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Why Endoscopy?

ENDOSCOPY: The Non-surgical Way of Foreign Object Removal, and Obtaining a Diagnosis and Treatment of Various Diseases

Our pets supply us with an endless amount of love and affection, as well as many hours of joy and entertainment with their silly antics. Anyone who has a puppy or kitten (or an energetic adult pet) can attest that they are curious, and some of these antics involve swallowing things they should not. Pets will sometimes ingest the strangest things like toys, bones, clothing – including underwear & socks, string, plastic, and even fish hooks! Unfortunately, these objects do not always pass through the intestines, and as a result, obstructions can occur, and without treatment can lead to serious illness and even death. Obstructions are not the only life threatening consequence if your pet eats something it should not. Did you know that ingestion of just 1 penny made after 1982 can cause acute zinc toxicity as the penny degrades, and can kill a healthy animal?

Endoscopy means looking inside, and typically refers to looking inside the body for medical reasons using an endoscope. An endoscope is an instrument used to examine the interior of a hollow organ or body cavity. There are different types of endoscopes (fiberoptic and video endoscopes) that may be long and bendable, or sometimes rigid – both having flexible tips that allows the veterinarian to actually visualize what’s inside. An endoscope could be used to remove some ingested items from the esophagus, stomach, a small portion of the upper intestines, and even the trachea if the object is accidentally inhaled. Inhaled objects, in some instances, could obstruct your pet’s airway, or potentially migrate to the lungs, causing – as you could imagine, a myriad of health concerns, or even fatality. In the past, a surgical incision was required to remove all foreign objects. However, with medical advancement for both humans and animals, surgery is no longer the only option. Retrieving a foreign object with an endoscope is advantageous because a potentially life threatening obstruction can be removed without surgery, there is no pain or surgical incision, thereby shortening your pet’s period of recovery. Endoscopes also have channels that allow the doctor to pass various tools used to grasp or snare foreign objects. I’m sure we can all agree that endoscopes are wonderful tools for veterinarians, but it has its limitations. They are not able to remove all foreign objects, and your pet may still require surgery. For example, foreign objects stuck in the lower intestines cannot be reached by an endoscope or cats/dogs sometimes have ingested more than one object that has traveled past the stomach and the portion of the upper intestines that can actually be seen with an endoscope, and surgery is still required. However, despite these limitations, endoscopy should be considered to remove foreign objects before going to surgery.

Although retrieving an object our beloved pet has recently ingested is a great reason for an endoscopy, foreign object retrieval is far from its’ primary use. It is an excellent, non-invasive diagnostic tool that acts as the veterinarian’s “eyes” and it is also used for investigating gastrointestinal disorders. Biopsies can also be collected through the endoscope using special instruments, allowing for diagnosis of GI disorders, cancerous growths, polyps, and more. A common reason for endoscopy is to investigate chronic vomiting problems. Colonoscopy (an endoscopic procedure where the tube is inserted into the rectum) can be used to help diagnose large bowel disease. Pets requiring colonoscopy are typically fasted, and given a liquid orally to gently cleanse the colon to make viewing the walls of the intestine easier. Mild anesthesia is typically required to keep your pet relaxed and still during the endoscopic procedure; however, the amount of anesthesia and subsequent recovery time is far less than that required for a major surgical procedure.

Very few veterinarians are trained to perform endoscopic procedures. In fact, according to the October 2010, Volume 22 issue of Veterinary Practice News, “less than 5% of U.S. veterinarians are trained in the modality”. Triangle Veterinary Emergency Clinic (soon to become Triangle Veterinary Referral Hospital) is extremely proud to be among the few hospitals that provide this service. We understand that your pet is a well loved member of your family, and is honored to work alongside your primary veterinarian in their care. Triangle Veterinary Emergency Clinic wishes all of you the best, and if you need us, we are there every step of the way. Please ask us about the other services offered here at TVEC.

Leetrice N. Lynn

It's Veterinary Technician Week!

The week of October 10^th through the 16^th is National Veterinary Technician Week. What does it mean to be a veterinary technician? Many of us consider ourselves pet “nurses”. We do many things that valued human nurses do and more. Veterinary Technicians wear many hats from holding pets for doctor exams to taking radiographs to treatments and procedures. When most clients meet a technician initially what they see is us holding an animal for the doctor’s exam. Behind the scenes it’s a whole other story.

Here at the emergency clinic, the technicians have quite a bit of responsibility because the doctors rely on us for help while they are busy seeing patients, writing records and figuring out the best treatment for the animal. For a typical patient that is staying in the hospital, the doctor will give us orders for what they want for the patient like blood work, x-rays, etc. Usually this will mean placing an intravenous catheter, drawing blood and running blood work, medications to be calculated and given, IV fluids to be given, getting supplies prepared to do a procedure like sewing up a laceration or unblocking a urine obstructed cat.

Do you ever wonder who does anesthesia for your pet during surgery, dental cleanings, or any procedure requiring sedation? Technicians do it all from setting up the OR, calculating drug doses, monitoring anesthesia, to recovering the patient post operatively. We don’t do the surgery however. We are also care givers because during this time it can be very scary for a pet. They are with people they don’t know, receiving drugs that make them sleepy then waking up in a strange place. We do our best to comfort them during this time. We are also care givers for the clients as well. Sometimes clients have to make very tough decisions regarding their pet and we try to make every situation as pleasant as possible.

Other technician responsibilities include walking patients, feeding, cleaning, and administering drugs, client education, discharge instructions, answering client’s questions and more. These are just a few things that technicians do. We enter this field of work because we love animals. It’s much more than playing with puppies and kittens. Many of us have a variety of our own pets. I have had the privilege of working with some of the most caring people I have ever met (doctors and receptionists included). To many people a pet is part of their family and the same is true for us. I treat patients the way I would like my own treated and so do my co-workers.

Being a veterinary technician is more than being a glorified holder. Veterinary technicians are an integral part of the veterinary team. Working alongside the doctors we try to provide the best possible care for our patients.

Michele Kendall, RVT

Do you feed your dog ham bones?

I had an interesting case this weekend. Sandy presented with a ham bone caught on her lower jaw . In the first two pictures you will see the bone is completely around the lower jaw and caught behind both canines. Even with sedation, I had a very difficult time removing the bone and was considering cutting it with a bone saw when it finally managed to pop back over the canines. The last picture is Sandy (sedated) with the bone next to her.

I'm sure there are a large number of people that give bones to their dog without ever having a problem. When problems do occur, however, they can be serious. Take a look at the following warning from FDA’s website. Item number three specifically discusses Sandy’s condition as well as more serious problems that can occur with bones.

http://www.fda.gov/AnimalVeterinary/ResourcesforYou/AnimalHealthLiteracy/ucm204796.htm

I do not recommend feeding any type of bone to dogs, especially since there are safer alternatives out there.

Jeffrey A. Nunez, DVM

A Letter of Thanks

Below is a letter we received this past week - we wanted to share it with you because we appreciate the kind words. Working in this field can be very stressful and depressing at times - letters such as these remind us why we are here.




9/7/10

Mike Grafinger, DVM, DAVCS
Triangle Veterinary Emergency Clinic
3319 Durham-Chapel Hill Blvd
Durham, NC 27707

Dear Dr. Grafinger,

Last tuesday as I got ready to go to work our 15 year old beagle, Sheba, fell off our deck 15 feet onto a flagstone path below. At 6 am in the morning our regular vet referred us to your clinic.

Like many of the animals you probably see, Sheba is a dear member of our family, growing up with our children, so gentle with our daughter Rae, who was 7, and in particular "raising" her boy Max from the time he was 10 and we got her as a puppy.

I heard the sickening thud as she hit the ground and the pitiful sounds that followed. As a physician myself, the images of broken bones, cord or neurologic injuries or internal bleeding that filled my mind as I tried to stabilize her spine and drive to your facility were distress beyond words. While she was breathing and even awake in my arms riding into Durham, with a fifteen year old dog the likelihood of choosing between suffering or euthanasia seemed almost inevitable.

I think you know the "miracle" or "ninja dog" story from there. Not a break or a bleed, hardly a bruise, home that same day with some IV hydration and off sedation in 48 hours. For the labor day weekend the kids were all home, and Sheba was her "old" self--I am attaching 2 pics of her on her favorite couch and with her boy.

It was my understanding that you are the owner of TVEC, and I am writing this email to you not only as the doctor who took over her care on day shift, but also on behalf of your facility. While I am sure you know in detail the comfort and support that your team provided to Sheba during her stay with you, I am writing to share with you how much the TVEC team meant to me and to our family during the 11 fearsome hours from arrival to discharge.

I particularly want to single out Dawn Lanza and the receptionist/technician who worked with her, a woman whose name I am sorry to say I did not get in the chaos of events. Quite literally from the moment I walked through the door of TVEC I was awash in a sense of compassion and competence. Sheba was briskly but lovingly taken into the back, and I was seated in the waiting area, filling out the basic forms. It seemed like Dr. Lanza came out every few minutes with an update, as well as with a brief and clear explanation of the next steps, from vital signs to x-rays, blood tests, IVs, and what each was intended to explore or reveal over the range of concerns for an elderly animal after this kind of fall. As she looked me straight in the eye with each of these encounters, I simply felt Blessed to have urgently plunged into the presence of a true health care partner, who seemed as able to do what had to be done first for Sheba, and yet remain so aware of her "family" in the waiting room.

As an interventional cardiologist for the past 3 decades, I have participated in a large number of acute care scenarios, from shock/trauma to acute cardiogenic shock and heart attacks. I know well that to be able to move briskly without giving the family or patient a sense of panic or a 'fire drill" in motion reflects a unique balance of experience, expertise and compassion. I can only say that if our emergency group at Duke Medical Center performed on a par with your team last tuesday am, I would be very proud of them.

I expect you get a lot of letters like this, judging from the kind of service you provide in the setting of veterinary emergencies. But all I can say, both as one doctor to another and as a family member from our entire family, is thank you all so very much for being there, for doing the kind of work that you do, and for taking care of our beloved Sheba when she, and we all, needed it most.



BELOW: Sheba “after the fall” on her favorite couch and with her “boy”, Max.



With very best regards,

M. W. Krucoff MD FACC, FAHA
Professor Medicine/Cardiology
Duke University Medical Center
Director, CV Devices Unit
Director, eECG Core Lab
Duke Clinical Research Institute

While Mommy's away, cats will play!

Sophie, a 3 year old kitty, had some fun with her favorite toy recently and had to come see the TVEC emergency service. She started playing with her favorite toy which her mom had tied to a few feet of fishing line. When Mom got home, Sophie had the toy and a few inches of line hanging from her mouth. Her mom acted quickly and brought her right in where an x-ray showed her intestines all bunched up together.

Sophie went to surgery and the length of the string had traveled from her mouth all the way down her esophagus into her stomach. It pleated her small intestines like an accordian and continued on into her colon! The line was removed and Sophie is doing great - but will have to find a new toy!

On another note - if you ever see a string hanging from your pet's mouth or rectum, you should never pull on it! If it is snagged then it can cause serious damage!

Congratulations Bethany!

Triangle Veterinary Emergency clinic is proud to have one of our own starting veterinary school at North Carolina State University. Dr Jeffrey Nunez presented Bethany with her “white coat” during the 2010 White Coat Ceremony in August. Each year, NC state host the ceremony to honor the incoming veterinary class. Each incoming freshman chooses a sponsor that has been influential in their career to present them with the coat. Receiving the white coat is the first of many milestones the veterinary students will pass in their goal of obtain their doctorate.

Good luck Bethany! We know you will be a great veterinarian.

An Ounce of Prevention is Worth a Pound of Cure

Ben Franklin once said "An ounce of prevention is worth a pound of cure." Being an attentive and proactive owner will give your pet a better quality life. One of the most important things you can do for your pet is having an established relationship with your regular veterinarian. Vaccines for rabies, parvovirus and leptospirosis are important in lowering your pet's risk of contracting these diseases. Rabies and leptospirosis are also zoonotic, meaning they can transfer between different species. Regular deworming is also important as intestinal parasites can cause problems like vomiting, diarrhea, weight loss, anemia, and dehydration. Many parasites can be picked up by children as well. Protect both your children and your pets by deworming your pets. Routine bloodwork is also important as serious diseases and conditions can be caught early and treated successfully if managed before it becomes an emergency. For example, many signs of diseases can be vague or easily missed. Common sign of diabetes are increased drinking and urination - these can easily be overlooked if one has several indoor/outdoor cats. Uncontrolled diabetes can be very serious and life threatening. If one has a purebred pet, do your research! Large breed dogs like Great Danes, Labrador Retrievers, Standard Poodles and German Shepherds are prone to "bloat" or GDV (Gastric Dilatation Volvulus). Bloat is a life threatening condition where the stomach inflates with air and rotates, this process compromises the dog's blood supply throughout its body. Bloat requires immediate veterinary attention. Some other purebred dogs that can develop problems are the brachycephalic dogs like English Bulldogs, Pugs, Pekingese, and Shih Tzu to name a few. Brachycephalic refers to the short noses or squished faces that these dogs have. These dogs can have compromised ability to deal with exercise and heat due to their confirmation. Be diligent in monitoring these dogs and seek immediate veterinary care if they show any signs of respiratory distress! Another recommendation is to have your pet spayed or neutered. Not only does this reduce the risk of any unwanted puppies or kittens, but it can also prevent you from having to deal with your older dog's infected uterus (also known as pyometra) or your cat's difficult and unproductive labor (dystocia). We, as an emergency and referral clinic, know that not everything is preventable but being an informed owner allows you to be better prepared for emergencies!

Another Pet Food Recall

If you use Iams food for your pets, please check out the following information:

http://veterinarynews.dvm360.com/dvm/ArticleStandard/Article/detail/681249

Progress!

Progress! Isn't that stone nice?

Moving Update

Things at the new building are moving right along. It's not really much to look at, but to us, it's beautiful! Enjoy the pictures.

Procter & Gamble Company recalls specific lots of Iams canned cat food

The affected Iams canned cat food is:

• Iams ProActive Health canned Cat and Kitten Food, all varieties of 3 ounce and 5.5 ounce cans, with "09/2011" and "06/2012" date stamps on the bottom of the can.

The date stamps are found on the first line of the two lines stamped on the bottom of the can. All cans of this food marked with these two date stamps should be discarded.

More information from Procter & Gamble

Kitty goes round and round...

Happily, this kitty lived through it's adventure in the washing machine. Apparently, it crawled into the open machine and was trapped when the owners started the machine, unaware that kitty was inside.

We've seen this happen at TVEC. A small dog was sleeping in a pile of laundry, was scooped up with the pile and put in the washer. This dog died, unfortunately.

Dryer accidents are more common. Someone leaves the dryer open while they transfer clothes, and a kitty climbs in to the nice, warm cave for a nap. Later, the dryer gets started and kitty gets burned and beat up in the tumbling dryer. Deaths have occurred.

Moral of the story: Be careful not to let your pets get in the washer, or the dryer!

Dr Grafinger in the news!

Take a look at this article in the Durham Herald News about our new clinic!

More Progress on the New Clinic

Here's some new pictures of the new clinic. The external walls are going up, plumbing is going in, and the steel has been delivered for the front archway. Enjoy!

Hard Working Dogs

This is Branco, one of our favorite Belgian Malinois police dogs. Branco works with his handler at the Durham City Police Department and brings his rope toy with him when he comes to see us. He's a handsome boy!

There are an estimated 2500 dogs working with law enforcement agencies in the U.S. The work that they do helps keep us and our communities safe.

As a part of Triangle Veterinary Emergency Clinic's commitment to the community, we provide emergency care for active duty police dogs free of charge.

Let's hear it for service dogs everywhere!

All you can eat buffet...

Anyone who's ever had a Lab knows that this breed likes to eat. I mean they REALLY like to eat. So when they accidentally get access to the entire bag of food, this is what happens.


This is an x-ray of the abdomen of a Labrador Retriever who managed to sneak his way into the food bag. Ouch! Talk about a tummy ache. Actually it can be a bit more dangerous than just an aching belly. The dry food tends to absorb water, and the food often swells. The result is that the animal can actually get dangerously dehydrated. And then there's the mechanical danger - the weight of the food can increase the risk of the stomach twisting on itself (GDV - gastric dilatation and volvulus). GDV is an immediate danger, and is often fatal without emergency surgery.

In the picture below the blue circle represents the approximate size of the normal stomach, the red circle represents the approximate size of the stomach after a normal meal. The green line is the outline of the stomach in this pet.


Some people jokingly say that Lab's don't have the "I'm full" neuron in their brain. But it's not just Labs; lots of different breeds of dog will eat themselves into a hospital visit. Fortunately, they also usually do quite well with appropriate treatment.

Delia

Isn't she awesome? Delia is a beautiful 10-year-old Staffordshire Bull Terrier who was very sick with a bleeding splenic tumor this past December. Emergency surgery fixed the immediate problem, but now she has a mass growing in her heart. We get to see her... She has to come in for periodic rechecks to monitor the cardiac mass. That means Delia has batted for the cycle, having seen all four of our services (Emergency, Surgery, Internal Medicine, and Radiology)!

Delia is a fantastic girl, and we enjoy seeing her. It's always a mixed emotion though; we love the patients, but we wish they didn't have to come see us so often!

That's not supposed to be there...

They say a picture is worth 1000 words. Look at the above images. Yes, that's right, that IS a sewing needle that is stuck in this cat's rectum. Ouch!

What usually happens is that the cat finds a piece of string and begins to play with it, as cats like to do. Inevitably, the string gets stuck on the little bristles (called papillae) on the tongue. Since these papillae all point backwards, the string only moves one way - down the back of the throat. Uh oh, what's that? A sewing needle on the end of the thread? Well, that will have to be swallowed also.

In this case the needle almost made it's way out of the large intestine. Unfortunately, the needle got caught at the level of the pelvis, and didn't want to come out. Fortunately, Dr. Grafinger was there to save the day! Surgery involving the large intestine is always dicey, and this needle had punctured the intestine on both sides, so the outcome was far from certain. But, this kitty recovered nicely, and is resting comfortably at home.

And all is well that ends well.

(PS: String is just bad for cats, even if there is no needle attached. Try to keep your cat away from string, thread, etc).