Reading · Vet Vault 3-2-1

From Episode 230 ECC Feed, with Dr Ryan Smith

I don’t know about you guys in the rest of the world, but here, where I live on the east coast of Australia, there are several things that can look a lot like anaphylaxis in dogs. All of them can kill your patient, and yet the treatment for each is different and specific. So - trying to figure out which patient has anaphylaxis and just needs fluid (± the adrenaline - listen to this episode to find out why I say this), which one needs antivenom, and which one is just trying to die from shock is important, but challenging. Which is why I love every little bit of information that can help me make this decision, like this one:

Canine anaphylaxis patients will often have a high normal to increased PCV. We’re talking 60% to 70% or more.
This is because one of the mechanisms of action in canine anaphylaxis is increased permeability of blood vessel walls. In other words: the anaphylactic reaction punches holes in the microvasculature - fluid starts leaking out, resulting in haemoconcentration.

Definitely not diagnosis by itself, but every clue helps! Which reminds me of another conversation I had off-ai recently that gave me this little pearl:

Studies have shown that CRP does not go up in canine anaphylaxis versus your dog that is collapsed because of many other systemic illnesses. So: collapsed dog - CRP up = probably not anaphylaxis.

From Episode 234 Medicine Feed, with Dr Chris Sun

Osteosarcomas are painful - we know that. And I imagine that a big bulging tumour pushing on your organs, or a nasty sarcoma eating away at some part of your body, would hurt. But for many of the neoplastic conditions we treat every day in veterinary practice I’ve never really considered pain as something we had to deal with. Which is why I’m so glad I had this conversation with anaesthetist and pain expert Dr Chris Sun. Here are some concepts that were new to me:

Did you know that in human med pain is present in approximately 30-40% of people when cancer is diagnosed? This approaches 90% with advanced cancer and approximately 80% of patients with haematological cancers and no gross visible tumour report somatic pain.
Why? Well, we don’t really understand exactly why. It’s often not due to inflammation or due to direct pain receptor activation or neuropathic pain. Best guess is that it’s due to a fairly new pain mechanism called nociplastic pain - too complicated to cover in a blog post but really interesting.
This pain is often hard to detect in our veterinary patients, who can’t tell us that ‘something hurts’ in a vague and non-specific way. In the absence of classic pain signs, as veterinarians treating cancer patients, our best strategies are:
- Looking for altered behaviour: cessation of something that the patient used to do, or some new behaviour that wasn’t there before.
- Assume this pain and trial treat for it with careful monitoring of response to treatment.

Lots more detail, including potential treatment plans, in the full episode.

From Episode 229 Surgery Feed With Dr Bronwyn Fullagar

That dog that comes in with an intestinal foreign body definitely needs fluids. It’s probably been puking for two days, and on presentation it’s as dry as Perth in January. But by the time you take it to surgery, you have fixed its hypovolaemia and its dehydration. (Hopefully!) But here’s what happens: it stays on surgical rates during surgery, and then someone arbitrarily puts it on 1.5 times maintenance after surgery - kinda just because it was so sick the day before and because nobody bothers to think about its actual fluid status. And then, to quote Dr. Bronwyn: … two days later, the copy monster has been at work, and the treatment sheet is still reading the exact same thing as it did the day of pre-op, and all of a sudden your patient is fluid overloaded.

This is why you, as the surgeon who did the op, should care:

Fluid overload causes oedema in the intestinal tract, especially where there’s damage. Like at that incision that you so beautifully closed after taking out the offending foreign body.
Intestinal healing is a fussy process - it likes perfect apposition of the cut edges. It does NOT like oedema. So now, 2 days after surgery, thanks to that copy monster and all of those IV fluids, your beautiful incision dehisces, and your patient has peritonitis.

Also - less dramatically but very frustratingly…

One of the big contributors to gastrointestinal ileus is oedema of the GI tract.

In this session Dr Bron gives some sound advice on the things that you can do as a surgeon to prevent common complications of GI surgery - essential listening if you’re cutting into guts.

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2 Other Things
“I believe in kindness. Also in mischief. Also in singing, especially when singing is not necessarily prescribed.”
Mary Oliver
“Love is the quality of attention we pay to things.”
J. D. McClatchy

Before you read this - know that I realise that what is about to follow might just be the first clear signal - a declaration of sorts - that I am fully becoming a grumpy middle aged old git. One of those killjoys who criticise anything that ‘the youth of today’ are into. Perhaps it’s inevitable, like bad eyesight and grey hair. I may as well embrace it, so here’s my rant: Please, PLEASE don’t have your kid’s birthday party at Timezone!

Timezone, for the uninitiated and those from outside of Australia, is a games arcade franchise - marketed as a great place for a family to have fun. (It is not.) They also cater for kids’ parties for busy parents who don’t have time or can’t be bothered (I get it - I promise - I’m not judging you) to bake a cake and host a few chaotic games of pin-the-tail-on-the-donkey and pass the parcel at their own house. (Remember the days when there was only ONE prize in the pass-the-parcel parcel? If ‘the youth of today’ really does have lower levels of resilience then I suspect this might have something to do with it.)

And so it is that last weekend I spent my third Saturday this year trying to pretend that we’re having fun - like the families in the ads - to hide the fact that I’m a grumpy old git from my son, while secretly wishing I could be at the dentist getting a root canal.

From a business perspective you have to hand it these venues - it’s very efficient and very effective: Give us 40 bucks per kid - great - here’s your glass cage, I mean, your party venue, and there’s your table - yes - that one RIGHT next to the other table where those other parents are squashed in awkwardly, slowly suffocating on the combined coughs and flatulence of sixty 8-year-olds in a poorly ventilated confined space. OK, now each kid gets a card preloaded with credits - the credits are only valid for all the slightly shitty games - no, those cool games are not included. Now - go forth into the bedlam! Parents - good luck with dealing with the frustration and disappointment that will inevitably follow each game - that’s normal. But don’t worry, we’ll give the kids a ‘meal’, ie a 20 cent juice box and 7 crisps each afterwards - that’ll fix ‘em! OK, your 27 minutes are up - get out. But wait - there’s one more special treat - on your way out each kid has 400 ‘points’ to spend in the gift shop to get themselves a keepsake of this magical day. No - the 400 points doesn’t get you anything that your kid actually wants - you’ll need to stick to the tiny bits of plastic garbage that will end up in landfill before the end of the week - little packages of disappointment. (Yes, you can pay extra to get a slightly better bit of garbage if you can’t deal with your kid’s face - that stretchy sticky hand that will definitely be broken before bedtime tonight will be $12 thanks.)

Even the teenagers who work there seem slightly disgusted with the whole affair, although that might just be normal resting teenage-face.

“Hubert - sugary snacks, landfill fodder and awkward conversations with people you don’t really know is par for the course for kids’ parties. So why your specific hatred for this version of it?” I’m glad you asked:

I can’t get the image out of my head of those giant rotating industrial milking machines we saw on prac back at vet school, where the cows are marched onto the machine, locked in place and distracted with food, and then attached to those sucker tubes that extract every last drop of milk. Highly efficient, highly effective. Except here the machines are not attached to your nipples, and instead of milk they extract dollars.

Now, having dollars extracted for the sake of entertainment, especially for any activity aimed at children, is also not unique. But what really bothers me here is how perfectly engineered for manipulation this extraction system is:

Let’s target kids - poor self-regulation, easy to overstimulate, no restraint. Add lots of noise and bright lights and images of dinosaurs and zombies and princesses to completely hypnotise them. Then we’ll design each game to be a perfect dopamine dispenser: good enough to make you want to do it again, yet short enough and frustrating enough that you’re never quite satisfied, so you HAVE to do it again. Now let’s leverage another core human trait: greed. We’ll fill claw machines with desirable toys, and large moving glass shelves with all the lollies an 8-year-old could ever dream of. All you have to do is put in a bit of money and then you can ALMOST get that thing that you wanted but oh no it slipped! Try again. And that bag of Skittles is just-teetering-ontheedge-I’msureitwillfall…with…one…more…coin… ah, so close! Maybe just one more round?

It’s gambling for kids. A wank with a broken wrist. (Not entirely unpleasant, but also painful, and definitely not the real thing - in case you lack the imagination to make sense of my horrible metaphor.)

And of course the kids, who are meant to be there to celebrate their little friend as a group, scatter into their own little worlds, with very little human to human connection. At least ‘back in my day’, when we suffered through the trauma of one-prize pass-the-parcel, we suffered as a group and were bonded by that shared trauma. Except for the kid who actually got the prize at the end, who’d be ostracised by jealousy for the rest of the day.

I know, I know. I did warn you that it’s going to be a rant.

I think it bothers me so much because it is the physical manifestation of one of my favourite new words: enshittification.

Enshittification, if you haven’t come across the term yet, recently came into being to describe digital services that hook you with a good offer and then gradually become more and more, well - more shit. You know how you started paying for that subscription TV channel because you wanted more choice and no ads, and now, 3 years later, you’re suddenly seeing ads in the middle of your favourite show? But you’re kinda hooked on that show, so you keep paying, even though it makes you furious. That’s enshittification.

But I like the word so much that I’m taking it out of the digital world and into every day life to describe anything that is just good enough to stop you from walking away, just on the right side of the line so that you don’t actually have a legal case against them, OK enough that you don’t finally snap and lob a Molotov cocktail through their front window. So your only recourse is to leave a bad Google review, or write a sarcastic blog post in your newsletter.

I didn’t have any specific message in mind when I started writing this - I just wanted to get it off my chest. But of course, now I’ve started wondering - is there any enshittification in the vet profession?

Maybe. Definitely not as systematic and as well executed as this, but enough of a sniff of it that I feel like we should be on our guard for anything that makes our clients feel like that cow on the milking machine. Perhaps it’s the diagnostic test that leads to nothing but uncertainty - and more testing. The supplement that might or might not help with the condition your pet has, or ‘let’s just put it on fluids to be safe’. Health plans that lure you through the door just so that we can upsell you on more stuff. “Would you like a dental with that? Great, but you’ll need some bloods first…”

I don’t know - maybe I’m just a grumpy old git. What do you think?

But while you think it over - please - if at all possible - just have a normal kids’ party at the local park or something.

Much love,

Hugh