Thursday, January 29, 2015

Medicine and cheesecake

cheesecake dog
Bosca eyeing off a bit of cheesecake.

What does cheesecake have to do with medicine? If you give yourself too much time to answer the question, potentially quite a lot. For example, it’s very high in glucose and if consumed in high quantities might contribute to the development of diabetes mellitus. Or someone might choke on a cheesecake, requiring a deft Heimlich manoeuvre to dislodge the would-be assassin. It could be contaminated with some sort of pathogen, resulting in violent food poisoning.

In this case it’s really not about the cheesecake but the Cheesecake Factory, a resterant chain in the US that serves more than 80 million people a year. In his essay “Big Med”, surgeon and writer Atul Gawande explores the commonalities between an organisation such as the Cheesecake Factory and medicine itself.

“In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost with a consistent level of quality,” Gawande says.

It’s a thought-provoking, humble reflection that applies to any aspect of health care, including veterinary medicine and surgery. While Gawande agrees that “good medicine can’t be reduced to a single recipe”, he provides some compelling arguments for standardisation of care (I recommend reading the article in full here).

cheesecake with rasberry sauce.
Cheesecake with rasberry source. Potentially, cheesecake may enhance the reading of this article.

Historically, healthcare has been provided by individual doctors and surgeons who, we hope, are the best at their area of expertise. For example, if you need a knee replacement you want to go to the best orthopaedic specialist. If you have cancer, you want to go to the best oncologist. You want them to treat you their way, the best way.

The danger is there is so much variation in treatment, and this emphasis on the individual doctor can drive egos a bit far. Some of these “experts” are not receptive to new ideas, or may resist taking them on (Gawande points out that on average it takes more than FIFTEEN YEARS for major medical discoveries to be applied in practice – even if that discovery is about an application of a treatment that is already registered and widely available).

Gawande persuasively argues that standardisation of care can improve outcomes (for example, more consistent and effective analgesia for people) and the patient experience of the totality of care. I had a friend who had major surgery last year, and whilst the surgeon was charming and wonderful and the absolute best at that particular surgery, the follow-up was appalling. He’d done his job and was busy doing his amazing surgeries on the next patient. How can someone be so awesome yet the system so flawed, allowing my friend to slip through the cracks? No one was overseeing the totality of her care.

The Cheesecake Factory approach is to ensure that the entire dining experience – or the entire healthcare experience – is quality-controlled.

So why don’t all doctors, hospitals and even veterinarians take this approach? While we are seeing, more and more, development of standard treatment protocols for common conditions, there is still scope for improvement. For example, we can’t seem to reach a consensus on vaccination protocols, despite the fact that the World Small Animal Veterinary Association (WSAVA) working committee has put together evidence-based guidelines.

We need to measure outcomes – not just in studies but real clinical cases. This data can be used to tweak the protocols. We need to think about the whole of the patient-client experience.

We are seeing more veterinary hospitals, for example, chains, where customer service, record-keeping, treatment protocols etc. are standardised.

One difficulty, and a source of much resistance to standardisation among vets and doctors, is that standardisation is so easily conflated with corporatisation. As Gawande points out, “Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health care systems that pursued size and market power were better at raising prices than at lowering them”.

The increase in the proportion of insured pet owners means that the gold standard of care is an option for more and more, but there will always be clients who cannot pay for or do not wish to pursue the gold standard of treatment. That doesn’t mean that the alternative/s can’t be standardised either. The aims of standardisation need to focus on clinical outcomes.

Gawande argues that the Cheesecake Factory chefs remain creative, retain autonomy and provide a better, more consistent service than some chefs in boutiquey restaurants. Definitely food for thought.

Reference


Gawande A (2012) Big Med. http://www.newyorker.com/magazine/2012/08/13/big-med Accessed 28/1/2015

Tuesday, January 27, 2015

Book review: The Dose Makes the Poison

When I started reading "The Dose Makes the Poison" in the bath, Hero decided it was a very good time to tap on the window.

When that didn't elicit a response, he got a bit vocal.
And roared like a wild beast. It was a VERY short bath.

Can a chemical be good or bad? Is natural better than synthetic? These are important questions raised and addressed in The Dose Makes the Poison: APlain-Language Guide to Toxicology.

The book addresses common concerns about chemicals and drugs, stressing that toxicity is relative and depends on the context. Take anything in a high enough dose and it can kill you. Even water (see this case report, for example).

As the authors state,

“The toxic effects of a given chemical depend on dose (how much), frequency of exposure (how often), and the route by which the chemical enters the body. It always has been thus, and there is no reason to believe it will ever be otherwise. Yet some people find it difficult to believe that chemicals follow any rules at all.”
The book challenges fears about chemicals and drugs, providing useful and very accessible information about what chemicals are, what harm they can cause, what toxicology is, how toxicology studies are conducted and factors that influence the toxic effects of chemicals (such as route of administration, metabolism, excretion and individual factors like gender, age, health and nutritional status of humans and animals exposed). 

It includes some fascinating history, including details about early toxicologists Paracelsus and Ramazzini. (The former refused to be a hoity-toity academic and hung out with labourers, Gypsies and other types avoided by genteel folk, and was killed due to wounds sustained in a pub brawl at the age of 48; the latter specialised in epidemiology and wrote an early textbook on occupational diseases. He hung out with those he wrote about – visiting workplaces like mines, factories and cesspools to experience the conditions in which people worked, and argued for better working conditions).

The book provides an excellent introduction to toxicology and addresses a lot of common concerns about risks associated with chemical and drug exposure. It challenges the concept that “natural” chemicals are “good” and “synthetic” chemicals are “bad”.

There are some minor factual errors, such as the comment that horses are unique in their inability to vomit (there are a few other species that can’t vomit, such as rabbits) and a bold statement that no one ever overdosed on liver (they have, and it can lead to vitamin A toxicity which is one reason for limiting liver in the diet).

The ethical implications of toxicology studies, though raised, could have been explored a little further, particularly around the subject of animal use and alternatives. Given the millions of animals used in toxicology studies, this is a major animal welfare issue with scope for massive reduction in suffering.

Nonetheless, the overall aims of the book are noble: to inform people how toxicology is studied, explaining its limitations, and encourage them to be informed consumers of the literature.

A good book for general readers with an interest in science, anyone interested in toxicology, pharmacology, chemicals or poisons.

Reference

Frank P & Ottoboni MA (2011) The Dose Makes the Poison: A Plain-Language Guide to Toxicology (3rd edition). John Wiley & Sons, New Jersey.


Monday, January 26, 2015

Animal defence mechanisms

An annoyed or startled whale may try to thwart personal space-invaders by stirring up a "poonado".

Have you ever been on the receiving end of an animal’s defence mechanism? A warning growl, a nip or kick perhaps, or even the unleashing of the dreaded anal gland secretions? The aim, of course, is to develop one’s approach and handling of animals such that one makes them at ease. But anyone who works closely with animals knows that they can feel defensive on occasion.

Canadian photographer KeriWilk, who was it must be acknowledged diving without equipment so he didn’t annoy the whale he was trying to photograph, annoyed the whale he was trying to photograph. How did the whale respond?

It defecated. Not an unusual defence mechanism for any frightened or startled animal. Just a lot more of it.

In one of the moreentertaining media interviews I’ve read, Wilk, who was with three colleagues, describes how the marine motion seemed to last for an eternity.

“For of us looked at each other with confusion, then back at the whale, expecting that any second its call from nature would come to an end,” he told News Corp.

“Instead, the whale bobbed up and down, spun in circles and waved the poo in every direction for several minutes while we just sat back and watched. The water was crystal clear, initially, and was the most idyllic Caribbean blue water than you could imagine.”

Several waves of whale faeces later, vigorously shaken and stirred by the whale, and the ocean looked like chocolate milk.  Engulfed in the 30-metre plume of poo, the divers momentarily lost visibility as whale excrement filled their goggles (and snorkels). The account of what the world’s media have dubbed the “poonado” is disgusting, yet fascinating.

It’s a reminder that no matter how large an animal is, humans can evoke a fear response. Animals – humans included – prefer it when we respect their personal space.

Learn more about reptile husbandry

If you want to learn a bit more about reptiles and their husbandry and you’re in Sydney or close to it, the Hawkesbury Herpetological Society is holding its Annual Reptile Expo on Sunday March 1 at Penrith Panthers Exhibition Marquee on Mulgoa Road, Penrith from 9am-4pm. 

Exotic reptiles and venomous snakes will be on display. Class 1 and 2 reptiles will be for sale, and reptile retailers selling enclosures, food, lighting and accessories will be there. There is an entry fee ($10 for grown-ups, $5 for kids <12 span="">

Saturday, January 24, 2015

The responsibility barrier and motivation, feline fashion and Phil's trip to the beach

Bosca meets a friendly Frenchie.
Has your motivation ever flagged? I don’t know anyone that is able to drive themselves at 100 per cent capacity every waking minute – and suspect such a state would be somewhat pathological. Recently I was reflecting on some of the challenges of keeping motivated in the final year of veterinary school.

One the one hand you’re so close to the finish – only months away from graduating and becoming the fully fledged vet you’d always dreamed of becoming. On the other hand, you’re still a student. At the pointy end of the degree there should not really be any difference between a final-year student and a new graduate – but there is one thing and I think it impacts on motivation.

The “responsibility barrier”. As a new graduate remarked to me when I was in final year, you don’t have responsibility for the case. Your decisions are all run by someone else, the buck does not stop with you. Which is a relief when you’re learning, but it can at times make one feel like one is just an observer. When you don’t have responsibility for the case, being assessed on how you’d manage it can feel like you’re jumping through a hoop for the sake of it.

When that responsibility barrier disappears, with its safety net, vetting gets more challenging. But also – even when you are doing the same thing – much more interesting. It’s easier for people in general to become emotionally invested and motivated to learn.

My best advice to students is to treat cases as if they are wholly your responsibility – in your head of course. Make your own problem list, create your own diagnostic plan, make your own therapeutic decisions – then compare them to that of the experienced clinician and the literature. It’s a much better way of learning than observing and analysing the decision making post-hoc.

Liza's Small World

If you’re into feline fashion, check out Liza and Archibald’s blog, Small World. I met Liza at a blogging workshop and she was dressed to the nine’s in cat themed clothing, from dress to shoes to accessories. You have to respect someone who dresses to a theme. I love this lazy cat ring she blogged about.

We’re looking forward to chatting with Liza and Archibald about their passion for felines.

Alicia at the beach with Phil (before the big scary wave).
Meantime there is a long weekend to be had, folks. We kicked ours off with a run on the beach (more accurately, a run FROM the beach as Phil got spooked by a wave - which, to lend some perspective, reached the Frenchie's ankles) and a Malaseb bath (the sand made him itchy). Which culminated in a lie-down.

Tuckered out. A small dog needs a big couch to recover on.

Friday, January 23, 2015

Keeping cats cool

Oh yes. Michael enjoys her cooler-bag bed. (Photobomb courtesy of Phil). How do you keep your pets cool in the heat?

Michael has worked out a way to beat the summer heat. She’s discovered cooler bags, the ones you can get for the supermarket when you’re stocking up on groceries for a field trip. They’re padded, cool (hence the name – though they are cooler if you whack an icebrick or frozen dinner in them), and big enough for a plus-sized cat (who has lost another 400grams on her diet thank you very much) to crash out on in this unrelenting Sydney heat.

If you position it the right way the cooler bag provides its own little head rest. Not sure why Mike feels the need to wedge her buttocks beneath the furniture but I am sure there is a rationale.
The guinea pigs have a little ice-bucket in their enclosures to provide a coolness-gradient, and Phil crashes out near a fan. Fortunately the reptile member of the household is thriving in the heat.

THIS JUST IN. Elephants at Taronga Zoo are keeping cool too.
Thong Dee plays in the waterfall. Image by Paul Fahy, Taronga Zoo.

That's better! Image by Paul Fahy, Taronga Zoo.

Thursday, January 22, 2015

Email management, digital veterinary pharmacology handbook and an airport for animals

Juvenile Central bearded dragon (Pogona vitticeps).

Its been hectic here at SAT HQ. I'm currently trying a new husbandry routine with the guinea pigs, monitoring a certain cat for recurrent urinary tract dramas, trying to persuade said cat to eat a prescription diet (I know Hero, sometimes I forget who is boss), running around trying to retrieve said cat from rooftops (not necessarily mine), and fostering a post-op bearded dragon which involves, among other things, ensuring exposure to adequate UVB light to prevent metabolic bone disease. 

And that's between some other important projects. 

Sometimes I feel though that before I can get to those I have to make sure I've responded to emails. Do you ever feel like these eat your brain? Daniel Levitin wrote this fantastic article about coping with information overload.

Plumb’s Veterinary Drug Handbook has been updated and fully digitalised. Or is that digitised? In my mind this is the best pharmacology handbook in the veterinary universe. Great in general practice but also good for pharmacology assignments (students take note) and a good read if you are so inclined (I've not read it cover to cover but have a colleague who reads whole textbooks cover to cover - she devotes six hours to the task every week)(don't think she's read Plumb's yet?).

ER and techy vet Caleb Frankel worked on the project and provides a behind-the-scenes glimpse at the VMD technology blog here.

Finally I am one of many many people who would like to see air travel more friendly for animals. This article is pinched from the mainstream press and leaves a few gaps but the concept of an animal airport is interesting. When I read about it (which was, I admit, in the early hours of the morning) I had a vision of dogs running security and getting humans to sniff the luggage. Have a look here.

Tuesday, January 20, 2015

Complication

Hero experienced complications following his surgery. You wouldn't know it now.
Feline urinary tract disease can be challenging and frustrating to treat. Recurrence of obstruction is common, although the reasons can vary. When I treated my cat Hero for urethraland bladder stones over Christmas he seemed to be recovering well. But he experienced a complication.

I want to discuss it here because a) complications are a normal part of medicine and surgery and I think we need to discuss them more; b) turns out this one is a lot more common than I thought and c) I’ll feel more like Hero didn’t suffer the experience in vain if others can learn from it. And suffer he did. Suffer everyone around him did. Many sleepless nights were had over the festive season and none of them were the celebratory sleepless kind!

It was day four post-op. Hero had been eating, drinking and becoming more active. He seemed bright and happy. His surgical wound looked beautiful. Then I watched him go to the litter tray. Not once to pass a nice stream, but twice. And he passed a few drops. And cried. My heart sank.

I palpated his bladder. It was large, despite the fact that he’d just “voided”. He reacted when I touched his tummy. There had to be a stone obstructing that little urethra of his. It sent my mind my mind into a vortex of retrospectoscopy…
At the time of surgery we counted the stones on radiographs and those we retrieved, and thought there may be a discrepancy. His first wee post-op had contained more blood than I’d hoped. The patches of urine in the litter tray were getting subtlely smaller.  I’m not going to lie. I did not like what this was telling me and did the whole “oh Anne, you’re just being a paranoid hyperchondriac by proxy”. It’s easy to do. But a little voice inside me said “or is this a complication?”.

Potential complications of cystotomy including uroabdomen (urine leaks into the abdominal cavity), urinary tract infection, surgical site infection, recurrence of stones (usually secondary to infection), lower urinary tract obstruction (mechanical or functional) and incomplete removal of uroliths (Appel et al 2012). I was concerned about the latter.

When it comes to uroliths that hang around post-cystotomy, MOST of these can be prevented by passing a urinary catheter and flushing stones back into the bladder intra-operatively, or - as US veterinary surgeon Howie Seim does in his fantastic video on urinary tract surgery – performing the “urogenital floss”.

In addition, post-operative radiographs of the entire urethra following surgery can identify stones that are left. A review of literature on veterinary cystotomies found that radiographically detectable uroliths remained in 14 to 20 per cent of dogs (Grant et al 2010).

BUT not all uroliths are radiographically detectable. Even if they show up on the rads, if they’re hiding behind the pelvis or beside a catheter in the lateral view, or below the spine on the ventrodorsal view, you won’t see them. How can they escape a catheter? Well, if they’re narrow enough a catheter can slip past them. You can urogenital floss all you like but there’s a chance they won’t be dislodged.

In a Canadian study of 106 veterinarians who performed cystotomies, 42 per cent reported that patients had recurrent uroliths, although it’s hard to know how many of these were true recurrences as opposed to those not removed at surgery. When I did the ring-around, lots of colleagues had experienced the pain (indirectly, of course – it’s the patient who feels it first-hand) of a retained stone.

But the data illustrates that even in the best hands (ie world-class veterinary teaching and referral hospitals) some uroliths inevitably escape the surgeon. Post-op rads confirmed my worst nightmare. A urolith the size of Tasmania (almost) in his distal urethra. I won’t lie: I felt sick. But I couldn’t leave that stone in there.

Evil, evil urolith.
Flushed retrograde into the bladder to allow it to be retrieved via cystotomy (bladder surgery) rather than by traumatising the urethra further. Why do that? Trauma to the uretha may cause scarring which can cause major problems in cats and may require removal of the end of the urethra (and the penis with it) - a procedure called a perineal urethrostomy. Worth doing if you have to but worth avoiding if you can.
So I flushed it back into his bladder and performed the second cystotomy in four days on little Hero. Are there alternatives? In humans, cystotomy is rare these days. In the US, open-surgical removal of uroliths was described in only 0.3-4 per cent of human patients (Defarges et al 2013). But non-invasive alternatives aren’t well established in companion animals. Voiding urohydropulsion is contraindicated in male cats because of the high risk of obstruction (sorry to say it Hero, but male cats have a tiny penis with a narrow urethra that is easily blocked), lithotripsy is still experimental, and laparoscopy remains uncommon in first-opinion practice.

My concern was that he was in pain. His urine was full of blood and that stone was tearing his urethral mucosa. The surgery was straightforward. Cystotomies are beautiful surgeries and I’ve said before that the bladder and urethra have extraordinary healing capacity. When I opened him up there was Hero’s bladder looking quite healthy despite being opened four days earlier.

I incised once again, locating and removing the stone within minutes. Its removal was confirmed (as much as it could be) on radiographs. Again I used multimodal analgesia (multiple drugs) to minimise his pain and of course checked on him through the night.

The following morning I helped him into his litter tray (he had kept the drip on overnight this time) and his post-operative wee was like Niagra Falls compared to the first post-op wee.

MUCH BETTER.
A few lessons learned here…

  1. The first, which I didn’t realise, is that the incidence of uroliths leftover after surgery (even in the hands of a specialist) is higher than I thought.
  2. The urogenital floss is good – but doesn’t prevent sneaky uroliths from hiding out in the pelvic urethra. And a catheter can pass adjacent to a particularly recalcitrant urolith embedded in the urethral wall.
  3. Post-cystotomy radiographs are essential but don’t absolutely rule out uroliths. In retrospect I should have taken a post-op rad of Hero WITHOUT the urinary catheter in just to be sure there was nothing in the urethra hiding beside the catheter.
  4. Know your cat’s wee. I was celebrating about a post-op wee that wasn’t as voluminous as it should have been.
  5. Phone a friend. I called a specialist friend for a debrief after cystotomy number two. He was the one who suggested I look at the literature about incompletely removed uroliths, and I have to say that was both educational and therapeutic.

Of course, all of this fiddling with Hero’s urethra – all done as gently as possible – wasn’t unnoticed by his urethral mucosa. Predictably, he developed a functional urethral obstruction (essentially his urethra just threw a hissy and clamped shut). 

So he was readmitted, I placed an indwelling urinary catheter, and kept Hero in hospital. Then plan was 48 hours of catherisation. Despite the world’s biggest Elizabethan collar, Feliway, a private cat grass/mint/nip garden in his cage and drugs galore, he protested. He removed collars. He removed catheters (urinary and intravenous), he threw a rockstar rampage in his cage and misbehaved for colleagues. But he put in 36 hours before I caved and took him home.

The urolith analysis returned a result of 100 per cent calcium oxalate. These types of stones tend to be sharp and prickly, whereas struvite (the other very common stone in cats) produces very smooth stones. So I had an inkling.

The bummer about calcium oxalate uroliths is that they can return after months or years even with IDEAL management. So whilst modifying Hero’s diet will hopefully slow the rate of recurrence, we’ll need to be vigilant. Fortunately I’ve taught him to tolerate a daily bladder palpation session by convincing him it’s a weird new patting style.

Interestingly, a very close family member of the human variety has experienced the woe that is a kidney stone. The medical team didn’t bother with x-rays and instead performed a CT scan to detect the 3mm-diameter offender (but amazingly, didn't show him a picture of it). In twenty years we might all be doing pre-and post- or even intra-op CTs or cystoscopies (with tiny, tiny, tiny cat-penis sized scopes) and we will be laughing about “ye olde days” when people had to worry about sneaky uroliths evading detection.

References

Appel S, Otto SJ & Weese JS (2012) Cystotomy practices and complications among general small animal practitioners in Ontario, Canada. Canadian Veterinary Journal 53 (March):303-310.

Defarges A, Dunn M & Berent A (2013) New alternatives for minimally invasive management of uroliths: lower urinary tract uroliths. Compendium: Continuing Education for Veterinarians January 2013:E1-E7.


Grant DC, Harper TAM & Were SR (2010) Frequency of incomplete uroliths removal, complications, and diagnostic imaging following cystotomy for removal of uroliths from the lower urinary tract in dogs: 128 cases (1994-2006).