The Big Dig
By Bill Stork, DVM
When a concerned client bursts through the door of our Veterinary Hospital like Kramer on crack, I reach for my inner Steven Wright.
"Doc! It’s like he’s being attacked from his rectum… out."
Four thoughts flashed through my head:
- That poor dog.
- How can we help?
- You couldn’t have delivered a more obvious lead line for a story if you’d wrapped it with a bow.
- Dr. Ronald Smith
Veterinary medicine is a famously collegial fraternity. This is fortunate. You can graduate from Cornell College of Veterinary Medicine, be certified by a half-dozen different boards, and have two dozen letters after your title; yet, when your own pet breaks a toenail, you lose your cotton pickin’ mind.
It’s good to call on these experiences, so that when a frantic client lands on your doorstep, you know exactly how not to react. Faced with a “hyper-concerned” client, it is constructive to invert their energy. It allows us to focus on the urgency of the condition, organize the staff, keep other clients from panic, and to minimize the stress of the patient.
It is equally important to communicate concern. Once we had some direction, and the dog relief, we’d surely share a laugh. For now that had to be stifled.
I chose a square angle to the client, put my pen to the record, and moved to the edge of my stool (pun incidental). We sometimes ask questions to give us time to think: “So, Ken, is this discomfort persistent or intermittent?” I ask, as if it really matters.
Some questions are out of our mouth before we have a chance to think: “How long has this been going on?” I bungle. His dog is acting as if he just lost a jalapeno pepper eating contest with Kishan, Naish and Sanje. You think he’s gonna update his status on Facebook and have a latte, then saunter on down to LMVC? It’s a 15-minute drive from his place to the clinic; the problem’s been going on for 8 ½ minutes.
Pruritus Ani (PA) may not be recognized by spell check, but for the staff of most any veterinary clinic the day is not complete without at least one itchy hinder. Presenting complaints are to the effect of “he’s been scooting on the carpet”, “he’s been licking his back side”, or in extreme cases, "he scooted clear down the driveway”.
Others require a degree of diplomacy. In a sundress and flip-flops, Michelle sat on the wooden bench. “His breath has just been horrid”, she says with a most tortuous expression, as the tri-color Jack Russell Terrier licks her impeccable complexion.
One would think that in 23 years you would have heard of every conceivable way for a pruritic perineum to present, but alas, it was not the case. To be "attacked from the terminal colon" is either a creative client's way to get moved to the front of the line, or canine discomfort of epic proportions.
Differential diagnoses for PA can include, but are not limited to: urinary tract infections, gastritis, food allergies and neoplasia. That said, the most implicated anatomy when presented with a history of an itchy butt, are the anal sacs.
Experience has taught me that in conversation with clients it’s best to enunciate that phrase VERY clearly, refer to them in the singular ("anal sac"), or to play it ultimately safe and substitute the word “gland” for “sac”.
Just a little sinus congestion, background noise, or a poor cell connection can leave a client confused about what exactly you are discussing, and a young vet Badger red in the face.
Though I have no personal experience, it is horrifying to note that this sensation of which we speak is not unique to dogs.
This point was demonstrated in unforgettable fashion to the U of I class of 1992 by Dr. Ronald Smith DVM, Ph.D.
Dr. Smith apparently has ears like a bat. I would have owed him an apology until the day I passed, were it not for a sense of humor equal to his knowledge of pharmacology and the timing to deliver a nearly surgical… touché!
The lecture hall in the University of Illinois - College of Veterinary Medicine Basic Sciences Building circa 1988 had seven rows of desks. The calf-poop brown counter was deep enough for notebooks, coffee cups and big bags of Corn Nuts. The permanent rotating bucket seats were as comfortable as a La-Z-Boy… for the first 12 minutes of each 3-hour lecture. The whole apparatus flexed just to the point that, on the off chance a student might doze, his or her head snapped back like a crash test dummy in a K-car.
In the semesters to come, we would learn ambulatory medicine from rock stars like Dr. “Chief” Hornbuckle, surgery from “Cowboy” Dale Nelson, and reproductive physiology from Randy “bigga is betta” Ott. It’s just not that hard to make collecting semen from a 1500lb Thoroughbred stallion who ejaculates while airborne, or doing a right flank standing omentopexy on a Holstein dairy cow exciting.
However, it is all for naught without a solid understanding of the basics. Professors like Dr. Smith (clinical pharmacology) were saddled with the onerous task of demonstrating the mechanism by which strategic sugar molecules are bound to the lactone ring of the macrolide antibiotics. As you have certainly deduced by now, it is that structure that allows them to disrupt protein synthesis of some of the more tenacious gram-positive bacteria and stifle an upper respiratory infection or a urinary tract infection.
Slightly built, Dr. Smith was not. One could have easily slipped a 3-ring binder filled with a semester’s worth of Biochemistry notes into each back pocket of his khaki pants that he cinched securely with a strained black belt, just below his armpits. In the plastic pocket protector he wore on his left breast was an inventory of utensils rivaled only by Office Max. Dr. Smith’s lectures were multi-media events, with projectors both overhead and slide. Without looking, he’d whip out the laser pointer and demonstrate the cyclic ester ring that rendered Erythromycin exquisitely effective. Then he would deftly switch to the Sharpie, acetate and overhead to specifically demonstrate the inhibition of protein synthesis that could stifle the advance of a stout case of Streptococcal Pneumonia.
As hard as he tried to make a Hollywood production out of antibiotics, he had to be as glad as we were when the intercom sounded for an 8-minute break.
Drs. Shackelford and Miz simply dropped their heavy heads onto the notes on their desks. Elizabeth Clyde and “Sparks” Revenaugh stood, stretched and assumed yoga poses. Mark Mitchell raided what was left of a 12-pack of diet Pepsi he had opened that morning. Matt Fraker added 12 ozs of lukewarm coffee to a cup already half-full of Folger’s instant crystals.
As we staggered into the hallway, I mumbled to my friend Jon Jorgenson, “He is a nice guy." Which would have been safe, but regrettably I continued, "but that man is dry as a popcorn fart.”
Clearly quicker than he appeared, following Jon through the door at that moment was Dr. Smith.
My mind raced to the red pen in his pocket protector and imagined the outright lack of sympathy I had just earned on the day we were tested on this material. I glanced quickly to the corners of his eyes, the edge of his mouth, and his brow: I wasn’t much for suspense and needed to know how many percentage points I had just cost myself.
The man did not flinch.
Six minutes later we returned to our plastic seats. Only two hours left. I thought I was safe from repercussions from my earlier remark.
We thought nothing of it as Dr. Smith seemed to fast-track through the clinical relevance of the “mycins”. Without so much as an inhale, he launched right off into the “cyclines”.
Not one of us minded as he flashed rapidly through slides demonstrating the four hydrocarbon rings that gave Tetracycline its name and function, but when he arrived at “precautions and side-effects”, he dropped right back down to granny-low.
Most of us were aware that tetracyclines administered to young animals could result in brown-stained enamel teeth. A few may have known that Doxycycline could cause esophageal strictures in cats if not properly irrigated with water or lubricated with butter.
None of us were aware of the potential side effects of tetracycline antibiotics in humans.
Dr. Smith featured a slide mentioning the tiny percentage of human patients who could experience a reflex intestinal dysbiosis as a result of the antibiotics. This is an overgrowth of bacteria in the duodenum and jejunum that, in the presence of adequate carbohydrates for growth medium, could lead in some cases to an inflammatory bowel.
Most professors think nothing of self-deprecation for the sake of education. Dr. Smith described a summer he spent at Rocky Mountain Biological Research Center in Gothic, Colorado. He came away with an album filled with pictures of Maroon Belles at sunrise, and the alpen glow of sunset over high-mountain lakes. He also returned with a debilitating case of Rocky Mountain Spotted Fever.
With his history of travel to the mountains, an alert physician at University Health put him on 100mg of Tetracycline every 12 hours, and promised an excellent prognosis for a full recovery. Within 72 hours the aches and fever began to subside, in precise coincidence with the onset of one of less frequently experienced side-effects of the drug in humans.
"Dr. Stork," he raised an eyebrow at me, “do you care to hypothesize as to the consequences of an intense case of inflammatory bowel, should it proceed ante grade in the tract?”
Rather than wait for me to stammer an answer, he began to walk slowly across the stage, then picked up speed rapidly. By the time he made it to center stage he was fast-walking like the Saturday morning tribe of soccer moms on the North Shore of Chicago.
Re-creating what had to be a harrowing experience for a self-conscious, introverted undergraduate, he mimicked ducking behind a tree, then reached around and buried his hand between the pockets of his khaki pants. Curling his fingertips, he dug and scratched furiously.
Stepping back to the podium, he winked and pointed in my direction. With a perfect poker face he waited as 80 veterinary students struggled to regain composure.
As you can imagine, an exaggerated case of lower GI inflammatory bowel becomes, by definition, an obligatory case of pruritus ani... of epic proportions.