La Dolce Vita - and hello weekend

This little dude was hanging out near Rome Zoo.

SAT has gone international this week...we're visiting beautiful Italy to work on a project, give some lectures (in English - my Italian is limited to useful phrases like "the cat meows" and "the dog is happy"), check out the animal scene and hang out with some of the world's coolest parasitologists and mycologists! We're also struggling with connectivity issues so profuse apologies to our regular readers. 

There's a lot of history to take in and dogs play a very important role, as in this legend of Romulus and Remus. The print is a bit small but basically Rea Silver was walking through the woods, got chased by a wolf, met Mars - the God of war - had a dalliance and subsequently gave birth to twins. Her uncle wasn't thrilled that she broke her vow of chastity, and very unkindly buried her alive. Charming as he was, he also asked his servant to kill the babies, but he couldn't bring himself to do it (good guy). Instead, he put them in a basket and floated down the river in hope that someone else would find them and take them in. Indeed someone did - but she was a wolf.

The legend of Romulus and Remus in pictures (and in Italian).

Rome is also home to the coolest doors ever.

The doors at Hotel Boscola. Love these.

It's also home to some fantastic parasitologists - more than usual this week as the Italian Society of Parasitologists (Societa Italiana di Parassitologia to be exact) congress took place. The changing landscape of vector-borne diseases was a hot topic (NB no one needs to convince world-leading parasitologists, or indeed parasites, that climate change is real), as were evaluation of different parasiticides and discussion of zoonotic diseases. Important tip: mosquito is zanzane in Italian. Now you know.

With Dr Patrizia Danesi.

Anyway, whilst I've been tippy-tapping away at this end (offline), the internet has offered some interesting tidbits.

Molly, famous for being the dog subject to the first peer-reviewed report of black whipsnake envenomation in Australia, made the NT News this week and looks stunning. Note that dogs bitten should not exactly "wait it out", they do need treatment. You can read the article (or at very least take in the gorgeousness that is Molly) here.

An enterprising couple with some obliging pugs have recreated Game of Thrones in canine style. The costumes are incredible and the dogs appear to be digging it (or at least playing along). Watch it here.

We loved this selection of images of foxes here.

Meantime the entries for our David Attenborough competition keep coming - and they're awesome.

Little Coco adopts her favourite TV position with human companion (under Coco) Merryn. She looks totally chillaxed!

Nothing like a beer and a cuddle from your favourite dog! Poppy and Greg are living the dream.

Keep them rolling in - its nice to see everyone enjoying some rest and relaxation with their non-human companions.

Kirstin's kitty is channelling Silver Chair here: "I'm watching you watch your TV..."

There's still time to enter. Check out the details on our David Attenborough Giveaway post.

The art of veterinary surgery: interview with specialist surgeon Sarah Goldsmid

Dr Sarah Goldsmid, surgeon at the Animal Referral Hospital in Sydney.

Veterinary surgery can be extremely rewarding, but it can also be extremely challenging. Surgical specialists take on the really tough cases. Dr Sarah Goldsmid, based at the Animal Referral Hospital, is one woman who has carved out a career at the cutting edge. Not only can she perform surgery that many others won't - she often gets out of bed in the middle of the night to do it. She's the kind of person we want to be when we grow up. But she was still happy to chat to SAT about her career.

It is often said that some people are born surgeons. So were you naturally good at tissue handling from the get go, or did you have to work on this?

I think it is true to say that good surgeons naturally have a reasonable amount of dexterity and creativity. I loved craftwork when I was young – especially needle work. I was good at making things with my hands and I think that is a good skill to start with. As far as dealing with body tissues – you need to be confident in your anatomical knowledge and you need to practice, practice, practice. Watching gifted surgeons at work is also an inspiration in how to handle tissues, hold instruments, retract and follow Halsted’s surgical principles.

There must have been a certain level of natural surgical skills, because I remember my first live dog spey when I was in 4^th year vet science (at Sydney Uni Camperdown). I did the procedure in ½ hour and it went really well. The surgical registrar was impressed and told me I was going to be a surgeon …. she obviously knew more than me at that stage. I hadn’t even considered specializing and had no idea what was involved.

Sarah performs surgery on a dog with a GDV (gastric dilatation volvulus).

How did you improve and hone your surgical skills? 

I have already partly answered this, but certainly practicing procedures is important. I learnt quickly and once I had done a procedure even just a couple of times, I became a lot more confident. As a surgical resident, the specialist surgeries were learnt by firstly watching specialists do the surgery at the university as an assistant. Then I would perform the surgery with a specialist assisting me. Finally I was let loose on patients without my hand being held. I paid close attention to any tips or pointers that other surgeons would give (some I found useful, but not all). I also tried to attend as many conferences on surgery as I could and even better if there was a practical component in the course.

Performing an L7-S1 laminectomy in a dog.

Specialist surgeons appear to tackle anything with ease. How much planning goes into your surgical approach? What procedures take more planning than others?

Any surgery requires planning. You need to consider your surgical approach, options when you are in surgery (always have a plan B and maybe a plan C and D as well), have an understanding of possible complications that might occur during surgery and postoperatively (and have a plan of how you would manage those complications if they arose).

A linear foreign body. Note the plicated intestine. Definitely a surgery you need a plan B, C and D for...

While some procedures that we do regularly do not require so much thought – some of the more unusual procedures require a lot more planning.

For instance – some of the mandibulectomies or maxillectomies to remove oral cancers are planned by creating 3D reconstructions of the lesion and skull from our CT images. Difficult fracture repairs can be likewise planned on reconstructions or using templates. For corrective osteotomies we might have the implants pre planned and pre made (such as Type II or III or Ring External Fixateurs). Reconstructive surgeries require a detailed understanding of skin flaps and grafting techniques. It is an artform (much as a sculptor plans in 3D) to create an appropriate flap from adjacent skin or move a free flap from another part of the body (carefully trying to match colour, hair type and hair direction) to end up with a cosmetic and functional result. Spinal and brain surgeries require careful planning to ensure an approach that is minimally traumatic and gives the best access to the site of the problem – usually with the aid of an MRI.

Pre-operative MRI aids planning.

Did you have any surgical mentors and heros/role models when you were training?

My two main mentors were Dr Chris Bellenger (particularly in soft tissue procedures) and Dr Ken Johnson (mainly orthopaedics). During my time as a resident at Sydney University, I was also lucky enough to be exposed to at least another 6 Boarded North American surgeons who visited and worked at the uni during the time I was there. It was like visiting all the major veterinary university surgical services in the USA – but they came to me. That doesn’t happen now and I think it was a wonderful learning experience for me.

Am I easily impressed...or is this the most impressive prostatic cyst you have ever seen?

What is your favourite surgery to perform and why?

That’s a hard one to answer, because I get a thrill from any surgery that goes well and the owner’s and patients are really happy. I love seeing a spinal patient (that was carried in to the consult) walk out the door to go home – that is a great feeling. I love hearing from the owner that their dog has become like a puppy again since I removed the chronicly infected ear canal with a total ear canal ablation and lateral bulla osteotomy. I find it really rewarding to see a dog walk and run after their fracture was repaired, or their cruciate ligament deficient stifle was stabalised. It is so rewarding when a dog with cancer can be successfully surgically treated and be cancer free, or a cat with 3^rd degree burns to all 4 feet can be managed to have fur regrow on all feet and walk, run and jump again.

I think what I really enjoy about being a specialist surgeon is the huge variety of cases and the unexpected and unusual cases.

Total hip replacement in a dog.

What surgeries do even specialist surgeons find challenging? > or what is your LEAST favourite surgery?

It is always a little challenging to be the second surgeon to perform the procedure. So, for instance, when someone has attempted resection of a cancer and has placed a drain several centimeters from the original mass – so you are forced to remove not only the original mass with a margin, but all the drainage tract with a margin as well. Or, having to reconstruct a fracture that is infected and has unstable implants already placed – that can be a little challenging.

I think the most frustrating cases are those that if you had only seen them a little earlier – the prognosis would have been vastly better. So particularly things like acute spinal cases, due to herniated intervertebral discs, that lost deep pain more than 24 hours ago ….. if you had just seen them a couple of days earlier the prognosis may have been 85-90 per cent chance of walking again (while they still had deep pain) vs  less than 10 per cent when they have lost it for more than 24 hours.

Sarah works with a dedicated team.

Complications occur in medicine and surgery. What is the most challenging complication you've ever dealt with?

When doing a PDA (patent ductus arteriosus) surgery – the biggest concern is the vessel you are trying to ligate may tear and the puppy will bleed out in a very few seconds, particularly when they are often only a kg or two in weight. Naturally you are thinking about this while carefully dissecting around the vessel and placing the suture. 

I remember one such surgery, right at the critical point when I was just passing the suture around the vessel – the surgical intern who was assisting me passed out and fell backwards. The vessel tore, the puppy started to bleed out and I quickly managed to get the suture around the bleeding vessel and tie it to stem the blood flow. Meanwhile yelling for someone to come and assist my intern while the nurse managed the anaesthetic. Both intern and puppy did well after the ordeal. My heart beat a little faster for a while.

A good surgeon is calm under pressure.

What character traits are desirable for a career in surgery?

I know I am female – but I often say you have to have “balls” to be a good surgeon. That is to say – you need to be confident, bold and definitive. It’s no good being really gentle, slow and hesitant. So when the bone is bleeding dramatically while you are sawing away part of the maxilla – you have to keep going because you cannot control the bleeding until you have the jaw removed and you can access the origin. When you are doing cancer surgery, you have to remove the cancer with a margin of normal tissue, in other words you have to be bold and make a damn big hole. Then you have to have a plan (or maybe two or three) of how to deal with the big hole.

To even get to be a surgeon you have to have perseverance, discipline and be prepared to work hard (day and night).

It is probably not the best career to choose when you are a mother – having said that I have successfully had two children and raised them to adulthood. Neither of them have become axe murderers, yet. I couldn’t have done what I do without a very supportive husband. It is tough to be working long days, trying to run away at the end of the surgery to pick up a daughter from childcare when they are charging you $8per minute you are late. Or getting called out in the middle of night, then rushing home to get them up to get to school, remembering the school project, gym clothes, softball bat and violin …. you get the picture. It can be done, but you have to be organized, resilient and have a sense of humour.

A surgeon's view...

What is the difference between a good surgeon and a great surgeon?

Communication skills. You can be the best surgeon in the world, but if you can’t communicate with your clients to explain the procedure, prognosis and complications in understandable terms and appear confident – then no owner will want you to operate on their pet.

Of course you have to be able to deliver on the surgery as well.

Thank you Sarah for sharing you're incredible story and case load with us - and thanks for these amazing photos. If you want to read more about inspirational surgeons, check out this post on pioneering neurosurgeon (and bloke of my guinea pigs is named after), Harvey Cushing.

Black whipsnake envenomation in dogs

Molly the day she presented with a black whipsnake bite (note bite on her right arm). The bandage is to hold the IV line in place. The two-toned style was because we ran out of blue so had to add pink. We weren't being fancy with the dressing!

Australia is famous for its deadly venomous snakes. Companion animals are often bitten when they are interacting with (chasing, playing with, attacking) snakes. There are plenty of reports of dogs and cats being bitten by brown and black snakes (elapid species), but until recently nothing published in the peer-reviewed literature on bites from Black whipsnakes (Demansia papuensis species group). As my co-author, herpetologist Glenn Shea, says, “Black whipsnakes are venomous, and similar in size to the ‘traditional’ dangerously venomous species, such as black snakes and brown snakes.

During a locum stint in Darwin I treated a 9-year-old Jack Russell terrier, Molly, who sustained a bite from a Greater black whipsnake. There were a number of interesting things about this case.

Poor little Molly 72 hhours after envenomation. Note extensive bruising and swelling. (Also a yellow bandage this time because we can out of pink and blue). Fortunately she made a full recovery.

First is that the bite wound caused severe, painful local necrosis, swelling and tissue damage that progressed from the time of initial presentation. Whilst there is no direct evidence that the venom is fatal, the site of the bite and subsequent swelling may cause life-threatening complications (for example a bite to the neck or chest which causes swelling that may affect the airways).

Second, Molly required treatment (pain relief, anti-inflammatories and supportive care) even though it is anecdotally reported that these snakes aren’t harmful (humans that have been bitten say that it really, really hurts).

Third, the dog tested negative on a snake venom detection kit which suggests (although N=1) that these kits cannot be used to rule out whipsnake envenomation.

A Black Whipsnake in the NT (note this snake was deceased when found).

Of course not all snakes are to be feared - just treated with caution and good care. All snakes are deserving of respect. Including this little cutie-pie here.

Reference

Fawcett A, Shea G and Cutter SM (2014) Black Whipsnake (Demansia papuensis species group) envenomation in a Jack Russell terrier. Australian Veterinary Practitioner 44(2):627-630.

Another reading on an article about the efficacy of rabies vaccination

Eddie and Ripley hang out in their winter jumpers.

If there is one thing I've learned from years of University study, its that no scientific paper is flawless (and if you've submitted a paper you might agree that nothing is as humbling as peer review). When I posted this piece on an article about protection induced by rabies vaccination it garnered a lot of interest.

Associate Professor Richard Squires, from James Cook University, wrote the following comment which makes some excellent points.

It’s actually published in a brand new journal named “Veterinary Record Open” (as in open access), not in the well-established Veterinary Record. 

[I stand corrected]

This article was published in the very first issue of the new journal.  It’s peer reviewed, but the stated aim of the publishers is to achieve very rapid peer review.

There’s no information in the paper about the quality of the rabies vaccines previously administered to these 300 dogs.  Some of the locally produced rabies vaccines in India are of questionable efficacy.

They used a “home-made” antibody titre test, with their results calibrated indirectly against international standards.  So the accuracy of the statement that “only 39.67% of previously vaccinated dogs had a protective titre” hinges upon whether their indirect calibration was reliable. Some direct cross-checking would have been good. They don’t tell us how many of the dogs had a “nearly” protective titre, so I can’t judge how important this issue might be.

We know that (single) vaccination and release programs have been highly effective, in the field, in some parts of India and Sri Lanka (for example, in Colombo, human deaths from dog-bite derived rabies were reduced from about 35 per year to 0 to 2). 

In addition, it is possible (but not safe to assume) that some dogs with suboptimal antibody titres would mount a rapid and effective immune response after the bite of a rabid dog.  The virus persists at the bite site for a while before getting into neurons, where it can evade the immune system.  It can be destroyed at the bite site if antibody levels rise rapidly after a circulating memory B cell encounters virus at the bite site, shortly after the bite.

I have hopes that oral rabies vaccine (a single dose per dog) can and will be used to control canine and human rabies in India, Sri Lanka and other countries where urban rabies is mainly a consequence of dog bites.  There is evidence (not least from wildlife vaccination programs in rich countries) that this approach can work.  I would envisage training people who habitually feed street dogs (via a DVD or web page) to maximise the number of dogs they can immunise (by feeding street dogs empty baits over several consecutive days to overcome mistrust of the bait and then feeding them vaccine-impregnated bait on the last day).

Thank you Dr Squires for this thoughtful response. Meantime I certainly wasn't pooh-poohing rabies control initiatives - far from it. We all need to contribute to the fight against this devastating and deadly pathogen.

If you have an interest in infectious diseases in general read this fantastic interview with Associate Professor Tom Gottlieb here.

Interview with Domestic Pet Goddess Amy Flint

Veterinary nurse Amy Flint with a very, very tiny patient.

I met vet nurse Amy Flint at the AVA Conference in May. She was the only delegate with a dog (Wicket, an assistance dog in training) so naturally she was mobbed. She offered to submit to SAT's probing questions about her interesting career in veterinary nursing and starting her own business for patients who don't cope so well in the hospital setting, www.domesticpetgoddess.com.au

Hi Amy, can you tell us a little bit about who you are and your background as a vet nurse? 

I am a registered veterinary nurse and have been in the industry over 16 years. As a kid I spent every Saturday on my grandparents working property, and the school holidays looking after neighours pets. I fell into vet nursing after a close family friend, knowing my love of animals, suggested I apply at her clinic where they were looking for a kennel hand. So at the tender age of 14 I started my first job, not knowing the career it would turn into!! Walking into a clinic over-powered by the pungent odour of parvovirus; that is a memory well scarred to my brain, didn't deter me and I continued to learn in a busy 4 vet general practice which has given me the foundation which I still rely upon to this day. 

During this time I also became heavily involved in my local dog training club (ACT Companion Dog Club), completing my Instructors course the same year I completed my Certificate IV in Veterinary Nursing. Working alongside a veterinarian with a strong interest in dog behaviour gave me the opportunity to learn volumes about dog behaviour and be at the forefront of modern training techniques and puppy training.

Wanting to see the world and leave my home town, but acutely aware of the resposibility I had taken on when I got my keeshond Kaz; I opted to move to Melbourne where I found myself discovering the nightowl world of emergency care and dipping my toes into dermatology (my tendency to faint from overheating in surgical attire has for many years ruled out any commitment to surgical nursing).

Kaz the Keeshond.

Having been bitten by the emergency bug I moved to Perth in 2008 to follow my interests in emergency nursing. Not only have I been able to fullfill my aspirations and complete my Diploma in Veterinary Nursing (Emergency & Critical Care), I also fell in love with Perth and now call it my hometown.

Kaz is still by my side and was joined a number of years ago by the man of the house Holstein, a DSH rescued from work. More recently Mr Marmalade, a DMH ginger who was also rescued; who due to his attitude spent many years in foster care, has solidified his place in my home.Outside of animal related pursuits I am currently studying photography and am keen to shake of my L plates and become a bonefide kiteboarder.

Amy's pictures from her kiteboarding holiday. OMG. Jealous.

What is "Domestic Pet Goddess" and who can use this service?

Domestic Pet Goddess is a mobile veterinary nursing service located in Perth, WA. It is a personalised service dedicated to helping owners provide the optimal care for their fur family, without having to compromise. 

Anyone across the Perth Metro region can readily access my services, I would also encourage those a little further a field to still make enquiries as I am willing to travel, depending upon my client load. Alternatively, depending upon the assistance required I can consult via phone or skype. My focus when nursing any patient is wholistic as opposed to holistic as I don't believe just one thing can make a patient feel better. I combine the many aspects of general nursing, treatment options and behavioural understanding to build and maintain the best relationship a client can have with their furkid/s, whether I'm needed for a day or several weeks.

Amy with a patient in hospital.

How did the idea for this come about?

The concept is one that had been on my mind for many years. All too often I've had patient's in my care and kept hospitalised longer because the owners don't feel comfortable, or are unable to manage the care on their own at home. I've always considered myself lucky as a VN, because if one of my furkids is sick I get to stay with them, however this is impractical in the veterinary hospital setting for clients. I wanted to be able to give everyone access to the same kind of care that I would give and want for my furkids. 

Patient blood pressure tends to be increased in the hospital setting.

Why is it so important for some animals to have in-home care?

In home nursing care is important for a variety of reasons and isn't only about the patient. As companion animals, who are part of our family we like to provide the same level of health care that we ourselves recieve, but being in hospital is distressing and not the ideal healing environment. Care provided may be as simple as administrating medications, through to dressing & bandage care and managing feeding tubes through to intensive recumbent patient care. Our relationships with our furkids are so precious and not a bond that we want to crush, so sometimes its just a case of "being the bad person" so that the client can maintain their loving relationship.

Some patients require involved at-home care.

What are the unique challenges that in-home care raises and what skill set does one require to deal with these?

The most challenging aspect to in home care is working outside of a fully equipped hospital. No matter how much you prepare your patient and the setting will always provide challenges and problem solving is in high demand; I have discovered curtain rods make a great make-shift fluid stand. I lean upon my years of experience every day from knowing how to approach the fiesty feline, through to knowing how to make that dressing stick.

Home care can make all the difference.

You're currently fostering an assistance dog. Can you tell us a bit about him?
I am a volunteer Puppy Educator for Assistance Dogs Australia; who provide trained dogs to people with physical disabilities to help them gain independent lifestyles. 

My current charge is Wicket a rambunctious 8 month old Black Labrador. As Puppy Educators our role is to socialise, train and provide the foundations so that when they are 16 months old and return to headquarters, they are ready to be formally trained and matched with a recipient. Its a tough but rewarding job and Wicket is both a challenge and delight to have as part of the family. His worst habit is his desire to chew anything and if I'm not on my toes I find his collection of items half chewed in his bed!! A somewhat strange challenge for me is his tail! I've only owned spitz breeds which carry their tails on their backs - Wickets waggy tail clears the coffee table and almost gets caught in doors!

Wicket. Cutest L-plater ever.

You have numerous qualifications in nursing and experience working in major clinics. How would you like to see veterinary nursing in Australia develop?

I'd like to see veterinary nursing evolve into a well recognised paraprofession. Nearly everyone I meet asks me "when am I starting vet school?", and I know I'm not the only VN to be asked this! We are still referred to by clients as the vet's "secretary" or "assistant", yet as nurses we are so much more and have such a range of abilities and knowledge. Its very disheartening giving your all for a patient or situation, only to be glanced over by public perception as an insignificant part of the veterinary team.

Some of the roles vet nurses play...(I love chew toy!)

Behind that friendly smile that greets you is a powerhouse of compassion, empathy, patience and knowledge. Our key focus is patient advocacy and care and though we may multitask to a range of ancillary duties such as reception and practice management, it doesn't change our primary desire to to assist animals in need and provide preventative health care.

Do you have any advice for veterinarians, nurses or pet owners? 
Vets: Never underestimate your nursing teams' abilities and take a moment each day to recognise their work.

Nurses: Follow your passions and skill sets. Never EVER stop learning.

Pet owners: PLEASE PLEASE PLEASE stop rushing to google or facebook for medical advice. Seek veterinary advice (yes this includes advice from your veterinary nurse) early. Prevention is always better than cure and all to often in the emergency setting I see patient outcomes that could have been very different and less financially distressing if treatment had been sought earlier. Sometimes it may be frustrating to hear the best advice is to have your veterinarian check your pet over, however we need to be able to examine your pet to get the full picture.

Thank you Amy! I hope your business continues to grow. Meantime Amy is currently raising funds to trek with orang-utans and aid conservation efforts in the process. Tax time is coming up so its a very good time to support this cause - check out her page here. Or see the article which appeared in the paper below.