One Health and Veterinary Medicine - More than Infectious Disease - A Boy Receives a Life-Saving Diagnosis.....At the Vet Clinic!!

Fundamentally, I just want to share someone's story of a borderline medical miracle....on a human patient....by a small animal veterinarian.  I saw it on Facebook on a private page.  I received permission to share it, but wanted to do more than just share it.  I think it needs some context.  The medical miracle is not an exaggeration, but let me set it up briefly.

There's a movement out there amongst the broader health community termed 'One Health.'  Technically, it's not new as it was advocated by Rudolf Virchow - the father of pathology - in the mid 1800s.  But the idea of 'One Health' experienced a resurrection in the recent 25 years, especially with respect to some infectious disease events - Ebola outside Washington DC in the early 90s with vets running to the rescue; West Nile Virus in New York 1999 with the human medical experts squashing the correct answer offered by the Bronx Zoo veterinary pathologist; the anthrax events of 2001; and on and on.

The simplest construction of 'One Health' is that there is a continuum of human health, animal health, and environmental health and true health success must address all three elements.  Again, for obvious contemporary events, the infectious disease angle has been the easiest element of One Health for people to understand.

But, let's stay in 'One Health' but move away from infectious diseases.

Here's the medical miracle - human patient - animal doctor - with anonymized names and animal circumstances, as told - excerpted verbatim with permission - by Dr. Dan Harmer.

<Begin excerpt>

Had a fantastic case that I just had to share!

8y/o pitbull came in with vestibular disease. When my assistant came out of the room, she told me that she could smell ketones very strongly (I can't smell them, so she always gives me a heads up).

Anyway, I worked up the vestibular problem and ran blood work to check for diabetes. It was completely normal, so I was really confused. I went in and talked with the family. The mom said something like "well, at least it's not diabetes, 'Timmy' has diabetes and it's miserable."

So, I look over at 'Timmy', her teenage son. He's really quiet and sort of a gray, pasty color.

Me: "Timmy, what's your blood sugar this morning?"

Him: "136"

Me: "BS. What was it really?"

Him: "250-something"

I didn't believe that one either. Anyway, I told the mom that she needs to take him to the ER right now. Owners are terrible about following our vet advice, but do believe our medical advice. Haha. She took him in. Today she came back for a recheck. The kid was in DKA and they are still treating him. (The dog is ok, too).

<End excerpt>

For the medically unacquainted, a few things defined:

1. Dog with vestibular disease.  This is a nervous system disorder.  The dog likely had an unexplained head tilt.

2. Ketones.  The most commonly recognized ketone is ACETONE.  Most of you know this as fingernail polish remover.  Ketones are produced by human and animal bodies in situations of insulin deficiency or resistance.  Blood sugar cannot be turned into energy, and the body begins to burn fat and turns this into ketones.  When the body has reached a certain level of bad/abnormal ketone production in the blood, it can be detected through our breath.  Bottom line: If a human or an animal smells like fingernail polish remover, then it is a medical emergency.  The ketones in high levels can contribute to an acidic blood profile that can be fatal.

3. Blood sugar: 136.  In most instances, that's on the high end of normal or low end of an elevation.  "250-something" is very high.  When ketones are detected via smell, blood sugar is often 400+.  I recall several cases of cat blood sugar being 600+.  That's why the vet knew 'Timmy' was lying.

4. DKA.  This is an acronym for Diabetic Ketoacidosis.  It is diabetes that is so uncontrolled that blood sugar is high (cannot be metabolized), ketones are produced, and ketones are produced in high enough levels to produce an acidic blood characteristic.  It can be and often is FATAL.

"Animals Get Diabetes?"

Yes, animals get diabetes.  Lay people are often surprised at that, and that is unsurprising.  But here's a surprise ----  I've lost count of the number of veterinarians who have told me their personal physician (M.D. medical doctor) had no idea that animals get diabetes.

(Guess which side of the veterinarian-physician divide is the strongest advocate for One Health.)

An important 'rabbit trail' into CLINICAL REASONING and the ART and SCIENCE of MAKING A DIAGNOSIS.

The odor of ketones as detected by the vet's tech set off a second problem based hunt.  As a reminder, the dog was at the vet because of a head tilt (problem #1).  With the vet tech's sniffer, and the vet's mind, he reasoned that diabetes was likely (given the ketone odor) and also knew that diabetic complications could sometimes affect the brain.  So, he did blood work.  Blood glucose on the pit bull was within normal limits.  The vet KNOWS that severe diabetes resulting in detectable ketones does not happen with normal blood glucose.  Thus, the thought process.....perhaps he thought: "Hmmmm....who is removing fingernail polish right now?"  A quick glance around the room and the remainder of the clinic probably ruled out that brief - but appropriate - thought.  

But the vet remained 'confused.'  Sadly, we tend to negatively stigmatize confusion.  Confusing situations and signals SHOULD be expected in medical practice, and as a quick aside - I recommend anyone to be skeptical of any physician or any veterinarian who immediately declares irrefutable diagnoses.  It's just bad and dangerous practice.  It's important to emphasize it is absolutely OK to be confused.  Too often we react with: "Don't just stand there - do something."  Sometimes, the most appropriate response for a medical professional - vet or human - is to reverse that: "Don't just do something - stand there!"

To a modest extent....I believe Dr. Harmer just 'stood there.'  Oh....he went on about his appointments and his day, but I assure you - this perplexing case was occupying a tremendous segment of his brain while he performed other tasks.

So the vet updates the dog's owner.  I imagine the conversation went like this:

DVM: "Well, Fido's head tilt is what we call vestibular disease.  There are many possible causes for this.  We're checking some out.  My team and I thought it might be diabetes, but Fido's blood glucose is normal, so diabetes is ruled out.  We need to begin the process to investigate other possibilities."

Owner: "Well at least it's not diabetes. 'Timmy' has diabetes and it's miserable."

DVM: (thinking....no one is using fingernail polish remover.....)

DVM: (Looking at 'Timmy'....quiet....pasty....pale)

DVM:  "Timmy....what was your blood sugar?"

And the rest is included above in the original story.

Thus, back to CLINICAL REASONING....the vet knew that a diabetic patient was in his exam room.  He knew it was not the dog.  He saw no fingernail polish remover.  Presumptively, other boarding and waiting patients were a fair distance away.  Fortunately, the DVM education and training program is inherently COMPARATIVE - how else do veterinarians acquire expertise and confidence to treat more than one species.  It is imperative that we ALWAYS think comparatively.  And light bulb!  The vet knew that one of the human clients might be producing these ketones.  Whether from a dog, or a cat, or a bottle of fingernail polish remover, or from a human, ketones smell like ketones.  The vet knew this and exercised a "heuristic" - a problem solving approach - that via process of elimination, one of the humans in his animal exam room was producing these ketones.  A quick cursory examination and recognition of the quite, pasty teenage boy, followed by some brief, yet pertinent and focused, questions revealed the source.

"Get Thee to an ER!  Now!"

Dr. Harmer quite likely saved this boy's life.  DKA in 'Timmy' was confirmed at the recheck visit for Fido.

And so, we return to One Health.  It's not all about infectious diseases.  It's also metabolic diseases.  Vets know diabetes....they know and manage obesity in pets....and know it compromises the long term health of their patients in the same way that physicians know that it compromises the long term health of their human patients.

It truly is "One Health."  Thank your local veterinarian today!  Someday they may save more than your pet's life!

About Fire: Part 2...Some Personal Stories and Lessons Learned

This post is about fire.  It's a follow up to the post on the 70 yr anniversary of the Mann Gulch Fire posted yesterday.
http://tsniderdvm.blogspot.com/2019/08/about-fire-part-1-70-yr-anniversary-of.html

I'm a bit of a fire-bug.  I enjoy building the fire in the fireplace.  I enjoy building the fire at a campsite.  I enjoy controlled, prescribed burns.  I'm frequently burning brush piles.

I'm generally safe with fire, though my track record would testify otherwise.  Some of the problems with fire that I have encountered have resulted in life lessons.  Many of my memories of fire involve my dad, as well.  Some of those memories are, in no particular order:

• Trash burning:  Growing up, my family didn't have a rural trash service between Cache and Lawton.  Like many, we burned trash in steel 55 gallon drums.  It was my job as a teenager, and I did it well.  I did it so well, I inevitably sought out new fire experiences.  Such it was one day when I thought I would burn some brush near the burn barrels.  I have no recollection of the wind that day, but it must have been breezy.  All I remember is a little experiment quickly grew out of control, and we soon had neighbors over at our place stomping, raking, and fighting my little experiment gone awry.  Lesson: Know the wind and humidity.  Be prepared with tools.
• Spontaneous combustion of bread products:  My FFA SAE project was raising pigs.  At my peak, I was farrowing 4-5 sows twice a year, which meant we ended up with about 40-50 pigs on feed that we were not showing.  This meant a massive feed bill for a small project, and I looked for ways to cut costs.  Circa 1984-1987, one could purchase 'racks' and 'half racks' of day old bread and other bakery products from the Lawton Wonder Bread outlet for pennies.  To reach some sort of economy of scale, we would purchase as many 'racks' a half ton pickup bed would fit, go home, and spend the evening stuffing old feedsacks with varieties of bread, Twinkies, donuts, gems, HoHos, DingDongs, and so forth.  Though we were initially discouraged from doing so, we (Holly and I) quickly learned that the day old sweets were still quite edible and bread night often turned into an impromptu (unhealthy) meal.  So, thus far in the story, I've outlined a labor intensive feeding strategy for pigs that was effectively free.  Summers in Southwest Oklahoma are BRUTAL.  One summer Saturday in the mid-1980s, post-lunch, Dad and I were doing some afternoon TV watching --> in rural 1980s Southwest Oklahoma with three channels, our choices were golf, an infomercial, or an old John Wayne movie.  So with the John Wayne movie halfway done, our day was suddenly interrupted by someone beating on our front door.  My dad rushed to the door to be met by a man with an urgent message: our barn was on fire, and my dad's pickup was parked right next to it.  The cause of the fire?  The high starch of the stuffed and compressed bread products, all stacked next to each other on a 105F Oklahoma day had spontaneously combusted and caught everything else on fire.  For those with hay experience, it was like putting up round bales of hay with 20% moisture content.  My most vivid memory is my dad heroically rushing to his pickup next to the fully engulfed barn, driver's door closest to the flames, him burning his hand on the hot door handle, and him driving the pickup away to safety.  Then, there was nothing left but to watch it burn.  And listen, too.....Dad's Marlin .22 was in there with about 200 rounds of .22 ammo, and it all started popping.  And smell, too.....about 600 pounds of burning bread and other bakery products.  Lesson: Know spontaneous combustion.  Don't stockpile bread in the summer time.
• Dad having a small heart attack fighting a fire in his 70s: I wasn't home for this one.  Dad had had heart disease the last 10-12 years of his life - stents and statins.  I think it was February 2017.  I don't know how the fire started, but I think it was similar to story #1 above.  Dad was hustling around dragging garden hoses trying to fight it.  Hours later, he was in the hospital with a reported mild heart attack.  Two months later, he successfully emerged from quintuple bypass surgery.  Lesson:  Don't fight fire in your 70s.
• Property clean up at my parent's house the day my father passed away:  My father passed away at 12:04am Dec. 16, 2018, in Lawton, OK.  After the initial bawling and grieving, I sought distractions that Sunday morning while awaiting the incoming visitors and family.  My distraction largely was to do what I was going to do anyway - clean up my parent's place around the barn.  Beginning around 7:30am, I had conquered a half acre unmowed field, and had a few round bale's worth of accumulated grass clippings in several piles, along with piles of limbs that needed burned.  Relying upon my success and experience with 100s of brush fires outside Stillwater, OK, I started a brush fire near the barn.  In Stillwater, OK, it is the land of "liquid air" about 300 days per year.  As long as there has been a recent rain and we are not in a burn ban, one can usually do any sort of burn in NE Oklahoma quite safely.  Indeed, there are some days you can't even get a fire started because the dewpoint is so high.  Not so in Southwest Oklahoma.  Drawing upon my teenage experience where I started a big grass fire, and also monitoring two different weather apps, I started the fire, got it 90% surrounded by black, had been spraying water intermittently on top of it and around it, and I thought I was making progress quite safely.  Needing a break and recognizing an increasing visitor count, I left the fire to run to the house to greet a few people, drink some water, and use the restroom.  Minutes later, glancing out the back door, I noticed that my fire had grown....and grown....and grown.  I yelled something and rushed out the door.  Long story shortened:  We got the fire under control.  My wife lost a pair of shoes. Some clothing was ruined.  The barn was intact. A fuel tank was melted and the 2 gallons of fuel remaining nearly ignited.  The lawn tractor was saved.  Examining the burn path of expansion from the central fire, it is clear that this fire tracked along the surface of dead thatch sitting ON TOP OF A PUDDLE OF WATER.  Lesson:  Just like oil on water, fire can burn grass sitting on top of water.
• A recent brush pile burn that did fine, but burned without my knowledge:  This happened just the other day.  North Central Oklahoma received about 3.5 inches of rain on Aug 2 and 3, 2019.  I tried to get a brush fire going in the morning of Aug 4 (Sunday).  I got the tinder and some feed sacks going, but could not get the brush (saturated from two days rain) to catch.  Eventually, I gave up, saw that it smoldered the next 3-4 hours, helped Julie with some goats from 11am-1:15pm, and at that point no smoldering smoke was detected.  I ate lunch, took a nap, watched a movie, went back outside 7pm.  Where has all the brush gone?  Sometime between 1:15pm and 7pm, this 'dead' fire with piles of rain-soaked brush fuel had ignited and successfully burned 90% of the brush.  With the pile surrounded by lush Bermuda grass and the atmosphere composed of about 3000% humidity, there was no chance it was going anywhere, but I was stunned that it caught fire at all.  Lesson: Where there's smoke, there's fire.  Indirect lesson: This is why Forest Service guides tell backpackers to DROWN a fire.

So the five lessons I've learned from these stories:

1. Know the present weather conditions.  Have tools at the ready.

2. Recognize moisture contributions to heat generation and the possibility of spontaneous combustion.

3. Don't fight fire in your 70s.

4. Fire can burn things near or on top of water.  Not just oil....even grass.

5. Where there's smoke, there's fire.  Drown the fire when done.

About Fire: Part 1 - 70 yr anniversary of Mann Gulch Fire

This is the first post on this blog in nearly 5 years.  Originally,this post was supposed to be an all encompassing post about fire....it got too long and is being split into 2-3 posts.  As this is the first post in nearly five years, this post is something of a Phoenix, consistent with the theme.

Today, Aug. 5, 2019 is the 70 year anniversary of the Mann Gulch Fire.  Mann Gulch is a ravine in Montana that feeds into the Missouri River there.  Now, why would an Oklahoma flatlander take note or remember such a date for an event in Montana.  Answer?  The truth is I didn't remember, but it popped up in my Facebook feed from several other contacts.  But, my interest in it is genuine.  More on that in a moment from the book I read in my 20s: "Young Men and Fire."

Never heard of the Mann Gulch Fire?  Option 1: Read this post.  Option 2: Read the linked article.  Option 3: Read the book I will briefly outline at the end.

Mann Gulch Fire:  The brief (and quite likely butchered) version of this story begin 70 years ago today: Aug 5, 1949.  A forest fire broke out (due to lightning strike) in a remote region of central Montana.  The exact location was Mann Gulch, a ravine that fed into the Missouri River.  A plane full of Forest Service employees known as "Smokejumpers" were tasked with the duty to jump out of the plane with parachutes and tools, join up, and cut fire breaks and fight the fire.  While en route to a fighting point where they could safely position themselves between the Missouri River and the fire, the fire switched directions, the wind speed increased, and the fire 'blew up' accelerating up the mountainside, cutting off nearly all ways of escape for the Smokejumpers.  Thirteen of the sixteen Smokejumpers at Mann Gulch died immediately that day, and the lessons learned changed fire fighting strategies on into the future.

A story of commemoration from the Missoulian:

https://missoulian.com/news/state-and-regional/a-retrospective-on-montana-s-mann-gulch-fire/article_372068a9-aa59-5f97-adb8-19e9b13a9538.html?utm_content=buffer5774d&utm_medium=social&utm_source=facebook.com&utm_campaign=LEEDCC&fbclid=IwAR310CVHHY3fWIdCE4lXpbbt6jFwD8nDCM97NImKok0Mo9TgLtXpGiJgClg

(If link becomes broken, the link was to a 8-5-2019 story about the Mann Gulch Fire 70 years later in the Missoulian, written by March Childress.)

How did I come to ever learn about this fire and its history?  I read a wonderful little book in my 20s entitled "Young Men and Fire" by Norman MacLean.  I don't recall how or who recommended it to me, but I'm so glad they did.  The book is non-fiction and is mostly biographical about the people who fought and died that fateful day.  And believe it or not, you've heard of the author Norman MacLean......."A River Runs Through It"?  The movie many of you love and enjoy is a short story written by Norman MacLean.  He wrote many other books.

Anyway, to bring this meandering post to a close, I truly appreciate firefighters.  Truly, all Americans hold a nostalgic spot in our hearts for all first responders, but I hold an extra measure of appreciation for firefighters, especially volunteer fire departments that service rural areas around the nation.  Living through the drought of Oklahoma 2011-2014, the volunteer firefighter should have been the Time Man of the Year one of those years.  By now, certainly 99.9% of the world has forgotten the Mann Gulch Fire, but this little post hopefully serves as tribute to our current firefighters and is a tribute to their bravery and to the bravery of those 13 brave young men that died that day, and hopefully, for the handful that read this, you might have learned something about some true American heroes.

You can fight city hall....you can't fight age and gravity.

About 10 years ago, the Stillwater hospital was expanding and needed to remove some trees to 'put up a parking lot.'

A lady protested. A lady chained herself to the tree she wanted to save. I'm unsure if hugging was involved.

If Google served me correctly, I think the story is archived here:

Woman Chains Herself to a Tree

The lady fought city hall and won.  The tree stayed.  Until now.  Yesterday, August 15, 2014, I was en route to work on 6th street - Highway 51, and discovered....

Age and Gravity wins.

 

 

Two major branches had broken and were in the rightmost, east bound lane.  The lane was closed and there were workers present to remove the large branches.

 

The picture above was shot later that afternoon and shows the main central branch missing and an additional branch partially cut back but otherwise resting on the grassy lawn.

 

Age and Gravity wins; Assist by 4 years of drought.

Kinder Goats

The Kinder Goat - LBS from Timothy Snider

Hello
We are on kidding watch this weekend.  Our family has become involved in goats - meat goats and dairy goats.  For dairy goats, we have initially elected to utilize the Kinder breed.  The embedded slideshare PPT above is a project of my daughter for her 4-H Goat and Public Speaking projects.  Due to some glitches beyond my control, the slideshare conversion corrupted some of the slide formatting, but there is still some good information.

Our first Kinder doe is Daisy May, and we are expecting twins (or hopefully triplets) sometime in the next 3-4 days.  We'll post some pictures of the babies soon.

Tim Snider

Ponies

I just discovered a new web-app called BillboardMaker. So, I just tooled around with it for a few minutes with a pic from my wife's blog. Voila! I made a billboard about ponies. This billboard features my favorite horse/pony named Trixie. She's an ostensibly registered Welsh Section B pony. My daughter Lillie rides her at county fair shows.

Blogging Again (?) - New Site; Old Details

I'm going to try blogging again. Just add it to the list of other things I don't have time to do. This new blogging effort (and blogging platform) are mostly motivated by the closing down of Posterous. Today (April 30, 2013) was the last day it was up, and I was informed I needed to migrate my old Posterous content to a new place or lose it forever. Hence, this new site. Note, all the posts starting this blog out that are dated April 30, 2013, were actually published in mid to late 2009 (UPDATE 9PM April 30, 2013: Blogger allowed me to revise the post date and the posts are now listed with the original date of publication on Posterous). I don't know if the original post date is embedded in the meta-data of the post anywhere, but I did want to record that little detail somewhere, so here it is. Have a good day. Tim