Dr. Phil Zeltzman’s Blog

To answer this excellent question, let’s go over 3 classic, real-life scenarios.

Amber and the torn ACL

Amber, a 9 month old Lab, was presented for a torn ACL. An ACL can literally tear at any age, so we see it in puppies, young dogs, mature dogs and seniors. Even cats can occasionally have a torn ACL.
And we certainly can address them at any age.

Because of a bit of denial and back-and-forth between rest and pain medications, Amber’s surgery was delayed for a couple of months.

During that time, the body tried to patch things up by adding scar tissue and bone spurs around the knee. After surgery, I described her arthritis as severe. Yet she was only 11 months at the time of surgery!

Why? Simply because the knee had been wobbly for a long time, which gave the body plenty of time to try to patch things up – which it did poorly.

By the way, please note that when I say “arthritis”, it’s a bit of a simplification.

It may be a bit oversimplistic, but basically:

Arthritis = osteo-arthritis = Degenerative Joint Disease = DJD = bone spurs.

Sweetie and the dislocated kneecaps

Sweetie, a 6 month old kitten, was really struggling to run and jump like her sibling Simba.

She limped and was painful in both back legs.

Her issue? Both her kneecaps (or patellas) were dislocating (or dislocated, or luxated).

Because of a common misconception that cats don’t need their kneecaps fixed, surgery was delayed by 3 months.

After surgery, I described her arthritis as severe.

She didn’t have that many bone spurs, but her cartilage was discolored. Instead of being white, shiny and smooth, it was pinkish, dull and irregular.

Worse, it was partially gone under her kneecap and in the groove where the kneecap is supposed to stay.

The reason for the “bone on bone” (instead of cartilage on cartilage) is that every time the kneecap popped in & out of the groove, it mechanically damaged the cartilage.

It’s simple wear and tear.

Tank and hip dysplasia

Tank, a 9 month old Cocker spaniel, was in severe pain in both back legs. He was very painful in both hips. His problem? Severe hip dysplasia, which means that his hips were not formed properly.

Similar to Sweetie’s case, the ball popped in and out of the socket. Not only did it mechanically damage the cartilage (wear and tear), but as in Amber’s case, that abnormal motion also led to bone spurs.

The hip is a ball and socket joint.

Tank got pain relief thanks to a surgery that removed the ball part (Femoral Head Ostectomy or FHO).

As you now understand, the severity of the arthritis in Amber, Sweetie and Tank has nothing to do with their ages.

It has to do with their conditions, and the duration of the issue before surgery took place.

By doing surgery early on, we can’t fix the arthritis.

Surgery can however correct the actual problem, and slow down the progression of arthritis.

If you would like to learn more about how your pet can have safe surgery and anesthesia, contact us through www.DrPhilZeltzman.com

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified
www.DrPhilZeltzman.com

Vets have been able to dramatically decrease the death rate under anesthesia thanks to better anesthesia drugs and better monitoring.

What does monitoring mean?

Let’s review some techniques we use at our hospital to reduce the risks.

Please understand that not all practices have this equipment, for financial reasons mostly. As a general rule, we perform higher-risk and longer anesthesia and surgery, so we have an obligation to provide the best equipment available.

Vital signs

One of the many roles of the anesthesia nurse is to record the pet’s vital signs and numbers indicated by the devices described below: body temperature, blood pressure, heart rate, respiration rate, temperature etc.

This is critical to determine if there is a trend.

For example, is the blood pressure slowly dropping?

The surgeon is then alerted, and decisions can be made in a timely manner.

ECG

Most people have had an ECG (aka EKG), so most are familiar with the concept. An ECG measures the electric currents generated by the heart. It helps monitor the heart rate and rhythm. It allows early recognition of heart issues, such as arrhythmias (extra heart beats), which can then be treated appropriately.

Blood pressure

Blood pressure measurement is probably the earliest indicator of problems with anesthesia in pets.

Pulse oximetry

This is a way to estimate how much oxygen is being carried by red blood cells.

You may have been connected to such a device at the hospital.

This is the clip that is usually placed on your finger.

In pets, the probe is usually placed on the tongue.

Temperature

Anesthesia commonly reduces the body’s temperature.

We are obsessed with maintaining pets’ temperature, especially small ones.

Opening a body cavity (chest or belly) leads to losing even more body heat.

So we use several modalities to keep the temp up.

For example, every single patient gets a “Bair Hugger,” which is a warming blanket, in addition to a heating pad under their body.

It is important to warm patients up after surgery as well.

Capnography

This is a fancier machine, not routinely available in general practices.

It monitors the amount of CO2 (carbon dioxide) in the patient.

If it becomes too high, it means that the patient is not breathing enough to “blow off” the toxic CO2.

The anesthesia nurse would then help the patient breathe.

Such equipment undoubtedly helps us greatly improve the safety of anesthesia.

By far, my favorite way to monitor my patients is my skilled nurses.

The risk obviously depends on the patient and the type of surgery.

For example, spaying a healthy 6 month old Lab puppy is less risky that removing a 1 pound cancerous tumor from the liver of a 14 year old diabetic, seizure-prone poodle with heart and kidney disease!

That said, the OVERALL death rate under anesthesia is:

. 0.06 to 0.43% in cats;

. 0.11 to 0.43% in dogs

according to several studies conducted in the late 1990s.

As you can see, careful monitoring makes the anesthesia as safe as possible, so that we can reach our ultimate goals: a healthy pet and a happy pet owner.

If you would like to learn how we can help your pet with safe surgery and anesthesia, please contact us through www.DrPhilZeltzman.com

Never miss a blog by subscribing here: www.DrPhilZeltzman.com/blog

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Surgeons love little sayings. One of them is “There are routine surgeries, but there is no routine anesthesia.”

It is a good reminder that while pets rarely die because of the surgery itself, they can die because of anesthesia.

This is why it is so important to do a thorough physical exam and blood work before surgery.

While not 100% foolproof, blood work helps us know whether internal organs are normal or not, especially the liver and the kidneys.

Those organs are especially important as they may filter some of the anesthesia drugs.

So we may change which drugs we use based on blood work alone.

This is much more important than only considering the pet’s age.

A (sick) 2 year old cat could have a higher anesthetic risk than a (healthy) 12 year old.

Another way to assess preop patients’ anesthesia risk is to determine where they fit in the American Society of Anesthesiologists’ (ASA) classification. This is a human scale, but perfectly adaptable to pets.

In fact, our wonderful nurses apply it to every single patient they anesthetize.

There are 5 classes.
Fitting a patient in one particular category is somewhat subjective, but here is the gist of the classification:

• Class 1 is “a normal patient with no organ disease”. This would be your happy, healthy, crazy 6 month puppy or kitten undergoing a spay or a neuter.
• Class 2 is “a patient with mild organ disease”. This is for example a puppy with a foreign body in the intestine or a cat with a fracture, or a patient with well-regulated diabetes or Cushing’s disease.
• Class 3 is “a patient with severe organ disease that limits activity but is not incapacitating”. This would be a patient with poorly controlled diabetes or hypertension.
• Class 4 is “a patient with incapacitating organ disease that is a constant threat to life”. This is a patient with severe heart disease or end-stage kidney failure.
• And let’s face it, class 5 is “a moribund patient not expected to live 24 hours with or without surgery.” In my opinion, the only reason to do surgery on such a patient would be to try to save his or her life. So it would be a risky life-saving procedure. Luckily, we are rarely faced with patients in that class…

Now let’s look at statistics from various scientific studies that answer this question: how often do pets die under anesthesia?

• The death rate for anesthetized dogs at the Colorado State vet school dropped from 1.2% in the 1950s to 0.43% during the late 1970s and has remained stable at 0.43%.
  The initial 64% decrease in mortality most likely reflects technological advancements in surgery, anesthesia monitoring, and availability of safer anesthetic drugs.
• The current feline mortality rate at the Colorado State vet school is also 0.43%
• Vermont family vets reported a 0.11% mortality rate in dogs and 0.06% in cats.
• In one of the largest studies ever, British vets reported a canine mortality rate of 0.21% and a feline mortality rate of 0.27%.

As you can see, even though there is no routine anesthesia, the overall death rate is very low in most cases: all studies show a death rate that is a fraction of 1%.

Accidents do happen, and our job is to minimize their occurrence.

Thankfully, in the very vast majority of cases, we can return a surgery patient to their family to heal after safe and happy anesthesia.

If you would like to learn how we can help your pet with safe surgery and anesthesia, please contact us through www.DrPhilZeltzman.com

Never miss a blog by subscribing here: www.DrPhilZeltzman.com/blog

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Before we start, I would like to point out a few important thoughts:

1. A specialist is not a competitor of your family vet. Rather, the specialist should be considered as an extension of your primary care veterinarian, similarly to what happens in human medicine.
2. The ideal situation is that your family vet and the specialist have a prior relationship. They may not have dinner once a week or be BFFs, but they should work well as a team and communicate well – for your benefit and your pet’s.
3. It is important to remember that there are many family vets with considerable expertise in various areas despite not being “specialists.” Yet it is not possible that any one vet can be an expert in all areas.
4. The only vets who can call themselves specialists, or “board-certified,” or “boarded” in short, are those who have gone through additional training beyond vet school (8 years): an internship (usually 1 year) and a residency (typically 3 years). Then, they must pass a very difficult exam. The only proof of all of that is extra letters after their name. For a surgeon, you should see DACVS or Dip. ACVS or Diplomate ACVS after their name.

That said, let’s go over my top 10 reasons to see a board-certified surgeon:

1. A surgeon has extensive training. You tend to do well what you do often.
2. A surgeon may have treated several patients like your pet. Surgeons naturally see more challenging cases because so many family vets refer to them.
3. A surgeon has the specialized equipment needed. There are surgeries you simply cannot possibly do without special equipment.
4. A surgeon can provide a second (or third) opinion.
5. A surgeon tends to know the latest research and advances, because all they read is surgery journals and all they attend is surgery conferences.
6. Some patients may need a high-risk or difficult surgery.
7. Some patients may require specialized anesthesia because they are “high-risk”.
8. A surgeon’s clinic might provide 24-hour care, which is extremely rare in family practice.
9. A surgeon and their nurses offer comprehensive pain management through multiple modalities. For example, in my practice, we use 10 different ways to prevent and treat pain before, during and after a TPLO (a surgery to address a torn ACL).
10. Performing a surgery is a technical act. Knowing how to prevent complications, or how to deal with them if they occur, is a whole different story.

Basically, you should see a specialist for your pet for the same reasons you would see a specialist for yourself for open heart surgery or joint surgery.
So if your pet needs surgery, have an open discussion with your family vet and decide if they can handle it, or if you should consider a surgeon specialist.

If you would like to learn how we can help your pet with safe surgery and anesthesia, please contact us through www.DrPhilZeltzman.com

Never miss a blog by subscribing here: www.DrPhilZeltzman.com/blog

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

I asked some surgeon friends what they would tell you if they could sit down with you and have a casual chat around coffee… (tea is allowed).

You can learn a lot from their answers.

There is no sugar-coating here.

I will share their loving, nurturing, bluntly honest tips, then mention their names & locations below. If you ever need surgery for your pet, they are excellent surgeons you can trust.

GENERAL ADVICE

• Dogs are not small people. Cats are not small dogs. Medications used on one cannot always be used safely on the other. Some drugs, given to the wrong patient, can even be deadly.
• If you are not sure about what to do, or if you’re confused about something, or if you forgot what you were told, ASK. There are no stupid questions.
• Your pet may be chubbier than you think. That little bit of chub that you think is hiding under all that fur is more than you realize. It might be cute on a baby, but not on your dog. Thin and fit are essential to a long and healthy life.
• Dr Google is not your friend. A Google search does not replace the years of education and practice needed to become a veterinarian – or a surgeon.
• Don’t be mad at your vet when they give you advice, yet you choose to trust Dr Google or your breeder and things don’t turn out the way you want.
• The receptionists and nurses who support your vet are critical to the function of a pet hospital and the care of your pet. We can’t work without them. Be kind. Treat them with respect. We ALL have your pet’s best interest at heart. That’s the only reason we chose this profession.
• Spay your female pet before the first heat to virtually eliminate the risk of breast tumors. And it will help decrease or eliminate all kinds of bad or expensive diseases.
• Neuter your male dog during puppyhood. It will help decrease or eliminate all kinds of bad or expensive diseases.

AVOIDING COMPLICATIONS

• Surgeons are highly allergic to complications. So we design our postop instructions to minimize the risks to your pet. Our postop instructions are based on science and years of experience.
• Postop care is harder than you want and more important than you realize. We don’t make up recommendations for fun. Or to torture your pet. Or to torture you. They have a purpose and we need you to follow them to reach a happy outcome.
• Why is confinement so critical after a TPLO or a fracture repair? Because if something goes wrong because your pet escapes your care, or because you didn’t follow the rules, the damage could be FAR worse than where we started. And sometimes, the damage is beyond repair… and could require amputation.
• Just because a pet complains about something doesn’t mean that you shouldn’t do it. Just because they don’t like confinement, work, physical therapy or taking pills does it mean they shouldn’t do it. For the same reasons we make kids brush their teeth and take a shower!

Now… also use your judgement.

If your pet hates it when you apply cold or heat, then discontinue it and don’t force it.

If your pet truly hates it when you do physical therapy, then discontinue it, don’t force it, and call your surgeon to try to find out what might be going on.

• Confinement after surgery is not a punishment. It’s a necessity to allow proper healing.
• How does your surgeon choose the duration of confinement? It has to do with how long it takes to heal. In an adult, bone takes 2 months to heal. In a puppy or a kitten, it could take 6 weeks.

It has nothing to do with you or our personal preference. It has to do with Mother Nature.

WHO TO TRUST

• Being a surgeon is different from doing surgery. Many veterinarians do surgery. Very few of us are actually trained as surgeons. Going to a weekend course does not make you a surgeon. Ask tough questions. Do your homework.
• You often get what you pay for. Don’t choose the cheapest option. Then again, don’t believe that the most expensive option is the best one… Choose the best surgeon you can find, based on experience, results and reputation.
• Any surgeon you work with should be willing to answer those 3 simple questions:

– How many times have you performed this surgery?

– What results do YOU get?

– Would you do it on your own pet?

• Being a surgeon does not give us superhuman vision. And NOBODY can give you a diagnosis just by feeling a mass or by looking at it. We need to submit tissue samples to a pathologist to look under a microscope to know what it is. Or we need to take X-rays to see what’s going on inside. Guessing does not help you or your pet.
• The kid at the pet store doesn’t know anything about pet nutrition. Trust your vet.
• Your breeder does not have a veterinary degree. Trust your vet.
• 80% of supplements sold online and at pet stores are complete junk. Trust your vet.

TUMOR REMOVAL

• The first time is the best time. Having someone remove a mass only to find out they didn’t get it all is not a great idea. A second surgery means more expenses for you, more trauma for your pet, and no guarantee that we can get it all the second time around.
• “Just watch it” are the least favorite words of surgeons and oncologists (cancer specialists) alike. Getting cells or tissue samples from a mass to evaluate under a microscope can be the difference between life and death for your pet. Or skip the preop testing, and put the money toward surgery and postop testing.
• Don’t wait until masses are big enough that they bother YOU. Deal with them while they’re small and manageable. Surgery will be cheaper, less invasive and possibly less dangerous if the mass is small.

PETS AND PAIN

• Animals are very good at hiding pain. Remember, in the Wild, animals that show pain get eaten. 

This means 2 things:

– Before surgery, pets will hide their signs and their pain until they just can’t take it anymore.

– After surgery, pain medication should be given as directed by your vet. Don’t stop early, thinking your pet is doing OK because they act normal. Pain meds also decrease inflammation and help rebuild muscles.

• Pets don’t become addicted to pain medications, including morphine-like drugs. Plus, they don’t have thumbs to open the pill bottles…

POSTOP CARE

• Dogs and cats feel better and act like they’re better LONG before they have actually healed. Don’t let those sad eyes trick you into shortening their convalescence period!
• Elizabethan collars (E collars) are used to deter your pet from licking, chewing, scratching or rubbing the incision. Most incision complications are due to self-trauma, ie licking or scratching. Despite the old wives’ tale that dog saliva helps with healing, the truth is that licking, chewing or scratching an incision can lead to skin irritation, infection, pain and prolonged healing if the incision falls apart. Not to mention more fees and more aggravation.
• Leave the E-collar on at ALL times. Your pet will be able to eat and drink and figure out how to get through that doorway eventually! Talk to your surgeon about which style is best for you and your pet’s particular condition.
• Yes, it is OK, and even preferred, for your dog to use the leg after TPLO surgery or a fracture repair. Exactly when they will start to use the leg is tough to predict, but rest assured that if they do use it, it’s because they can.

If you would like to learn how we can help your pet with safe surgery and anesthesia, please contact us through www.DrPhilZeltzman.com 

Never miss a blog by subscribing here: www.DrPhilZeltzman.com/blog 

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

SOURCES:

Thank you to my amazing colleagues for their generous contribution:

• Kathy Collins, board-certified surgeon at Veterinary Surgical Services in Rochester and Buffalo, NY.
• Jennifer Wardlaw, board-certified surgeon at Gateway Veterinary Surgery in Saint-Louis, MO.
• Mario Cabrera, surgeon at Cutting Edge Surgical Referrals in Miami, FL.
• Tony Kahn, board-certified surgeon at Anchor Veterinary Surgery in New York, NY.
• Tracy Nicole Frey, board-certified surgeon at SoftSurg in San Diego, CA.
• Jeremiah Moorer, board-certified surgeon at Trek Veterinary Surgery, in Denver, CO.
• I also contributed a few gentle & loving thoughts… Phil Zeltzman, board-certified surgeon in Bethlehem, PA & Harrisburg, PA.