“Look Dad!” Chuck exclaimed, pointing out the window of the car.

It was a sunny Sunday afternoon and Chuck and his dad were on their way to the little league baseball fields near their home to take some batting and fielding practice before the season got underway.   Chuck’s dad, Dr. Carson, was a veterinarian and the drive from their home to the baseball field happened to take them right by the veterinary clinic that he owned.  Chuck’s dad turned his head just in time to see a bicycle lying on its side in the grass in front of the clinic and a young boy standing outside the front door.   On Sundays the clinic was closed and locked up tight.  The only people that came in were the technicians who took care of the sick dogs and cats that were staying over the weekend.  The young boy, however, was standing on the front stoop pounding mercilessly on the door of the building.  In his arms, seemingly lifeless, he cradled a small beagle puppy.

“Aw, Chuck…” Dr. Carson started to say.

“I know dad, practice can wait for a few minutes.  We can’t just drive off and leave that kid with the sick dog back there.”

“I’m glad to hear you say that.” Chuck’s dad agreed. “But, from the looks of that little puppy he’s carrying, there may not be very much for us to do.”

“Maybe it’s not dead” Chuck added optimistically. “Maybe there is something you can do to help it.”

“We can always hope,” responded Dr. Carson – less optimistically.

Dr. Carson pulled into the very next parking lot, turned around and headed back to the clinic.  As they drove into the drive, they saw the little boy getting back on his bike with the sick little puppy stuffed inside of his jacket.  His dark brown eyes were swollen and red from crying, and his tears had left wandering wet streaks down either cheek.

“Wait a minute son,” Dr. Carson called out. “I’m the veterinarian that works here.  Maybe I can help you out.  Why don’t you come on inside so we can have a look?”

The boy’s face showed a faint glimmer of hope when he heard those words.  He leapt off his bike leaving it, once again, in a heap on the front lawn and rushed awkwardly toward the front door.  He carefully cradled the puppy as it bounced to and fro inside his jacket.  Dr. Carson held the front door open for him and motioned toward the open door to their left that lead into the first exam room.

“Let’s see what you’ve got there,” Dr. Carson offered.

The boy opened his jacket and laid the limp little body on the table. It was a little female beagle, probably not over five weeks old.  The outline of her ribs and the regular bony prominences of her spine were easily visible through the thin skin that covered her body.  Her eyes stared blankly straight ahead, unblinking and half-open.  Periodically, her chest would rise to take in a breath of air then slowly return to its resting position as she exhaled.  Chuck’s dad lifted the little puppy’s lip and pressed his finger against the white flesh inside her mouth.

“Well.  She’s still alive,” Dr. Carson observed. “But barely.  When did you first find her like this, son.”

“Yesterday she seemed fine,” the little boy answered.  “I dunno.  Maybe last night she started to get sick, and then this morning she couldn’t walk.  She just lay there in the box. The other puppies were crawling all over her, and she never moved.  She has always been the smallest, but I feed the mama dog everyday and give her clean water.”

“I’m sure you take great care of her, son.  What’s your name?” Dr. Carson inquired.

“Bobby,” the little boy answered.

“Well, Bobby.  Your puppy is very sick.  Let me run some tests and we’ll see if we can figure out what’s wrong.  Chuck, could you please get me a purple top blood tube and a 3cc syringe with a blue-capped needle on it?  I’m going to need your help.”

“Sure, Dad.”  Chuck had spent enough time in the clinic to know where most everything was, and what a lot of it was for.  He hopped off his stool at the counter in the lab and grabbed up the supplies his dad had requested.  As he entered the exam room and moved into position beside the table, he handed his dad the syringe and needle.  He kept the blood tube and slipped it into his pants pocket where he could retrieve it quickly when his dad was ready for it.  Chuck cupped the little puppy’s head in his hand and gently extended her neck.  Using his left hand, Dr. Carson slipped a couple of fingers under the puppy’s neck and applied pressure with his thumb to a little groove at the point of her shoulder.  Chuck could see the vein in the side of her neck fill slowly with blood.  He watched his dad gently slip the tip of the needle under the skin and into the vein.  With the thumb and forefinger of his right hand Dr. Carson pulled back gently on the syringe plunger.  The barrel of the syringe filled quickly with blood.  Not wanting to take too much from an already very weak patient, Dr. Carson stopped as soon as he had enough to run the test.

“Let’s see what we can learn from this,” he said as he carried his samples into the lab for analysis.

Bobby watched from the exam room as Dr. Carson and Chuck scurried around the lab with the samples they had taken.  He stroked the little puppy’s head gently with the tips of his fingers as he waited.  He heard machines whirr and click as they analyzed the blood.  He saw Dr. Carson peering into a microscope then looking up to scan the results on the printer.  Bobby couldn’t tell what they were doing, but he hoped whatever it was would help his puppy.  He looked away and tried to think positive thoughts.  A second later Dr. Carson stepped back into the room.

“Well, Bobby.  I can tell from the samples we took that your little puppy has a terrible infestation of hookworms.  It has made her blood very thin.  There are barely enough red blood cells left to carry oxygen to all the organs in her body.  That’s why she’s so weak.  We should be able to save her, but she’s going to need a blood transfusion.”

“Take mine!!” little Bobby exclaimed, holding out his arm and rolling up his sleeve. “Can’t you take some of my blood and give it to her ??”

Dr. Carson smiled and tussled Bobby’s hair.

“There won’t be any need to donate blood today.  People blood wouldn’t do a dog much good.  I happen to have some blood in the refrigerator left over from another case this week.  I was getting ready to throw it out, but now I’m glad I saved it.  Although, please understand Bobby, your puppy is still very sick.  She needs the new blood, but we also need to kill all the worms inside her.  Sometimes that can result in complications.  Sometimes the blood can cause them to have a reaction.  We’ll do everything we can, but there are no guarantees of success.”

Bobby nodded his head.

“I understand.”

“Alright then.  Let’s get started.”

Dr. Carson left the room for a couple of minutes then returned with four syringes in his hand.

“I need to give her some shots, Bobby.” Dr. Carson explained. “One of these will make it less likely that she’ll have a bad reaction to the blood.  One of these will kill the worms that drained all her blood.  The other two are vitamins and iron that will help her body make new red blood cells.”

The little puppy hardly flinched as Dr. Carson gave one injection after another.  Then, Bobby looked on as Dr. Carson clipped the hair from a patch of skin on his puppy’s front leg and washed it with some brown soap.  He watched in amazement as Dr. Carson threaded a tiny plastic tube with a long thin needle going through the middle of it into the vein in her leg.  With white tape Dr. Carson secured the little tube in place and screwed a little rubber cap on the end.

“There. That, Bobby, is an intravenous catheter.  This way we’ll be able to give her medicine, or in this case blood, right into her blood stream without having to stick her over and over again with needles.  Chuck, will you hand me that bottle of blood we got out of the refrigerator earlier?”

Dr. Carson attached a long clear plastic tube to the bottle, gave it a swirl and hung it from a hook in the ceiling.  Bobby saw the blood drip from the bottle into a chamber with some sort of filter inside.  The chamber gradually filled up.  When it got about halfway full, the blood started to fill the rest of the tube and ran quickly toward the end.  Just as it was about to drip on the floor, Dr. Carson turned a little wheel on the tube with his thumb.   The flow of blood stopped right at the end.

“Chuck, will you hold this leg for me?”  Dr. Carson asked.

Without saying a word Chuck reached over and stabilized the little leg by gripping it behind the elbow.  Dr. Carson unscrewed the cap from the catheter and inserted the fitting on the end of the tube in its place.  He then reached over and used his thumb to turn the little wheel on the tube in the opposite direction.  Blood once again started to drip from the bottle.

“Well, Bobby.  It’s a waiting game now.  After she’s gotten all the blood she needs, we’ll fix her up a spot in our kennels for the night.  She should have a lot more strength then.  By tomorrow afternoon we should have a much better idea about her chances of survival.  Why don’t you just stop back by tomorrow after school and check in on her.  We’ll look after her for you until then.”

“Ok,” Bobby answered with a worried look on his face.

“Can we give you a ride home?  I’m sure your bike would fit in the trunk.”

“No, sir. Thank you, though.  I’ll come back tomorrow after school. Thank you, again.”

Bobby turned and walked back through the lobby to the front door.  He strained against the weight of the heavy glass for a second before it yielded to his pressure and allowed him to go outside.  He picked up his bike and rode slowly down the street.

“Do you think she’s going to live, Dad?” Chuck asked.  He knew better than to ask questions like that in front of clients.  He had waited until the coast was clear before raising any additional doubts about the outcome.

“She’s got a good chance now.  We’ve done all we can do.  I think she’s had about all the blood she needs.  Let’s disconnect that line and get her set up in a kennel.”

Chuck and his dad had enough daylight left to get in some good batting practice and shag some ground balls.  They were worn out from all the excitement that evening when they finally got home.  Chuck’s mom listened intently to the details of their encounter with the little boy and his puppy.  They all openly expressed their hope that their efforts with the puppy that day would lead to a complete recovery.  At the evening meal, Chuck offered a little prayer on the puppy’s behalf as an addendum to his normal blessing.

The next morning when Dr. Carson walked through the back door of the clinic he heard a high-pitched series of yips coming from the kennel room.

Sandra, the veterinary technician, met him in the hall.  “That sure is a lively little beagle pup you took in this weekend.  We can hardly hear ourselves think back there.”

“Wonderful!” Dr. Carson exclaimed. “That’s fabulous.  You wouldn’t believe how she got here.”

He filled them all in on the events of the previous day.  Everyone was touched at Bobby’s devotion to the little puppy.  They wondered how far away he lived and at how many veterinary clinics he had stopped before Dr. Carson happened to see him.  They eagerly awaited his arrival that afternoon to tell him the good news about his dog.

At exactly three thirty that afternoon the front door opened and in strolled a young boy that none of the staff recognized.

“You must be Bobby,” Deidre, the receptionist, exclaimed.  “My name’s Deidre. Dr. Carson has been waiting for you.  Let me see if I can find him.”

Deidre disappeared through the double doors that lead to the treatment area.  She found Dr. Carson writing on a patient record in the lab.

“You have a visitor!” Deidre sang happily.

“Is it Bobby?” Sandra quickly inquired.

“It’s Bobby.  Who wants to give them the good news?”

“I think I’ll talk to him,” Dr. Carson stated plainly with a little grin, as if there was ever any question. “Sandra, why don’t you get Bobby’s dog for him and meet us in the first exam room.”

Dr. Carson walked into the lobby and saw Bobby slouched down in a chair against the wall.

“Bobby! It’s good to see you again.  I think I have some news that might make your day just a little bit brighter.  Your puppy has made a remarkable recovery.  She’s doing great.  I think she’s ready to go home.”

Bobby jumped up from his chair.

“Can I see her?” he asked.

“Of course.  Sandra is bringing her up to the front room as we speak.  Come on back.”

Bobby walked cautiously into the exam room and glanced around.  A second later Sandra came through the other door to the room holding a squirmy, impatient little puppy.  Bobby’s face became alive with joy.  He reached out and took the puppy from Sandra.  The puppy climbed up his chest licking his ear and cheek furiously and clawing at his shirt.  Bobby laughed and scolded her playfully as he dodged one lick after another. Dr. Carson and Sandra witnessing the reunion couldn’t help but smile.  The bond they witnessed between a little boy and his dog filled their hearts with warmth and threatened to fill their eyes with tears.

“I should have asked you this earlier, Bobby. But, does she have a name?” Dr. Carson interrupted.

“Sally,” Bobby replied. “I call her Sally.  Thank you for what you did.”

“No thanks necessary, Bobby,” Dr. Carson replied.  “Seeing you two together is all the thanks I need.”

Bobby reached deep into his front pocket and retrieved a wad of crumpled up money and gum wrappers.

“I can pay you for what you did,” he offered.

“No thanks,” Dr. Carson insisted.  “Keep your money.  Use it to buy Sally some food or toys.”

Everyone in the clinic looked at each other and smiled.  It was heartwarming to see such a joyous reunion.  Even Dr. Carson sensed an extra measure of satisfaction from his efforts with Sally.

As Bobby was leaving to take Sally home, Dr. Carson held the front door open.  “Bring her back in a week or so for her first set of shots!” he called out as Bobby was arranging Sally in the front of his jacket for the trip home.

“Sure thing!” Bobby answered.  “See you then!”

Bobby pedaled off down the street with his puppy.  As he began to disappear from sight Dr. Carson turned toward the clinic.

“Alright.  Let’s get back to work,” he chided playfully.  Everyone groaned in unison and shuffled their feet as they headed back inside to resume their activity.

That night at the supper table Dr. Carson recounted the events of the day to everyone in the family.  Chuck was especially interested and pleased with the outcome.  It was though his prayers from the night before had been answered.  He listened intently to his Dad’s story.  Then he began to think.  He had seen his dad come home many nights with stories about things that had happened at work, but this time it was different.  Chuck could tell by the way his dad talked and by the expression on his face that he had been very deeply touched in his dealings with Bobby and Sally.

“Hey, Chuck!” his dad called out. “Whatcha thinkin’ about?”

Evidently, Chuck had a funny expression on his face as he sat there motionless over his plate with these thoughts running through his mind.

“I dunno,” he answered. “I guess I was just thinking about Bobby and Sally.  It sounds like Bobby was awfully happy to see that Sally was better.  And, the way you tell the story it sounds like seeing those two reunited made you almost as happy as Bobby!  I guess that’s the good thing about doing something nice for someone.  It makes the giver feel almost as good as the getter!”

For veterinarians in rural America, holidays evoke conflicting emotions.  We – like normal people – enjoy spending time visiting with family and friends.  We look forward to tables filled with more food than we can possibly eat and the occasion to have a cocktail or a glass of wine in the middle of what would normally be a busy afternoon at the office.  Yes, holidays are marvelous – except that they encourage us to make plans.  Which can be problematic for those of us in the care giving professions because we don’t always get to choose when we work.  Our schedules are often dictated by the needs of our patients.  And, as anyone who has ever worn a pager or been on-call can attest, formal plans pretty much guarantee that some variety of mayhem will erupt and hi-jack your agenda just as you are about to walk out the door.  For the veterinarian on-call holidays can be cruel torture, bringing the possibility of celebration like normal people just within our reach only to be snatched from our grasp by a colicky horse or a vomiting dog, or, in this case, by a cow in labor.

It was Valentine’s Day 2001.  Our older son, Will was three.  My wife, Leigh, and I had plans to get the kiddo in bed a little early and savor a quiet, candlelit dinner at home.  I scoured our favorite cookbooks and picked out the perfect recipe.  It was a pasta dish from Olive Oil’s, one of our favorite little Italian restaurants in Aiken, SC.  I envisioned us sipping on a glass of wine and listening to Van Morrison as the smell of tomatoes, spinach, parmesan, garlic and heavy cream simmering on the stove filled the kitchen.  Then, we would enjoy a quiet dinner – just the two of us – on our wedding china before we, and our full bellies, retired to the living room to sit by the fire to finish our wine.

I had it all planned out in my head.  I stopped at the grocery store to pick out a Valentine’s Day card while I was coming back from farm calls that morning.  By mid-afternoon getting home on time was starting to look like a very real possibility… until the phone rang about 4:30 that afternoon.  It was a cattleman from about 45 minutes away in Sparta, GA.  He raised purebred Gelbvieh cattle, and he had been keeping a close eye on one of his heifers that was due to calve.  He found her off by herself about 10pm the night before.  Her tail was raised and she had a clear, gelatinous discharge hanging from her back end.  He fully expected her to have a calf by the next morning.  But, we were going on 16 hours now and she still had not calved.    He asked if we could come out and check her.  I glanced at the clock and sighed. We had no choice but to go.  I started doing the math in my head.  If I leave right now and make a bee-line for his farm I should get there around 5:15.  If the calf is just positioned wrong in the uterus…  I tried to estimate how long it generally took me to correct some of the more common malpresentations in cattle.  Sometimes it was a pretty simple issue.   Maybe the calf’s head is just turned back or maybe it’s breech…  Truthfully, I always lost track of time when I was working and I had no idea how long it usually took.  I knew some cases were pretty quick and some took a long time.  Anyway, I thought to myself, hopefully, this one won’t take too long, and I’ll be able to get home at a reasonable time…

Since we weren’t very busy at the clinic I talked my boss into letting me take one of our assistants with me on the farm call.  Having an extra set of hands, I reasoned, may save me 10 minutes or so.  Without wasting anymore time we hopped in the truck and sped off down the road.

I had never been to this particular farm before, and I was impressed when we pulled up to what I reasoned must be the entrance based on our directions.  It wasn’t fancy or pretentious, but everything looked very well built and maintained.  A barbed wire fence skirted the ditch to our left and our right as we pulled through the gate onto the dirt drive.  Rolling hills of fescue grass faded into the tree line in the distance ahead of us.  And, there on the edge of the field stood a large hay barn with a catch pen on one side.  The catch pen consisted of a corral made out of 6×6 posts and treated 2×6 boards spaced about 8 inches apart and at least 6 boards high.   On one end of the pen a crowd gate directed the cattle into a long curved chute that ended with a new Powder River head gate.  A head gate is a contraption that is designed to close on either side of the neck and keep the cow standing relatively still.  Catching a wary old cow or bull in a head gate requires more skill than you would think!  Plenty of cowhands have endured endless torment from their coworkers for being just a split second too late on the head gate and allowing a cow to squeeze through!

I parked the truck, climbed out and walked over to introduce myself to the farmer.  He was waiting for us in his truck.  The driver’s door was open and he was sitting sideways in the drivers seat.  He stood up and started toward me as I approached.  He was an older gentleman with a bronze, deeply lined, leathery face from a lifetime spent in the fields.  He wore a straw cowboy had that had a permanent sweat stain around the base of the crown.  His denim jacket and denim blue jeans were clean, but each showed the characteristic signs of clothing that was meant for work.  He stood about 6 feet tall, even with a slight stoop, and he moved easily like a man who didn’t stay still very long.  He was thin – built like a stalk of bahia grass – tall and slender, without the fleshy middle that most men his age cultivate in their later years, but not frail.  I introduced myself and we exchanged pleasantries.  I was eager to get to work so I suggested we take a look at our patient.  I climbed up on the fence and peered over.   She was standing on the opposite side of the corral with her tail slightly raised.  She was a nice looking beef cow,  good size, nice bone structure, ample body capacity, level top line, elegant head and neck with a size-able udder tucked neatly under her hindquarters.  I pursed my lips together tightly when I saw that there was no portion of the calf visible at this point.  That worried me because with most of the more common malpresentations at least a portion of the calf will be visible.  It might only be a tail or one leg, but usually you can see something.  I needed to get my arm inside her and have feel around to see what was wrong.

Between the three of us we coaxed the cow into the corral and we slipped a post in behind to keep her from backing up.  We didn’t bother to catch her head because I was going to be working at the opposite end!  I handed her tail to my assistant for her to hold and I quickly cleaned up her back end with scrub soap and water. I slipped on my shoulder length plastic glove and squirted some sterile lube on the back of my hand.  Gently I slipped my hand and arm inside the birth canal.   About a foot or so from the entrance I encountered two very large feet.  The soles felt like they were pointing downward and the dewclaws were on the bottom.   That meant the calf was likely coming out headfirst.  I reached in almost as far as I could go and my fingertips were able to make out the features of a very large head.  I stuck a finger in the calf’s mouth and felt a slight movement of the jaw and the tongue.  The calf was still alive!  However, the gigantic head and front legs felt too large to fit into the pelvic inlet at the same time.  All my optimistic premonitions about getting this calf out easily evaporated in that instant.  This calf was presenting perfectly normal, but it was just too large to fit through the interior diameter of the pelvis.  That happens sometimes in cattle because the bull, and to some degree energy level in the diet during the last three months of gestation, largely determines the birth weight of the calf.   When you have a size mismatch of this magnitude it means that this calf is not coming out vaginally.  We were looking at a c-section.  Just to convince myself, I placed OB chains around each front leg and the behind the calf’s ears like a bridle on horse.  I pushed and pulled and pulled and pushed, verifying that indeed the calf’s front legs were fully extended and no, the head and legs were not going to fit into the pelvis.

I pulled off my sleeves and turned to the farmer to explain the situation.  He understood and agreed to go ahead with the c-section.  However, as well built as his facilities were, they were not very conducive to doing cow surgery.  I preferred to do all my abdominal procedures on cows with the patient standing.  Between my boss and I we did about 175 standing abdominal surgeries in cows every year.  It sounds a little bizarre, but it’s the safest position for the patient.  Cows have very heavy viscera and relatively small lung fields, when they lay down for long periods of time they don’t breathe well.  And, because they are ruminants, they tend to regurgitate stomach contents more easily, which can cause aspiration pneumonia.  Also, even as a young surgeon, I had a history of chronic lower back pain.  I had my first back surgery at 19 years of age and doing surgery on a patient at working height was much easier for me!  However, to do standing flank surgery on a cow, one must be able to restrain the cow and still have access to her side.  The solid sides on this particular chute prevented us from getting to her side with her in the head gate.  I considered our options.  If we had some portable panels we could set up a temporary chute on the other side of the head gate and run her in the opposite direction, but we didn’t have any portable panels.  Nor was I convinced that we would be able to confine this cow in portable panels.  Beef cows are typically much more fractious to work with then their dairy cow cousins.  Dairy cows are handled and moved multiple times daily during most of their life.  Beef cows are usually handled once or twice a year – and then it is usually to give injections or take away their calf!  This girl was already getting anxious from being separated from the others, penned up and violated.  I feared if we let her out of the chute we would have our hands full getting her back in.  I surveyed the corral.  There were plenty of substantial posts and a water trough along the fence on one side.  I decided the best thing to do would be to make a halter for her out of my catch rope and tie her up short along the fence by the water trough.  To do that I would need to sedate her first, make the halter out of my catch rope, back her out of the chute and then tie up to one of those posts.  I’d operated on plenty of dairy cows tied up like this, I reasoned.  It should work just fine.

I gave her a dose of sedation and waited for it to take effect.  When her head started drooping and drool begin to hang in long ropey strands from her chin, I knew she was ready.  I secured the halter around her head and backed her down the chute.  Her steps were clumsy, but we made progress.  When she got out into the open area of the corral she tried to make a break for freedom, but the sedation slowed her down just enough for me to take a wrap around a post with my rope and bring her to a stop.  With a little more coaxing we were able to move her closer to the post where she was anchored until she was tied with her head right up against the fence.

We quickly gathered all our supplies and surgical instruments.  With water from my scrub bucket I soaped up her left flank and shaved off all the hair with a surgical razor.  I prepped the bare skin three times then numbed up an area of tissue with lidocaine that was about two inches wide by fourteen inches long.  During this entire time our patient had not so much as lifted a foot.  She seemed oblivious to what was going on around her.  I laid out my surgery instruments and suture anywhere I could find a clean dry surface.  I turned my attention from cleaning and prepping the cow to cleaning and prepping my hands and arms.  I was taught in vet school to use sterile sleeves and gloves over my surgically scrubbed skin, but the sleeves are loose fitting and extremely awkward.  I was also taught that in surgery it is imperative to minimize the impact of the three T’s – time, trash and trauma.  The gloves may have been cleaner, but for this particular procedure they increased the time and trauma factors considerably by reducing manual dexterity.  Plus, as my boss explained to me once, my scrubbed skin is every bit as clean as the cow’s scrubbed skin, and we can’t avoid contact with that!  So, on that brisk February afternoon I stripped down to my undershirt and scrubbed from the tips of my fingers to my shoulders.

Once scrubbed up, I opened up my surgery pack and asked for my scalpel blade.  I fitted it onto my scalpel handle and created a 14” incision through the skin in the left paralumbar fossa, it separately cleanly and neatly beneath the pressure of my blade.  I finished my approach into the abdomen with a combination of blunt and sharp dissection through the multiple layers of abdominal muscles and finally, the peritoneum.  I returned my scalpel to the surgery pack and reached deep into the cow’s abdomen with both arms.   By feel I navigated my way around until I located the calf’s hind leg through the wall of the uterus.   I cupped one hand around the hock and one hand on the hoof and gently but firmly guided the uterus with its unborn payload toward my incision.  With a little maneuvering I was able to bring the calf”s rear leg – still inside the uterus – just outside the opening of the incision.  I asked my assistant to scrub up and help out.  I showed her how to hold the uterus in place by holding onto the calf’s hock and fetlock.   Up until this point our patient had not so much as lifted a foot.  And, to this day, I’ll never know what triggered what happened next, but as soon as I handed off the uterus to my assistant, our patient leap sideways away from where we were standing.  In a flash the uterus disappeared back into the abdomen.  In it’s place out came the caudal compartment of the rumen.  I rushed over and cradled the dangling blob, about the size of small beach ball, in my arms trying to keep anymore of the organ and/or it’s contents from coming out.  The cow had slowed her dancing down considerably, but she was still moving back and forth.  I tried my best to keep time with her rhythm as I held her stomach in my arms like a trash bag full of water.  The farmer, witnessing our predicament, stepped up from where he was watching at a safe distance and put a hand on the cow’s hip to try to quiet her down.

A cow’s rumen is the largest compartment of their four-chambered stomach.  It is the fermentation vat.  In a large cow it can easily hold 30-40 gallons.  I wanted to get what was hanging out back inside as quickly as possible!  Trying to remain calm, I asked my assistant to go back to the truck and draw up another dose of sedative for our patient.  She scurried off and returned a minute later with a syringe in hand.  I didn’t usually rely on her to give injections to my large animal patients, but she had plenty of experience giving injections to dogs and cats.  I couldn’t let go of the stomach to give it myself, so as she approached I nodded my head and asked her to give the injection in the hip muscle.  I also suggested she come stand close to me and not directly behind the cow.   There are a few things to always keep in mind when giving injections to cows.  They have been prey animals for millions of years.  Their eyes are set in the side of their head to allow them to see everything going on around them in all directions.   And, despite their relaxed appearance and reputation for pastoral behavior, cows have lightning fast reflexes and amazing range of motion with their hind feet.  Not only can they kick straight back, they can also lift their hind foot and kick impressively high to the side.  For these reasons there are places you should and shouldn’t stand when giving a cow an injection in the hip.   Unfortunately, I had the prime real estate occupied as I cradled her rumen in my arms, desperately trying to keep anymore of it from coming out.  From her position beside me she reached over and poked the needle into the muscle of the cow’s hip.  Instantly, as soon the needle touched her hide, the cow fired off a vicious round house kick with her left hind foot that brushed me and caught my assistant squarely in the lower quadrant of her abdomen.  I heard the sickening thud as the hoof drove her back three or four steps.  I saw her double over as she struggled to regain her balance.  I briefly thought about the possible internal injuries she may have sustained, but my thoughts were interrupted before they could form by the cows continued rampage.  Like a boxer throwing jabs at his opponent, my patient immediately fired off a second shot with her opposite hind foot aimed at the farmer standing on the other side from us.  He had stepped into range earlier in order to help steady her as she danced from side to side.   The glancing blow combined with his attempts to dodge the kick caused him to loose his balance and fall to the ground beside her back feet.  The cow bellowed and stomped and jumped like a bucking bronco pulling against her halter rope.  I could see her hind feet landing beside the farmer’s spindly legs as he scrambled to back up out of range like a crab skittering across the beach.  I was certain she must have stepped on him at least once if not several times.  My assistant recovered enough to run over and help the elderly farmer to his feet.  I gave up on trying to hold the rumen and rushed over to help them both.

The farmer was wobbly on his feet, but we managed to walk him over to his truck.  His jeans and denim jacket had large spots of mud and cow manure all over them.   I asked him where it hurt, and he just grunted that he was ok.  I tried not to panic as I mentally assessed the situation.  I felt like we should take them both to the hospital to get them checked out, but the nearest hospital was at least 45 minutes away.  I wondered if I should just euthanize the cow and focus on caring for the human casualties.  However, both victims assured me they were ok.  The farmer asked if we would please do what we could to save his cow and calf.  My assistant was standing upright again with a perfect hoof print on the front of her jeans.  She laughed that it sounded worse than it was.  I didn’t really believe her.

Our bovine patient was standing rather calmly now at the end of her halter rope, looking rather inebriated still from her original sedative.  At least half of her rumen was hanging out of her side by this point dangling like a stretched out water balloon just inches away from the ground.  Periodically she would lift her foot and kick clumsily at the unusual structure swinging from her side making it jiggle like a huge pink udder.

I questioned the farmer about the extent of his injuries.  He assured me that she had just grazed him with her feet as she was stomping around on top of him in the straw.  I thought to myself how fortunate he was to have such skinny legs, they must have been a pretty elusive target for the cow!  He assured me that he did not need to go to the emergency room, and he implored us to try and save his cow and calf.  I left him sitting in the cab of his pickup and turned my attention back to the cow.  She was standing quietly now, but I wasted no time administering the second dose of sedation.  I scrubbed my hands and arms again and washed the rumen as thoroughly as possible with tap water from the hose supplying the water trough.  However, so much of the rumen was hanging out now that no matter how hard I struggled, I couldn’t get it to go back into the incision.  In desperation, I made a small incision in the rumen and dumped about half of the contents of the portion that was hanging out onto the ground at my feet.  The footing beside the cow was already pretty poor from the mud we created with our wash water and all of our stomping around.  Adding several gallons of putrid slurry from inside her rumen to the mix made the footing even more treacherous.  I did a double layer closure on the rumenotomy and lavaged the visible portion of the organ with several more gallons of water.  This time I was able to coax the unwieldy organ back into the incision.  I breathed a brief sigh of relief.  However, at that point, my heavily sedated and no doubt exhausted patient decided it was time to lie down.  I cursed quietly under my breath.  As she settled down into her sternal position, I leaned against her and struggled in the slick goo to gain a little traction, hoping to push her over onto her right side to avoid contaminating my incision.  Miraculously, she ended up with her legs in the correct position for me to finish rolling her onto her right side by grabbing her right rear leg and pulling it under her body.

I paused to catch my breath.  I noticed at this point that it was dark outside now.  The farmer had trained the headlights from his truck in our direction – makeshift surgical lights. I wondered to myself how long it had been dark.  I had long since given up on the possibility of getting home in time to make supper for Leigh.  I sighed in resignation over the reality that our evening together that we had planned wasn’t going to happen like we envisioned.  I knew she would understand, but my irregular, unpredictable schedule was difficult for us both.  I also wondered to myself if my back would tolerate having to perform the rest of this surgery bent over my now prostrate patient.  I scrubbed my hands and arms – again – and resumed the surgery.  I felt the tension in my lower back as I bent over the incision wrestling once again with the pregnant uterus.  It was a vivid and uncomfortable reminder of why I always tried to avoid having to do abdominal surgery on cows with them lying down.  I chuckled as an obvious thought just occurred to me.   I ALWAYS tried to avoid EVERYTHING that had gone wrong that night!  The fact that my patient was lying down was a pretty minor issue in the scheme of things.  I shook my head and silenced my thoughts, focusing again on manipulating the pregnant uterus.

This time as I pulled it up into the incision my patient offered no resistance.  My assistant held the uterus in place my holding onto the calf’s hind leg like I showed her before.  I incised and reached in and pulled out a huge bull calf!  He weighed every bit of 110 pounds and looked as if he was already two weeks old!  I held him head down for a second by wrapping my arms around his mid-section and letting his front end dangle.  Thick, mucousy secretions drained from his nose and mouth. I handed him off to my assistant for her to finish drying him off and stimulating him to breathe.  I turned my attention to the tedious task of closing the gigantic incisions I had created in the cow’s uterus and body wall.  I used heavy #1 chromic gut to close the uterus with a double layer inverting pattern before rinsing it clean and replacing it in the abdomen.  The muscles of the abdomen are under much greater strain than the wall of the uterus.  To close them I used #3 chromic gut – practically a climbing rope in the world of absorbable suture!  I laced the severed muscles together with a simple continuous pattern, then closed the skin with an equally heavy non-absorbable synthetic suture in a continuous interlocking pattern.  The neat appearance of the 14” long incision gave no indication of the chaos we experienced during its creation!  My back ached as I struggled to stand straight.

To this day I don’t know how long it takes me to sew up after a C-section.  I just get lost in the task and tune out everything around me.  I knew that we had arrived on the farm about 5:15 that night.  I dried my hands and dug my watch out of my pocket.  It was 9 pm.  So much for a Valentine’s dinner, I thought to myself.  I knew Leigh would understand, growing up on a pig farm that morphed over the years into a dairy, she knew farm emergencies were never planned or convenient.  I resolved to make up our lost evening as soon as possible.

I gathered my supplied and began the process of washing and repacking all that we had used into the truck.  Our bull calf was starting to make his first wobbly attempts at standing.  Momma cow was worn out, but she was sitting up sternal.  I worried that with the length of time we had her abdomen open and the potential contamination from the rumenotomy and c-section that she might develop peritonitis.  Fortunately, cows are remarkably adept at walling off infection.  Thus, they make very forgiving patients for surgery in the field! Nonetheless, I gave her high doses of antibiotics to help guard against infection and some anti-inflammatory for pain.  I gave the farmer a few follow up doses to administer over the next couple days.

I finished washing and packing our supplies.  We said our goodbyes and piled in the truck.  I made a mental note to call and check on everybody the next day.   Mentally and physically exhausted, I headed for home, stopping by the clinic just long enough to drop off my assistant.

Our little farmhouse in Greensboro, GA was set up perfectly for a large animal vet.  The washer and drier were on the back porch right next to where I parked the truck.  I could walk in, take off all my filthy clothes and throw them right into washing machine before entering the living quarters.  That’s exactly what I did that night.  It was already 10 pm and my son had been asleep since 8:30.  Leigh was standing at the stove when I stepped into the kitchen.  She had prepared our Valentine’s dinner by herself and it smelled amazing!   I apologized for being so late and for ruining our plans.  I offered her a hug, but she politely declined, wrinkling her nose at the lingering odor of manure, mud and amniotic fluid.  She suggested that I head to the shower while she finished setting the table.  I happily obliged, stealing a little peck on her cheek – despite her half-hearted objections – as I turned to head for the bathroom.

The Valentine’s dinner that I imagined didn’t turn out quite like I had planned, but, thanks to Leigh, it was wonderful nonetheless.  As we enjoyed our meal, I filled her in on the events of the evening.  I felt the tension begin to melt away as we talked.  It’s amazing how a full belly and a glass of wine can alter your perspective.  Mostly, I was just glad to be home with my wife on Valentine’s Day celebrating like normal people – almost!

P.S. – When I called the next day to check on our patients, the farmer was out feeding all the cows.  His wife said he was a little slow to get out of bed, but otherwise just bruised.  Our mama cow finally got up during the night and little bull calf was enjoying his newly found freedom outside the womb!

So it was for Jasper’s family when he came to live in their household.  An 8 week old, energetic little yellow Lab full of spunk and wiggle and kisses for anyone willing to pick him up and hold him close.  I met him a week later when the Scott family brought him to my office for his first puppy visit.  He pranced through the door sporting a brand new John Deere leash and collar ensemble, supremely confident that everyone inside must have come specifically to play with him!  He made his way around the room introducing himself to staff and clients alike, seeming to delight in the opportunity to collect as many pats and hugs and ooh’s and aahh’s as possible.

When it was his turn to come back to the exam room his whole body wagged with anticipation as I reached down to pick him up.  He clambered up my chest and onto my shoulder with his front feet, and I dodged his repeated attempts to lick me on the face and head.  I hugged on him for a few minutes, enjoying the unbridled enthusiasm and the pleasant smell of puppy breath!  Needing to stay on schedule as much as possible, I peeled him off my shoulder and handed him to my assistant.  She would attempt to hold him somewhat still while I examined him from head to toe, feeling, listening, smelling him until I was convinced I had examined him thoroughly.  His family looked on with proud smiles and anxious anticipation of a good report from the doctor!

Jasper passed his physical exam with flying colors.  He seemed to be the picture of health.  I updated his immunizations.  We treated him for internal and external parasites.  We discussed nutrition, heartworm prevention, potty training and all the normal stuff we try to talk to new puppy parents about on their first visit.  Jasper was as rambunctious as ever and by this point he was bored with this vet visit stuff.  The Scott’s gathered up their paperwork and headed up to the front desk to check out.  The whole process was complicated slightly by the impatient puppy tugging on the end of the leash and hopping around as Ms. Scott attempted to retrieve her wallet from her purse and locate her debit card!  Eventually they got checked out and on their way.  We watched them all get into the car and drive away with smiles on their faces.  It never ceases to amaze me how even with all the sleepless nights, potty accidents, chewed up belongings and other headaches associated with owning a new puppy, the joy and love that they bring into a home with their infectious good nature and never ending supply of welcome home greetings somehow makes it all worthwhile.

I saw Jasper back for more immunizations a few weeks later and I was pleased to see that everything was going exceptionally well.  He looked great on physical exam.  His growth was appropriate.  He was fully assimilated into the family now.  Everyone was sleeping through the night.  The potty training was coming along faster than expected, and everyone – human and canine – seemed to be doing great.

However, when he was around 6 months old the situation began to change drastically.  At first the Scott’s really didn’t think much of it.  They figured it was probably normal – maybe just a phase of development.  Each week, though, it seemed to get worse.  Jasper was scratching himself constantly!  He could hardly take two steps now without stopping to scratch or bite.  His once thick, full hair coat became thin and sparse.  Bald spots started showing up on his chest and legs.   He shook his head frequently and pawed at his ears with his back feet.  Eventually the bald spots developed scabs and scaly lesions that looked angry and painful.  The Scott’s were at their wits end.  They had done everything they knew to do.  They treated him for fleas.  They dipped him with some dip they bought at the pet store that said it cured mange.  The added oil to his food and even tried giving him benadryl on the advise of a neighbor whose dog was prone to spells of itching.  Nothing seemed to help.  They called and scheduled and appointment to bring him in.

When I saw him in the exam it was hard for me to believe he was the same dog I had seen a few months earlier.   He had grown considerably and lost some of that “puppy” look, but mostly I was struck by the appearance of his skin and hair.  His once luxurious blonde coat looked moth-eaten.  His skin was bright pink and he felt greasy to the touch.  There were scabby sores randomly scattered all over his body.  His ears were red and swollen and filled with stinky yellow goo.  When I would touch him his skin would crawl and he would scratch with a hind foot at an imaginary spot in the air. He looked pitiful!  I thought to myself, he looks like a smelly version of the Velveteen Rabbit after all his fuzz was worn off !

Despite the appearance of his skin he seemed to feel fine otherwise.  His body never stopped wagging.  As I ran my fingers over his inflamed skin he licked me on the forehead and whacked me with his tail.  He was eager to flop over on his side for a belly rub so I could inspect the condition of his underside.  Despite his skin condition, he was still a happy-go-lucky Labrador Retriever with limitless energy and an insatiable appetite for attention.  This time, though, the Scott family watched with furrowed brows and anxious anticipation for what I was going to say about Jasper’s skin.  We didn’t know it at the time, but this day would mark the beginning of a long and difficult saga for Jasper and the Scott family.

Itchy dogs and cats are one of the most common presenting complaints we encounter in private practice.  Unfortunately, it’s a relatively non-specific sign. There are probably a dozen reasons or more why pets get itchy skin.  External parasites like fleas, ticks and mites are a common cause of itchy skin, as are fungal skin infections like ringworm and chemical irritants that might be present in plant resins or certain shampoos.  Biting flies and mosquitoes can make dogs itchy, as well as less common autoimmune diseases like pemphigus or lupus.  However, one of the most common reasons for dogs and cats to present with itchy skin in the southeast is allergies.

Allergies are a type of hypersensitivity reaction to small substances in our environment that are not usually harmful.  In individuals that are prone to allergies contact with these substances activates the immune system and triggers an inflammatory cascade.  Any substance that elicits an allergic response is called an allergen.  For humans the word allergy conjures up images of people with runny eyes, sneezing, snuffy nose and congestion.  However, the allergic response in canines and felines differs from that of humans to some degree.  Whereas most allergic humans manifest their allergies in the respiratory tract, dogs and cats primarily manifest their allergies through their skin.  Thus, instead of getting runny eyes and a stuffy nose, (although this can happen) dogs and cats tend to get red, itchy skin.   The ears and feet seem to be especially sensitive to allergic skin disease.  Recurrent ear infections and/or feet chewing may be the only signs of allergies we see in some patients.

When I am discussing allergies with my clients in the exam room I find it helpful to break the major sources of allergens down into three categories – flea, food and environmental.  Most allergic patients have contributions from at least two of the three categories.  Some patients may have contributions from all three categories.  This occurs because patients that have allergies are genetically predisposed to allergies and they are never allergic to just one thing.  Normally, the clinical signs that we see in an allergic patient are the result of contributions from a handful of different allergens.  In our quest for a solution to the problem our goal is not to systematically address every single allergen, but to somehow identify the main contributing allergens.  If we can address the top few allergens we normally see a stepwise reduction in the severity of the skin problem.  Some patients may appear to be “cured” at this point whereas others may just be improved.

Usually, the first category we discuss is food allergens.  The most common offending ingredients for dogs are beef, wheat gluten and dairy, but there are other ingredients that may be problematic for certain patients.  Patients suffering from food allergy are often some of the itchiest.  They may also have intermittent GI upset as part of the history as well.  Patients with food allergies will often become symptomatic at an earlier age than those suffering from other types of allergies.  The signs and symptoms are usually less seasonal.  Food allergy patients don’t respond to medication to manage the itching as well as patients with allergies to other things.  In many cases patients with food allergies have recurrent ear infections and/or an itchy, swollen anus.  Veterinary dermatologists have a saying – ears and rears in combination is food allergy until proven otherwise!  There are no reliable tests for specific food allergens so our approach to diagnosing food allergy is to select a hypoallergenic food and feed only approved ingredients for 8-10 weeks.  Normally at this point we are trying to get secondary bacterial and yeast infections under control as well.  The hope is that once the secondary infections are cleared up and enough time as elapsed on the hypoallergenic diet for the allergic response to quiet down, that the signs will not return.

The second main category of allergen we discuss is flea saliva.  Any pet that is allergic to anything will be allergic to flea saliva.  It is one of the most reactive allergens our pets encounter.  Many times I have pet owners tell me in the exam room that fleas can’t be making their pet itch because they only see an occasional flea.  In response to that statement I usually remind them that people that are allergic to bees don’t have to be stung by the whole hive to have a reaction.  Recurrent exposure to even small amounts of flea saliva can be enough to keep an allergic pet itchy all summer long.  Dogs with flea allergy tend to have a very characteristic pattern of hair loss and skin lesions.  The worst areas tend to be around the base of the tail and down the backs of the thighs.  The scabs and hair loss will often be noticeable further up the middle of their back as well.  If I see this pattern on an itchy patient I’m immediately considering flea saliva as a possible contributing factor even if I don’t see any live fleas on the pet.  One other factoid to keep in mind with flea allergy is that flea allergic dogs will be itchy for up to two weeks after the last flea is gone if the itching is not addressed with medication.   This causes many pet owners to question if fleas are really an issue because they expect the itching to stop within a few days of applying flea medication.  When, in fact, they may just need to keep applying monthly flea products and be patient.

I mention these two categories first because in formulating a treatment plan for an allergic pet, which I will touch on shortly, these categories are the easiest to address.  There are good topical and oral medications for fleas as well as good limited ingredient diets available over the counter for dogs now.  However, if addressing these two major categories doesn’t solve our problem we have to consider the third main category – environmental allergens.

Environmental allergens are small particles present in nature that are either breathed in or in contact with an animals skin.   This includes every type of weed, grass and tree pollen, every variety of mold spore, cat dander, dust mites, mold mites and storage mites.  Anything that a human could be allergic to in the spring, a dog or cat can be allergic to as well. This variety of allergy is called atopy.  Atopy is a collective medical term for reaction to any of these environmental allergens.  You will often see the word used in the context of an atopic patient or atopic dermatitis.  That’s just dermatology lingo for an animal that has significant environmental allergens or a skin condition due to environmental allergens.  Differentiating atopy from food or flea allergy is necessary because, through skin testing or serologic allergy testing, it is possible to determine which of these environmental allergens a patient reacts to.  If specific allergens can be identified then extracts of those allergens can be prepared for immunologic allergy therapy.  How immunotherapy works is beyond the scope of this blog.  But, the basic idea is that allergens are injected into a patient to hyposensitize (make them less reactive) them to those allergens.  Seventy percent of patients with atopy undergoing immunotherapy are significantly improved after a few months of therapy.

As I mentioned earlier, there are normally other secondary lesions present in a allergic patient that have to be addressed before we can expect significant improvement.  Most patients with allergic dermatitis regardless of the underlying cause have significant skin infections – either bacteria and/or yeast.  Getting these secondary issues under control requires managing the itch AND eliminating the infection.  Usually a combination of oral and topical therapy is necessary for a minimum of three weeks.  If the under lying allergen can be identified and eliminated then there is a good chance the skin condition will not return.  However, if it can’t then this will likely be a recurrent problem!

One of the main concepts I try to convey to my clients with allergic pets is the fact that we cannot cure allergies.  We manage allergies.  Managing allergies requires diligence and commitment and a genuine desire to help a pet improve.  I also tell my clients that problems associated with allergies vary greatly in severity.  There is an entire spectrum of allergic patients from those that only need good flea products, to those that require regular immunotherapy.  Each pet is different and we need to let our response rise to the level of the problem.  If your allergic pet just needs a round of corticosteroids and antibiotics twice a year to keep them comfortable then we probably shouldn’t consider food trials, allergy testing or other daily medication.  However, if your allergic pet gets itchy and uncomfortable as soon the meds start to run out, then we need to consider taking additional measures to address the underlying allergies.

What do I mean by addressing the underlying allergies?  Typically there is a progression that I go through with an allergic patient in trying to determine exactly what our treatment plan should include.  I usually start by trying to eliminate the easiest two of the three major categories of allergens that we discussed previously.  That means our first order of business is religious flea control!  You remember when we were talking about flea allergies I stressed that any pet that is allergic to anything will be allergic to flea saliva.  No matter what lengths we go to to manage allergies, if the allergic patient has fleas it will be a waste of time.   My favorite products for controlling fleas in the allergic patient are spinosad (Comfortis/Tifexxis for dogs or Assurity for cats) or imidocloprid (Advantage, Advantix, Advantage multi).  Both of these products work well when used regularly.  There are other products that work well like Vectra and Frontline.  Sometimes it just takes a few months of regular administration to determine which product is going to suit your particular situation best.  It is possible to treat fleas in the environment as well.  That can dramatically reduce the overall flea population.  If you choose to do an area treatment be certain to choose a product with an insect growth regulator. Insecticides that only kill adult fleas don’t really impact the population very much when applied to the environment.  Remember, most allergic patients have multiple allergens contributing to their condition, however, just eliminating fleas is often enough to move a patient from the poorly controlled category to the well controlled category.

The second order of business for a severely allergic pet is to eliminate any contribution from food allergy – even if the condition is seasonal.  Remember, our signs – itching, inflammation, etc – are the culmination of all the allergens present in the environment at any one time.  If food allergens are a smoldering, relatively small source of allergen exposure, they may not be causing severe signs in the winter when environmental allergens and fleas are scarce.  However, when spring arrives the contribution of environmental allergens may cause a patient to cross the “allergic threshold” and begin to become symptomatic.  If we can eliminate the contribution from dietary allergens we can reduce the allergic “burden” on the pet and we may see a reduction in the severity of the condition.  Eliminating dietary allergens requires feeding either a limited ingredient diet or a prescription, hydrolyzed diet like Purina HA or Hill’s Z/D.   The most common reactive ingredients for dogs are beef, wheat gluten and dairy.  Other ingredients can cause reaction in certain pets.  There is no way to know for sure.  The least reactive protein sources are duck, venison, rabbit and fish – usually in that order.  Good carbohydrate sources are potato, sweet potato and rice.  Hydrolyzed diets seem a little hocus-pocus at first glance, but it is technology borrowed from the infant formula industry.  The protein sources are cleaved with enzymes in the production process so theoretically the molecules are too small to trigger the allergic response.  My clients sometimes find that confusing because the ingredient label doesn’t look very hypoallergenic, but it works.  It is critically important when conducting a diet trial that all other sources of dietary allergens are eliminated.  This means using only approved treats and giving only approved snacks from the table!  It can take up to 10 weeks to really evaluate the effects of a low allergen diet for some patients.   I’ll just mention that with some allergic pets we end up discovering that they can’t eat dry dog food.  It may be due to storage mite allergies.  We don’t usually know for sure, but in these patients the best alternative is a canned or home cooked diet.  Cooking for your pet can be a good, lower cost alternative for managing the diet.  There are great cookbooks available with recipes for different types of food.  Many of the less common meats can be ordered on-line or located at specialty grocers.  Most of my clients who cook for their pets fix a big batch once or twice a week then refrigerate individual meals in Ziploc bags until it is fed.

My other recommendation for all allergic pets doesn’t specifically target food or fleas. However, weekly medicated baths are an an effective way to help with atopy and recurrent skin infections.    Allergists used to believe that atopy was strictly an issue of inhaled allergens.  More recent evidence points to the possibility that many of these environmental allergens may be surface active.  That is, direct contact with skin may also result in triggering the allergic response.  These allergens build up over time in the hair.  Washing regularly with a medicated shampoo removes the allergens and it also helps keep the yeast and bacterial populations on the skin in check.  Using a hydrocortisone leave on conditioner after baths is an additional step that is often very effective at controlling the itch.  There are other steps we can take to help manage allergies such as using antihistamines daily. Antihistamines don’t work very well for dog allergies if we wait until they are already itchy.  That is partly because of the pharmacology of the drug and partly because histamines seem to be a minor player in dog allergies.  Supplementing the diet with omega fatty acids can be beneficial, as well as installing HEPA filters in the HVAC within the home.

If these steps are taken and a pet is still poorly controlled, then it is time to talk to your vet about allergy testing and immunotherapy or regular administration of cyclosporine orally.

As you can image, determining how to manage a patient with allergic dermatitis can take several visits and involve considerable cost.  It is often very frustrating for a pet owner when signs keep returning regardless of what we do.  In Jasper’s case, his owner’s were very persistent and determined.  We did skin scrapes to check for mites and we didn’t find any.  We treated empirically for a type of contagious mite that is commonly found in dogs, but is hard to find on skin scrapings.  We tried different prescription diets.  When he was taking prednisone and antibiotics he was moderately well controlled, but lifelong prednisone administration is fraught with serious risk and complication.  Almost every allergic pet will require short courses of prednisone or similar medication to control their itching, but it is not a good long-term maintenance strategy.

When our efforts didn’t result in satisfactory results for Jasper, I convinced Jasper’s owners to take him to see a veterinary dermatologist.  They weren’t happy with the plan that came out of that visit.  They ended up back in my office even more frustrated and no closer to a solution.  We decided to refer Jasper to the University of Georgia College of Veterinary Medicine.  There they developed a plan that managed his skin fairly well.  For the first time in his adult life Jasper had a full coat of hair again and smooth, white skin.  But, it came at a considerable cost.  He was taking cyclosporine, an immunosuppressive drug used commonly in human medicine for recipients of organ transplants to prevent their body from rejecting the transplanted tissue.  He was receiving immunotherapy for a long list of allergens that he had reacted to in his allergy testing.  He was on a strict hypoallergenic diet.  And, he still had to take a low dose of methylprednisone every other day to control his itching in the summer time.  As often happens with cases like his that are extremely labor intensive and incurable, fatigue sets in after a while – emotional, financial and physical.  The family gradually stopped coming back for their scheduled recheck visits, and eventually we lost contact with them.

I still think about Jasper from time to time. I hope his skin is fairly comfortable. I get occasional second-hand updates on him from neighbors or friends if they happen to be in the office.  It makes me sad that as a profession we don’t have better tools to manage his disease.

Cases like his stretch the limits of the human-animal bond.  Jasper is fortunate to have a family with the determination and the financial means to continue dealing with his skin.  Many animals are not so fortunate and either end up being humanely euthanized because of their terrible skin problems or just living a miserable, itchy existence.  Fortunately, dogs with allergies as severe as Jasper’s are relatively rare.  Nonetheless, if you are considering getting a puppy, it pays to do your homework.  Allergies are largely hereditary.  Ask the breeder if either of the puppies parents have recurrent skin problems or have to be fed a special diet.  Being selective and diligent in your search for your next four-legged family member, no matter how cute and cuddly they might be, can help insure a long, happy itch-free relationship!

Allergies are a menace to humans and pets alike!  If you think your pet may suffer from allergies, talk to you veterinarian.  He or she is you best source for good information and guidance.

I was the first associate ever hired at Durham Veterinary Clinic since it was founded in the 1940’s by Dr. C.J. Durham.  His grandson, Dr. Rob Durham, hired me to help shoulder the burden of the increasing workload in the growing practice as his father, Dr. Bobby Durham, eased gradually into retirement.  I was welcomed into the family with open arms and treated like one of the clan.  They knew better than I did how much I still had to learn, but I was overflowing with ambition, enthusiasm and unwarranted confidence.  I had no idea at the time how significant and formative my time with them over the next six years would be.  Nor did I have any appreciation for how thankful I would become for their tutelage and patience with me as I began the painful process of learning a difficult craft.  I was just ready to get started.  My head was stuffed with information for which I was convinced the animal owning public in Greene and surrounding counties was desperate!  With great zeal, I plunged into my new life as country vet!

Durham Veterinary Clinic is located in Greensboro, Georgia, a quaint little town of 3200 people about 45 minutes south of Athens.   It is the county seat of Greene County, which along with Putnam and Morgan counties, once was the major milk producing region in the state.  In 1997, dairy farms still dotted the countryside in every direction and on most county roads there were more hayfields than houses.  The farm families that we served, be it dairy, beef or horses, were some of the most hard working, pleasant, genuine people I have ever had the pleasure of meeting and I miss them to this day.  Going out to their farms and homes to care for their livestock gave me a unique opportunity to interact with them in their element and to experience their world in their normal surroundings.  I became a part of their normal routine and they became a part of mine.  As a young man just entering the workforce and learning a new trade, they were as gracious and forgiving with me as the Durham family.  I owe those clients who endured my early years of practice a tremendous debt of gratitude!

Each farm where we worked was a unique creation with it’s own character that reflected that of the family that lived and worked there.  A farm is always a work in progress and most of the small family operations that we worked on spanned several generations.  The mixture of old and new equipment and buildings from each successive era in the history of the farm told the story of the family that poured their effort, money, worry and time into building and maintaining the enterprise, much like layers of artifacts in an archeological excavation tell the story of the ancient people that lived there.  A keen observer could get a pretty thorough introduction to a farm family just by taking a good look around.

The working conditions on the farms varied as much as the farms and farmers themselves.  Not all our clients could afford the most modern animal handling facilities.  But, all of our clients understood our needs and worked diligently to help us contain their cows and horses so we could care for them.  We prided ourselves on our resourcefulness in adapting to almost any situation or set-up in order to get our job done.

I’m sure some of that must have been going through Dr. Bobby’s mind when he answered the phone at the clinic about 5:30 one evening.  It was a client we hadn’t done any work for in quite some time.  The number of animals around his place had gradually dwindled and his needs for our services decreased proportionally.  This particular evening, however, he had a horse that had snagged the skin on his cheek on a nail in the barn.  Ever since humans first introduced horses to fencing they have been good at getting cut.   He was probably trying to stick his muzzle into a tight space between the boards in the old barn to get to some hay that was stored inside.  Maybe something startled him or possibly one of his pasture mates wanted to try for a bite and shoved him aside.  In either case, he withdrew his head quickly and the nail caught and peeled a significant section of skin back on the side of his cheek.  Farmers are accustomed to livestock getting injured.   Had this particular wound not been so gruesome he may have elected to just manage it himself with some antibiotic ointment and “tincture of time,” but this wound looked like it needed more than a few stitches.

Dr. Bobby listened intently to the farmer on the other end of the phone.  As he listened he thought back to the last time he remembered going to this particular farm.  It had to have been over a year ago.  He remembered clearly that the barn was old and in need of repairs back then.  He doubted any improvements had been made since.  It sat at the bottom of a hill and collected rainwater that ran off the hillside in the center aisle of the barn.  When the horses came in to get out of the rain their hooves became pistons in the wet clay and quickly created a sticky quagmire that could easily become ankle deep.  There was a single incandescent bulb that dangled from a wire in the center of the center aisle.  It had been an upgrade twenty years ago during a “remodeling” project.  When the bulb was new it cast soft light in a circle in the middle of the barn and threw long shadows into the stalls on either side of the aisle.  In that environment, though, it didn’t take long for the dust and spider webs and fly specks to accumulate on the bulb in a layer thick enough that the glow was diminished considerably.  If it was dark outside, it might provide enough light to find the feed buckets when it was feeding time, or to stack hay in the stalls after a long day in the field, but it wouldn’t suffice for suturing a wound.

It was late November and the sun was usually below the horizon by 6 pm.  Dr. Bobby glanced out the window at the grey sky and the puddles all over the ground.  It had rained considerably that day and he could imagine what the conditions in the barn would be like that evening.

After listening to the farmer and assessing the situation, Dr. Bobby told the farmer that Dr. Rob was already out on a call on that end of the county.  He asked him to hold the phone while he tried to raise Dr. Rob on the radio.

“Base to 102, base to 102, you copy?”

“This is 102. I copy.” Came the reply from Dr. Rob.

“Can you stop by the Lawson place on your way home and sew up a cut horse?” Dr. Bobby inquired.

“Sure thing.” Came the reply, just a hint of weariness in his voice.  Dr. Rob had already been on several farm calls that day and no doubt he was hoping he had finished up when the call about the horse came over the radio.

“I’m finishing up here at Tom Spiers’. I’ll be 45 minutes or so before I can get there.”

“10-4,” Dr. Bobby replied.  He picked up the phone.  “Rob says he’ll be at your place in an hour or so.  Why don’t you just go on and bring the horse up to the house where he can work on him?”

“Aah-ight” Mr. Lawson replied, “Gladly.”

Dr. Rob finished up the call he was on and packed his equipment away in his truck.  He waved to the Spiers family as he pulled around to leave.  Once on the main road he pointed the truck towards the Lawson place and settled in for the ride.  Even on the busiest days, the drive between farms was a welcome respite that gave us a chance to catch our breath and collect our thoughts.

The Lawson’s lived at the end of a long dirt driveway that was more like parallel ruts than a road.  The house had to be at least a hundred years old, white, lap sided exterior with a wide front porch and a smaller porch on the back that entered right into the kitchen.  Friends and family were accustomed to coming and going through the rear entrance so the front door got very little use.  A knock on the front door always meant a stranger had come calling.  That usually meant a sales person or a census worker.  Mr. Lawson didn’t have a lot of patience for strangers so rarely did they answer the front door.   Consequently, the parallel ruts continued past the front porch and beside the house where they fanned out into a grass-less hard packed delta in the rear of the house where everyone parked.

As Dr. Rob pulled in the driveway, he could see the lights on in the house through the front windows.  It had been dark for at least 30 minutes now.  The outside lights were on too, but he didn’t see anyone in the yard.  He thought to himself, they must have him around in the back yard.

He was pulling up along side the house when an odd shape in the kitchen window caught his eye.  He eased the truck forward a few more feet and craned his neck to get a better look at the figures visible through the kitchen window.   As he pulled even with the kitchen window his eyes widened with disbelief and a huge smile spread across his face.  In all his years of going on farm calls he had never in his life witnessed what he was seeing tonight.  There, plain as day, in the breakfast area of the old farmhouse, cut cheek and all – stood the horse!

Dr. Rob parked the truck behind the house and climbed out.  As he began to gather his surgical supplies and medication, Mr. Lawson poked his head out the back door and hollered, “We got him right up here for ya Rob.*  Just come on in when you get your stuff together!”

Dr. Rob acknowledged him with a head nod and replied, “I’ll be right there.”

He shook his head and chuckled to himself.  He was having a hard time believing that he was about to work on a horse inside a person’s home.  He couldn’t for the life of him figure out what possessed the farmer to bring the horse into his home to sew up this cut.  He carried his surgery box in one hand and his scrub bucket in the other as he made his way up the flight of old wooden steps to the back porch.  There wasn’t even a handrail.  He thought to himself as he ascended the creaky old stairs that he better make sure the farmer wasn’t planning on bringing the horse down these steps.  If he did there would likely to be a much more serious injury in the horse’s immediate future!

The family all greeted Dr. Rob cordially as he made his way into the kitchen.  The breakfast room table and chairs had been pushed to one side to make room for the over sized visitor.  The horse didn’t look the least bit concerned about his new surroundings.  He just stood there quietly with a gaping hole in his cheek.  He turned his head and ears slightly toward Dr. Rob as he entered the room and gave him a little nicker as if to say, “What took you so long?”

The Lawson family stood there in the kitchen and watched as Dr. Rob laid his supplies out on the kitchen counter.  He wasn’t accustomed to having such a nice work surface to spread out on.  Normally it would be a board or an upside down barrel, and there was never enough space to have everything right there at his fingertips.  This was pretty nice! He thought to himself.

“How have ya’ll been doing?  Been awhile since we’ve been out this way.” Dr. Rob inquired as he got his instruments out.

“Fine, thank you.  Appreciate you coming out this late to look after Shorty here.”

Nobody acted like the horse in the breakfast room seemed the least bit out of place.

“Glad to.” Dr. Rob replied as he continued to make ready for surgery.  “If you don’t mind me asking, I’m just curious.  What made you decide to bring Shorty here inside the house to work on him?”

“Well.”  Mr. Lawson glanced down and pushed his cap up slightly to scratch his head, “It seemed like an odd request but we figured Doc musta’ had a good reason.  When we called the clinic to see if ya’ll could come out he told us to have the horse up at the house when you got here!

Dr. Rob doubled over with laughter then struggled to compose himself before he made his clients feel bad about the miscommunication.  Rob knew exactly what his dad had meant when he said, “Have the horse up at the house.”  He meant have him near the house where there was good light – not in the house!

Wait till Dad hears about this! Rob thought to himself.  He’s never gonna believe it!

Rob smiled from ear to ear at the odd situation in which he found himself.  He was already carefully planning the retelling of this evenings adventure to everyone back at the clinic as he finished getting out his surgery gloves and suture.  He pulled up a barstool to sit on as he drew up his sedation then chuckled at the absurdity of having the luxury of a barstool to sit on!  He looked up at his patient to verify in his mind an approximate weight and as he looked him over an odd thought occurred to him.  “Just how much sedation do you give a horse so that he’ll stand still for surgery without falling into the china cabinet??”

*When all of our older clients used the title “Doc” they either meant Dr. Bobby or Dr. Bobby’s dad, C.J. Durham.  If they didn’t clarify, you had to infer from the timeframe of the story to know which they were referring to.  They all had seen Rob grow up from the time he was a baby so they couldn’t quite bring themselves to call him “Doc”.  They just called him Rob.

My wife, Leigh, and I extracted ourselves from work for two days earlier this week. My wonderful mother-in-law agreed to put aside all of her obligations for a few days so that she could come up and care for our boys, and we went to sit by the seashore. And, sit we did! We basked in the sun. We absorbed the beauty of the salt marsh and savored the healing power of the ocean. We held hands as we walked along the beach like a couple of school kids without a care in the world. We talked about our lives – past, present and future. We sat next to one another as we read and we napped in the sun. It was a marvelous sabbatical from the strain of our busy daily schedules that tend to drain our energy and constantly pull us in different directions. It was a welcome opportunity to recharge and recuperate!

My wife is a youth minister, and I think all of us in the care giving professions experience a special kind of exhaustion in our lives and in our work. It creeps up on us while we are distracted with one crisis or another and engulfs us slowly like fog. We love what we do and we devote ourselves to our calling day after day, often sacrificing hobbies or personal time with family and friends in order to meet the needs of those entrusted to our care. We don’t even realize it is happening. We just start to feel dispassionate and tired. It’s not until we step out of our routine that the fog begins to lift and we realize how depleted we have become.

Veterinarians seem to be especially vulnerable to this form of sacrificial burn-out. A study published last March in the British Veterinary Record identified a disturbing trend among members of our profession. Their research indicates that the suicide rate for veterinarians in Britain is four times higher than the general population and twice as high as that of physicians. When I originally read the report of that study, it just made my heart hurt to think that so many members of our profession would feel so desperate and lost, presumably because of occupation-related stress, that they would consider taking their own life. It caused me to wonder what it is about our vocation that is different for us than for other care providers. There is no doubt that, like any other medical field, we face difficult, life-or-death, stressful situations almost every day. However, I do believe we contend with issues that are unique to the veterinary field that may explain why we would be at greater risk.

I think as a group, our natural skill set, our driven nature and the reality of our role within society put us at risk of attempting to live up to impossible expectations. Most veterinarians I know are genuinely caring, altruistic, thoughtful people who are exceptionally bright and insightful. In choosing our profession each of us consciously gave up considerable financial rewards in other fields in order to care for God’s creatures that can’t speak for themselves. Everyday we struggle to tease the secret sources of disease, pain and dysfunction from exquisitely complex and cryptic organisms that are incapable of providing us with a first hand account of how they feel or where they hurt. We employ all of our senses to observe their miraculous biological machinery in hopes of discovering the source of disease that robs them of their vitality and quality of life. But, even with all of the diagnostic tools available to us in general practice, biological organisms begrudgingly divulge their secrets and we see but a glimpse of the total picture. We peer into an immense biological factory through a peep-hole and do the best we can to draw accurate conclusions about what is functioning well and what is not.

Meanwhile, our concerned clients – the animal owners – are anxiously observing our efforts and trying to digest the volumes of information we heap upon them. We do our best to explain how the physical findings and laboratory results fit together. We walk them through our mental algorithm as we rule-in or rule-out potential diagnoses. We endure the glassy eyed stares and the furrowed brows – tell tale signs that worry has given way to confusion. We do our best to explain what our findings seem to indicate about the case without jumping to conclusions or overstating – always careful to mention the alternate possibilities that may be hard to prove. All the while we strain credulity in our efforts to come across as calm, confident and reassuring.

Then, as if that is not enough to deal with, inevitably around this point in a complicated case the issue of money has to be addressed. I sincerely believe this contributes more to our mental anguish than any other single case-related factor. The reality of our practice model is that we have to function as a business in order to provide care. As compassionate and caring as we may be, I, unfortunately, have to remind my staff repeatedly that if we are going to be of any use to anybody we’ve got to keep the doors open. We have no government assistance to lean on. We have a limited third party payment system that few clients take advantage of. Most of the medication, supplies and technology that we use in our practice costs the same, if not more, than it does on the human side. Yet, our average invoice is considerably less.

Entering into this discussion about money is difficult. Clients feel guilty for putting a price tag on the well being of their beloved pet as they try to decide which diagnostic and therapeutic plan makes the most sense for them in light of their personal finances and their pet’s condition. It requires great creativity and flexibility on the part of the veterinarian to develop a alternative plan for a client to consider when we recognize that the most desirable approach to a case may be priced out of reach. I often tell my clients they are paying for degrees of certainty and the likely-hood of a positive outcome. The outcome with a less expensive approach may eventually be the same, but the degree of certainty about the diagnosis is never as high and the positive outcome is less likely. As the advisors in the case and the gate keepers for the medicines and technology within our reach, we often feel some degree of guilt for having to withhold a useful test or treatment because of our clients inability to pay.

The other single most taxing factor we contend with in patient care is the fact that so often the veterinarian on a case bears the full weight of an uncertain outcome on his or her shoulders alone. For our counterparts in human medicine, they often have the benefit of sharing that burden. When a tough case is admitted to the hospital and there is uncertainty as to whether a patient will survive, legions of specialists swarm to the bedside and begin to divide up the master problem list. Kidney disease becomes the responsibility of the nephrologists, bone disease the orthopedist, brain disease the neurologist and all the mysteries of the case that are left over fall into the hands of the internists.

In our practice, when I am faced with a similar situation, I am elated when an owner has thousands of dollars of discretionary funds with which to pursue specialty care. I encourage them to accept a referral that means they will have access to the most advanced diagnostics and treatments for their pet. However, that doesn’t happen very often, which leaves me in a difficult situation. I offer to do what I can, with what resources I have, within the bounds of what the owner can afford, and I hope. And, I worry. And, I carry that burden home with me at night.

If our patients begin to show signs improvement it’s like choirs of angels singing overhead! Our spirits soar! Our clients praise our acumen and hug us like long lost children! However, when our patients don’t improve…when days go by and they refuse to eat, or the lab values continue to deteriorate, or the diarrhea just won’t stop, we feel the burden of their demise press in on us from all sides. It’s crushing, and although we recover to fight another day, it takes it’s toll.

In essence, we are a held to a high standard of care and expected to achieve desirable outcomes under very difficult circumstances within a society whose adoration for their pets continues to increase as their experiences with death and loss continue to decrease. We as a profession need to be mindful of this.

If you are reading this and you are not a veterinarian you may be wondering why I’m devoting so much time and energy to this topic. I guess it just happens to be on my mind as I sit here by the seashore with my wife, whom I adore, contemplating my life’s work and how I might better serve my clients and patients. To put it in writing helps me to organize my thoughts and thoroughly explore the issue. I’m also inclined to share this with you because I see understanding and trust as symbiotic forces within the veterinarian/client/patient relationship. The better we understand one another, the more we are able to trust and trust is what truly potentiates quality care.

If you are a veterinarian reading this, I hope it serves as a reminder that before we can care for anyone else we must care for ourselves. We want our clients to see us as somehow super-human, but we cannot live up to those expectations for long. In the words of one of my favorite authors, Rob Bell, if we are to truly thrive as human beings and as professionals we must kill “super-vet” before “super-vet” kills us. Take time for yourself. Enlist the resources of the veterinary community around you for support. Attend good continuing education seminars. Unplug from the practice machine from time to time and be in community with the people you love. Sit by the sea or on a mountain side or by trout stream or wherever you are inspired by the raw, unspoiled beauty of creation and let the cosmic power of nature seep back into your soul. Rediscover an appreciation for the complexity, intricacy and finite nature of life. And, emerge ready to rededicate yourself to your mission of caring for the speechless members of God’s animal kingdom.

I believe that our animals sustain us in vital ways and that in the process of learning to better care for our fellow non-human inhabitants of the earth, we have an opportunity to learn something about better caring for one another.  I also believe that examining and celebrating the human-animal bond gives us a window through which we can observe and appreciate how our lives can be enriched and fulfilled by the time we spend with our pets.  Thus, in weekly posts my goal will be to educate, entertain and inspire you to better care for the pets in your life by providing you with a glimpse into our world at Foothills Veterinary Hospital as we go about the business of caring for people by caring for pets.

Daniel C. Randall, DVM

Foothills Veterinary Hospital strives to provide comprehensive, proactive wellness plans, thorough medical diagnostics and therapeutics, and advanced surgical techniques.

We pledge to listen, educate, and offer what we feel to be an optimal care plan for your pet based on his/her stage of life and risk factors for disease.

• Including a thorough history and physical exam
• An assessment of possible genetic breed related abnormalities
• Blood analysis
• Urinalysis
• Survey and contrast radiography
• Non-invasive blood pressure measurement
• Electrocardiography
• Ultrasound

We are proud to serve our community in working closely with Speak for Animals, Kitten Action Team and Foothills Golden Retriever Rescue.

We’re proud to announce our affiliation with Pet Peace of Mind Program through Lutheran Hospice. Our purpose is to recognize and actively support keeping patients and pets together during their time in hospice care.

Our resource section is full of helpful articles, timelines, videos, and printable brochures all designed to help keep you informed about the care they’re need to live a long, healthy life.