Dr. Phil Zeltzman’s Blog

As a surgeon, my goal is to eliminate pain as much as humanly possible.

Let’s go over a few stubborn myths related to pain in pets.

1. My pet doesn’t cry out

“My pet is not crying and therefore is not in pain” has to be one of the most stubborn myths vets face on a daily basis.

When a pet limps or favors a leg or doesn’t put full weight on a leg, they are most likely in pain.

When a pet’s activity decreases, they may be in pain.

When a pet’s routine or habits change, they might be in in pain.

When a pet’s appetite decreases, they could be in in pain.

The fact is, most pets, especially cats, do not cry out when they’re in pain. Of course, if you step on their foot, they will cry out in pain, but that is short-lived because of what we call acute pain. Long-term, ongoing, continuous, sustained pain is called “chronic” pain.

Similarly, a dog may cry out in pain when (s)he initially tears a ligament, such as an ACL. But then the pain becomes subtle or low-grade and there’s typically no more crying.

Yet as long as they’re limping, it means that pets are in pain.

It’s the same idea as when you have a pebble in your shoe. You will shift weight to the other leg to decrease the pain. But as long as you put weight on the foot with the pebble, there will be some degree of pain.

Pain in cats is even harder to assess than in dogs. Cast tend to change their habits: less grooming, less jumping up or down, decreased appetite, hiding, fewer interaction with humans, withdrawal.

2. My pet is just old

Age seems to be the catchall excuse for multiple ailments. For example, urinating in the house is often blamed on old age, even though a bladder infection or bladder stones ( https://www.drphilzeltzman.com/blog/?p=1841) might be present.

When it comes to a pet’s decreased athletic ability – unwillingness to play, using stairs or jumping on furniture – many pet owners believe that age is the culprit.

Before we get to that conclusion, it’s important to make sure your pet doesn’t have a torn ACL, or severe hip dysplasia, or a bulging disc.

3. Pets don’t feel pain like we do

Some people still think that pets don’t feel pain like we do. Yet mammals have the same type of nerve endings, pain pathways and pain perception center in the brain as humans do.

To think that an animal in pain doesn’t deserve the same kind of treatment as humans is simply wrong.

4. There’s nothing we can do

Some pet lovers are told that because one pain medication doesn’t seem to work anymore, there are no other options.

Yet there are almost always other options: other pain meds, surgery, physical therapy, acupuncture, weight loss etc.

If all options have truly been explored, then maybe it’s time to have a discussion about quality of life, but not until then.

When the end finally does come around, you can rest assured that you truly did everything possible.

5. Postop pain is beneficial

Vets used to say that postop pain is a good thing because it keeps pets quiet, and that helps prevent injury to the surgery site.

We now have a much better understanding of the implications of untreated pain.

In my surgery practice, we routinely use 4-6 different techniques to prevent and treat pain. The drugs and techniques are well known, it’s just a matter of using them.

6. Minor procedures don’t need pain medication

This is another stubborn myth. Even what seems like a minor procedure, like a neuter, a mass removal or a tooth removal causes pain and should be treated.

7. Pain medication in old or sick patients is dangerous

There are multiple pain medications we can choose from. Each drug has potential side-effects, for example related to the kidneys and the liver.

This is a manageable risk. It’s a matter of pros and cons. We can easily monitor consequences on kidneys and liver with regular bloodwork. In a healthy pet on an anti-inflammatory, bloodwork is typically recommended every 6 months. In a pet with kidney or liver issues, bloodwork can be performed every 3 months, or even more often.

Another strategy is to decrease the dose of “risky” medications, usually an anti-inflammatory, or stop it altogether. We can also replace it with other, safer pain medications.

8. My client won’t pay for that

Some vets are concerned that you can’t afford proper pain prevention and treatment.

There, I said it.

If that is your case, then you should discuss it honestly with your vet.

If not, then you should demand the best possible pain management for your pet.

9. Surgery causes pain

A few of my clients have declined surgery for this reason.

As a surgeon, I’m not naïve enough to ignore the fact that left untreated, pain will occur after surgery. Again, most of my patients benefit from half a dozen pain management techniques.

This includes IV medications, special IV fluids, local pain meds, pain medications by mouth, pain medication injected directly into joints, pain medication injection around the incision etc.

So being fearful of surgery because of the fear of pain does not make sense. We can prevent and treat pain. In fact, a common reason to do surgery is specifically to treat pain.

Think of a broken leg. One consequence of surgery is to decrease the pet’s pain.

So it is quite the opposite: surgery helps decrease pain and eventually, it eliminates it.

10. My pet is not in pain

With all due respect, I would argue that many pet owners do not realize how much pain their pet is before surgery. Why is that? Possibly because everybody (humans and pets) slowly got used to it.

Case in point, we recently did a Total Ear Canal Ablation (TECA) in a Cocker with severe ear infections.

TECA is a pretty invasive surgery that has a reputation for being painful. So we use as many pain medications as possible, as mentioned above.

The very next day, the owner sent an email with an update: “He had a few rough moments trying to get comfortable. But once we got him to take his pain medication, he fell asleep and slept through the rest of the night.

(…) He woke up like a new dog today!

You would never even guess he had surgery. He had a full appetite, and is walking around very alert and actually attempting to play which we are trying to discourage at this point.”

Keep in mind, this comment came from a very smart, attentive and loving pet owner. She is very in tune with her dog. She was surprised by how comfortable her dog was after such an invasive surgery and went out of her way to email me to acknowledge how much pain her dog must have been in before surgery. And how comfortable he was after surgery.

This is actually one of vets’ biggest frustrations. We know when a pet is in pain and it’s sometimes difficult to convince a pet owner that their pet is in pain.

By the same token, if you feel that your family vet does not believe you that your pet is uncomfortable or painful, then it is your absolute right to seek a second opinion until you find somebody who takes you seriously (here is a perfect example: www.drphilzeltzman.com/blog/joshuas-story-taking-pain-seriously).

As I always say, “pain is not acceptable.”

We are extremely fortunate to have access to all kinds of pain medications and surgery options to make many pets more comfortable.

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

www.DrPhilZeltzman.com

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