Dr. Phil Zeltzman’s Blog

Matilda, a 12 year old Lab, had difficulty urinating, frequent urination and blood in the urine.

A physical exam and X-rays at her family vet revealed that her bladder was literally full of stones!

This is a serious condition, but it was reassuring that she did not have a bladder tumor, which could cause the same signs.

The solution to remove Matilda’s stones was bladder surgery (please note that what follows pretty much also applies to male dogs and cats, as well as female cats).

Blood work was normal, including kidney values, which confirmed that Matilda was a good candidate for anesthesia.

The surgery is called a cystotomy. An incision is made in the belly, then into the bladder. The stones were then physically removed.

Here is a very short video showing removal of the bladder stones – BUT PLEASE BE AWARE THAT IT IS A BIT GRAPHIC AND NOT FOR THE FAINT OF HEART!!!

https://youtu.be/6DWEWU333D4

Removing the stones is the easy part. The sometimes tricky part is to remove stones that may have gone down the urethra (i.e. the tube between the bladder and the outside world). Stones can get stuck there and cause a blockage, preventing a pet to pee.

In males, another surgery is occasionally needed to create a new opening to allow peeing (this is called a urethrostomy).

Two tests are routinely sent to the lab:

. A stone analysis. The goal is to figure out which minerals the stones are made of. This is critical for vets to recommend the proper diet to prevent the stones from coming back.

. A culture. This is a sterile swab to determine if a bladder infection (UTI) might be the cause for the bladder stones – or a consequence. This is also a critical test to choose the proper antibiotic to take care of the infection.

This is all the stones we removed!

Once the bladder is all cleaned out, it can then be stitched up, as well as the belly. Recovery is typically 3-4 weeks.

Interestingly, bladder surgery patients can continue to experience the same urinary symptoms postop as before surgery – for different reasons:

. frequent urination, because the bladder is irritated and things feel weird “inside.”

. blood in the urine, because the bladder is very rich in blood vessels, and the bladder just had an incision.

These signs can last a week or two.

Matilda went home the next day, with antibiotics and 2 pain medications. She was progressively switched to a special food over 10 days.

A week later, the culture results showed that the antibiotic had to be changed. And 3 weeks later, the stone analysis confirmed that she was on the proper diet.

Committing to using the special food exclusively – for life – is extremely important. Bladder stones are formed because of an imbalance between minerals (most commonly calcium or magnesium), or a change in the pH of the urine.

So giving the special food for a few months, then going back to the old food, usually to save money, is a recipe for failure. Likewise, giving people food or treats may sound like a generous and loving idea, but you might recreate the imbalance between minerals and can be enough to cause more bladder stones… which means the poor dog may need another surgery.

Surgical removal of bladder stones is the most efficient way to address this condition. It also may be the only option when the urethra is blocked by a stone (urethral obstructions), which is a life-threatening emergency.

After 4 weeks of rest, Matilda was allowed to progressively return to her normal life, couch surfing and chasing tennis balls.

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

www.DrPhilZeltzman.com

Daisy, a 1 year pitbull, was found as a stray in the woods. She had wounds on her face and body, as well as an issue with her left eye. She had a hard time opening her jaw. Here is a picture of her head while under anesthesia.

She was taken to her family vet for medical care. A physical exam revealed a large, firm swelling on her lower left cheek. The mass was draining.

To be safe, the vet wisely decided to take some X-rays to see what was going on inside. To everyone’s amazement, Daisy had a huge nail inside her head!

At this point, the vet contacted me regarding surgery to remove the nail.

We were able to fit Daisy in our schedule the very next day. This couldn’t wait!

There were multiple unanswered questions: How complicated would the surgery be? How was the nail involved with the jaw bone? How about the eye?

Luckily for Daisy, the surgery turned out to be simpler than anybody thought. I made an incision over the firm lump on her cheek. Once we found the nail head, I grabbed it with an instrument and gently pulled, and pulled, and pulled.

Here is the amazing, very short video showing removal of the nail – BUT PLEASE BE AWARE THAT IT IS A BIT GRAPHIC AND NOT FOR THE FAINT OF HEART!!!

Link to https://youtu.be/bjccCGAjXXk

After surgery, we measured the nail at a whopping 3.5 inches long (9 cm). That’s more than half the width of this poor Daisy’s face! She recovered smoothly from anesthesia.

Her treatment nurse commented: “Daisy did very well after surgery. She was comfortably standing up in her run. Her vitals are normal. She can safely go home.”

So Daisy was sent to her new home, where she will hopefully live happily ever after.

Her new owner shared the following observations:

“Before surgery, she had this bizarre howl/growl/squeal. She now has a real bark.

Before, she couldn’t fully open her mouth. She can now, and she’s eating well.

She is acting like a real puppy. So happy! She is almost smiling!

She acts like a NEW dog today.

Thank you again!!!!!!!!!!!”

No one knows how Daisy ended up in the woods. Nobody knows what tragic events happened prior to her discovery. And certainly, no one knows how she ended up with a giant nail in her head!

She is lucky to have found such a generous soul, so willing to adopt her and care for her.

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

www.DrPhilZeltzman.com

Rosalina, a 3 month old kitten.

Lukas, a 2 month old coyote.

Pup, a 3 WEEK old puppy.

What do these tiny patients have in common? They all needed a broken bone repaired. And they all super young.

Rosalina the kitten had a broken femur (thigh bone).

Lukas the coyote had a fractured humerus (arm).

Pup the puppy had a broken tibia (shin bone).

Their surgery was definitely challenging because of their soft bones. But the biggest challenge is really anesthesia.

Why is the risk of anesthesia in pediatric patients higher than in other patients?

Younger patients are at risk for hypoglycemia (low blood sugar), hypothermia (low temperature) and hypotension (low blood pressure).

Hypoglycemia

Younger patients have very little body reserves on board. So they are at risk for hypoglycemia (low blood sugar).

Patients who are old enough are often fasted at 8 pm the day before anesthesia.

In young puppies and kittens, we can’t do that, precisely to prevent hypoglycemia. Babies are typically allowed a small meal the morning of surgery.

Their blood sugar should then be monitored before, during and after anesthesia. If it’s too low, we can give sugar IV (in the form of dextrose) or by mouth (in the form of Karo syrup).

Hypothermia

Another struggle is keeping very small patients warm. All patients rapidly loose body heat under anesthesia. Super young patients are an even bigger challenge.

Of course, the solutions are well-known: warm air blankets, warm water blankets, IV fluid warmers etc.

These warming devices actually need to be put in action early and systematically to keep your pet safe.

Hypotension

Our pediatric patients may also have trouble with low blood pressure as a side effect of anesthesia.

Low blood pressure can be very dangerous if not corrected. Blood needs to appropriately move through the body to carry oxygen to all vital organs, such as the kidneys.

Decreased oxygen makes just about everything unhappy. It’s so important, that we monitor all of our patients’ vitals, including blood pressure, so changes can be identified early and corrected.

Blood work

Another way to decrease the risk of anesthesia is to run blood work. This helps us ensure that vital organs like the kidneys and the liver are healthy, and your baby can safely go under anesthesia. Of course, this applies to adults as well, and especially to seniors.

If the blood work does uncover an abnormality, it does not necessary mean that surgery will be canceled. However, it will often mean changing the anesthesia medications & postop pain medications used.

One specific thing we look for in young patients is abnormal numbers that could indicate an important condition called a liver shunt.

None of this information should change your mind about doing surgery. What it should do is educate you to make sure you and your vet can come up with the best plan for your baby, with the safest anesthesia and the smoothest recovery possible.

Hypoglycemia, hypothermia and hypotension are pretty straightforward to prevent when you are working with an experienced team. So don’t be shy about asking questions, so your super young pet is safe during anesthesia and surgery.

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

www.DrPhilZeltzman.com

I recently repaired a fracture on a 23 year old cat. Some of my nurses aren’t even that old! It’s a true story with a very happy ending.

Basil, the 23 year old cat, had a broken tibia. The shin bone was broken in 3 main pieces. He went to the local ER, where his owner was told that he was too old and should be put to sleep.

That did not sit well with Basil’s owner. He may be 23 years old, but he was healthy otherwise, so why end his life? His owner contacted me regarding Basil’s situation. We agreed that it was ethical to perform surgery on him, since he was healthy otherwise, and we scheduled him for surgery.

Fixing the shattered bone required 1 pin, 1 plate, 4 wires, and 9 screws to repair! A bone graft was added to speed up healing. Surgery went well and sweet Basil recovered smoothly under the close supervision of his nurses.

At home, he was strictly confined for 8 weeks. At suture removal, after only 2 weeks, he surprised everybody by walking around using the leg very well.

And after 8 weeks, follow up X-rays showed that the bone had healed nicely and we could start to increase Basil’s activity.

And after one more month of that, Basil returned to his normal Grandpa life.

So what’s the moral of this story?

As I always say, “Age is not a disease.”

A few conditions need to be met for surgery to be a valid option in my opinion:

. The patient should be reasonably healthy

. The condition should be fixable.

. Quality of life should be good after surgery.

. The owner should be 100% on board.

Two months after surgery, Basil’s owner writes: “My sweet 23 year old cat is finally back on the couch with me. He is getting giant hugs. He’s really doing great. I really have no words to thank you enough.”

I don’t see why we should deny help to a patient who fulfills these criteria.

Basil’s owner certainly felt that way, and I am sure Basil did as well…

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

www.DrPhilZeltzman.com

Ah, the dreaded “cone of shame…”

After any surgery, we strive to send your pet home with an incision that looks as nice as possible. The plastic cone or E collar (short for Elizabethan collar) was created to prevent licking. Without it, licking or chewing can cause irritation and discomfort.

At best, that may leave a hairless, discolored, ugly scar – for life.

Or it could lead to an open incision, that needs another surgery to close it up.

At worst, it can cause a serious infection.

WARNING: some pictures below might be disturbing to some sensitive readers.

Despite the stubborn urban legend that animal saliva speeds up healing, licking an incision is a sure way to slow down healing. The tongue, especially in cats, is so rough, that it can destroy healing tissue, and therefore delay healing.

Depending on the particular pet or level of discomfort, licking can lead to nibbling and chewing, especially when nobody is around to watch or distract them.

Pets have an amazing inherited skill, which allows them to chew up twenty stitches or staples in less than two seconds flat. By the time you realize it, it’s too late!

Below is an example of a dog who was caught in the act. She went home with a cone that is too short, and does not prevent reaching the incision. Clearly, the correct fit is critical.

I cannot begin to count how many times pet owners have asked me if their pet really has to wear an E collar.

And I cannot begin to tell you how many clients thought their pet was different, or well-behaved, or well-trained, or smarter, and didn’t need a cone.

Or how many pet owners were in tears after their pet chewed the incision open after they removed the cone “for only 5 minutes” or “just to give him a break” or “because she looked so sad.”

Below is a (mild) example of what happens when a pet licks the incision.

I cannot begin to add up all the extra money owners have paid to fix open incisions at their vet or the emergency clinic.

And I cannot tell you how many clients swear that they will not leave their pet’s side for 2 or 3 weeks. Meanwhile, I’m pretty convinced that these clients will need to sleep, or go to the bathroom, or get a bite to eat. There is no such thing as 24/7 supervision with a pet!

Depending on how bad the damage is, treatment may require rinsing the open area, cutting out damaged tissue and re-stitching the entire incision. For a little bit of perceived freedom from the evil cone, clients sometimes end up spending more money in anesthesia, surgery and antibiotics to fix an entirely avoidable problem, not to mention the discomfort the pet goes through – and a longer recovery. And ironically, then the pet needs a cone for even longer!

Below is another (mild) example of what happens when a pet licks the incision.

Leaving the E collar on at all times is the best way to get your pet used to it. If you feel bad for your pet and take the cone off, then put it back on when you leave, your pet may take it as a punishment and may try to remove or destroy it.

Patients can absolutely eat, drink, walk, pee, poop, and sleep with a cone on. In fact, the stricter you are with the cone, the quicker they will get used to it. In addition, pets do not hold grudges, so they will not be mad at you for being strict with the rules.

Collars are not to “shame” pets or annoy owners, they are essential for quicker and better healing of the incision. Call it a necessary evil or a cheap insurance policy. Next time your vet recommends an E collar or a similar device, please follow their advice. It truly is in your pet’s best interest.

Moral of the story?

The plastic cone is your pet’s best friend.

Any surgery has complications. Some are not predictable. Licking an incision is totally avoidable. We know how to prevent that. Please trust us, and please be part of the solution.

Your pet, in the end, will thank you for it.

What about alternatives to the plastic cone?

Marketers spend a fortune trying to convince pet owners that their alternative is better than the hard plastic cone.

There are soft cones, hard cylinders, foam “donuts,” inflatable “donuts,” various covers and sleeves and more.

As a surgeon, I have witnessed what seems like every conceivable complication.

Experience has shown me that these options are not as fool-proof as the standard plastic cone.

A stubborn or itchy pet will lick around a donut or soft collar, we see it all the time!

Bitter Apple or similar product may be placed around the incision – not directly on it. However, this does not deter some pets at all. Some actually love the taste!

So again, the hard plastic cone is your pet’s best friend… and the cheapest insurance policy against licking.

Phil Zeltzman, DVM, DACVS, CVJ, FF certified