Veterinary surgeons, like all specialists, have all kinds of little tricks that help prevent brain damage, decrease frustration and get answers faster. Here are 10 hacks to help you diagnose and treat better and faster.
1. Diagnose an MPL
Diagnosing a medial patellar luxation can be difficult in a tense patient. A simple way to help with the diagnosis is to grab the foot and hock and rotate them internally. This will displace the tibial crest and patellar tendon medially, which will help luxate the patella more easily.
If the luxation is lateral, the foot and hock are rotated externally. To be thorough, rotate the foot and hock both ways to rule in or out the possibility of a patellar luxation of any type.
This simple test should be part of any physical exam, especially in small dogs that are at risk.
2. Have the ultrasound reflex
Think of your last frustrating ADR abdominal case. What did you do? A physical exam? Blood work? More blood work? Radiographs?
Much time, frustration and money could be saved if an ultrasound were performed early in the course of the workup of a nebulopathy. In good hands, an ultrasound can yield a wealth of information that no other test can provide. Unless a fine-needle aspirate or a biopsy is required, ultrasound is completely noninvasive.
Then, if your patient needs surgery, you can offer it much sooner. Rather than getting lost in multiple tests, have the ultrasound reflex early on. To quote Eric Lindquist, DVM, Dipl. ABVP, a mobile ultrasonographer and the author of “The Curbside Guide: Diagnosis and Treatment of Common Sonographically Detected Disease, Canine and Feline”: “Don’t drag the diagnosis over two or three days. Be a one-day diagnostician.”
3. Measure masses
How can you measure a small mass or excisional margins with no special equipment? What if your blade handle is not engraved with a ruler? You can use the plastic package most suture packs come with. The width of the plastic is exactly 3 centimeters. (See Photo 2.)
Phil Zeltzman, DVM, DACVS, CVJZeltzman, DVM, DACVS, CVJ
Photo 2: The plastic part of a suture pack measures 3 centimeters wide.
4. Don’t fight, sedate! (Part 1)
Performing an orthopedic exam on a tense or painful patient can be difficult. Asking five technicians to “sit” on a patient so you can feel a joint is not considered appropriate. For everybody’s sake and safety (the patient, your technicians and yourself), embrace the Fear Free movement and don’t hesitate to sedate your patient.
There are many safe, short-acting or reversible drugs that allow you to perform a more thorough exam and reach a more precise diagnosis.
The vast majority of owners would accept the additional fee for sedation if it helped decrease stress or pain in their pet.
5. Don’t fight, sedate! (Part 2)
Similarly, doggy torture and kitty manhandling on the X-ray table is not appropriate. It is virtually impossible to take specific radiographs on a patient who is awake.
Case in point: Taking a good, symmetrical, OFAstyle “VD pelvis” requires sedation in the vast majority of patients. In fact, the OFA recommends general anesthesia for hip radiographs to ensure proper positioning.
Some colleagues believe that sedating a pet is too time-consuming. In reality, fighting with an uncooperative or painful patient takes much more time and causes increased stress to all involved. In addition, the use of sedation will decrease the need for multiple radiographs and reduce X-ray exposure by technicians.
6. Take a good history
A lot can be learned from paying attention to what pet owners say. One recent client had a severe case of logorrhea (i.e. verbal diarrhea). I could not stop the flow of information after naively asking for a quick history. This sick 12-year-old cat was ADR, not eating, lethargic, walking funny, weak, and on and on.
In the midst of the never-ending flood of vague signs, one minor detail piqued my interest. The cat seemed to have difficulty holding up his head.
What easily could have been overlooked led to a suspicion of hypokalemia.
Long story short: An adrenal mass was producing an excess of aldosterone, which led to hypokalemia, which led to hypokalemic polymyopathy, which led to a weak kitty who couldn’t hold up his head. The poor cat had ventroflexion of the neck.
This tiny, critical detail provided the correct diagnosis.
Not all lameness is due to an orthopedic condition. Holding up a front leg can be a sign of a cervical spine problem (root signature). And what looks like hind-leg lameness might be related to a thoraco-lumbar or lumbosacral spine condition. If your orthopedic exam does not explain the symptoms, perform a neurological exam next.
8. Measure blood loss
Blood loss can be estimated by counting blood-soaked sponges:
- A 4-by-4-inch, 12-ply woven sponge can absorb from 5 to 12 milliliters of blood.
- A 4-by-4-inch, four-ply non-woven sponge absorbs from 10 to 18 ml of blood.
- Therefore, non-woven sponges are much more absorbent than woven sponges. (See photo at left.)
- A woven laparotomy sponge can absorb about 50 ml of blood.
9. Take 2
Many findings are missed because only one radiograph was taken. Countless others are missed because the wrong view was taken.
Ideally, two orthogonal views should be taken of virtually any body part. In some cases, even more views are needed: the opposite lateral thoracic or abdominal view (i.e. a three-view study), or stress views of a joint, or oblique views, or a “frog view” of the pelvis.
Phil Zeltzman, DVM, DACVS, CVJZeltzman, DVM, DACVS, CVJ
Photo 3: An MRI reveals a mass between L5 and L6.
On that topic, abnormalities can be missed because of poor exposure or X-ray technique.
10. Trust your client
Sure, pet owners at times can seem high-maintenance, delusional or affected by Munchausen syndrome by proxy.
I remember a 3-year-old beagle that was presented because of unusual neurological signs. “My dog won’t lift his tail and is in pain when wagging it,” his elderly owner explained.
She had gone to a half-dozen colleagues and nobody took her seriously. They thought she was a lonely old lady with too much time on her hands. The dog sometimes had muscle spasms—the owner was convinced—“because he is painful.”
A neurological exam revealed a few subtle abnormalities, which prompted an MRI. The high-maintenance client went for it. The test revealed a spinal tumor between L5 and L6 in a 3-year-old dog! (See Photo 3.) I removed an intradural chondrosarcoma.
Part of the art of veterinary medicine is to know when you should trust clients and listen to them.
Dr. Phil Zeltzman is a board-certified veterinary surgeon and author. His traveling practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his website at www.DrPhilZeltzman.com, and follow him at www.facebook.com/DrZeltzman.
Kelly Serfas, CVT, of Bethlehem, Pa., contributed to this article.
Originally published in the April 2016 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today!