hours to fit in those requests between getting home and people going to bed. And then those Saturday mornings where you wake up and you’re like, “Oh, I should have called the vet on Friday.” Everyone knows what calling a vet on Fridays is like, so that’s the way we started in the beginning. But now as we’ve grown, we have the luxury of having 24/7 or 7-day a week help during our peak hours.

Dr. Andy Roark:

Gotcha. Okay.

Summer Burke-Irmiter:

And also, especially early on but they still do a ton now. There was a lot of duties that the in-hospital doctors were doing that remote is able to help with and Dr. Lau and Dr. Nakamura are able to help with. So they actually do a few things. They do a lot of the general refill requests, so that now goes on a live spreadsheet online that they can access so they can go through there, especially for doctors who are on vacation, who aren’t going to be in for couple of days. So instead of the technician or the pharmacy tech having to go to that doctor at their desk and be like, “Hi, sorry, but you look at this heart garden prescription.” They actually do that first thing in the morning.

Summer Burke-Irmiter:

And so pharmacy gets in, they’ve got meds to fill or clients to immediately call back and say, “I’m so sorry, the doctor’s really suggesting that we need to do this blood work first. We’ll get you a couple days worth.” So they do a lot of that. They’ve also taken on a lot of doctor flow things in regards to, “You know what? It’s that last day of your work week and you just did blood work on a patient. They need to be called the next day. It’s not one that should wait until next week when you’re back, the remote doctors will help with that.” And they also can help with bridging even if you have two doctors on a case, that’s outpatient, then they can actually help bridge with some of those callbacks as well.

Summer Burke-Irmiter:

And so they’ve helped with a lot of in-hospital things. During COVID, we were doing our shelter in place here in the Bay Area. They also became what we call the COVID doctor would help with all kinds of things just because we did go curbside, which was a huge change for Adobe from open hospital. And so all that extra work, they really helped out a ton with that. So we did initially, they weren’t booked with video visits all the time, they were helping with that. We’ve actually, over the last couple years had to reduce how much that they’re doing of that admin work because they are getting busier and busier there.

Summer Burke-Irmiter:

And actually he’s okay with me being pretty open about this. When COVID hit, Dr. Nakamura’s immune compromised. He had to leave. And if we didn’t have this option, he wouldn’t been in the hospital for a year and a half. So we didn’t lose the doctor, added a doctor. He sees exotics as well, and a lot of the husbandry for exams is really nice to do because you can see the tank, you can see what they’re using, what they’re set up is by using that video camera.

Dr. Andy Roark:

Yeah. So that makes a ton of sense. So we’ve talked about chat, we’ve talked about video consultations. What are some other jobs that you guys are doing now remotely at Adobe?

Summer Burke-Irmiter:

Yeah. I’ve actually got the list in front of me. Christina, do you want me to read it-

Christina Freeman:

Go for it.

Summer Burke-Irmiter:

… off real quick? Okay. So with our entire remote team, they do voicemails. So this is doctor voicemails transcribing them into an online live document. Doctors, go on and say, “I’ll call this one, I’ll just call this one back and do a recheck.” They’ll then go ahead and call that client. They’re doing our advice lines. So we do allow clients to still call in if they be to for medical advice and or triage. And so they’re doing those advice lines, they’re doing live chat, they’re also looking and using TeleVet, especially for prepping clients for their video visits, things like that. They do pharmacy. We actually have a large pharmacy group now of pharmacy technicians who do all the admin work for on the floor pharmacy techs. Surgery, this is actually, I want to say something here. Surgery scheduling. Sorry.

Dr. Andy Roark:

Okay. Yeah. That’s appears [crosstalk 00:41:50] like virtual surgery.

Christina Freeman:

Little robotic arm.

Dr. Andy Roark:

Yeah, exactly. We have a robot and they log in with a PlayStation controller.

Summer Burke-Irmiter:

Well, actually that’s our next, that’s where we’re going to.

Dr. Andy Roark:

That’s where we’re going next. Yeah.

Christina Freeman:

We’re headed there.

Summer Burke-Irmiter:

Is robot doctors. But until then. So surgery scheduling has been an issue in Adobe since I started 14 years ago. We’ve always had our surgery team on the floor who scheduled. And then we had one full-time scheduler in-house. Pre pandemic, it was sometimes embarrassing to admit this. It was up to 14 days before you might get a call back to schedule a surgery. And we were just so busy, the team was busy, our single scheduler was busy. And with all of our different doctors, it’s not easy to schedule. And it’s not because of the team. The team is just busy. And so we have now through a year long process, fully moved this over to remote.

Summer Burke-Irmiter:

We have a surgery scheduling team. They schedule all of our surgeries. We are within actually a couple of days of them. 100% taking it over after training and a prolonged period there, they got to same day callbacks within less than a week. So they now do same day call back for all of our surgery scheduling, take care of the entire process. We do now still have our surgery scheduler in-house when she came back from COVID and maternity leave. So get this, during a time when we’re all short staffed and crazy, we were actually able to add a service. So be because this full-time scheduler is not doing any of the emails or voice messages that we’re getting for surgery, she’s able to go directly into the room. If somebody wants a schedule right now, she’s in the room and she’s scheduling it. So we have an in-house in-room scheduler because we have this team taking care of everything else.

Dr. Andy Roark:

Yeah. That’s amazing. Let’s go ahead and unpack here at the end where we started. Talk to me about the video client representative and how that works and how you rolled it out and what the reaction has been to you having virtual CSRs, actually working with clients who were in the building.

Summer Burke-Irmiter:

Yeah, I think it’s probably the craziest idea my team has let me do.

Dr. Andy Roark:

I saw photos and I was like, “This is bonkers.”

Summer Burke-Irmiter:

Yeah. When I brought it up, I think they all thought it was crazy. You could have beat it, Christina.

Christina Freeman:

Nope, totally on, totally on. It was born out of true necessity. We just didn’t have enough people in the hospital to cover the front desk. And so, someone and I were talking one day and we’re like, “Why don’t we just turn one of those screens at the front desk around and put me on it?” And that’s what we did. And we tried it out. And so it grew into… It started out with we wanted to do in-room checkouts. So each room has a computer, the doctors use to access the medical records. And so we just hijacked that computer and added a camera on. And so that was where we wanted to start, but it grew into the whole process being a virtual. So each exam room, we just added a camera to the screen. So super easy and take a lot of extra tech to do.

Christina Freeman:

And so now when you’re finished with your visit, one of us pop on the screen and we are able to talk about your private address and getting all of your personal information correct in the system, your phone number, your email address, things that people don’t like shouting out in the lobby. So we’re able to go over that. We’re able to talk about the finances, which is not great to talk about in the lobby. You’re able to stay in the room with your pet, you don’t have to juggle the leash. You’re able to pay. We have TeleVet that we work with got really excited when we wanted to do this and so they’ve helped us build this process but we have credit card terminals in the rooms. And so you’re able to pay.

Christina Freeman:

So the checkout process has been a real value add to the client. Clients are thrilled, they enjoy it. They’re like, “Oh, this is so nice.” And we’ve seen adoption. I have not run into someone yet and we’ve been doing it since November, that’s been displeased with that. So that has been nice. Now the front desk video screen is a little bit harder to sell because people are used to having a person up there, but it works. And we are able to do everything via this screen that we would do in person, the only thing Summer and I teased about, but she solved that problem too. I was like, “Well, we can do everything except clean up the pee in the lobby.” And Summer’s like, “Oh, there’s robotic-

Summer Burke-Irmiter:

Roomba.

Christina Freeman:

… Roomba.

Dr. Andy Roark:

Like a Roomba. Yeah. With a wet-

Christina Freeman:

A mop.

Summer Burke-Irmiter:

Right.

Dr. Andy Roark:

A wet mop Roomba.

Christina Freeman:

So if there’s a problem, we keep figuring it out. But so when clients come into the hospital, there is a monitor there on the front desk with signage that says, “Check in here.” And it’s cute. Clients smile and also they recognize us. So a lot of us used to work in the hospital, or all of us right now used to work in the hospital. So they’re seeing familiar faces, they’re hearing familiar voices and they’re like, “Oh, I missed you. How are you?” And so we’re able to keep connecting with our clients.

Christina Freeman:

And so it doesn’t… I think Summer and I both had the worry that the monitor on the front desk would feel a bit impersonal. We’ve actually found this the opposite. We’re chatting of, they’re holding up their little pets, we’re chatting with the dogs as well and so we’ve been pleased with the adoption. And also with COVID, it’s been a safety measure as well, a surprising safety measure. We’re able to speak to them without a mask, they’re able to hear us because we’re remote. And so that’s helped with this process.

Dr. Andy Roark:

Yeah. I imagine it’s like self checkout at the grocery store. If there’s a cashier standing there, I’m going to that person. But as soon as there’s two people in line, totally self checking out.

Christina Freeman:

But imagine that self checkout with a human talking to, because that’s the problem, you get your broccoli and you don’t have your code number and you’re like, “Ah.” But you’ve got a human there to help you with your broccoli. So we are-

Dr. Andy Roark:

Well, I know it. That’s it, they can recommend ice cream flavors. All right guys, where can people learn more about Adobe and your amazing hospital?

Summer Burke-Irmiter:

Yeah. So few different areas. You’re welcome to come our website, adobe-animal.com. And you’ll probably see our chatters on there. If they are busy, they’ll ask you to leave a message that they will respond to. And so that’s the other thing with chat is you don’t have to take them live by That moment if things are busy. And then also I think we sent over some picture.

Dr. Andy Roark:

Yes.

Summer Burke-Irmiter:

You guys, and so you can check out some pictures. Because I know initially when we talk about VCR, it can seem like this big wild concept. Once you see how simple it is. I feel like it’s the post-it note for veterinary hospitals right now. Everybody in a year or two is going to be like, “Oh yeah, VCR, whatever. We’re all doing it.” Because it’s so easy. But right now it can be hard to conceptualize and so check out those videos where you’ll see Christina and her backdrop in her home. Yep. With our lovely vinyl background, that’s the background of our reception areas, and fools a lot of clients. And then you’ll also see though pictures of her on the monitor around the hospital, checking people in.

Dr. Andy Roark:

That’s awesome. So I’ll probably put a link to our blog post about the episode and then I’ll put the photos in there for sure. Also guys, we are posting podcast episodes as YouTube videos. And so we’re going to drop them in there as well if you guys like your podcast as YouTube videos, you got to see photos there. Last question, Christina. I have thought the whole time that you were in some remote location because there’s an Adobe Animal Hospital, big logo on the wall behind you, and that’s your house?

Christina Freeman:

Yes. This is my house [crosstalk 00:50:52] here in North-

Dr. Andy Roark:

What does your family think about the fact that you have a work logo? Your husband was like, “What the heck is this?”

Christina Freeman:

Honestly, they love it. It’s been a very exciting crazy journey which is my life is, but one of the great things is I’m here. I have three children, they know exactly what I do. They see it, they hear it. Sometimes they’re… Actually, my five-year-old got a pencil from the pencil box while we were talking. But so that’s been a great thing for myself and my family. If your kid grow up and don’t know what you do, but they know exactly what I do. And it’s cute because in the background, they’ll be like, “Shh, mommy’s helping a pet with diarrhea.” And they’ve learned so much too. They’re like, “Are you going to tell them about the bland diet?”

Dr. Andy Roark:

Yeah. I could totally see that. I would be getting advice from my kids in no time. And they would be like, “Dad don’t forget.”

Christina Freeman:

Yeah. Oh yeah, they keep me on track too. So live chat has little auditory cues when you have an incoming chat. And so it says in a British accent, “Incoming chat.” Now guys. Nope, nope, Nope. [crosstalk 00:52:05]

Dr. Andy Roark:

Now they’re making appear on camera. Okay. All right. The wheels are coming off here. Yeah. I know how that goes. That’s-

Christina Freeman:

Hi, darlings, now you heard what I said, y’all have to go downstairs.

Dr. Andy Roark:

That’s me. That’s my life all day, every day. I love it. It’s so true.

Christina Freeman:

They heard me. I’m sure they were downstairs like, “What’s she saying?”

Dr. Andy Roark:

[crosstalk 00:52:24] She’s talking about us let’s go.

Christina Freeman:

Like, “It’s her chance roll the ball.” But they made up Carol of the bell at Christmas, incoming chat, incoming chat. So they’ll run behind me and sing that and freak me out. Because I’m like, “Where?” Because once you’ve been chatting forever, you know the words incoming chat, [crosstalk 00:52:47]

Dr. Andy Roark:

Where you’re here and just-

Christina Freeman:

Exactly. Start to salivate, so.

Dr. Andy Roark:

All right.

Christina Freeman:

They love to sneak up behind me and go, “Incoming chat.”

Dr. Andy Roark:

Oh, so cruel. I love it. All right guys, thanks for being here. Guys, thanks for listening to the podcast. I’ll talk to everybody next week.

Dr. Andy Roark:

And that is the episode. That’s what I got for you. Guys, I hope you enjoyed it. I hope you got something out of it. If you did, share the episode with your friends, spread the word. This podcast is growing like crazy. I have been blown away by how many new listeners each month are coming into The Cone of Shame. And it’s a world to me. I’m so thrilled that we’re doing stuff that people find value and are excited about. But yeah. Share the podcast, tell your friends if you feel inspired. Write us an honest review, wherever you get your podcast, it’s how a lot of people find the podcast. So anyway, gang take care of yourself. Be well, I’ll talk to you soon. Bye.

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

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

We have a wonderful (but anxious) German Shepherd with chronic diarrhea that just isn’t going away. Her owners would like to handle this without medications if possible. Veterinary nutritionist Dr. Raj Naik is here to talk about the case, our options, and the importance of considering the microbiome as we treat GI disease.

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

LINKS

Purina Institute Microbiome Forum: 
www.purinainstitute.com/microbiome-forum

Purina Institute: www.purinainstitute.com/

Charming the Angry Client On-Demand Staff Training: drandyroark.com/on-demand-staff-training/

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. Raj Naik developed a special interest in clinical nutrition while at the Virginia-Maryland College of Veterinary Medicine. After completing a rotating internship at a large specialty hospital in New Jersey, his love of nutrition brought him to the University of Tennessee to pursue specialty training in small animal clinical nutrition. Dr. Naik joined Nestle Purina shortly after completing his residency. As a Veterinary Communications Manager and one of several board-certified veterinary nutritionists at Purina, Dr. Naik serves as a liaison between Purina and the veterinary community. Outside of his day job, Dr. Naik recently served on the Board of Regents for the American College of Veterinary Nutrition. In his free time, you will find Raj attempting to entertain his son along with his wife, dog, and two cats.

EPISODE TRANSCRIPT

Dr. Andy Roark:

This episode of the Cone of Shame Veterinary Podcast is made possible ad free by our friends at Purina Institute.

Dr. Andy Roark:

Welcome, everybody, to the Cone of Shame Veterinary Podcast. Guys, we’ve got a great episode today. It’s me and my friend board veterinary nutritionist, Dr. Raj Naik. And we are talking about a poor German Shepherd with chronic diarrhea and anxiety. I love the GSDs, they tend to be anxious dogs, and anxious dogs tend to have soft stools sometimes. What do we do about it? How do we break this thing down from a nutrition standpoint? 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. Raj Naik. Thanks for being here.

Dr. Raj Naik:

Thanks for having me.

Dr. Andy Roark:

Oh, my pleasure. My pleasure. I’m super excited to talk to you today, I love having you on the podcast. I have a case that I want to break out with you. You up for this?

Dr. Raj Naik:

Absolutely. I love cases.

Dr. Andy Roark:

All right, perfect. I have an interesting one. I have a five year old female, spayed German Shepherd named Aspen, who she’s a chronic diarrhea dog. Well, I see this client a lot, they’re in and out. Aspen is an anxious dog, she’s a clinger, she barks when moms leaves, just a regular high strung German Shepherd that keeps having these bouts of diarrhea.

Dr. Andy Roark:

Mom is a bit of a naturopath. Not, not over the top, she doesn’t hate medications or anything that, but she is having some concerns about continuing just to medicate this dog to deal with diarrhea. She wants something that’s going to be sustainable, that’s going to help get these outbreaks under control. That just doesn’t feel so heavy handed to her. And so I wanted to bring that to you and have you coach me through this. Raj, how do you treat that?

Dr. Raj Naik:

Oh man, so this is such a good case because this is, I think a classic case that you’re going to see in general practice. And of course, we’re going to go through the initial diagnostic workup of what can we do to figure out what is the chronic diarrhea? What is the cause of the chronic diarrhea? What is the main root cause of these anxiety concerns? But, as a nutritionist, I almost immediately go to what’s going on with this dog’s microbiome? How can we modify this dog’s microbiome to help whatever other treatment we’re going through? And so I think about things like probiotics and prebiotics and how we can actually modify that dog’s microbiome to help enhance their recovery.

Dr. Andy Roark:

Okay. All right. Let’s unpack this because you jumped to … It was interesting that your mind went there. That’s not where my mind went so I want to walk with you. So high level real quick, give me a breakdown. Your mind goes straight to microbiome, tell me about that. Define some terms for me, give me an idea of why in the disease process your mind goes here.

Dr. Raj Naik:

Yeah. The microbiome is really interesting, especially in this particular case because we have a behavioral issue as well as a GI issue. And the microbiome is, the definition is the collection of microorganisms and their genes and the microenvironment that they’re in, in a specific area. And for this particular dog, I’m thinking is GI tract. So this dog’s GI tract is the home to a lot of beneficial bacteria, as well as some potentially pathogenic bacteria that is, it’s kept in balance normally. And when that balance shifts, we can potentially run into health issues, like maybe we’re seeing in this dog. So what that shift is called, it’s called a dysbiosis. We can correct that dysbiosis, then maybe we can have an effect on this dog’s particular issues.

Dr. Andy Roark:

Okay. So I think about what I know about microbiome and we talk about the GI tract being the gut shock organ for dogs, is that why the anxiety does that? Is that why that plays into your assessment in this case?

Dr. Raj Naik:

Yeah, absolutely. So, you hear this term like, “Oh, I have a gut feeling about this particular subject that we’re talking about”. There is a true actual gut feeling because there is a vagus nerve running from your GI tract up to your brain. And so there is a strong influence from the microbiota that are in your GI tract on your brain function through various metabolites, through various neurotransmitters. And what’s interesting is we now know that with certain probiotics, you can actually affect brain function by altering GI microbiome. And so for this dog, I’m thinking, oh, I have this back of my mind, all this research on, say for example, a Bifidobacterium longum bacteria, BL999. And if I can use it as a probiotic in this dog, then potentially I can help mitigate some of those anxious behaviors that we’re seeing.

Dr. Andy Roark:

Okay. Are there diagnostic approaches that you take to look into this? Do you start empiric treatment and see if you get results? How do you start to unpack that?

Dr. Raj Naik:

The nice thing about some probiotics is they’re very, very safe and so you can start them right off the bat without necessarily doing indices ahead of time. But that being said, if you’re trying to really work up this dog, there are things like a gut Dysbiosis Index that can be very beneficial before and after you start treatment to say, “Hey, this treatment is actually working to help stabilize that gut microbiome and we’re it to a place where we really want it”.

Dr. Andy Roark:

Okay. Talk to me a bit about probiotics. Walk me through a little bit of the science of probiotics in general and then specifically how we start to introduce them in a case like this. How do we bring that across to the pet owners?

Dr. Raj Naik:

Yeah. So probiotics are a bit mysterious, you hear all this kind of hoopla around them and you don’t really necessarily know how they work. The whole goal of probiotics is to change that micro-environment in wherever you’re administering them. So in this case, we’re going to change the micro-environment of the gut. So those probiotics are going in there, they’re competing for nutrients with those potential pathogens, they’re physically blocking the pathogens from attaching to the GI tract epithelium. They can produce antimicrobial compounds and metabolic products that can actually fight off those pathogens. And when we are trying to figure out what probiotic to use, there’s a few actual considerations that we want to take. There was a study done a few years ago by a gentleman named Scott Weiss, who does a lot of this infectious disease research.

Dr. Raj Naik:

And he looked at a few labels of 25 different probiotics on the market for veterinary species. And he found actually that only two, two of the 25, had a label that was accurate and actually accurately described the contents of that particular probiotic. Which leads to a conversation about regulation by the FDA and things like that. But the point is, we’re looking for something that is safe, it’s viable, it’s going to be alive when you actually administer it to the animal and it’s efficacious. So how much research has gone into that particular strain of probiotic? And is it done by a reputable company because that’s really key, quality and safety, efficacy.

Dr. Andy Roark:

Okay. So, yeah. All right, that makes sense. When we start to administer to our patients and things, how many set expectations for the clients here? So I’m going to talk to them, I’m talking to them about Aspen. I’m like, “Hey, she’s an anxious dog. We can have these things, I want to put her on a probiotic”, in your mind to put this probiotics use, is this a daily thing forever? Is this an as needed? Is it a pulse treatment and then we’re going to withdraw after we’ve reset the microbiome? What walk me through the actual mechanics of me putting this into play in a meaningful way.

Dr. Raj Naik:

Yeah. Good question. So for acute situations, potentially, we only have to do it for a certain period of time. So let’s take Aspen’s diarrhea, if it’s acute, we can do it for just a set number of day. If it’s chronic, a good probiotic is actually, what it’s going to do is it’s going to go in there, it’s going to do its thing, and then it’s going to get pooped out. And that the whole goal is we don’t want it to take up residents in the GI tract. And so because of that, you do have to use a lot of probiotics daily in order to achieve that effect long term. But that’s a good thing, that’s really, really what we want.

Dr. Andy Roark:

Okay. What’s the response time on treatment like this? Are we looking at five days, is this an immediate thing? Again, people don’t get upset about what you give to them, they get upset about the difference between what they got and what they expected to get. So I don’t want to over promise because we’ve all seen that where, I had a client call me just a couple of days ago and he was like, “Oh, you know my dog’s having these soft stools and things”, and then he listed nine different things that he had done and five different diets he’d been on. And I was like, “When did this start?”, and he’s like, “Two weeks ago”. And I’m like, “Oh, buddy, okay. We’re going to start over”. But again, that happened. And people have expectations in their mind, I want to set good expectations.

Dr. Andy Roark:

So help me understand this, when I present this as a therapeutic option, I think a lot of us send home and I’ll just be honest with this. When I comes to GI upset, diarrhea, things like that, I go back and forth with being a good antimicrobial steward and also wanting to give the pet owner something where I’m like, this is a thing that is actually addressing your problem because I want you to see value in coming in the visit. And I’m just being honest about how I have those thoughts, I know I’m not the only vet who has those thoughts. I am increasingly trying to lean on the side of good antimicrobial stewardship. I know it’s important, but I still sometimes worry. I go, what if I send them home and this persists? What if it takes too long? What if they’re impatient? What it’s not robust enough a response? And so, yeah, help me with that as far as what expectations I should set in their mind and what I can expect as the doctor treating it.

Dr. Raj Naik:

I can’t tell you how much I love that you brought up antimicrobial stewardship, because it is one of my soap boxes. I’ll start with how long. Usually if we’re talking about an effective GI probiotic and there is, this goes back to a good company doing great research. You have probiotics out there that we have control studies looking at diarrhea and acute diarrhea in dogs resolves after four and a half days with metronidazole. But if you use Enterococcus faecium, SF68, which is that effective probiotic, that resolves up almost two days earlier. So it can be highly effective very quickly and say a little over two and a half days.

Dr. Raj Naik:

But I think setting those expectations, like you brought up is so important. These aren’t miracle drugs and they’re not drugs at all. And that’s the point. So you have a situation where you may be able to resolve acute diarrhea very quickly. Some dogs have to be on this for say, a couple weeks before you’re going to see effective control of their diarrhea. And then you have another probiotic that we’re talking about with anxiety that you don’t necessarily see full effects until up to six weeks after they’ve started. So if you’re trying to manage something like fireworks anxiety, certainly you’re going to have to start that well ahead of July 4th.

Dr. Andy Roark:

Right.

Dr. Raj Naik:

Yeah.

Dr. Andy Roark:

Okay. So, yeah. So for Aspen, then we’re probably talking about a pretty significant runway, right? If we want to have maximum benefit and we continue to have diarrhea with this dog.

Dr. Raj Naik:

Yeah. And so if I may with the antimicrobial stewardship.

Dr. Andy Roark:

Please.

Dr. Raj Naik:

I think the way you’re approaching it is absolutely fantastic and I see that need between I need something that’s going to work really effectively now. And with some of those antimicrobial drugs, things like metronidazole or Clavamox, if you use a probiotic at the same time as you’re administering those, they may get killed off depending on the probiotic. There are probiotics available, like Enterococcus faecium SF68 that are not killed off by certain antimicrobials like metronidazole. And so doing the research to find out which ones actually stay alive is very important.

Dr. Andy Roark:

Okay. So talk to me a little bit about that with the antibiotics then. So you were saying, if you’re going to do antibiotic therapy and you want to do a probiotic as a supplement to that, so I’ve seen, I know with people, a lot of times we’ll take antibiotics and then start to start a probiotic to repopulate the gut. Do you recommend doing some sort of probiotic therapy through the course of antibiotics? Is this something that we want to add towards the end of the antibiotic therapy? Talk to me a little bit about the integration of antibiotics and probiotics, if we want to use them together.

Dr. Raj Naik:

Absolutely. I would start them at the same time if you can. And again, key is finding out that probiotic that actually will survive that antimicrobial. The earlier that we can institute probiotic therapy, the more like we are to mitigate that, say antibiotic associated diarrhea that we see with Clavamox. In cats, you actually see that if you start, you mentioned FortiFlora at the same time as Clavamox, you reduce the incidence of diarrhea in these cats. And so, as early as possible is my answer.

Dr. Andy Roark:

Okay. That makes sense. And then we talked about treating through the end of clinical signs. Do you usually tell people you’re in this for X amount of days, just plan on it? Do you tell them to continue beyond remission of clinical signs? So we talked about onboarding with this, where is where’s the off ramp?

Dr. Raj Naik:

Yeah. Acutely, I would say within, you could probably stop after resolution of clinical signs within three days or so. A lot of these dogs, especially this German Shepherd that we’re talking about, chances are he’s going to have to stay on it long term because he’s got some sort of German Shepherd chronic enteropathy that we would love to actually diagnose. Maybe the owner’s not going to let us this particular time. So they may need to stay on it for life.

Dr. Andy Roark:

I like this interaction between probiotics and other therapy modalities. Talk to me a little bit about how nutrition integrates into this. So you’ve got these diarrhea dogs or repeated diarrhea dogs. Are we changing that dog’s diet to something that supports GI health in the short term? Are we leaving them on their regular food to avoid transitioning back and forth? What are your thoughts on changing diet while using a probiotic, trying to get through these bouts of repeated diarrhea?

Dr. Raj Naik:

Yeah. I think that’s such an excellent point. Having the right diet there available for that dog is critical because we need to supply that probiotic with the food that it needs to do its job. And often that food comes in the form of what we call a prebiotic. Prebiotic is just a fancy term for a, usually is some sort of fiber source, a non-digestible carbohydrate that the probiotic can munch on and then create short chain fatty acids, which are beneficial to the host and sustain itself that way. And so if we’re providing the right food for not only the probiotic, but for the pet him or herself, that could go a long way in resolving some of the issues that we’re seeing. What’s interesting about microbiome research and diet is that when you shift, when you change a dog’s diet to something completely different, their microbiome shifts with that diet.

Dr. Raj Naik:

And so in the short term, if you were to change to a highly digestible diet, which is often what we’ll use for this chronic diarrhea patient, then you are potentially shifting that microbiome back to, closer or to the baseline for that dog. Oftentimes these dogs need to stay on that diet long term in order to maintain that good microbiome level for them. But you may be able to change it back once they’re actually a little bit better. Or, what diet am I going to choose for this dog? I think is probably where you’re hoping to go [inaudible 00:18:03]. Yeah.

Dr. Andy Roark:

Yeah. That’s why we’re starting to drill into this. I’m seeing some, you’re advocating it seems a more high fiber diet, as opposed to some of the, I don’t know, more easily digestible, fully digestible diets. So, yeah.

Dr. Raj Naik:

Yeah.

Dr. Andy Roark:

Talk to me about that.

Dr. Raj Naik:

I think that, so starting out a highly digestible diet doesn’t necessarily mean that it doesn’t have any fiber in it. So, that-

Dr. Andy Roark:

Right. I didn’t mean to, I know, I heard that coming out of my own mouth. I’m like, that’s not exactly what I’m getting at. But, yeah.

Dr. Raj Naik:

No, it’s confusing. It’s confusing. You hear this term highly digestible and you think, oh, well, it’s just chicken and rice, right?

Dr. Andy Roark:

Yeah. I’ll be like, that is the metaphor in my mind. When you say, explain this to the pet owner in a simple metaphor that they’re going to get. I taught to them about chicken and rice, just in a metaphorical sense, not in an actual sense. But I’ll be honest and say that’s what’s in my mind.

Dr. Raj Naik:

Yeah, absolutely. And I think that’s a good metaphor. What we remember with these therapeutic, highly digestible diets is they’re complete in balance. So you can feed these diets long term to these pets and they’ll be usually totally just fine as long as they’re formulated for adult maintenance. But if we have a dog that isn’t necessarily responding to that highly digestible, complete and imbalanced diet, the next place I would go is that high fiber diet that you were talking about. If this dog has a large bowel diarrhea, that’s where I’m going. And I think that’s an overlooked therapeutic modality for a lot of these dogs, especially this German Shepherd. He’s most likely got, just based on his signal, he’s most likely got a large bowel diarrhea.

Dr. Andy Roark:

Right. Is that a breed specific? Because when I see the German Shepherds, it immediately goes to it. The big thing is, it’s a luxury dog, for whatever reason, I’m immediately going to large bowel. And then the other thing is when I see, and again, correct me if I’m wrong here, but when I see those 10, 11 month old puppies that are just having ongoing diarrhea fiber responsive colitis, things like that into my mind, just based on the age of the pet. First of all, is that accurate? And then second of all, are there other signals that really make you think large bowel?

Dr. Raj Naik:

Yeah. I think that’s a really good example and a good watch out because if you have a 10 month old puppy that is having large bowel diarrhea and chances are, if it’s this breed, yes, you’re right. That is what we’re seeing. We have to be careful with those higher fiber diets that I was talking about because some of them are not formulated for puppies. We have a high protein requirement in these dogs, we have other macronutrients, micronutrients that we have to have at certain levels. And the fiber sometimes gets in the way of absorbing some of those nutrients. So what I always do is look at the patient in front of me. What what can I do for this particular patient? What have I tried already? And do I maybe need to consult with a nutritionist to come up with a plan to make sure that this dog is getting what they need?

Dr. Andy Roark:

So when you see those cases again, so especially, let’s talk about the young dogs. And we say, hey, we’ve got these young dogs, there’s an ongoing problem, we’re trying to increase fiber, we’re still want to make sure that growth needs are being, things like that. We need to talk to the nutritionist. How do you bring that to the client? How do you say to them, hey, I know you think this is just some soft stool that’s going on and on, but we need to bring this other person in and really start to get serious. How do you broach that conversation? How do you get them on board with the changes that we’re making? Because now we’re no longer talking about grocery store dog food, we are a hundred percent into the realm of like, okay, this is nutrition and we’re doing this and your dog is special. At least in the short term, give me some communication approaches to help people explain it and to get pet owners on board with going on this journey with me.

Dr. Raj Naik:

Absolutely. It’s such a good question because I think a lot of people struggle with this in practice, is talking about nutrition as a therapeutic modality. One, talking about it as a therapeutic modality and two, talking about it as a diagnostic tool potentially. So, the third option that we haven’t talked about yet is a hydrolyzed or elemental type diet, where we are trying to figure out if this dog has a IBD or a food allergy or something like that. And so I always talk to owners about this being something that they’re doing every day already. Number one, you have to feed your dog and two, something that we can use as a tool in the toolbox. We’re going to look at the animal as a whole and tackle things from all different angles. And I think most owners are happy once you explain to them that you’re using it as a therapeutic tool and a diagnostic tool. Are happy to go down that road with you at least for a little while. And you say, let’s reevaluate this in a month and see what’s happening.

Dr. Andy Roark:

No, that makes sense. I do appreciate that. Okay, good. All right, cool. I’m feeling pretty good about where we are with Aspen. I think I can work with mom and explain to her what the plan is and why the plan is, I think I can meet her needs. Are there any last words of advice? Are there any pitfalls I need to look out for? How do you see GP’s get this wrong? What can she talk me into that’s ultimately a bad idea or where do I go off the rails here and get myself in trouble?

Dr. Raj Naik:

Yeah, and it’s not necessarily that you… It’s not your fault, it’s nobody’s fault. It’s just that we’re busy. The follow-up, the follow-up is really what’s critical. So I can send a bag of dog food home with this client, or a probiotic home with this client and say, good luck. Or I can have a technician call them back in, say a week or two weeks and work through any issues that they might be going through. I’ll use a completely separate disease process as an example, but obesity is the number one disease that I see a problem with this for. So we send home a bag of dog food, we say, good luck, we’re going to get some weight off your dog. Then the owner gives up a weekend because they can’t deal with the begging, they can’t deal with not giving treats to their dog or giving fewer treats. And then you check back three months later and they haven’t done anything with the actual plan. And same goes with any other disease process that we’re going through. So the follow-up is key.

Dr. Andy Roark:

No, that totally makes sense. Awesome, Raj. Thanks for being here. Where can people learn more if they’re getting a lot out of this and they want to dig deeper, you and I just touched on the microbiome concepts and the science that’s there. I know that there is a lot of information education coming out in this realm. Help people get started unpacking this and exploring more.

Dr. Raj Naik:

Yeah, there are fantastic resources on the purinainstitute.com. So purinainstitute.com, and then if you’re interested in the microbiome, there’s a microbiome forum tab that you can click on and deep dive into all of this. If you’re interested in learning more about those conversations that you brought up, Purina Institute has a lot of resources to help you have those conversations about nutrition with owners. And I really, I point this website out to students to general practitioners, to specialists often to say, here’s how to talk about nutrition. So I’m a huge advocate for that platform and it’s called Center Square. That can be found on Purina Institute.

Dr. Andy Roark:

All right, thank you very much. I’ll put links to all this down in the show notes. Thanks for being here and thanks for your help.

Dr. Raj Naik:

Thanks for having me. I really appreciate it.

Dr. Andy Roark:

And that is our episode. Guys, I hope you enjoyed it, I hope you got something out of. I did, I like this episode. I was jotting notes down, this is stuff that I’m going to use in the exam room. Guys, thanks again to my friends at Purina Pro Plan Veterinary supplements for making it possible for us to bring this to you. Gang, take care of yourselves. Be well. I’ll talk to you soon. Bye.

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