Posts Tagged ‘medical advocate’

The Most Important Thing a Client Ever Taught Me

Sunday, September 8th, 2013

When I met Martha in 1985 I was an internal medicine resident at the University of California, Davis Veterinary Teaching Hospital. Right from the get-go, Martha impressed me as a kind, soft-spoken, intelligent woman, devoted to her one-year-old Cocker Spaniel named Murphy. Upon entering the exam room I learned that I would be providing a fourth opinion. Three vets prior to me had run most every test in the book, but could find nothing amiss. According to Martha, they believed the patient was normal and the client was a hypochondriac.

Martha readily admitted that she could not identify any clear-cut symptoms. Yet, she was certain beyond a shadow of a doubt that something was troubling her beloved Murphy. His appetite and activity level at home were completely normal. There had been no vomiting, diarrhea, coughing, or sneezing. It was while Murphy was on his daily walks that he appeared abnormal to Martha- a bit less exuberant than normal.

I examined Murphy from teeth to toenails hoping for the clue that would help guide the diagnostic process. I found nothing. I reviewed all of the laboratory test results and X-rays previously generated. Still nothing. Was I truly face-to-face with a hypochondriac? Listening to Martha and observing her body language, my gut told me otherwise. I believed her conviction that something truly was wrong with her darling dog- something a trio of veterinarians had yet to figure out. More than anything, I admired Martha’s calm perseverance. She had been turned away three times, yet here she was before me in her ongoing efforts to be an effective medical advocate for her beloved dog.

Although Murphy had no heart murmur, based on the change in his energy level while out on walks, I opted to proceed with an echocardiogram- an ultrasound examination of the heart. Lo and behold, this study revealed the abnormality responsible for Martha’s concern. Murphy had a birth defect within the heart known as a patent ductus arteriosus (PDA). The ductus is a normal structure through which blood flows in the developing fetus. The ductus normally closes shortly after birth. In some puppies, this ductus remains open causing abnormal blood flow that can ultimately result in heart failure. This abnormal flow typically moves from the left side of the heart to the right side and is associated with a loud heart murmur. The left-to-right PDA can be quite readily corrected. In rare instances, as was the case with Murphy, the abnormal blood flow moves from the right side of the heart to the left. This “reverse direction” does not cause an audible heart murmur- the reason why three vets before me had been stumped. Unfortunately, there is no feasible way to correct a right-to-left PDA and symptoms invariably progress.

When I delivered the diagnosis to Martha I recall that she burst into tears, a combination of sadness and relief that her concerns had finally been validated. Martha expressed profound gratitude. The search for a diagnosis was over and she now knew what to expect. Martha and Murphy enjoyed another 18 months of good quality time together. When his symptoms intensified, Murphy was euthanized after which Martha sent a note once again thanking me for having believed in her.

I’ve always remained profoundly indebted to Martha as she taught this young veterinarian a most valuable lesson. I learned the importance of trusting my clients’ instincts, gut feelings, and intuitions about their pets, even when others are demonstrating doubt. Martha helped me understand that no one knows my patients better than my clients- the people familiar with the nuances of their pets’ daily routines and behaviors. If they sense something is wrong, those hunches are deserving of my attention and some investigation. In more than 30 years of practice I can count on less than one hand the number of clients I’ve encountered who falsely reported symptoms for reasons other than the best interest of their pet.

It’s been so long that I honestly don’t recall if I purposefully thanked Martha for the lesson she taught me. I do know that, in my mind, I have thanked her hundreds of times over the course of years as I’ve evaluated animals with ill-defined or subtle symptoms that other veterinarians have doubted. Martha’s perseverance was inspirational to me and I am profoundly grateful that our paths happened to cross.

Have you ever had a hunch that your pet had a medical issue based on a subtle symptom?

Best wishes,

Nancy Kay, DVM

Diplomate, American College of Veterinary Internal Medicine
Author of Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Author of Your Dog’s Best Health: A Dozen Reasonable Things to Expect From Your Vet
Recipient, Leo K. Bustad Companion Animal Veterinarian of the Year Award
Recipient, American Animal Hospital Association Animal Welfare and Humane Ethics Award
Recipient, Dog Writers Association of America Award for Best Blog
Recipient, Eukanuba Canine Health Award
Recipient, AKC Club Publication Excellence Award
Become a Fan of Speaking for Spot on Facebook

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot and Your Dog’s Best Health.   There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot and Your Dog’s Best Health are available at www.speakingforspot.com, Amazon.com, local bookstores, and your favorite online book seller.

 

 

Anesthesia Guidelines from the American Animal Hospital Association

Sunday, January 22nd, 2012

Photo Credit: The Pet Doctor Inc.

I have great respect for the American Animal Hospital Association (AAHA). One of the many wonderful things this organization does is the gathering of experts within the profession to create practice guidelines for veterinarians. In the past, for example, I’ve exposed you to AAHA guidelines for vaccination protocols. Not only are such guidelines helpful for veterinarians, they are also available to you, the consumers of veterinary medicine. With such information in hand, I’ve no doubt that you will be better able to make informed decisions for your pets. And there’s nothing I like better than helping people become better medical advocates!

AAHA’s latest endeavor has been the creation of guidelines for anesthesia for dogs and cats. They cover multiple aspects of anesthesia including preanesthesia patient evaluation (detailed medical history, thorough physical examination, assessment of risk based on breed, age, and overall health), diagnostic evaluation, preanesthetic medications, recommendations for induction and maintenance of anesthesia, monitoring parameters and equipment, pain management, staffing recommendations, and monitoring of the patient following anesthesia. Did you know that 47 percent of canine deaths and 60 percent of feline deaths associated with anesthesia occur during the anesthetic recovery period rather than during the actual anesthesia? I had a hunch about this, but was unaware of these statistics until I read the Anesthesia Guidelines.

As a small animal internist, it’s a given that I only see patients who are sick. (I truly miss all of those well puppy and kitten exams!) So, I truly appreciate the section written about managing anesthesia for patients with preexisting medical issues including kidney disease, diabetes, heart disease, and liver disease.

Although the AAHA guidelines are written for veterinarians, I encourage you to take a look. Let me know if you need any help interpreting what you read. Keep in mind that these guidelines are simply that- guidelines. Veterinarians are not required to follow them. This is why it is up to you to ask the right questions to learn how your veterinary staff members anesthetize and monitor their patients. In addition to reading these guidelines when formulating your list of questions, I encourage you to also read the chapter called “Important Questions to Ask Your Vet…And How to Ask Them” in Speaking for Spot.  There, you will find a thorough list of questions to ask your vet when anesthesia is recommended. Perhaps the very first question should be, “Have you read the new AAHA Anesthesia Guidelines?”

What have your experiences been with pets undergoing anesthesia?

Best wishes for a happy new year,

Nancy Kay, DVM

Diplomate, American College of Veterinary Internal Medicine
Author of Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Author of Your Dog’s Best Health: A Dozen Reasonable Things to Expect From Your Vet
Recipient, Leo K. Bustad Companion Animal Veterinarian of the Year Award
Recipient, American Animal Hospital Association Animal Welfare and Humane Ethics Award
Recipient, Dog Writers Association of America Award for Best Blog
Recipient, Eukanuba Canine Health Award
Recipient, AKC Club Publication Excellence Award
Become a Fan of Speaking for Spot on Facebook

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot and Your Dog’s Best Health.   There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot and Your Dog’s Best Health are available at www.speakingforspot.com, Amazon.com, local bookstores, and your favorite online book seller.

 

 

 

When the Doctor Becomes the Patient: Not Always a Pretty Picture

Monday, May 2nd, 2011

While in the midst of my post-surgery “down time” I’ve been chuckling a bit about what my own physicians have endured as a result of my medical background.  How commonly is a surgeon interrogated about what type of suture pattern and material he intends to use? How often does an anesthesiologist need to provide a detailed pharmacologic rundown of the anti-emetic (anti-vomiting) drugs that will be used to keep the patient with a queasy stomach from puking post-operatively? 

© Steve Horton

I remember one particular appointment with my family physician a few years back.  When we discussed the reason for the visit I began with, “I think I have cancer!”  I explained that I’d been losing weight even though I’d been eating normally.  After all, a diagnostic workup on a middle-aged dog or cat losing weight in the “midst of plenty” often results in the diagnosis of cancer.   My physician worked hard to hide a grin as he explained that, given my age, sex, and overall vigor, other diagnoses were far more likely. Thankfully, he was right, and the next time I saw him he asked for permission to share this “amusing patient story” with some medical students he was training.  

Sometimes, the medical knowledge I have can be a detriment to my own peace of mind.  As the story above illustrates, I’m always keenly aware of the worst-case scenario (tough on a person who is a natural born worrier). Would I trade being a veterinarian for any other profession?  Not in a million years.  Not only do I love what I do, I love that my medical background (along with a bit of chutzpah) allows me to be a stellar medical advocate for myself.  And if you’ve read much of what I’ve written in the past, you know that I am all about medical advocacy! 

Do you work within the medical profession?  If so, how has this been helpful or detrimental when interacting with your health care professionals (including your veterinarian)? 

Best wishes for good health,             

Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Author of  Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Recipient, Leo K. Bustad Companion Animal Veterinarian of the Year Award
Recipient, American Animal Hospital Association Animal Welfare and Humane Ethics Award
Recipient, Dog Writers Association of America Award for Best Blog
Recipient, Eukanuba Canine Health Award
Recipient, AKC Club Publication Excellence Award
Become a Fan of Speaking for Spot on Facebook 

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot is available at Amazon.com, local bookstores, and your favorite online book seller.

What is a Veterinary Specialist?

Sunday, March 21st, 2010

I participate in a list serve for veterinarians who specialize in internal medicine. The list serve “topic de jour” concerns veterinarians who are general practitioners (also known as family veterinarians), yet bill themselves as “specialists” in specific venues such as surgery, dentistry, or cardiology.  The responses have been strongly disapproving, and here is the reason why:  The American Veterinary Medical Association dictates that the term “specialist” be reserved only for veterinarians who have completed all of the requirements to become a “diplomate” within a specialty organization. What must a veterinarian do to become an official specialist/diplomate? Trust me, it is a long and arduous process! After graduating from veterinary school, wannabee specialists must complete a minimum three-year internship and residency training program, author publications in peer reviewed journals, and pass some insanely rigorous examinations specific to the specialty they are pursuing.  (Note that the requirements differ for those who become specialists in complementary/alternative medicine fields of veterinary medicine such as homeopathy, acupuncture, chiropractic, and Chinese herbs.) If one is successful in completing this rigorous and extensive training they achieve “board certification” status and are deemed to be “specialists” or “diplomates” within their chosen specialty.  This is much like the process physicians go through to become specialists.

The world of veterinary specialists has grown by leaps and bounds.  Much like Starbucks®, if there’s not already a group of specialists in your community, there likely will be soon!  Veterinary specialists are found in university teaching hospitals and in some private practices.  They often “cohabitate,” sharing specialty staffing, equipment and laboratory services with specialists in different areas of expertise.  When this is the case, you, the lucky client, end up with access to multiple specialists under one roof.  Not only is this convenient, it also focuses a lot of brainpower and experience on your pet- group discussions about patients (medical rounds) typically occur daily in such specialty hospital settings.

When might you need the services of a veterinary specialist? Just as your family physician refers patients to specialists, your family veterinarian should be considering referral in the following three situations:

  1. A second opinion is desired by you or your veterinarian.  Yes, you definitely have the right to request a second opinion.  I know it can be tough telling your vet you would like a second opinion, but as your beloved pet’s medical advocate, you are obligated to do so just as soon a your “gut” starts suggesting that a second opinion makes sense. I encourage you to read the chapter called, “A Second Opinion is Always Okay” in Speaking for Spot- it will provide you with plenty of helpful coaching about how to tactfully broach the subject with your veterinarian! Hopefully your vet has established relationships with local specialists- the kind she would trust to take good care of her own dog should the need arise. Not all family veterinarians are keen on “letting go” of their patients, so self-referral might be your only way to seek out the help of a specialist.
  2. Help is needed to figure out what is wrong with your pet. Specialists have advanced diagnostic tools (ultrasound, endoscopy, CT imaging, MRI scans, etc.) and have developed the skills to use them. Additionally, because of their extensive experience with challenging cases, specialists often have the ability to hone in on a diagnosis in the most direct and expedient manner.
  3. Your vet doesn’t specialize in the disease your pet has or the therapy he needs.  Just as with our own health issues, treatment is ideally managed by someone who works with that particular disease issue day in, and day out, and regularly pursues continuing education pertaining to that disease.

How can you tell if a particular veterinarian is truly a specialist?  Simply examine the initials following his or her name. See the list of specialties and their corresponding initials below. For example, if you look at the initials following my signature (ACVIM), you can tell that I am a specialist in The American College of Veterinary Internal Medicine. To learn more about any of these areas of specialization, pay a visit to the websites.  Those listed below are within the United States, but you will find comparable organizations in many other countries or continents.

Have you ever taken your pet to a veterinary specialist?  Have you ever wanted to do so, but had trouble getting “buy in” from your family veterinarian?  If so, please share your experience.  I’d love to hear from you.

Diplomate, ACVIM Internal medicine (acvim.org)
Diplomate, ACVIM, Cardiology Cardiology (acvim.org)
Diplomate, ACVIM, Oncology Oncology (acvim.org)
Diplomate, ACVIM, Neurology Neurology (acvim.org)
Diplomate, ACVS Surgery  (acvs.org)
Diplomate, ACVD Dermatology (acvd.org)
Diplomate, ACVR Radiology (acvr.org)
Diplomate, ACVO Ophthalmology (acvo.org)
Diplomate, AVECC Emergency and critical care (acvecc.org)
Diplomate, ACVA Anesthesiology (acva.org)
Diplomate DACVB Behavior (dacvb.org)
Diplomate, ACVN Nutrition (acvn.org)
Diplomate, AVDC Dentistry (avdc.org)
Diplomate, ACT Theriogenology (theriogenology.org)
CVA Veterinary acupuncture (Ivas.org)
TCVM Chinese veterinary medicine (tcvm.com)
AVH Homeopathy (drpitcairn.com) or (theavh.org)
ACVA Chiropractic (animalchiropractic.org)
CCRP Canine rehabilitation (caninerehabinstitute.com)

Best wishes to you and your four-legged family members for abundant good health,

Nancy Kay, DVM
Diplomate, ACVIM
Recipient, American Animal Hospital Association 2009 Animal Welfare and Humane Ethics Award
Recipient, 2009 Dog Writers Association of America Award for Best Blog
Recipient, 2009 Eukanuba Canine Health Award
Author of Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life

Website: http://www.speakingforspot.com
Become a Fan of Speaking for Spot on Facebook

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot is available at Amazon.com, local bookstores, or your favorite online book seller.

An Herbal Addendum and Vital Information About Vitamins

Monday, March 1st, 2010

My most recent blog focused on potential pitfalls associated with treating our pets with medicinal herbs.  As so commonly happens, I received wonderful feedback, and one comment in particular, I would like to share with you.  Dr. Susan Wynn, a much-admired veterinary colleague offered this sage advice, “I think your conclusion is appropriate – if you’re interested in herbs, talk to your vet.  I think you need to go one further, though, since most veterinarians know little about herbs – find a veterinarian who has a special interest in herbal medicine.  Not only are they more aware of interactions and toxicity, recent research and clinical experience, they also take great care to source their products from American companies, some of them organic, that employ knowledgeable formulators. About the PDR recommendation – that will not be as helpful as it is for people only.  Please see Veterinary Herbal Medicine (Elsevier, 2007).  Disclaimer – I’m the first author on it – but it was written to collect the most comprehensive available information on herbs and their use in domestic animals.  There are thousands of references, detailed information on over 100 herbs including known toxicity and interactions, species specific cautions, traditional ethnoveterinary uses and scientific support.”  

Just as many people are giving their herbs to their pets without veterinary supervision, so too are they providing them with supplemental vitamins.  I wish I could tell you that vitamins are perfectly safe to give.  Alas such is not the case and here is why.    Vitamins come in two basic varieties; they are either water soluble or fat soluble. Vitamins B and C are water soluble meaning that any excess in the body is readily eliminated from the body within the urine.  I certainly take an abundance of vitamin C when I feel a cold coming on (thanks to Linus Pauling) with no worries of an overdose.  Not true for vitamins A, D, E, and K.  These are fat soluble vitamins, meaning amounts above and beyond what the body needs cannot be readily eliminated. Rather, the excess is retained within the body’s fat stores which can result in hypervitaminosis (symptoms caused by a vitamin overdose).  For example, too much vitamin A can cause horrendous bony abnormalities and too much vitamin D can wreak havoc on normal calcium metabolism resulting in muscle tremors, gastrointestinal issues, and even kidney failure. 

What’s the bottom line?  As tempting as it is to believe that over the counter herbs and vitamins are safe for any and all living beings, take the time to discuss these products with a trusted veterinarian before you provide them to your beloved pets.

Best wishes to you and your four-legged family members for abundant good health,

Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Recipient, American Animal Hospital Association 2009 Animal Welfare and Humane Ethics Award
Recipient, 2009 Dog Writers Association of America Award for Best Blog
Recipient, 2009 Eukanuba Canine Health Award
Author of Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life

Website: http://www.speakingforspot.com
Become a Fan of Speaking for Spot on Facebook 

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot is available at Amazon.com, local bookstores, or your favorite online book seller.

Medicinal Herbs: Not to Be Taken (or Given) Lightly

Tuesday, February 23rd, 2010

As a small animal internist, the majority of my patients are referred by their family veterinarians.  By the time I first examine them, they are usually receiving a laundry list of conventional medications (antibiotics, nonsteroidal antiinflammatories, etc.) and/or complementary medications (herbs, homeopathic remedies).   I’ve always scrutinized the conventional medications on the list because their potential side effects and the ways they might impact my diagnostic and therapeutic planning.  I’ve tended to pay far less attention to the complementary medications because of my impression that these medicinals are unlikely to cause significant harm or interact unfavorably with other things I might prescribe. Well, there will be no more of this “ignorant bliss” for me! Not after reading, “A Review of the Potential Forensic Significance of Traditional Herbal Medicines” from the Journal of Forensic Science (January, 2010).  The author, Roger Byard, M.D. undertook a review of herbal medicines based on their increasing popularity (there has been a steady 10% increase in spending on botanical remedies in the United States) and the fact that access to such products is largely unrestricted- they can be purchased without prescription. Keep in mind that herbs are manufactured and sold without any FDA approval process.

Here are some of Dr. Byard’s comments and findings:

-An analysis of 251 Asian herbal products from stores in California identified arsenic in 36, mercury in 35, and lead in 24. There have been reports of lead poisoning and mercury poisoning in people caused by such contamination.
-Less expensive herbs are sometimes intentionally used to replace those that are more costly. A case is referenced in which an herb designed to promote weight loss was replaced with another. The unfortunate result for the patient was kidney failure.
-Accidental substitution can occur if plants are incorrectly identified or if the name is misinterpreted. Apparently, some traditional herbal preparations have multiple names. To make matters even more confusing, some herbal preparations that are different from one another go by the same name.
- Failure to process fresh herbs correctly can have serious consequences. Processing is designed to clean and preserve the desired material while removing or reducing any unwanted toxic components. The example provided was aconite root, a plant that must be soaked in water and boiled to reduce toxicity. Failure to do this can result in heart rhythm abnormalities and/or heart failure.
-Some herb manufacturers purposefully adulterate their products with drugs presumably to increase their efficacy. Yet no mention of this is made on the packaging. Examples of hidden products found in herbal preparations have included conventional medications to treat pain, inflammation, seizures, heart failure, and asthma.
-Herbal medicines can interact with conventional drugs and other herbs to cause undesirable side effects. For example, St. John’s Wort can decrease the blood level of some medications by impacting how they are metabolized within the liver.
-The American Society of Anesthesiologists has recommended discontinuation of herbal medicines at least two weeks prior to surgery because of their potential for causing complications. Although only eight herbs were identified as being potentially dangerous, they accounted for 50% of all single herb preparations of those sold within the United States. For example, Ginkgo has the potential to increase the risk of hemorrhage and Valerian can exacerbate the sedative effects of anesthetic agents.

Although Dr. Byard’s review is based on findings in human medicine, I have to believe that the general points he makes likely apply to veterinary medicine as well. His review has certainly served as a wake up call for me. If you use herbs, for your pets or yourself, perhaps this information will prompt you to think about things a bit differently as well. What is a practical approach for avoiding the potential pitfalls associated with herbal medications? I encourage you to consider doing the following:

  1. If you are giving herbs to your pet based on your own initiative, schedule an appointment with your vet to discuss and verify that what you are doing is reasonable and safe.
  2. Have a look at the blog I posted in July, 2009 (http://speakingforspot.com/blog/?p=407) called, “The Lowdown on Nutritional Supplements.” It will teach you how to use the ACCLAIM system to evaluate the quality of herbal products.
  3. Pick up a copy of the Physician’s Desk Reference (PDR) for Nonprescription Drugs, Dietary Supplements, and Herbs. It provides information about the indications, contraindications, and warnings for all commonly used herbs. This PDR is readily available via major online book vendors. I will certainly be using my own copy a whole lot more than ever before!

I hope I have not created fear or anxiety by presenting this information. Rather, my goal is to help you become the very best medical advocate possible. Now, like me, you know that herbal medications should not be taken (or given) lightly. If you provide herbs to your pet(s), I would love to hear from you. Please let me know which one(s) you are giving and whether you or your veterinarian initiated this treatment.

Best wishes to you and your four-legged family members for abundant good health.

Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Recipient, American Animal Hospital Association 2009 Animal Welfare and Humane Ethics Award
Recipient, 2009 Dog Writers Association of America Award for Best Blog
Recipient, 2009 Eukanuba Canine Health Award
Author of Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life

Website: http://www.speakingforspot.com
Become a Fan of Speaking for Spot on Facebook

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot is available at Amazon.com, local bookstores, or your favorite online book seller.