Author

Stephen J. Birchard DVM, MS, Diplomate ACVS

Saturday, March 29, 2014

More on Mental Health in Veterinarians: Commentary from an expert in suicide prevention

Finding Calm Amid the Chaos: 
When its not the patient that needs a wellness check, but the veterinarian.
by Malinda Larkin. JAVMA News: November 15, 2013 Vol. 243, No. 10 

Commentary from Fe Anam Avis (J. Russell Crabtree), an expert in suicide prevention:

As a person who has worked in the field of suicide awareness for 15 years, trained thousands of persons, and was, myself, suicidal for a period of time, I am heartened to hear of a major journal addressing the issue of suicide among veterinarians.  There are a variety of risk factors for suicide that vary from one profession to another.  It makes sense to take steps to address the risk factors related to any profession, including those listed in the JAVMA article.

However, it is important to note that addressing risk factors alone is not an adequate approach.  The reality is that many persons with these risk factors will never contemplate suicide.  For example, not every veterinarian who is perfectionistic, neurotic, or conscientious will become suicidal.  Nor will every veterinarian with student debt, demanding clients, and working long hours become suicidal.   Even if we could deal with all these issues (and many others), the cost would be prohibitive, and the possible threats to privacy unacceptable.

Given a particular set of stressors, some persons will become suicidal.  Whether they act on that impulse depends largely upon the readiness of the community around them to spot behaviors that signal suicidal thinking and to engage them in conversation about suicide that is honest, open, and respectful.  When a professional community decides to engage in these conversations, they solve the biggest problem for a person who needs to talk about suicide:  finding someone to talk to.

Few people realize that with a relatively small amount of training, they can save a life.  So while the costs of addressing all risk factors would be astronomical, the cost of training a professional community to engage in life-saving conversations is relatively modest.  By way of analogy, we undoubtedly saved thousands of persons from death to the H1N1 virus, not through a perfect anti-viral medication, but by training people to simply wash their hands and sneeze into their sleeves.  Finally, it is important to note, that the H1N1 virus has killed about 15,000 people since 2008.  In that same period of time, 200,000 persons have died from suicide.

Fe Anam Avis
Author of A Second Day

Tuesday, March 25, 2014

Veterinarians and Suicide: Why does it happen and how can it be prevented.

Finding Calm Amid the Chaos: 
When its not the patient that needs a wellness check, but the veterinarian.
by Malinda Larkin
1368 JAVMA News: November 15, 2013 Vol. 243, No. 10 

Summary

This JAVMA article addresses a sensitive but important subject, the mental health of veterinarians. While the general public seems to view us as the happiest people in the world because we love animals and have devoted our lives to helping them, the truth is that it's a profession that demands a lot of its doctors and takes a toll on their physical and mental well being. In this article the author sheds light on some disturbing evidence that some veterinarians find the job overwhelming. As a result their mental health suffers, sometimes even to the point of suicide.

Selected key points of the paper:

  • Veterinarians are 3 – 4 times more likely to commit suicide than the general population.
  • Veterinarians tend to have personality traits that predispose us to mental health problems (perfectionism, neuroticism, and conscientiousness).
  • Many veterinarians with suicidal thoughts or behavior choose not to talk to anyone about their problems.
  • Female veterinarians, young veterinarians, and those working alone are at more risk for mental health problems.
  • Suicidal thoughts are first encountered during the transition from vet school to private practice.
  • Resources for prevention and treatment of mental health issues are lacking in many areas.
Veterinarians face incredible stress everyday. As the article states, student debt, demanding clients, keeping up with new information, increasing levels of standard of care, and competition from spay/neuter clinics and specialty practices are all factors leading to frustration and unhappiness. Long hours in clinics contribute to both mental and physical health problems. Veterinarians have ready access to controlled drugs, and we are trained to help owners consider euthanasia of their animal as an option to end pain and suffering.

An increased awareness of the problem is discussed in the paper. Presentations at veterinary conferences have addressed the issue, and The Ohio State College of Veterinary Medicine recently hosted a Health and Wellness Summit to create an open forum where people could talk about the problem. At the summit there were attendees from 22 veterinary colleges including administrators and mental health professionals. The issue appears to be getting more exposure, and more people are talking about it.

To help prevent mental health issues, the author includes “Strategies for enhancing and sustaining individual well-being”, such as connecting to people, regular exercise, life long learning, maintaining a positive attitude, and accepting who you are and what you have to offer. The AVMA website (www.avma.org/wellness) now has information in its “Peer Assistance and Wellness” section to assist struggling veterinarians. Resources such as a stress checklist and a work-life balance reading list are available on the site.

Commentary
Many years ago I experienced the loss of a colleague due to suicide. I worked with her at the Animal Medical Center in New York City. She was an intelligent, energetic, and highly motivated veterinarian. It’s sad to think there are so many members of our profession who have these kinds of struggles.  The job demands a lot, and sometimes it is simply overwhelming. Unrealistic and angry clients, animals with terminal illnesses, euthanasia, and handling fractious animals are just a few of the daily duties that can stretch our physical and mental capabilities to their limits. We are very good at consoling owners with sick and dying animals, but who consoles us? I’m glad the JAVMA published this eye-opening article; hopefully it will stimulate an ongoing discussion of the problem and how it can be treated. Maybe the old adage: “Physician, heal thyself.” should be modified to: “Veterinarian, heal your colleagues.”

Tell me what you think about these issues.

What are the most frustrating or stressful aspects of your job?

How do you cope with the rigors of being a veterinarian?

What would you add to the list of wellness strategies that the article outlines?

What does the profession as a whole need to do to help our colleagues who are struggling?

References

Veterinary surgeons and suicide: a structured review of possible influences on increased risk. Bartram DJ, Baldwin DS. Vet Rec 166(13):388-397, 2010.

Thursday, March 20, 2014

Case outcome: Punch skin grafts help Toro make a full recovery from his severe burn injuries!

Outcome on Toro:

Burns in dogs and cats are classified as either full or partial skin thickness. This classification system is different than the 1st degree, 2nd degree, and 3rd degree scheme used in people. The blood supply to the skin is dogs and cats is different than in humans. Dog and cat skin does not blister as in people, hence the need for a different classification system for burn injury. Toro’s burns were a combination of both partial and full thickness.

Our initial therapy consisted of supportive care with analgesics, antibiotics, and wound management. The wounds were clipped, cleaned, lavaged with sterile saline, and surgically debrided where necessary. Wet to dry tie-over bandages were placed over all wounds including along his back and down the right thigh. The bandages were changed daily under general anesthesia.
 
Wet to dry tie-over bandages being applied to Toro. 
Completed tie-over bandage on Toro
The wound progressed well and good granulation beds developed in all areas. 
Appearance of wounds 4 days after admission; daily wet to dry
bandages had been applied under general anesthesia.
Four days after admission, punch skin grafts were performed on the granulated areas to encourage epithelializatization. Non-adherent tie-over dressings were used over the wounds after grafting to prevent dislodgement of the skin punches.
Punch skin grafts are being harvested from adjacent skin and applied
to several areas of the granulation tissue.
Appearance of Toro's wounds immediately after punch
skin grafting procedure performed.
6 days after punch grafting was performed.
9 days after punch grafting performed. Note multiple rounds areas
of epithelium forming at the site of each graft. 
Toro was discharged 15 days after admission to the hospital. Oral analgesics were prescribed and further bandage changes performed by the referring veterinarian. A recheck exam was done on Toro 18 days after admission. His bandages were removed and topical silver sulfadiazine cream was prescribed for topical treatment of his remaining wounds.
15 days after admission. Toro was discharged from the hospital
Two months later Toro came back to OSU for a recheck. His wounds were almost completely healed and he was doing well. Toro’s aggressive personality remained, however.
 
Here is Toro 2 months after initial treatment at Ohio State.
Toro's left side.
Close up of the epithelialized and contracted wounds over the right flank.
The remaining small granulated wounds gradually healed over the next several days.
Punch Skin Grafts

Punch grafts are a practical form of free skin grafts that are easy to perform and require no special instrumentation. If performed properly and skin punches are placed in healthy granulation tissue they usually take very well. However, since little to no hair growth occurs punch grafts do not provide a high degree of cosmetic benefit.  In Toro our goal was to accelerate epithelial coverage of the large areas of granulation tissue.

For more information on skin grafts, see: Birchard SJ, Smeak DD. Selected skin graft and reconstructive techniques. In: Saunders Manual of Small Animal Practice. 3rd edition, Birchard and Sherding, eds., Elsevier, St. Louis, 2006. Pg 557.

Thank you for participating in the story of Toro! I'll be happy to answer any questions you have about Toro either here or on facebook.

Tuesday, March 18, 2014

Case Study: Toro, a mixed breed dog with extensive burn wounds over his back and rear legs.


Toro (the cage muzzle had to be kept on for aggression)
Toro was a 1.5 year old in tact male mixed breed dog who was caught in a house fire.
Multiple veterinarians had treated him for several days for extensive burn wounds to his body, but he was difficult to manage because he was fractious and aggressive. One week after the injury he managed to get his Elizabethan collar off and he ate some of the dead skin off the wounds on his back.

He was presented to the Emergency Service at Ohio State Veterinary Hospital 16 days after the initial injury. On physical examination he was alert and ambulatory and his vital signs were normal except for his temperature that was 103 F. He was noted to be very dog aggressive. A complete blood count and serum chemistry profile revealed the following abnormalities: PCV 31%, neutrophilia (23,000), K 3.9, and albumin 2.8.

Toro’s burns covered an extensive area of his back and right thigh. He also had healing wounds on his nose, scrotum, thorax, and ventral abdomen.

The following pictures are all from day 2 after admission to the hospital at OSU.
Appearance of Toro's wounds over his back
Toro's wounds over his caudal back and right thigh
Close up of Toro's wounds over the more cranial aspect of his back.

Questions:
  • How would you classify Toro’s burn wounds?
  • What would you do initially for his wounds, and what is your plan for the next several days?
  • Besides wound care, what other treatments would you prescribe?
  • What is Toro’s prognosis?
Toro's treatment and outcome on the next post.


Saturday, March 15, 2014

Jackson Pratt Drains for Wounds in Dog and Cats: So much better than the Penrose!

Penrose drains are so last century. 
Does this look like effective wound
drainage in this dog?
Penrose drains are considered “open” drains, which means they establish an open pathway from the wound to the outside. They require bandaging to protect the drain and collect the drainage fluid, and they allow ascending infection by wicking bacteria into the wound. Pen rose tubing is soft and collapsible. Drainage occurs mostly via the outside of the tubing material and is prone to obstruction when the fluid is thick and viscous.

Closed suction drains, such as the Jackson Pratt (J-P), are a more effective method of wound drainage. 
Jackson Pratt closed suction drain
Negative pressure generated by the drain reservoir (also called the “grenade”) pulls fluid out of the wound rather than relying on passive drainage. The J-P tubing exits a location distant from the wound and is secured with a purse string and Chinese finger trap suture, preventing ascending bacterial contamination.

The J-P drain is composed of a soft, white, silicone drain tube that is implanted into the wound. This is connected to clear tubing that exits the wound and terminates in the reservoir.  There are multiple sizes of tubing and reservoirs. Negative pressure is generated by closing the reservoir cap while compressing it. Emptying the reservoir is simply done by opening the cap and pouring the fluid out. It does not have to be disconnected from the tubing to be emptied. 
  
Implantation of a JP drain after removal of a large lipoma
in a dog.

Same dog as above with J-P in place and secured with suture.
The grenade has been compressed and the cap closed and fluid
is being suctioned from the interior of the wound.
Closed suction drains are indicated in wounds that are being closed but have large areas of dead space that can fill with fluid. The only bandaging necessary in most patients is some stockinet or other light bandage material used to stablilize the reservoir. The drain is well tolerated by animals and they can even be sent home and owners taught how to drain the grenade. 
Large cervical bite wound in a pit bull dog.
Initial therapy was with tie-over bandages.
After several days of open wound management,
closure was performed over a JP drain.
Another advantage of the Jackson Pratt is that the amount of fluid being produced by the wound can be quantified. This is especially helpful when used for generalized peritonitis in dogs or cats. (1) (See blog from 11/21/13 on treatment of intestinal dehiscence).

J-P drains are more expensive than pen rose drains but I think their effectiveness justifies the cost.  They are available through amazon.com for about $9 per unit. That’s a pretty small price to pay for such a versatile and effective drainage apparatus.

References

1. Mueller MG1, Ludwig LL, Barton LJ. Use of closed-suction drains to treat generalized peritonitis in dogs and cats: 40 cases (1997-1999). J Am Vet Med Assoc. 2001 Sep 15;219(6):789-94.

Saturday, March 8, 2014

Here's What 14 Years of Aging Did To My Dog Otis.

The first picture was taken in my back yard when Otis was 1 year old.
Then it fades into a second picture taken in the same location, 14 years later.

Awww!






Still pictures:
1 year old male pug named Otis

15 year old male pug named Otis

Thursday, March 6, 2014

Ovariectomy vs. Ovariohysterectomy: Which is better, and why?


Ovarian remnant (arrow) in a dog found several years after ovariohysterectomy

Making a Rational Choice Between Ovariectomy and Ovariohysterectomy in the Dog: A Discussion of the Benefits of Either Technique
BART VAN GOETHEM, DVM, AUKE SCHAEFERS-OKKENS, DVM, PhD, Diplomate ECAR, and JOLLE KIRPENSTEIJN, DVM, PhD, Diplomate ACVS & ECVS
Veterinary Surgery 35:136–143, 2006

Summary and Commentary: In this paper, the authors reviewed the pertinent literature on studies addressing the choice between ovariectomy vs. ovariohysterectomy for gonadectomy in female dogs. The papers were analyzed for study design, surgical technique, and follow-up information.

No difference in short term or long term complications were seen in dogs undergoing the 2 techniques, including urogential problems, endometritis or pyometra, and urinary incontinence. Based on these findings, the authors concluded that ovariectomy is the preferred sterilization procedure for dogs since it is a faster and technically easier technique.

This is certainly not a new paper, or a new concept. I thought this topic would be a good follow up to our discussion of gonadectomy in Vizslas. Ovariectomy has been the “spay” of choice in several European countries for many years, yet in the USA ovariohysterectomy remains the most common procedure performed. Laparoscopic ovariectomy appears to be becoming a more popular choice among surgeons who have the equipment and expertise.

Question:
If you believe that the long-term results are the same between these 2 procedures, why do we still perform ovariohysterectomy rather than the simpler ovariectomy? What is your opinion? How do you spay dogs and why?

Sunday, March 2, 2014

Should We Stop Spaying and Neutering Vizslas? Read on!

Evaluation of the risk and age of onset of cancer and behavioral disorders in gonadectomized Vizslas
M. Christine Zink, DVM, PhD; Parvene Farhoody, MA; Samra E. Elser, BS; Lynda D. Ruffini; Tom A. Gibbons, MS; Randall H. Rieger, PhD

JAVMA, Vol 244, No. 3, February 1, 2014

Commentary: Vizslas born between 1992 and 2008 were surveyed by an online questionnaire; 2505 dogs were included in the study. Dogs that were spayed or neutered were more likely to develop several types of cancer (such as mast cell tumor, lymphoma, and hemangiosarcoma) compared to in tact dogs. Behavioral disorders, such as storm anxiety, were also more common in gonadectomized dogs. The younger the dogs were spayed or neutered, the earlier they would develop the above problems.

The authors felt that more studies are needed to confirm their findings, but that owners should be made aware of these adverse effects of spay and neuter in addition to the benefits.

In the Discussion section of the paper, the authors cite other studies in animals associating gonadectomy and increased incidence of cancer. They also postulate on the mechanism of the association, including studies showing that sex hormones may play a role in maintaining immune surveillance for cancer cells.

Of course the benefits of spay and neuter, such as controlling dog and cat populations and the many other medical benefits currently outweigh the adverse effects. But this study shows that we need to maintain a healthy level of surveillance of the potential adverse effects of gonadectomy and attempt to determine: is this association between cancer and spay/neuter true for all breeds, even mixed breeds, and what is the pathophysiology behind it.


What do you think? Share your opinions either on facebook or here on the blog site.