Friday, February 15, 2013

Our Dogs and Coughing

At some point, all of our dogs have likely coughed.  It happened a few times and stopped, or it persists.  As armchair doctors, we can find ourselves brushing it off.  Naturally we don't *want* anything to be very serious, and a cough seems simple enough to brush aside.  Even though stated several times on this blog, let me reiterate, before spending too much time considering your dog's cough, rely on your veterinarian for a diagnosis.  If your dog is coughing, read and educate yourself, but always take your dog to the clinic for an exam. Never wait, as many conditions only worsen if untreated. Below I describe only some of the more common reasons for coughing, but it is not all-inclusive.

Some sounds our dogs make can be easily described as a "cough", but often they sound like they are gagging, and is often described by owners as "it sounds like they are trying to spit something up", because they often make a retching sound at the end. I've met many owners who didn't think their dog was coughing at all.. instead they were "gagging", and the owners brushed it off that they "had something stuck in their throat". I've also met many owners who brush off coughs because they think it's allergies or that their house was too dusty. What is key to understand about coughs, is that not all coughs are indicative of a contagious infection.  While some coughing can be easily diagnosed and treated to be revealed to be just that, what's important to know about coughing is that there are many other potential reasons for it, and some quite serious.

If your dog presents to the clinic with a cough, the doctor will want to understand how long it's been going on, what "kind" of coughing it is, and other factors such as exposure to other dogs.  When a doctor hears "the dog is coughing", they may immediately glance at the age and breed of the dog to already begin a working list in their minds of what is the likely culprit. How long have they been coughing? Is it worse or unchanged? What else is wrong with them which may paint a larger picture?

If your dog is a puppy or young adult, or was recently adopted from a shelter or rescue, or they go to the dog park or daycare, their first inclination may be to rule out diseases such as Bordetella or Canine Influenza.  There are vaccines for both, but those are only 2 respiratory diseases in a sea of many.  Dogs *of any age* can get these, but younger dogs are most at risk. There is no way to "test" to determine what kind of respiratory infection your dog has, short of a more significant procedure called a 'tracheal wash'. Doctors only tend to recommend them if they do not respond to obvious therapies, and they need to take further steps to isolate what is going on.  If your puppy is around other dogs and hasn't completed their full vaccine series, they are still susceptible to infections.

Naturally dogs with pneumonia may cough.  Pneumonia can be secondary to another respiratory infection that was allowed to get worse, but it can also be created by things such as "aspiration", where they accidentally breathe in something, usually when vomiting.  Dogs with short airways, or "brachycephalic" dogs are more prone to aspirating, as are dogs who have seizures.

While dogs of all ages can get these infections, if they are older, especially seniors, your doctor may want to rule out more potentially serious things.  When our older dogs begin to get a cough, I've experienced many owners too quick to brush it off.

If your dog is a toy breed, be aware that they can develop a condition referred to as "collapsing trachea".  This is literally exactly what it sounds like.  The causes are largely unknown, but there is a frequency seen in smaller, toy breed dogs.  How much they are impacted can vary greatly, and typically doctors only treat the symptoms. Dogs with this condition can get an implant called a "tracheal stent", but there are risks so discuss this with your veterinarian.  An x-ray can help to diagnosis this in your dog, but they can sometimes miss it if the dog isn't taking an inspiratory breath as the x-ray is taken. There is an extremely specific sound dogs with collapsing trachea make (it has a bit of a honk), and experienced doctors will "know it" the minute they hear it regardless of the x-ray.

A serious concern with symptoms such as a cough is left-sided Congestive Heart Failure.  It is crucial to bear in mind that a dog of any age can have severe heart disease, and even puppies can be in heart failure if they were born with a defect.  Dogs with heart disease and no failure who cough tend to be smaller breed dogs.  They are coughing due to heart enlargement, and the heart grows big enough to press against the trachea and create the cough.  This can happen in dogs of any size, but is infrequent in larger dogs due to their confirmation.  Dogs in heart failure will cough because the heart has failed to be able to push blood through properly, and the fluid overload will back up into their lungs and create a condition called "pulmonary edema" (fluid in the lungs).  If your dog goes into heart failure and gets this fluid accumulation, it will *not* go away by itself and the dog must be seen as an emergency.  The fluid will continue to accumulate until treated, or they will succumb to it by essentially drowning. Not all dogs in heart failure will cough!  Dogs with failure to the left side of their hearts will cough, while right-sided heart failure may create fluid in the abdomen or around the lungs instead.

Anything putting pressure on the trachea can cause coughing.  So naturally, we need to rule out masses (tumors).  An x-ray may diagnosis this, but sometimes the doctor may recommend further diagnostics.

Sadly, and it goes without saying, dogs with lung cancer will have changes in their breathing.  Whether just labored or perhaps coughing, this can be visualized on x-ray.

 Lastly, it's key to understand that our dogs cannot catch colds from us.  Many owners have made the mistake of thinking that their dog caught the same bug going through their family.  Dogs have their own specific infections they can only get from other dogs; not us or even our cats can transmit them. 

I think it's easy for owners to consider their dogs "caught something" from the kennel, doggie day care, or the dog park.  Think hard on your dogs age and environment, concurrent illnesses or heart murmurs, and consider if you are making light of something potentially more serious.  For diagnostics, be prepared to partner with your veterinarian to properly diagnose your pet.  Chest x-rays will always be recommended, and potentially a cardiac ultrasound, or echocardiogram, if they are concerned about heart disease.

Sunday, February 3, 2013

Saying "Goodbye": When Angels become Angels

Throw a rock, and you will no doubt find endless resources regarding the death of our pet and grieving, and naturally guides and suggestions on how and when to face one of the hardest decisions in your life.  My work environment is such that I am around death, or the possibility of death, every single day and I witness many grieving, confused, and tormented pet families.

I've had the pleasure of working with many amazing veterinarians, all of which offer very different guidelines, perspectives, and experiences to the owners who seek their guidance regarding making the decision to euthanize their dog or cat.  On the whole, I have never truly disagreed with any perspective or advice I've overheard, but naturally the bedside manner and approach can leave me with things to be desired (but even that is the exception, not the rule). 

My largest observation is that the doctor tends to, whether realizing it or not, balance the emotion and approach in the room.  If the owner is being purely subjective and emotional, they will offer balance and objectivism.  They will focus on the "facts", whether it be the morbidity of the pet, the owners finances, or a combination.  Contrarily, when owners are cold (and that can sometimes mask how "in pain" they truly are) focusing only on finances, I see doctors bring more emotion to the table.  They don't want owners to make decisions purely based on financial constraints, and I see them appeal to the love the owners have for their dog or cat to make their decision; so they can "live" with their choice better and feel settled about it.

My own observations tend to cause me to feel that 1 in 3 owners wait too long, 1 in 3 euthanize too soon, and 1 in 3 do it when the time is right.  This observation, however, I reserve exclusively for dog owners.  With cats, I feel like everything changes, so for the purposes of this blog and site, I am going to focus on dogs.

The "too soon" is usually glaringly obvious to any of the medical staff observing, diagnosing, and treating your animal.  If you are actually worried it's "too soon", you are probably wrong.  The fear of this drives many owners into the "waited too long" category, so you really need to understand what not giving your pet a chance really means. 

Are they young, and can it be cured, fixed, or reasonably medicated?  I must stick to the description "young", here.  When I think of young, I do not think of young in terms of their breed's life expectancy... are they "young" for them?  I personally stress to owners that while your breed's life average may be 10, it's an average.  This means that some will live to be 8, and maybe some even 15.  It's wrong to condemn your dog based on a number that has little relevance to your relationship, observations, and overall health status of your dog.  Surely if we applied this approach to human medicine, we'd never come to terms that people die at 50, while some can live to 100.  Every animal is unique.  It is not wrong to take their expectancy into consideration, but don't let it be the only thing you consider.

Again, people who euthanize too soon may unfortunately have to take financial constraints into a much more weighty consideration than others, and we cannot condemn them for that.  Does it suck when people have diamond rings and euthanize over money?  Yes, but often it's the teary-eyed mother of 3 driving the used car and struggling to make ends meet.  It just doesn't *feel* that way sometimes, because those other types of people stick in your memory so much firmer.  When you think of it, we compromise our own health in our human lives for financial constraints, and I don't think it's always unique that some have to do the same for their pets.  It's key to ask and do your research however, because there are a lot of charities who help financially support the medical needs for owners without resources.

Cured, fixed, or reasonably medicated:  a dog with diabetes can be reasonably managed.  A hypothyroid dog, a dog with allergies, a broken leg;  there are so many diseases that can be reasonably managed with a little money, time, and medicine, leaving the dog with a great quality of life.  Too soon, you ask... yes, people have euthanized over the slightest medical concern..  and sadder than it being financial are those who feel they just "don't have the time" to help manage a condition.  Let's not think about those people too much.

The owners who wait for too late are often hit like a ton of bricks, because their emotional journey has made it such that they have lost their ability to "see" their dog through unbiased eyes.  I feel they live in a fair amount of denial, whether they are treating and medicating or just avoiding the vet's office because they don't want to know the truth.  By the time they arrive to euthanize, it's usually at the behest of a friend or family member who nearly forces their hand.  "Mom, you really need to let him go now".  They arrive on gurneys, unable to lift their heads, and perhaps haven't eaten in days and days.  To the defense of these individuals, they likely have been seeing "good days and bad days" with their dog.  While the idea of euthanizing has been looming for weeks, one day he seems more bright, more alert, and they convince themselves perhaps he is going to get better.  All the same, a tail wag is all it takes for an owner to put it off another day.  

For those in this difficult position, remember that our dogs are not objective, and lack the complete ability to be so.  Never mistake a tail wag for a desire to persist:  they live and breath and desire nothing other than pleasing you, seeing you, and making you call them by their sweet nick names.  If that desire is still present, it doesn't mean they aren't ready to go.  If that desire is totally vacant, you probably definitely have waited too long.  Perhaps that last tail wag can reassure you they still recognize you, and recognize that you haven't left them alone for their last, final journey.

I've heard many doctors give people the suggestion that they should really bare in mind the things that make their dog "them" and happy.  When that list of items diminishes to only a couple or none, then the time may be right.  For example, five things he loves: 1. walks in the park, 2. his treat routine, 3. chasing the squirrels, 4. snuggling on my lap watching TV, 5. doing tricks.  The theory is that if most of these things can no longer make him happy, perhaps his quality of life is such that the timing is right.  I like this idea, but I don't know if I could follow it.  The reason being is that I feel this list changes through life stages.  What made me happy at 20 certainly won't make me happy at 80.  Sure, maybe he cannot physically enjoy many of the outdoors and play activities he once did, so?  He's 100 years old in dog years, and systemically healthy for his age.  He's arthritic and his pain and discomfort can be reasonably managed to a degree, and maybe snuggling and watching TV with you is enough for him.

All things boil down to one important question:  "Is he suffering, and how can I ease his suffering?"  We can all struggle as we age: things hurt, joints are achy, but it doesn't mean we suffer.  An achy dog is suffering because if he was properly medicated, he would be reduced to struggling a little every day, but his suffering would taper.  An anorexic animal is suffering, but they can be potentially reduced to a a struggle if we can stimulate their appetite and try to manage underlying diseases.  The suffering begins when we either don't try to help them, or our help isn't working anymore.  How can I ease his suffering?  When medical treatments no longer work, then we must turn to letting them go.

We are all familiar with the suggestion "You will know when it's time".  I meet this expression with guarded agreement.  I think people on the whole are largely indecisive and unsure of themselves, and this has to play into the flaw in this phrase to some degree.  I think some owners are objective and healthy enough to really look into their dogs eyes and communicate with them, and they walk away feeling very confident they fulfilled their dogs wishes.  The rest, however, walk that line of "I think maybe", and they look to others to assure them it's time.  I think a healthy plan for people who know they are the later personality type need to orchestrate a proper objective support system of friends and/or family during this process.  "Dad, I'm going to rely on you to really tell me when I need to stop trying".  Find someone you trust, or even 3 people to preside over your intensely emotional state.

When it comes to end of life decisions, I cannot stress enough how important I feel it is to have found a veterinarian you truly, truly love and trust.  Someone who has known you and your dog for years, and someone whose advice you won't question after the fact.  Avoid getting lazy with your vet visits, settling for a less-than-ideal bedside manner because it doesn't matter to you, so long as he gets his vaccines.  I've seen people panic to find someone they like better at the last minute, because now is when it really matters, because their friend is sick, and they are not finding the kind of comfort and guidance they feel good about.  Unfortunately, some disasters happen where your pet must see ER and a vet you've never met before.  My only advice in that scenario is to really vocalize to that doctor what your needs are.  Tell them how you need to be communicated with, and how you need your pet to be handled.  It's your pet, your money, and your horrible moment.  It's very, very difficult to be a veterinarian, especially in emergencies and crisis, and they only want to do their job to the best of their ability, serving the best interests of the dog.  And remember, they are advocates for the pet first and foremost, not for you.  Doctors so rarely cannot come up with a treatment plan, so when they tell you it's time to let go, let go.

The one thing I hear often, that I am in complete agreement with, is that it's better to let go when it feels like "too soon" versus "too late".  This is a far cry from those who euthanize quickly at the slightest announcement of disease, rather I mean those of us who's mortgage our homes to save our pet, but we know they are terminal, critical, or chronic and it's only going to keep getting worse.  If it were you, what would you want?  As humans, we tend to cling very tightly to our own personal sense of dignity, having very clear lines in the sand of how we "wouldn't want to live".  Draw this line for your dog as well.

My hope for anyone who has faced this tough day, or will face it eventually, is to give themselves the courtesy of avoiding things like "I know he's just a dog, but.."  It's hard enough, and so many owners feel compelled to explain why they are in so much pain and why the decision is difficult.  Remember that your audience (doctors, techs) so love animals that they choose to spend their lives fixing them.  They are objective in your presence for your benefit, but given their own dog would likely be a frothy, wet mess just like you. 

There is nothing more pure, rewarding, and beyond define than the love and the relationship we have with our dogs.  They are like magical, mythical beings in that they can love so truly and without restraint, all while truly knowing the "real" you in so many ways and judging you only on how you treat and love them, purely and truly.  They never leave us, never lie to us, and never knowingly hurt us.  Their ability is such that even the most hateful, cynical, or jaded person can love and be loved by a dog.  Even the most independent or reclusive of types can find comfort and companionship by them.  As a society we have accepted they are family, and we have accepted that those who would consider them otherwise or use them for selfish or evil intention are the worst kind of humans.  We know that people who do not like dogs cannot be trusted, and we know that people who dogs don't trust are questionable.   It is no wonder saying goodbye to them, when it's entirely in our control many of the times, is the worst day in our lives.  

You may never feel good about your decision, but find a way to make peace with it.  Ask yourself: did you love him, and treat him with love every day? Did you always make decisions for him based on what you truly believed was best for him?  If the answer is yes, then cherish your memories, frame your pictures, and speak about them often in loving memory.