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Friday, November 22, 2013

Another Bulldog Tail Issue

Lynda sent me this email....

I was googling about options for my (child's) dog's tail and came across your blog post on the tail surgery. I have an amazing 2 month old English bulldog who has had a few tail infections over the past year.  It seems to be getting more regular and worse.  I took him to the vet to get x-rays this week but they said his tail is too hard for them to do the surgery in-house so we should wait on the x-rays until I see a specialist and try to clean it and treat it aggressively first. I thought I would be ok with waiting and trying the culture and more antibiotics but I am having a very hard time cleaning his tail and more so keeping it dry. He is obviously uncomfortable and the smell is taking over the house.

I saw that you went to NC State and that you are in Georgia now. I went to UGA, got my dog in Athens, and my first dog spent a lot of time at NCState vet school with Addison's disease and muscular distrophy.  I will do anything for my dogs.

I heard that there are multiple options for Geno's tail, but don't know who to trust or listen to. I heard they could seal up the folds with surgery without removing any part of the tail, I heard they could remove part of the tail to make the space less crowded and easier to keep clean and then I've researched the full amputation (which seems dangerous and risky). Can you tell me what options there are, (though they may not actually be options for us if he isn't a good candidate)? Is there anyone you would recommend that is a specialist in this specific area here in the Raleigh/Durham area?

I cried when I thought he was going to get x-rays so I can only imagine how I will be with surgery. But bottom line I want him to be happy and comfortable. Thank you in advance for any help and guidance.

Lynda was referring to a post I made earlier this year (click here).  This is certainly not a simple situation, but here is my reply to her.

I'm curious as to why they would take x-rays for a skin infection.  Were they worried about infection in the bone?

Doing an amputation of a bulldog's tail is certainly NOT easy, and if they don't feel comfortable with it I wouldn't want them to try it.  I also have some surgeries that I won't do because of lack of proper skill or abilities.  However, a skilled general practitioner should be able to do it, and it isn't necessarily something that can only be done by a specialist.  It all depends on the vets at that clinic or in the area.

One of the problems we see with infections in skin folds is the recurrent nature.  This can happen in deep folds around the face, tail, vulva, and just about anywhere else.  Yes, you can typically cure the infection for a time with appropriate antibiotics, topical medications, and cleansing.  But often these infections have yeast and not just bacteria, so you have to use multiple methods.  And because the reason for the infection is at least in part the deep folds themselves, it's likely to keep coming back until you fix that particular problem.  Many times you'll also find an underlying allergy disorder which needs to be addressed.  Even so, most sources I've seen agree that the best long-term management involves eliminating the deep fold itself, which requires surgery.  Facial fold removal, vulvoplasty, and even tail amputation are not uncommon surgeries for severe skin fold infections.

In my experience, the really deep folds around the tail in a bulldog make amputation the best option.  In order to remove the skin of the fold you have to cut so deep and extensively that you're just about amputating the tail anyway.  Personally, I find it easier to remove the stub of the tail (which they don't need) than to try to get the skin off the bone and then close the defect over the stub.  I would also question the idea of a partial amputation on a bulldog.  The problem isn't so much the tail itself, but the very deep skin folds around it.  Yes, you could remove the outer part of the tail, leaving the deeper bones and skin.  But is that really resolving the issue?  Is that taking enough of the fold away to keep the problem at bay?  If you remove ALL of the tail and skin fold, then you simply don't have that problem at any other point in the future.  The few cases in which I've recommended amputation have been so bad that a partial surgery wouldn't have fixed the problem.

If done properly and with a skilled surgeon, tail amputation is not a highly risky surgery.  You're not in danger of affecting the nerves or muscles of the rectum in most cases, and any bleeding or pain can be controlled.  I've done many partial and full tail amputations for various reasons, including everything from short bulldog tails to long, whip-like tails.  I've never had any serious complications and once they are healed the patients have always been better off than before the surgery.

As far as recommended referral practices, there is one in Cary that one of my former surgery professors, Dr. Gary Spodnick, left the vet school to help found. It's Veterinary Specialty Hospital of the Carolinas (, and they have multiple locations in the Triangle. I don't have much personal experience with them as I haven't lived or practiced in that area in over seven years, but I think they would be considered high quality.  Although if you're in that area the vet school is always a great option.

If you still have questions about the best option, I think it would be worthwhile to spend the money to get a couple of opinions.  Talk to your own vet about your concerns, as they know the case better than another doctor and may have very good reasons as to their recommendations.  If you're not quite satisfied, find a high-quality vet in your area and go for a second opinion.  If both doctors agree (which happens commonly), you'll have more assurance in your decision.  It may also be a good idea to consult with a veterinary dermatologist, looking for non-surgical options first.

Hope that helps!

Sunday, November 3, 2013

More Ethical Challenges With Euthanasia

Ryan emailed this to me....

As a second year vet student, one thing I often think about is euthanasia.  I want to make sure that when I perform a euthanasia it is for the right reasons.  In regards to convenience euthanasia, I was wondering how you deal with the clients that you turn away.  I've read many blog posts about euthanasia (both yours and others) and I have heard that owners often threaten to kill the animal themselves.  This seems like a very troubling moral dilemma.

So, I guess my question is how do you react to different types of euthanasia requests and the clients behind them?  If an owner gets belligerent or threatens to harm their animal do you call animal control?  Warn other veterinarians that this client might be coming?  And I know this varies by location, but what can animal control officers do to owners that threaten to kill their animals?  Is merely trying to get a convenience euthanasia done grounds for calling animal control?  

This is not an easy or black-and white issue as it deals with often subtle differences as well as possibly varying systems of morality.  I've been a vet for over 16 years now and have learned to treat each euthanasia situation as a separate incident, dealing with the emotions and reasons individually.  I can't predict a person's feelings or reactions before I go in the room, so I have to be a bit flexible in how I handle them.

Let's look at each question separately.

1.  "How do you react to different types of euthanasia requests and the clients behind them?"
On either side of the spectrum the decision is easy.  If a client wants euthanasia because their pet is in the process of dying I gladly agree.  If someone wants it because they decided they don't want their otherwise healthy and happy pet anymore, I quickly decline to perform the procedure.  But the further away from the extremes you get, the trickier the decision can get.  What about the healthy 6 month old golden retriever with a badly fractured leg that the owner cannot afford to treat?  Do we euthanize a very sweet, young, healthy dog with a serious but very treatable problem when the barrier is money?  After all, if treatment can't be done the pet is going to suffer horribly.  Or what about a completely healthy cat that has been showing increased aggression to a member of the family, resulting in a few visits to the doctor to treat bite wounds?  There are many difficult decisions and you have to take them one at a time and judge the merits of each one separately.

2.  "If an owner gets belligerent or threatens to harm their animal do you call animal control?"
In general, no.  I've had many people threaten to go home and just shoot their pet after I've refused to treat due to lack of funds or I've refused to euthanize because I didn't think it was justified.  I really believe that very few of those people every followed through and were using the threat as a way to try and guilt me into doing what they wanted.  If I actually witnessed the person being violent or abusive to their pet, I would first sternly warn them and if it continued I would absolutely call animal control.

3.  "Warn other veterinarians that this client might be coming?"
This is a stickier moral situation.  Another vet might have a different viewpoint than my own, though in my experience it actually ends up being the other way around (they feel as I do).  I'm not going to tell another vet what they should or should not do in a situation like this, since euthanizing a healthy pet isn't illegal.  Also, while most vets in an area at least know of each other, the degrees to which they regularly communicate or are friends varies greatly.

4.  "What can animal control officers do to owners who threaten to kill their animals?"
I'm not a lawyer or police officer (which is what animal control falls under), so I have incomplete knowledge of the laws.  I don't know that a mere threat to kill an animal is sufficient grounds to arrest someone and confiscate their pet.  I also don't believe it's illegal to kill your own pet or livestock, as long as it's done in a recognized humane way and the animal doesn't suffer.  After all, domestic animals are legally a special form of property, and it's not illegal to destroy your own couch or car.  The AVMA does recognize guns as being a humane method of euthanasia, as long as it's done in the proper way.  But for a more complete answer you'd have to talk to some one in that profession.

5.  "Is merely trying to get a convenience euthanasia done grounds for calling animal control?"
I firmly believe that the answer is "no".  Part of this answer goes back to the things I've discussed above.  But making the inquiry alone isn't illegal.  In fact, I WANT clients to ask about that if it's on their mind.  Having a conversation with them allows me the chance to give them other options and convince them that what they are seeking is the wrong thing.  If I called the police merely because someone asked about it I would be losing that chance to save a life.

Ryan, I hope that helps!

Friday, November 1, 2013

What's Up With The Skin?

Here's a question from Victoria...

I have a 10 year old pure bred lhasa apsa who seems to be experiencing some kind of dry skin condition on his lower back. I initially brought him to our vet when he presented with what appeared to be cuts on his lower back,to my knowledge he hadnt injured himself so i was concerned. The vet explained he may be hypo glycemic and that can cause thinning of the skin. I.proceeded with the blood test to confirm this and when the test came back negative the vet concluded the dog must have cut himself on something without me knowing. I,thinking that was a totally plausible situation took my boy home and kept an eye on the healing of the cuts. The cuts have now healed but his skin seems to be blackening all on the lower back and almost 'flaking' off. The vet has said it is likely dry skin but hasnt really offered any reasons this skin condition would arise or how i can go about treating it. Any advice or insight you could offer would be much appreciated.

While diabetes can cause skin problems, it's not my first thought when dealing with a dermatology issue, especially if there aren't other symptoms.  The single most common symptom that leads to a diagnosis of diabetes in pets is an increase in drinking and urinating.

Victoria, a full exam and questioning would be necessary for me to give you a good answer, but here are some of the things I would consider in a case like this.  Are there any signs of fleas?  Has he been noticeably scratching or rubbing his skin?  Has he been going under low furniture such as beds, low tables, etc.?  Has he been anywhere new?  Has he been exposed to anything different recently?  Has he ever had any skin problems in the past?

The next thing that I would normally consider would be the trifecta of skin tests:  a skin scraping, skin impression, and fungal culture.  Every dermatologist will do these tests on pretty much every case, even if the referring vet has already done them.  A skin scrape looks for mites, the impression looks for bacteria and yeast, and the culture looks for ringworm.  If none of these are noted then it may be skin irritation or an allergy.  Unfortunately, many disorders can look the same and it make take several tests or treatments to make the proper diagnosis.

When dead skin scabs, it can look black and start to come off.  Also, chronically irritated skin will develop a dark pigment, though the pigment itself is normal and harmless.  Excessive flakiness is not normal and may be related to changes in the skin, nutritional deficiencies, and so on.  If the problem persists it should be further evaluated until appropriate treatment is determined and used.

I would first start with talking to your vet and asking more details.  The vet may actually have other ideas or directions to pursue when it becomes evident that the problem isn't simply some scrapes.  If your vet still doesn't want to look into it further, I'd look for a second opinion.