Cat bite abscesses are one of the most common presentations in general practice.
Even in an emergency setting, I see a number of these patients. Usually they are obvious, but, occasionally, they’re not so obvious and the patient comes in lethargic, inappetant and often “painful”.
Overly dramatic?
One thing I’ve learned in my time is a cat bite abscess should be considered for all cats that have pyrexia. For a pyrexic outdoor cat without an obvious cause, I include a whole body clip as part of my diagnostic process. This is because a cat bite can start as a cellulitis and bite wounds are very small.
Whole body clipping may sound dramatic, but it has saved me many times and helped rule out cat bites as a major differential for cats with pyrexia.
Standard approach
Everybody treats cat bite abscesses in their own way, but here’s my approach:
Any warm, painful area or swelling should be clipped to look for bite wounds.
I always look for all four tooth marks – you can miss wounds and other developing abscesses by focusing only on the obvious bite wounds.
You must establish drainage, surgically explore and lavage. This means patients are always placed under heavy sedation or a full anaesthetic. Why do I always recommend this? I have found cat nails, hair and teeth in abscesses before; without removing those foreign bodies, the abscess won’t heal and antibiotics won’t be effective.
I almost always administer antibiotics, even if I have removed an abscess en bloc and no contamination exists.
Pain relief is always indicated, depending on the age and stability of the patient. An NSAID is my preference, but only after I have corrected my patient’s fluid deficits, otherwise I select a different type of analgesic.
Drains? Sometimes I place drains in very large abscesses, but mostly I prefer to close primarily after appropriate debridement.
Following on from July’s post entitled Urinalysis: the neglected test, let’s have a look at the dipstick – it’s a very easy part of a urinalysis and essential to perform.
Here are some of my tips in regards to using dipsticks:
Dipstick: despite the name, DON’T DIP!
It may sound obvious, but you should always use veterinary-specific dipsticks. Human-specific dipsticks include panels for urobilinogen, nitrates and leukocytes, which we often do not interpret in small animal patients, as they are neither sensitive nor specific.
DON’T DIP! Use a syringe and drop samples on to each square, leave for 10 seconds, then flick off the excess.
Any amount of protein in dilute urine should raise suspicion. A reasonably large amount of protein has to be present in the urine for it to be positive on a dipstick. A urine protein to creatinine ratio may be the only way to quantify the amount of protein present, but first you must rule out evidence of inflammation or haematuria via a sediment examination.
The ketone panel on the dipstick test is only for acetoacetate (and not beta-hydroxybutyrate), although it is extremely rare for diabetic ketoacidosis patients to not produce any acetoacetate.
Trace blood can be a common artefact finding, especially during a cystocentesis where needle trauma can contaminate the sample with blood.
In our feline patients, any hyperbilirubinuria is abnormal, but this may be normal in a dog depending on urine concentration.
Adverse events during anaesthesia in otherwise young and healthy patients is a rare occurrence. However, with low incidence of adverse events could come an increased risk of complacency on the part of the veterinary team.
Take the following case as an example:
Clicky the cat with Gerardo and his team.
“Clicky” is a young and healthy cat that underwent a routine dental prophylaxis procedure. A few days after the procedure, she developed respiratory difficulties and presented to our emergency clinic.
Possible problems
She was diagnosed as having severe subcutaneous emphysema, most likely from a tracheal wall compromise that would have occurred as an adverse event from tracheal intubation.
We need to handle cats very gently while they are intubated as their tracheas are nowhere near as robust as their canine counterparts.
Overinflating the cuff is another cause of tracheal necrosis.
Never be complacent
What we think happened was the patient was repositioned during the dental procedure and the endotracheal tube was twisted in the process, causing either ischaemic compromise to a portion of the trachea or direct damage to the trachea.
Thankfully, “Clicky” made a full recovery, but this case certainly highlights that we must never be complacent when it comes to handling our anesthesia cases.
Low incidence does not mean no incidence, and individualised anaesthetic plans – along with in-depth training for the anaesthetist (who most often are veterinary technicians and nurses) – will help reduce the chances of adverse events occurring.
If used by an experienced ultrasonographer who knows what to look for, ultrasound can be a highly sensitive and specific diagnostic test.
What do we look for?
Remember not all patients will have intestinal dilation as the linear foreign body may be only causing a partial obstruction. Alternatively, it could be occluding the gastric outflow completely.
Intestinal plication, which looks like intestinal loops bunching up on each other around the tether.
A central discrete hyperechoic line running along the middle of the bunching intestine. This bright line is the tether. Often when looking closely enough, the tether will have distal acoustic shadowing as the ultrasound pulses cannot pass through it.
The leading aboral segment and the trailing adoral anchor will have acoustic shadowing.
The adjacent mesentery is often hyperechoic compared to other areas in the abdomen, indicating inflammation.
Gastric dilation with fluid is often seen if the anchor is in the pylorus, as it causes an outflow obstruction.
Free abdominal fluid may be visible and a sample should be collected for assessment. If bacteria can be demonstrated in one of the following ways:
By visualising free or intracellular bacteria under the microscope.
By finding that the glucose is lower (lower than 20mg/dL) and the lactate is higher (2mmol/L) in the abdominal fluid sample compared to peripheral blood then this indicates perforation of the gastrointestinal tract has occurred and septic peritonitis is present.
In the third and final post, we will cover things to consider when deciding whether to perform the exploratory laparotomy yourself, or if you should transfer the patient to a referral facility for surgery.
Linear foreign bodies can be tricky to diagnose, compared to normal foreign bodies, for many reasons. Mostly because you often don’t see the classic obstructive pattern appearance on radiographs or ultrasound.
In this short blog series, we are going to cover some hints and tips that can make diagnosing a patient with a linear foreign body easier. Then, we’ll discuss things that should be considered when deciding whether you are the right person to take the patient to surgery…
So, let’s start with radiography.
Not all patients with a linear foreign body will be completely obstructed. This means you won’t always visualise classic intestinal dilation. In fact, it has been reported that up to 50% of patients with a linear foreign body will not have an obstructive pattern present on radiographs.
Look for the characteristic small “comma shaped” gas pattern. This is caused by plication and bunching of the small intestine around the tether.
The small intestine can appear to be bunched up in one area, rather than spaced out around the abdomen. However, obese animals – especially cats – can have “pseudo-bunching” due to large amounts of abdominal fat bunching the intestine together.
Loss of serosal detail is often seen due to inflammation surrounding the affected intestine.
Always include a left lateral radiograph in your series. Gastric contents will fall to the fundus on the left of the abdomen and gas will raise to the pylorus, which will highlight the foreign body anchor in the pylorus.
Perform thoracic radiographs to assess for aspiration pneumonia and a potential oesophageal component of the linear foreign body. If aspiration is present then you know you will need to continue antibiotic therapy postoperatively.
In the next post, we cover some key points for diagnosing linear foreign bodies on ultrasound…
Less than a month into my master’s degree in wildlife health and rehabilitation, and it’s already become apparent that a vast array of misconceptions are held by the public concerning local wildlife.
I’m already armed with far more wildlife facts than I ever thought my brain had room for. For example, did you know that a group of hedgehogs is called a prickle? Or that bees have five eyes?
The vet course is a lengthy and arduous endurance, and even so a whole wealth of animal knowledge gets left out because, for the average vet, there’s little need to know that a kangaroo has three vaginas. Unless, of course, you’re a vet working in Australia – in which case, g’day!
The unfortunate facts
In my lectures, alongside these charming facts came the statistic that in the majority of wildlife rescue centres, more than 50% of “abandoned orphan” admissions are a mistake on the well-meaning public’s part and are, in fact, just young fledglings still getting used to their wings.
That’s in excess of 50% of “avian orphan” admissions that have to be assessed, put through the system, housed and then released back into the wild – more than 50% of resources wasted.
It’s also true that feeding hedgehogs milk and birds bread can make them ill, and that setting out food or bird feeders can provide a breeding ground for disease transmission and propagation.
And it’s a truth that is kept somewhat from the public that, for a large proportion of wildlife casualties, there is little to be done but palliative care and euthanasia.
Small acts of kindness
This topic really gets me down, because with all of the ecological, environmental and diversity destruction ongoing around the world, small acts of kindness and sympathetic good deeds seem few and far between – and as someone passionate about wildlife and conservation, the last thing I want to do is discourage them.
A lot of problems exist in this world, and humans cause 99% of them, so when someone goes out of his or her way to try to do the right thing and it ends up causing more harm than good – whether he or she knows it or not – it seems like such a waste of good intentions.
The real crux of the matter is the paradox of education. It’s understandable that the public make mistakes regarding wildlife when so much is still unknown to the professional community.
That being said, if the wide range of new data at our fingertips could be available for the layman, such mistakes might be mitigated. However, there’s only so much unrequested education people can tolerate before they just give up.
Similarly, if you let every member of the public who brings in an injured animal know the percentage of animals that have had to be euthanised that day, they might just take it on themselves not to bring it in at all, or (an even worse possibility) attempt to care for it themselves.
Sad, but true
Stories of people attempting to hand-rear everything from birds to large cats are, while superficially admirable, most often doomed to failure.
Research is constantly being conducted into nutritional requirements, behavioural norms and habitat necessities on all the species we’re still not 100% on… and that’s pretty much all of them.
If the leading minds in the field are still messing it up, there’s not much hope for the average Joe – even with all the good intentions in the world.
The right intentions, a friendly smile, a warm introduction and appropriate touch – four easy ways to help you foster connection with your clients, as described in the previous post.
This part will look at two more common-sense strategies to help you forge fast bonds with your clients and ensure problem-free consults: finding common ground with your client, and using humour to expedite connection.
Common ground
Like it or not, us humans like to belong to a “tribe”. We’re very quick to judge a stranger as “one of us”, or “one of them”.
Hopefully we’re all fighting against our biases, but it’s very likely parts of your subconscious mind is still making snap judgements about those around you, including your clients – and that your clients are making similar judgements about you.
It’s in everyone’s best interest if you’re able to find common ground with your clients, to put you on the same “team”. When a client can relate to you around one or two shared interests, your level of connectedness will instantly jump up a few notches.
Sometimes you’ll get lucky with an obvious commonality – like a shared background, an accent, or a T-shirt from a favourite sports team. Case in point: whenever I hear a Welsh accent in a consult room I point out the fact I lived in Wales for three years earlier in my career and tell them how much I loved it there. This ridiculously small incidental bit of shared history almost always assures that the client in question will insist on only seeing me in future.
Other times you have to dig a little bit by asking a few questions about their work, their children, their hobbies, their holiday… anything you can bond around. And if all else fails, you can be certain you have at least one thing in common – animals, and in particular their animal.
A sincere comment about their pet, or even just the breed of pet, shows you are paying attention and suggests you care. You don’t even have to lie – no need to go on about how lovely little Lucifer is after he’s tried to slash your eyes out; instead, an anecdote about your angry cat, or another patient, or why Lucifer is so angry, or about how hard it must be to get him in his cage at home…
Any shared experience will lubricate the path to connection almost as much as a glass of wine lubricates a social event.
Humour
Here’s another hack straight into the workings of the limbic system of those around you: humour makes people feel good. It buffers stress and increases intimacy by reducing cortisone and adrenaline levels, and increasing the activation of the dopaminergic reward system.
People who are seen as humorous are perceived as more intelligent and trustworthy. Research shows it even makes you appear more attractive.
You may think a visit to an emergency vet clinic is no laughing matter, but even in the midst of a crisis very few situations exist where it’s not possible to find a little bit of humour, even if it is bittersweet.
Besides the obvious comedic gold that surrounds rectal thermometers and the shamelessness of most animals (okay, maybe not cats), humour can be found in just about every situation. Yes, even euthanasias can offer opportunities for an appropriate remark or anecdote – perhaps about the animal when it was younger or a shared memory with enough nostalgic humour to increase the warmth in the situation without detracting from the gravity of the situation.
Added benefit
The jokes will not be lost on your own brain. The same feel-good chemicals that you’re inducing in your clients will be hitting your neurones and improving your own sense of well-being.
Most vets who still love being vets after a decade or more in practice will cite “having fun” at work as one of the most important safeguards against burnout.
The next post will take a deeper dive into what I think is the most important tool for good client relationships and a happy career in veterinary science: Empathy.
VN Times calendar competition 22 voting – terms and conditions:
From all of the photos submitted as part of the VN Times Makes Me Smile calendar competition, 30 entries have been shortlisted by our panel of judges. We are now asking readers of VN Times and Vet Times and users of vettimes.co.uk to vote for their favourite image from the final 30.
Five voters will be picked at random from the votes received on vettimes.co.uk to each win a £10 Amazon.co.uk gift card. The winners will be notified by Monday November 9, 2020. Winners can only be registered users of www.vettimes.co.uk who are veterinary professionals.
Voting begins on October 1, 2020 and votes must be received by midnight (UK time) on Sunday October 25, 2020 via vettimes.co.uk
The entry with the most votes will win a £500 Amazon.co.uk email gift voucher and his or her picture will feature both inside and on the cover of the 2021 calendar. The remaining months inside the calendar will feature 11 entries with the next highest votes and will each win a £50 Amazon.co.uk email gift voucher.
Only one vote per person.
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The VN Times 2021 wall calendar will be mailed with the December 2020 issue of VN Times.
I read somewhere in the early days of lockdown that several rescue shelters have been experiencing 100% empty kennels for the first time since opening.
This was truly heart-warming to hear, and seemed at first as a small silver lining around the dark clouds of the pandemic. However, it shortly came to light that demand for new pets, both young and old, was sky-rocketing.
More households were finding they had more time on their hands. People were lonely and in need of company, or learning to better appreciate the outdoors during the unprecedented good weather and fancied a four-legged companion by their side.
Think before you buy
I’ve spoken before about the dangers of buying a pet during the passion of the moment, without proper consideration or planning, but as long as both are present I’m wholeheartedly for the mutual companionship that both dogs and cats can bring, especially in the current climate.
It was only after a conversation concerning a friend’s adorable young dog – who is both the most friendly and energetic creature in the world and a little bashful when it comes to running into other dogs on her walks – that I began to think of the future and the ways in which lockdown might have inadvertently shaped the next generation of pets.
Phoebe – pre-lockdown puppy of Eleanor’s friend Felix.
Opening the social window
A social window is a short period of time when dogs and cats are growing up, in which they are the most open and absorbent to new experiences.
After this window has closed, these animals can become suspicious or downright terrified of anything they didn’t come across during their early days – sort of like the grandparents who are a little wary of the iPad, saying: “We never had that in my day.”
This window has always posed a tricky obstacle in the past, as neither puppies nor kittens can legally be sold until eight weeks of age, but the social window for cats is nearing its end at around only seven weeks. So, in the past – unless breeders were well informed, educated, and responsible – lots of owners could end up with a bit of a scaredy-cat (I‘ll pause for the eye-rolls).
The outside world
During a young animal’s “social window” they should be experiencing a variety of scenarios and situations in both a positive and safe manner, to avoid sensitisation and steer towards a comfortable association. In the same way many of us have aversion to traumas of our past, our dogs and cats too can hold an almost unconscious grudge.
The thing about lockdown that most new pet owners probably won’t have thought about is how it has unfortunately deprived an entire generation of young dogs and cats from experiencing enough of the world around them.
The decreased access to outdoors and the different smells, sights, and sounds it brings might be leading to a wave of pets that will always be just a little bit trepidatious.
I think it needs mentioning that there is, for the most part, nothing wrong with a cautious pet – as long as the owner is aware of their pet’s disposition and knows how to manage it.
Management can be as simple as taking them for walks during less busy times of the day, or brightly coloured coats, leads, collars or reigns to alert other dog walkers that they’re in need of a little extra space
Addressing any behavioural ticks with proper therapy or training can also go a long way. Therapy in this case does not mean lying back on a sofa to delve deep into childhood traumas, but a gradual, supportive normalisation of stressful triggers.
Next gen
If we really are producing a generation of nervous pets, then it is the fault of no one person – no “bad” owners, mistakes, or malpractice; simply a product of the times – crazy, unique and unpredictable times.
However, it is the responsibility of any owner to be supportive, observant, and proactive, regardless of your pet’s quirks or the times we live in – another example of why taking on a pet is such a huge commitment that can never be taken lightly.
Consult with your vet if you have concerns and always be patient with your animals, just like us, they are trying their best to keep their balance on unsteady ground.
I feel the phrase “the show must go on” is going to apply heavily to the student community over the coming months – vet students included.
Universities across the country are moving their teaching and examinations to an online platform, which means that for a lot of young academics, come rain or shine (or, it seems, the apocalypse), we will be working until the bitter end.
In other words, the pubs may be shut, but the textbooks are staying open.
Bitter pill
While it may seem cruel that the rest of life has to grind to a halt while studying and exams carry on (as someone who will shortly be spending her 21st birthday in lockdown, let me just say I know – trust me, I know), it’s especially important for professional courses to carry on as best they can.
As medical students we don’t only learn to pass our exams, but to better equip ourselves for a workplace where our decisions can be the difference between life and death.
I strongly commend the staff who’ve had to work tirelessly behind the scenes to reorchestrate an entire term of teaching in a matter of weeks to make sure our learning doesn’t have to suffer.
Analogue girl in a digital world
Not only are the staff having to adapt, but so are the students. As an analogue girl myself I really do fail my generation’s reputation for being “good at technology”, so I can tell you my own experience of moving to an entirely online learning platform has been… shall we say, interesting?
And while it is nice to have a timetable (and, therefore, a reason to remember what day it is, let alone the date), I thought I would share a few pearls of wisdom for making it through one of the weirdest periods of study any of us is probably ever going to experience – and that’s saying something as we stick our hands in some seriously weird places.
No. 1: Maintain boundaries between work and home
You know how some animals, like cats, have a special place for everything? A place to eat, sleep, wash, defecate etc, while naturally roaming animals such as the horse do not have this talent and will happily poo in their freshly made stall as the heart-broken yard worker looks on in anguish?
Well, for as long as this lockdown lark continues, do NOT be like the horse.
Designating different areas in which to work and unwind will not only give you a feeling of routine, but will also help you work hard and switch off when you need to. Just because you can literally wake up, roll over, do a day’s work and then go back to sleep, does not mean you should.
No. 2: Play to your strengths
One of the few silver linings to come out of the change in learning environments is that it puts you, the student, well and truly in the driver’s seat.
Studying has now become a lot more independent – and while this does mean you have to work to motivate yourself a little harder, it also gives you the power to work in the way that’s best for you.
Everyone learns differently, whether it’s visualisation, reading through articles or breaking up the work into lots of manageable chunks. Find which method works for you and own it.
Just because you’re learning from home now doesn’t mean the whole concept of “uni” has disappeared.
You can no longer talk to your lecturers in person, but, let’s be honest, that was quite intimidating anyway. If you have a question, drop your tutors an email; if you don’t understand the new system and need some help, email or phone up your admin team. They may take a little longer to reply than usual, but you are not alone.
With this in mind, if you’re a person who works best in groups, who said FaceTime had to be all fun and games? Virtual study groups can be a great reason to put on actual clothes, brush your hair and work that little bit harder on your assignments.
No. 4: It’s okay not to be okay
Now, this is the most important one, so I’ll say it again for those at the back: It. Is. Okay. Not To. Be. Okay.
Never in the history of civilised society have we experienced anything exactly like this before. It is confusing, lonely and scary at times, and having to study and revise on top of it all can seem like an impossible task.
If you are struggling, please talk to someone; if you know someone who you think might struggle right now, please reach out to them. The veterinary community has a reputation for appalling mental health, and it is more important than ever before to look out for one another.
If you’re having a low day, it’s okay to take it slow to focus on yourself and start feeling okay again. Draw something, write something, buy yourself that dress you’ve been ogling for the past three months.
Or, if you just feel like curling up on the sofa and watching the entire Lord of The Rings trilogy (the extended editions), back to back, with a litre of ice cream and your favourite onesie… that’s okay, too.
