Coffee heat rising

In the Dog (and Doc) Dept: Trust Your Gut…

Remember how I was wondering whether a possible misdiagnosis of Valley fever by MarvelVet might be what’s killing my dog? Well…yeah. Just talked to NewVet: the results of the second Valley fever test are back. And no.

No. She does not have and never has had Valley fever.

So basically: we have destroyed this dog’s health and very probably killed her by giving her fluconozale on top of prednisone. Or prednisone on top of fluconozale, however you wish to look at it.

That is not a benign combination. What can it cause? Adrenal gland dysfunction.

And yeah, again. That is exactly what has happened. It destroyed Cassie the Corgi. Her health is permanently ruined, and really, if I had a backbone I’d put her down now.

This has happened under the watch of the Great Skeptic. Remember, I am the one who keeps carping away that one should QUESTION AUTHORITY. Don’t take what your doctor (or a vet) says without looking it up yourself, understanding what ails you, and understanding what the proposed treatments will do for you and to you. Sometimes the treatment is worse than the disease.

That certainly is the case here. We basically killed this dog by putting her on a cough suppressant with prednisone plus an antifungal in the absence of no empirical evidence that a fungal infection was what ailed her. Instead, what ailed her was what was obvious: a bronchial infection that was going around the city at the time and that, probably thanks to the dog’s old age, advanced to pneumonia. She should have been treated with an antibiotic. In fact, when NewVet put her on doxycycline for a UTI, her cough cleared right up.

Shit.

Trust no one. Believe nothing.

 

Dogruminations…

Okay, I may be one of two things:

a) Pathologically skeptical; or
b) Grasping for straws.

Lemme tellya…I  think there’s something mighty fishy about all this Cassie Standing at the Gates of Heaven narrative. My sense about this is that either there’s something MarvelVet isn’t telling me, or there’s some part of his story that just plain isn’t straight.

Let us consider what the story is. Or rather, what the stories are. Or were.

First, the dog comes down with a cough. I call the vet’s office and am told not to bring her in because something is going around, they know what it is, and they’ll give me a drug to ease it. I drive over to his place and pick up a bottle of Temaril-P, which is a combination of an antihistamine and prednisone. Its purpose is to suppress coughs.

She goes through the prescription, administered according to his instructions, but is still coughing.

If the human had been a bit less trusting — as it should have been, already, it would have come across this warning:

Do not give Temaril-P to your pet if the pet has a serious viral or fungal infection. Temaril-P can be given in the presence of acute or chronic bacterial infections provided the infection is controlled by antibiotic. Temaril-P may weaken the pet’s immune response and its ability to fight infections.

When I report that she’s still hacking, he has me bring her in. He does a blood panel on her and then, with no evidence in the results to prove this, tells me she has Valley fever. He then tells me to keep her on the Temaril-P and give her fluconazole.

Folks. Valley fever is a serious fungal infection. If he knew what he was doing (or believed what he was telling me…), why would he have me continue to give her a drug that is specifically contraindicated? And if she’s not getting better, why put her on a drug that reduces her ability to fight an infection? Assuming it is an infection.

The fluconazole makes her extremely sick. So much so that twice I think she is about to teeter over into the grave.

When I look this stuff up and discover a list of a half-dozen dire side effects, a couple of them life-threatening, he tells me oh, those are symptoms of Valley fever. By now I know that…well, no. No indeed, they are not symptoms of Valley fever. Not by a fuckin’ long shot.

I take the dog to another vet, who says it’s pretty ambiguous and there’s good reason to doubt that she has Valley fever. But by now she’s very sick, indeed. It appears she’s not going to make it. And by now, too, my skepticism is fully aroused. I decide to take the dog off the fluconazole on the chance — which I think is pretty good — that she doesn’t actually have this dread disease. Show me some empirical proof, and I’ll reconsider.

As the fluconazole clears out of her system, she  slowly improves. You can’t just stop taking prednisone: you have to titre off of it. But before long I have her eased off that stuff, to no ill effect. The incontinence stops. Prednisone, as it develops, can cause incontinence in dogs. Meanwhile, I happen to know that you can give Benadryl to dogs — have done so before. She’s wheezing, as though she has asthma. Of course, asthma has many causes…but one of them is allergies. She gets markedly worse on a day when heavy winds and rains blow through. Why not? think I…

Put her on a couple of doses of Benadryl, morning and night. Within a couple of days, she’s markedly better. Meanwhile the vet has me bring her in for this supposed “free” ultrasound scan.

Free? Really? Hm. Well, whatever.

Not surprisingly, the result is dire: he tells me she has adrenal cancer.

I say, “Well, then. We’d better put her down right now.”

His response is to say that it’s not necessary, because she seems to be doing all right for the moment. (Benadryl is some kind of chemotherapy, is it?) He says we should wait until she seems to get a lot worse, and remarks that she’ll have her ups and downs.

I ask how long she’s likely to live.

He says, “About three months.”

Uh huh.

I now look up this new drama and find a number of things out.

You can’t know whether something that looks like a tumor on a dog’s adrenal gland is malignant without doing surgery to biopsy it.

If the dog actually does have a tumor on her adrenal gland (I’m beginning to wonder; see below…), it may be harmless. About half of such growths are what is known as “nonfunctional,” meaning they just sit there and do nothing. Half are malignant and cause the dog to exhibit symptoms that look like Cushing’s disease. This dog does have a few such signs: thirst, vigorous appetite (which she’s always had: a corgi will eat until it explodes!), unusual lethargy. Alternatively, the mass may be an adenocarcinoma: an aggressive malignancy that indeed will spirit the dog away sooner than later. Interestingly, though, when you look that one up you find she exhibits exactly zero symptoms of it.

Hm. Day by day, she gets a little better. The Benadryl — or tincture of time, could be either one — seems to be bringing her back to normal. She still chokes and wheezes when she drinks water…but she’s always choked on water. Corgis do that: Ruby does the same thing. She’s now barking in her accustomed excessive way, and not wheezing every time she yaps. Or even any time she yaps. She’s beginning to lose the “tragic” expression and looks far more normal.

I’ll tellya what I think.

I think MarvelVet made an incorrect assumption on the fly. Chances are his original diagnosis — a bronchitis that was going around at the time — was right. But the assumption that a week on Temaril-P would cure it was incorrect, because of her age.

If you believe those silly dog-to-human-years charts, this dog is the same age I am. The last time I got a cold — apparently a fairly ordinary cold — it took me six months to get over the cough. A 12-year-old dog is not going to get over a bug as fast as a two-year-old or a five-year-old or even a seven-year-old dog. If my theory is correct, the cough hung on because it would take her longer to throw it off. And if she actually has a symptomatic cancer of the adrenal gland, she would not be steadily improving.

If my alternative hypothesis is correct — that she had asthma from the git-go — then what happened was the storms aggravated allergies that were developing and growing more bothersome as she has aged. One way or the other, the reason she did not show signs of Valley fever in the blood panel was that she did not have Valley fever.

I think he realized he’d misdiagnosed the dog, and that the meds he put her on made her extremely sick. May even have caused permanent damage. And between you and me and the lamp-post, I think this scan thing is a diversion.

He probably figures that if I don’t put her down and she gets better over the next three months, he can claim a miraculous cure. Or simply say the alleged tumor is of the “nonfunctional” variety and so, whaddaya know! It didn’t kill her…

Tellingly, his office has not responded to Second Opinion vet’s requests that they send the scan over to them for a look-see.

I wonder, really, if his alleged colleague even did any such thing…if they simply shaved her belly and told me this story. Even though I asked, I was never given a chance to see the scan — and when he was telling me she had Valley fever, he did show me an X-ray that he alleged to be her lung and heart.

Now admittedly: all of this speculation may be the product of a fevered brain. Or some part of it may be and some part may not be. We all know I’m a crazy little woman, and what we see here may simply be a manifestation of that, eh?

BUT…for a dog that’s pounding at death’s door with cancer, Cassie seems to be surprisingly well. Once she got off the toxic drugs, she began to come back to normal. Right now she’s barking without coughing, eating cheerfully, bright-eyed, and alert. Under the influence of 1/2 Benadryl in the a.m. and 1/2 in the p.m. (she only weighs 20 pounds!), she seems kind of sluggish and tired. But lo! Look it up and you find Benadryl has the same sedating effect on dogs as it does on humans:

The most commonly reported side effect is drowsiness. This is so common that many people give Benadryl to their dogs to help them calm down. (Diphenhydramine is even marketed and used as a sleep-aid by many people.)

The second most common side effect is mild disorientation. We recommend paying attention to your dog’s behavior after giving them Benadryl to make sure they don’t experience this before giving them a second dose.

Hell, I weigh more than six times what that dog weighs, and a half-pill of the stuff will knock me out all night! I use it as a sleeping pill.

Dollars to donuts, once she’s off that stuff, she’ll be her same old normal self.

Will she die within three months? Maybe. But that wouldn’t be surprising: I’ve never had a dog that lived longer than 12 or 13 years. And she’s at least 12 right now.

 

Sick Dog: Deciding what to do…or not to do

Cassie is getting steadily worse. Today she can barely drag herself around, and she refuses to eat anything, even a single piece of the fancy kibble I give her for treats. Twice now, this dog has been so sick that I thought she might die, very soon.

I’ve made another appointment with the “second opinion” vet — turns out the one I saw out there was actually a part-timer, a kind of visiting vet, but now the regular guy (who sees my son’s dog) is back. This afternoon, he will have the joy of seeing a cranky old lady and her sick little dog.

This is what I think…oh, no. Make it this is what I’m sure of: The drug given for supposed Valley fever, fluconazole, is making her very sick. All of the symptoms she’s suffering, except for the bloody urine and the wheezing, are listed as side effects of fluconazole. We do not have any empirical proof that the dog actually does have Valley fever: the first test came back negative for Valley fever. This is not uncommon, and so we moved forward with the first vet’s diagnosis.

The longer the dog is on this drug, the sicker she gets. Today she will eat nothing at all, and she can barely move around, except to piss out an occasional lake on the family room floor. She is incontinent and unable to get to the back door before it all comes pouring out. Of the phenomena she’s suffering, almost every one of them appears in the University of Arizona Medical School’s list of fluconazole side effects in dogs:

  • loss of appetite
  • nausea
  • vomiting
  • diarrhea
  • excessive drinking and urination, or leaking urine while asleep
  • lethargy

If she doesn’t start to eat, she’s going to starve to death. I cannot afford to hospitalize a dog and keep it on life support so as to administer a toxic drug on the off-chance that three to six months of such treatment will beat back a fatal disease.

I can see four reasonable scenarios to explain what’s going on:

Possibility 1: She in fact had the contagious bronchitis that was going around, but because she’s elderly, it took longer for her to get over it and so it was mistaken for a chronic, endemic disease. In this scenario she does not now and never has had Valley fever; what ails her is either a respiratory infection or the side effects of the drug.

Possibility 2: She does have Valley fever acquired fairly recently and, as is not uncommon, it hasn’t shown up as a positive titer yet. In that case the drug is causing most of the symptoms, with the exception of the cough.

Possibility 3: She’s had Valley fever for awhile (just about any human or dog or horse that lives for any length of time in the low deserts of Sonora, Arizona, and California harbors Valley fever, usually asymptomatically) and it has advanced to the point where it is causing symptoms. In that case, the drug is still causing most of the symptoms, but it’s not likely to do much good.

Possibility 4: Now for something completely different! She has neither bronchitis nor Valley fever, but some as-yet-undiagnosed ailment that is much more serious. Her symptoms may be indicative of that…or may be the side effects of a drug she doesn’t need.

Just talked to First Opinion Vet, who finally had time to call me (it’s the lunch hour here). His money is on Possibility 4. He thinks there’s something more going on than Valley fever. He says the only way we can find out is to mire ourselves in every more complicated and expensive tests, and where the end-point would be is anyone’s guess. He feels that is not a good thing to do to the dog…and I will say, neither do I. Even if I could afford to be sucked into a vortex of medical testing for a dog that is at the end of its natural lifespan, my sense is that it would be cruel to put her through that — especially since it’s likely to be pointless.

As for me, I’m putting money on Possibility 1: she had bronchitis, was inappropriately treated for it, and got over the cough in the normal course of events. And what we’re looking at now is the result of a drug that did nothing for the ailment but has worked wonderfully to make her spectacularly sick.

I had already decided, before His Vetship called, to take her off the drug, stand back, and watch what happens. If she dies, she dies. Like all of us, she’s gonna die anyway. When he called and heard my whinge — and more to the point, heard that the dog not only is not improved but is lots worse — he agreed that we should quit giving her ALL the drugs, including even the small amount of Temaril-P. If it’s true that the worst of the ailment arises from the drugs’ side effects, she may feel a little better even if the underlying problem is something we haven’t figured out yet.

Which, IMHO, is a veterinarianly way of saying “ooops!”

Let’s see what happens next.

Doggie Update

So Charley the Golden Retriever is still alive. And I had the locale wrong, for reasons attributable only to senility: somewhere along the line “Show Low,” the garden spot where M’hijito and his dog are presently becalmed, morphed in my aged mind into “Snowflake,” a different  wide spot in the Arizona road. Show Low is even further from lovely uptown Phoenix: it’s about a five-hour drive. Images all seem to be copyrighted, but you might enjoy this rustic piece of public relations

Nice and cool up there, though. It’s hot, humid, and rainy down here.

The vet’s office in exquisite Show Low is closed on the weekend, but they’re kindly letting M’hijito visit his dog while staff go in to check on the imprisoned livestock. They also hope to get a vet in to talk with him this afternoon, maybe.

Charley lives, to the surprise of all concerned. The vet expected him to die and prepared M’hijito (repeatedly) for that eventuality. Apparently he’s stronger this morning and able to sit up (which was not so before this). However, his bloodwork still ain’t great: they’re telling M’hijito that the platelet count is low.

However, he had a bowel movement that was not bloody diarrhea — which would have been the case had the predicted devastation to his intestines occurred. I have not heard that he’s bleeding from the nose, gums, or anus, which would be the case if the low platelet count indicated internal hemorrhaging. There’s some indication of harm to the liver, but the vet says a dog may recover from some injury to the liver.

The vet would like M’hijito to take Charley to a 24-hour veterinary facility. Here in the Valley, these places are billed as “emergency animal clinics,” and they charge $1300 (!!!!) just to walk in the door. Got that? It’s just the down payment. If you say “we can’t afford that,” they will summarily turn you away! Customers either love them or hate them: some people report good experiences, but evidently if you’re unfortunate enough to have a bad experience, it’s very, very bad.

At any rate, it’s unclear that the dog needs that kind of high-powered treatment: he hasn’t died yet under the care of the small-town vet, and my guess is that if he hasn’t died yet, he’s not going to.

M’hijito says tomorrow morning he will call his vet’s office (she actually retired, but at least he’s on record as having been a customer there) and follow their advice, although clearly his inclination is to take the dog to a 24-hour place.

Meanwhile, as reported yesterday, one researcher found that all the hyperthermic dogs in a study survived if they made it through 72 hours in a veterinary hospital.

Additionally both hypothermia (getting too cold) and hyperthermia (getting too hot) can on their own cause platelets to die off. In vitro (i.e., in glass: in a lab), they readily regenerate at room temperature. This suggests that if the dog actually is not hemorrhaging internally, his blood count should recover in due time. If he were bleeding much internally, he would not appear to be getting steadily better, a little each day. Presumably, he would not even be living at this point.

And I also learned that, at least in humans, hyperthermia can be psychogenic — that is, stress can bring it on.

A more technically inclined report says that in humans stress can lead to transient hyperthermia, which will not respond to aspirin (and similar drugs used to treat fever) but which may respond to sedatives and antipsychotics.

As far back as 2008, researchers were talking about stress-induced hyperthermia — the vets up there should know about this, you’d think.  Presumably, though, because they’re in a rural practice they have no need to.

My son says the dog was never exposed to high temperatures en route, not even when they were stalled for an hour by the road construction in the Salt River Canyon. In fact, he says, the inside of the car was “cold as an icebox.” He let Charley out of the car while they were stopped, to let him walk around…and noticed then that he was panting and wild-eyed. This he attributed to the dog’s usual dislike of riding in the car. For unknown reasons, Charley was OK with the decrepit Honda sedan M’hijito used to drive, but he hates loathes and despises the Ford Escape that took its place. Under normal circumstances he freezes up and goes all rigid, M’hijito says, and sharing the back of the vehicle with camping gear evidently got him massively overwrought. M’hijito thinks he became so frantic in his fear or phobia or whatever the eff that he worked himself up into overheating. That possibility seems to be confirmed by the studies above.

Less evident is whether it’s really necessary to consign this dog to a 24-hour emergency veterinary once he’s well enough to travel five hours inside the hated vehicle, or one like it. These places are renowned for bills that run well over $1,000, and one person reported a bill of $22,000. It’s hard to get a straight story, unfortunately, because most of the sites discussing this subject bear all the hallmarks of paid posts, at one point or another coming around to a pitch for pet health insurance.

Herein lies the problem, my friends, with raising children in an upscale urban setting. Well. One of the many problems.

In a setting where dogs and cats are “members of the family” and animal owners go around calling themselves “pet parents” (for godsake), it’s impossible — it surely is socially unacceptable and it probably is objectively impossible — to communicate to a young person the ethos that a dog is a dog.

It is not your friend and it is not your “packmate” and it is not your baby: it’s a dog.

A symbiote.

It cannot understand why it’s suffering, and its concept of the future does not include “someday maybe I’ll recover and sure, I’ll be a cripple but that will be OK because I’ll still live to see my grandpuppies graduate from Harvard.”

So moderns like M’hijito whose parents did not grow up in rural settings aren’t prepared to deal with the eventuality of putting an animal down as the kindest thing for all concerned.

You know, my father grew up as a cow-puncher and my mother’s family scratched a living out of a dirt farm in upstate New York. Neither one of them would have wanted to put a pet down. But neither of them would have impoverished themselves to keep a seriously injured or sick dog alive, or forced that animal to live through a lot of suffering on a long-shot chance that it might survive.

Nor, I might add, would my father have put up with a supposed hunting dog that was so neurotic you couldn’t take it for a four-hour ride in a car without it collapsing in a phobia-induced state of hyperthermia.

This is my fault. I should have made my son understand that a dog is a dog, not a four-legged person…I mean, understand that on a gut level.

My own sense is that one should do what one can, within reason (got that? within reason is the operative term here) and then let nature take its course.

Our ranch manager once told me that. I asked him if we shouldn’t call in a vet for a very aged horse that was suffering an ailment. He said, “No, we should let nature take its course.” And he was right. I would have called the vet; still would, being a city girl. Nothing much would have happened. The vet would have charged more than the horse was worth; the horse would still have died. But I wouldn’t have felt guilty about it, anyway. I guess.

About eight times out of ten, I expect, letting nature take its course is the most merciful thing for all of us. All told.