Lumps and bumps part 2: lump-be-gone

In part one I talked mostly about benign lumps such as lipomas, fatty tumors, that can often be left alone unless they are causing a specific problem.  This blog is dedicated to lumps that should not be left alone.  As a veterinarian, it makes me sad when I see a pet brought into the clinic with a tumor that has grown too large to be removed.  Usually the history given to me is that the growth showed up about a year ago and didn't look too bad.  Then it suddenly started to grow over the last week or two and by the time the pet is brought in for an exam it is either too late to do anything or if surgery is possible it would be so extensive that a referral to a board certified surgeon is necessary.  This is especially true of lumps and bumps on legs.  Remember that when a surgeon cuts a lump off an animal almost always they will have to remove the skin over the lump as well.  On legs especially, there is just not enough loose skin available to cover the surgical wound at least without using some special techniques. It is so much easier to just remove a leg lump when it is small.

As I mentioned in Part 1, I think part of the hesitation about bringing a pet in for an exam to have a lump checked is that we as humans are all afraid of getting a bad diagnosis.  But the good thing about lumps on the outside of the body where they can be seen is that we can do something about them early and that can lead to a good outcome.  Within the past year, I said goodbye to two of patients that will always remind me of what is possible by taking care of cancerous lumps earlier rather than later.  Both patients were diagnosed with cancer.  Buddy had a fairly aggressive mast cell tumor diagnosed in 2008.  Buddy actually had two surgeries to remove his cancer.  Daisy Mae had mammary gland (breast) cancer in 2007 and had a partial mastectomy.  Buddy and Daisy Mae both lived to around 16 years of age which is a fine lifetime for a dog.  I have no doubt that both their lives would have been considerably shorter if they had not had surgery early on to remove their cancerous tumors.

Buddy at age 16  

Gosh I love old dogs.

Unfortunately I don't have a picture of Daisy Mae, but I do want to discuss mammary cancer in dogs for just a bit.  There are many things unknown in our lives, but one thing that has been proven is that if you get a dog spayed before she is two years old, you can really decrease the risk of mammary cancer later in life.  Because of a dog's anatomy, a female dog has on average 10 mammary glands or a chain of 5 on each side, plus or minus.  Sometimes dogs will develop mammary cancer in multiple glands and when that happens, a complete mastectomy is done.  First one side and then the other if appropriate.  A female dog's mammary chain runs from the "armpit" area under the front leg all the back to the groin under the rear leg.  That means to get all the cancer, a surgeon has to make a VERY long incision.  It looks like this.

This little dog was 8 years old, not spayed and never used for breeding.  All this pain and suffering, and nearly always preventable by spaying while young.  Fortunately for this dog, she had an owner that was willing to treat her disease before it became inoperable.  If she makes it one year, she has a very good chance of her mammary cancer being gone for good.

The moral of Part 1 and Part 2 of the lumps and bumps blog?  If your pet  has a lump and you don't know what it is, please have it checked out sooner rather than later.  Time is ticking.

Lumps and bumps part 1: Do you want to see a one pound lipoma?

I have learned a couple of things from blogging.  Number one, the first picture contained in a blog post is often the thumbnail that is used by other web sites when a linked back to the blog.  Number two is that some people don't enjoy looking at gross pictures of tumors and body parts.  I can't quite figure out why someone wouldn't want to look at something as fascinating as a one pound lipoma, but I accept that some people really do feel that way whenever I show someone a recently removed tumor and they turn white as a ghost and leave the room.  Oh well.  I guess the fact that I am fascinated by how things look underneath that covering of skin makes me well suited to being a surgeon.  And so to kick off this blog about tumors and lumps and bumps, I give you a picture of my dog Buddy.  He is lot cuter than a one pound lipoma anyway.

Onward to the blog about lumps.  I decided to write this blog because I have seen a few tumors lately where owners ignored a lump on their dog until the lump was so big or so aggressive that nothing could be done to save the dog's life.  I don't know quite why people wait so long, but it is not uncommon.  Sometimes it is money, but many times it is not.  Maybe it's that we all get busy with other things in our lives or there is some underlying fear that the lump may be something bad, but it is a common human reaction to put things off until they jump up and bite us.  So I thought I would share some examples of when lumps can be ignored and when they can't and how some lumps can be prevented and how some cancers in our pets can truly be cured.  Part 1 will be dedicated to benign lumps that can sometimes be left alone except when they are in bad locations or get really large.

Lumps and bumps are really common especially in dogs.  Lumps can be caused by infections (e.g. abscesses) or irritations (e.g. lick granulomas - that's a good one to type into a Google Image search) or lumps can be caused by abnormal growth of cells (tumors).  Tumors can be either benign or cancerous.

The case of the one pound lipoma

definition of lipoma = a benign tumor made of fatty tissue

Lipomas are one of the most common tumors we see in dogs.  They are benign although there is a cancerous counterpart called a liposarcoma, but those are relatively rare.  Most lipomas occur along the side or the lower part of the chest or the belly, but I have seen them on legs or the head on occasion.  One time I removed a lipoma from the side of a Labrador Retriever's head that was literally as big as the lab's head.  It looked like the dog had two heads.  This dog had been adopted from the local shelter with this growth and his new owners were kind enough to have this monstrous growth removed.  I just want to give people a big hug when they take on a senior dog from a shelter with a problem.

Some dogs get so many lipomas during their middle age to senior years that it would be impossible to remove them all.  Retrievers are especially noted for getting lots of lots of these growths as they get older. These growths are not painful, but if they grow in a bad spot, they can cause difficulty walking or moving.  Because lipomas are common growths that don't bother dogs very much, they are one type of tumor that is often left alone.  They can however get quite large.  My personal record was an 11 pound lipoma that I removed off the side of the flank of a dog.  The dog weighed (after surgery) 17 pounds.  That tumor was nearly 2/3rds of the dog's post-surgery weight.  Holy lipoma batman!

Some lipomas are soft and others have a more firm feel to them.  Some of them are quite easy to determine where they stop and where normal tissue starts.  Others "infiltrate" into normal surrounding body fat.  Through experience, most veterinarians can tell you whether they think a lump is a lipoma or not and most of the time they will be right.  But the truth is that none of us can truly know what kind of lump your pet may have without a biopsy (taking a sample of the cells from a growth and looking at them under a microscope).  And the other truth is that there are some cancerous growths that can feel identical to lipomas.  Hemangiopericytomas and mast cell tumors are two examples and those two growths can be very difficult to deal with especially if you let them get big.  I will say that I don't necessarily recommend a biopsy of every single "lipoma-like" lump, but there are times when I think it is a very good idea.

Teddy was a retriever that came to see me because his owners noticed a swelling in his upper thigh on the inside.  By feeling it I could tell it was a mass of some sort so the next step was to do a needle biopsy.  A needle biopsy (fine needle aspirate) is done by sticking a small needle into the lump and sucking out some of the cells with a syringe.  The cells can then be put on a slide and looked at under a microscope.  Needle biopsies are not nearly as accurate as taking a whole slice out of  a lump, but the nice thing is that most dogs don't need any sedation to get a needle biopsy sample.   Some tumors are really hard to diagnose with a needle biopsy but lipomas are pretty easy most of the time.  I did a needle biopsy on Teddy's lump and the report came back it was a lipoma. We decided to leave it alone for several reasons.  It was in kind of a bad spot to remove, it wasn't causing him any symptoms and because I knew it was a lipoma, I also knew that if it got a little bigger it would not be much harder to remove than it already was.

Teddy did just fine, but about 10 months later, his owners noticed that the lipoma was getting bigger and it was starting to affect how Teddy was using his rear leg.  We decided to remove the lipoma.  I was happy that this lipoma was one of the non-invasive kind and even though it was in a really bad location, it came out relatively easily.  As is typical of growths that are a little larger than average, I like to get them weighed and photographed.  And so here is a one pound lipoma hanging out next to a regular sized Sharpie for size comparison.

Even though lipomas are abnormal growths of fat cells, they are fat cells none the less. If you are carrying a little extra weight, just think about 10, 20, 30 or more of these little buggers hiding out under your skin.  I know I think about it every time I have that extra slice (or two or three) of pizza on a Saturday night.  Certainly gives me some motivation to get out and ride my bike.

Enough about lipomas.  Next blog is part 2 about lumps that should not be left alone.

Dude

I finally have a moment to sit down and do a little thinking and typing.  This post is what I call a "feel good story".  Sometimes I have to retrieve a feel good story from the recesses of my brain when the stress of dealing with sick patients and death starts taking a toll.  The days on end of dealing with incurable diseases and euthanasia can weigh a person down.  But then there are those patients that come along and teach us that at least some of the time we can make a difference.

Dude came into my life this past August.  It was a Friday and our receptionist received a frantic call from one of our clients saying that he was bringing in a very sick cat right now.  When he got to the clinic, he told us everything he knew.  Dude was a cat that belonged to one of his renters.  The cat had gotten outside and had been missing for 6 days.  The client had just found the cat laying on the floor of his outside shop.  

Dude was about as close to being dead as a cat can get without being dead.  He was laying flat on his side and only his breathing told me he was still alive.  He would cry out when I touched him though.  He was cold and about as stiff as a board.  His body temperature was 95F (normal in a cat is around 101-102F).  He had a huge old rotting wound over his right shoulder and his entire right front leg was swollen shoulder to toes and oozing smelly fluid from multiple spots.  The only reason there were no maggots involved was that we were right in the middle of the 2012 midwest summer drought and there were no flies around and about.  Dude had other wounds as well.  There were some on his head.  There were even more to found hiding beneath his thick fur in the next day or two.  He smelled like a dead rotting animal.

So now decision time.  The actual owner of the cat did not have money for any treatment at all, but Dude had fate on his side.  The client who brought Dude to the clinic really liked this cat and felt bad for the owner who was a single mom with a very sweet daughter who was mentally handicapped.  He offered to pay for Dude's medical care, but there would not be unlimited funds available and transfer to a 24 hour care facility could not be part of the plan.  This is one of those times when you want to throw everything but the kitchen sink at a case, but can't.  This is when you do the best you can with what you have available.

IV fluids, various and sundry drugs, and active warming was begun.  By Saturday morning, Dude was showing signs of being a live cat, still smelly, but alive.  His wounds were bathed and some of the dead skin on his shoulder was starting to slough off.  By Saturday evening, Dude was able to lay upright on his chest instead of laying flat out on his side.  It was becoming apparent though that he suffered some kind of spinal cord trauma.  He could move all his legs, but was unable to stand up.   He wouldn't eat on his own, but he readily accepted some food offered to him out of a feeding syringe.

Sunday morning came with more improvement.  Dude was starting to get a little feisty and he ate just a little on his own.  Unable to stand at all, he was starting to drag himself around the floor some.  His wounds were bathed again on Sunday and more skin was sloughing off.  By Sunday night he was eating on his own.

On Monday his owners came to visit.  Dude was still unable to stand, but he was eating on his own and was urinating on his own.  After one more hydrotherapy session in the tub to cleanse his wounds, the owners decided to take Dude home.

As is always the case, more healing happens at home than at the hospital.  Dude's owners provided excellent nursing care.  Within 3 days Dude was taking his first steps at home and started using the litterbox on his own.  I saw Dude in the office about 2 weeks after he went home.  He was fully mobile and up and walking normally.  The skin over his shoulder wound was nearly closed.  He still has a little swelling in his leg, but overall he looked amazing.  Snatched from the jaws of death as the saying goes.

This story isn't just mine.  Saving Dude's life was indeed a team effort.  From the man who found him, brought him to the clinic and then paid the bill to the hardworking staff at the clinic that bathed, fed and tended to all of Dude's medical needs in the hospital and finally to Dude's owner who provided such loving care after he went home. And so Dude has become somewhat of a mascot for making a difference here at the clinic.  Whenever we have those tough days, Dude's name always seems to surface.  And that is the power of the "feel good story".  I hope each and everyone of you out there have your own personal "feel good stories" that make you smile and feel better when you are having a blue day.  At the end of the day, every single one of us makes a difference in this life.  We sometimes just need a little reminder from time to time.

Paying for veterinary care

Well, well, well, it has been some time since I have blogged.  My only excuse is life being busy.  Not only is May, June and July the busiest season for veterinarians, it is also busy farming season and I have responsibilities on the farm too.  Keeps me out of trouble, but also keeps me off the computer.  Which is probably a good thing in a way. The best part is I have a few blog topics lined up ready to go.  One is a REALLY happy story that I want to share and I also have a sad and hopefully thought provoking story to share.

One of the very self indulgent parts about blogging is that along with passing on (hopefully) useful information, I get to clear my head of junk that is building up inside.  One of my staff said I was getting feisty today.  I think that is an accurate assessment.  99% of my clients are beautiful people.  I am blessed to spend my days with such wonderful people.  We laugh together, we cry together and we enjoy life with our pets together.  But there is that 1% that makes you wonder and when you get a few one percenters stacked up back to back in a few days, it can drive a person to become feisty.  Like the person who brought their VERY healthy looking overweight cat to me to be put to sleep.  When I asked why, they said the cat has a tendency to throw up and they were getting new carpeting and didn't want to deal with the mess.  Really? (I did not do the euthanasia by the way.)  Or was it the person who brought their sick dog into the clinic and when I asked them how long it had been since the dog had not been eating normally, they told me 6 months.  Really?  Or was it the guy in the exam room who was upset about the estimate I gave him and became very irate with me and said "Look here girlie"?  Really?  You are really calling me "girlie"?  Come to think of it, maybe I should have taken that as a compliment.  I was at least about as old as he was and probably older.  I feel much younger now.  Thank goodness for the ninety-nine percenters.  I love you all and you keep me sane.

And so I am going to re-start my blog with a topic that always seems to get those feisty feelings going:  Why most veterinarians will not bill clients for veterinary care, but instead ask for payment at the time of service?  And then my goal is to put a positive spin on the topic and list some suggestions for pet owners so they can be prepared financially in case of a pet health emergency.  And because I really like reading blogs that have pictures attached and because I do not have any pictures lined up for this topic, I am going to randomly insert pictures of my chickens.

Mama Chicken.  One of four hens that have been elevated to "pet" status on the farm.  She is a barred Plymouth Rock.  My oldest chicken.  I think she is around 5 or 6 years old now.


Give this some thought.  If people you barely know came up to you on a daily basis looking for a loan and told you "My family won't loan me any money.  My friends won't lend me any money.  The bank won't lend me any money.  But I really think you should lend me money because I need some."  How would you feel about that?  Would you lend them money?  Maybe you would lend money to the first few people who asked because you are kind hearted and feel bad for that person's plight.  How would you feel if at least 90% of these people never paid you back?  What if you were lending so much money to people that now you yourself were not able to pay your bills?   I guarantee that after weeks, months, years of this, you would feel taken advantage of and you would not want to lend money to strangers any more.  This is the scenario that plays out in every veterinary clinic multiple times every day.  People who we barely know are asking us for money.  I'm sorry, but if friends, family and banks won't lend you money, that is a red flag as to your reliability in repaying your loan back to the clinic.

This is Whitey.  Also a pet hen, she is a Delaware.  Whitey is my most social chicken and follows me around a lot when I am working around the barns.



So we have a dilemma.  Someone calls or shows up with a very sick pet needing medical care and they have no money to pay for treatment.  They are distraught because they love their pet and don't want it to die.  On the other side we have the veterinarian.  He or she loves animals (yes, we all do.  It is why we got into this business.)  We do not want to see animals die either.  But we have a business to run.  If we do not make money, our business ceases to exist.  We employ people who need money to live.  They have their own families to take care.  If the veterinary practice where they work ceases to exist, they lose their means of supporting their family.  This is an emotionally charged issue on both sides.

So I bring you a real life story to make a case for the veterinarian's side of this issue.  After 20+ years of being a veterinarian, I am pretty adamant about not allowing people to run up a large balance for veterinary care at the clinic where I work.  But because I do love animals, there is this soft hearted side of me that creeps into the picture about once a year.  I always seem to get burned, but that is the name of the game.  About 6 months ago, a woman who had never been to the clinic before brings in a sick dog.  The dog is VERY sick and will die without treatment.  The disease is bad and the treatment is complex and time consuming and therefore expensive, but there is a VERY good chance that with treatment the dog will live.  I start talking to the woman about how she is going to pay for the treatment.  She does have some money, but not nearly enough to cover the entire cost.  She is crying.  I feel bad.  We try to get her approved for our clinic's third party payment program.  She is declined.  She cries.  I feel bad.  I know I can save this dog's life.  I explain that I cannot let people I don't know charge for services because there is a tendency to not pay.  She looks me straight in my eyes and tells me that she is not like those other people.  She is different.  She will pay her bill.  She sounds so damn sincere.  She cries.  I feel bad.  I give in.  I get my staff to reschedule all my afternoon appointments so that I can perform emergency surgery on this woman's dog.  I am now relying on this woman's word to pay my staff for that day, pay the electric bill for that day, pay the rent for that day, pay for the drugs I used on her dog, and many many other bills that need to be paid to run a veterinary practice.

A box of day old Golden Buff laying pullets arrives at the farm.  There are few things cuter that day old baby chickens.




So what happened?  The dog is alive and doing well.  The clinic has received one very small payment since the dog went home and that was about 3-4 months ago.  Nothing since.  This one woman's bill is nearly 10% of our entire accounts receivable balance.  It's ok though.  I have used up my quota of random lending of money this year, but next year is open if you want to come see me then.

So let's take all the negativity out of this topic and let me lay out some positive steps that pet owner's can do in order to have money in a pet health care crisis.

1. If you borrow money from ANYONE, pay it back.  OK, this one might sound kind of flippant, but it really works.  You have a much better chance of borrowing money from someone you know in a crisis than from someone you don't know.  However, if you borrowed $500 from your brother 3 years ago and never paid him back, he is probably not going to want to lend you more money now.  Common sense, eh?

2. This is a corollary to #1.  Establish a relationship with a local veterinarian.  Take your pet in for regular check ups.  Even if you cannot afford to do every preventive medical recommendation your veterinarian gives you, at least do something.  And do it every year.  This is just human nature, but I am much more apt to lend money to someone I know.  Most veterinarians are the same way.  We want to know that people are at least putting some effort into caring for their pets.  And if you can't afford to spend at least $100 per pet per year on a veterinary visit, perhaps you should not have a pet.  (I think a good blog topic would be how can people who love animals, but who have very little money, still have animals as part of their lives.  I have some ideas on that one.)

3. Get a credit card.  If you do not like credit cards because you have no self control and spend beyond your means, then get one anyway.  Give it to your meanest family member and have them hold on to it and only give it to you for emergencies.

4. Start a pet health care savings account.  OK, this one takes some motivation, but it works and is probably the smartest choice financially.  Might want to enlist the help of that mean family to oversee this account too.

5. Ask your vet about third party payment programs.  Most vets use them.  Get approved ahead of time.  If you are declined, find out why and fix it.

6. Pet health insurance.  This business is in its infancy, but it may be a good option for some.  It forces you to put money aside for your pet's health care and can often cover a higher dollar amount than some people can save on their own.  Most veterinarians will give you pointers if you want to go this route.  Ask.

7.  Lots of communities have programs to help senior citizens and those on fixed incomes pay bills.  Our county senior center has set up a program with donations from the local kennel club that helps seniors pay veterinary bills in case of a treatable illness.  Ask around your community BEFORE the crisis happens to see what programs are available.

8.  Look online.  There are many organizations from veterinary associations to humane societies that have money earmarked to help people with veterinary bills. 

So there are my 8 ideas, anyone else have any good ones?