The Vet Vault 3.2.1.
The dreaded forelimb lameness, age of desexing debate, rhinoscopy pro tips, and tired, or bored?
3 Clinical Pearls.
1. The dreaded forelimb lameness.
From the Advanced Surgery Podcast, with Dr Mark Newman.
How much do you like seeing forelimb lameness dogs? If your answer is ‘not so much’ - don’t worry, Dr Mark says that even the specialists love them much less than the hind limb with its well-defined set of problems with clear treatment options. But the series of episodes we did with Mark (who happens to be the one surgeon who loves forelimbs!) on the elbow has given me a lot more clarity. Here are a few of my highlights:
Lameness in a young dog is very abnormal, and needs investigation, especially forelimb lameness. Thinking (hoping!) that it’s ‘just a strain’ that needs rest and NSAIDs can lead to you missing the window of opportunity to do something about the underlying orthopaedic disease that may well be the main issue. (Think elbow dysplasia )
Forelimb lameness is genuinely tricky to pick (it’s not just you!) and easy to miss. Remember ‘down on sound’ for the head bob in a unilateral lameness (ie the dog’s head will bob down on the good side), and look out for the common scenario of a young dog with bilateral disease where the owner thinks it’s ‘just a bit lazy’. The young large breed pup that runs around at the park and then just wants to sit down, or not walk back to the car, or is reluctant to jump down from the couch, is not just being a lazy teenager - it probably has two painful elbows.
Clinical exam tips to hunt for medial coronoid disease:
Flex the elbow while concurrently pronating the limb (push the paw laterally: a dog with coronoid disease will always react to this. Note that some normal dogs won’t like this either, so it's not specific, but if your patient is not reacting to that, it's highly unlikely to have a medial coronoid lesion.
PS: If you haven’t come across our advanced surgery podcast yet (separate to the surgery stream on the normal vet vault clinical podcasts) - we’re making a high-level surgery podcast series aimed at people who are studying further in surgery, or who are serious surgeons. Lots of pathophys, and deep dives into the actual surgery. The elbow series, for example, goes super deep on all things dysplasia, including a great analysis on all the surgical options. Good for study purposes, but also great for anyone wanting to get a deeper understanding of the surgeries they’re already doing. Here’s the link.
2. Sex hormones vs fat.
From a episode 162 on our surgery stream. With Dr Mike Farrell.
Where do you stand on the whole ‘age of desexing’ debate? In case you missed it - in this episode surgeon Dr Mike Farrell gave some thought-provoking feedback on the Davies studies that gave us the breed-specific guidelines. A few of his thoughts that really stood out for me were:
Regardless of the effects of sex hormones on joints and cancer, we also know that they have a significant effect on body fat. In some breeds (think labs) desexing will increase body weight by up to 30% if calorie intake is not adjusted.
We also know that increased body fat has a HUGE effect on risk of joint disease, as well as lifespan.
What I didn’t know was that fat wis highly pro-inflammatory, and significantly increases the risk of cancer.
Key takeaway for me: whatever your stance on the pros and cons of desexing, don’t get so distracted by the details that you forget about the really important issue of fat.
3. Rhinoscopy pro tips.
From episode 169 on our medicine stream. With Dr Johan Schoeman.
Something else that’s challenging is diagnostics for nasal disease. Even if you do have a scope - it’s very hard to identify the problem area when the entire nose is filled with blood, right? Some pro tips to reduce this from medicine specialist Dr Johan Schoeman:
Pre-scoping: Soak some swabs in a 50/50 mixture of lignocaine and a decongestant nasal spray containing oxymetazoline hydrochloride (trade name Iliadin). Shove (gently!) these soaked swabs up the nostril as deep as it will go with artery forceps, and leave them in for 5-10 mins. This will reduce bleeding significantly while you scope.
Note - don’t use adrenaline at this stage - it will blanch the mucosa excessively, which can make interpreting pathology tricky.
Post-scoping/ post- biopsy: Soak cotton ear buds in 1 ml of adrenaline diluted in 100ml of saline (don’t use un-diluted adrenaline) and pack as many of these into the nostril as it will hold. This will stop that torrent of blood that we hate so much and that discourages us from taking decent biopsies.
2 Other things
“Consistent purpose is not enough to make life happy, but it is an almost indispensable condition of a happy life. And consistent purpose embodies itself mainly in work.”
- Bertrand Russell
“Research has shown that the most effective way to increase your energy levels and stay in peak physical shape is to be 20.”
- Internet meme
1 Thing to think about.
Tired, or bored?
My brain has started doing this really annoying thing: every time I do live podcasting at a big conference, it decides, the night before the conference starts, that we’re WAY too excited to sleep. Which is less than ideal, seeing as, on an average day at these conferences, I’ll interview 4 to 6 of the smartest people in their field, so I REALLY need to be at my sharpest.
It happened again before Science Week a few weeks ago, so the 4 day marathon of interviews began on about 90 minutes of sleep. And yet, I felt totally energised the entire time. I was focussed and present, with none of the dull lethargy that normally follows even a moderately bad night’s sleep. I didn’t think: ‘I’m so tired,’ even once, and as bedtime approached the next night I was happily at my computer preparing for the next day. And I easily kept this up for the full conference.
Now, if you’re also heading further and further away from that magical age of 20 noted in our second ‘other thing’, then ‘tired’ is probably a very familiar feeling. You don’t even need a sleepless night to bring on this feeling - just looking at your to-do-list can do it.
So why is it that in a normal week with normal sleep (sleep is usually my super power) my biggest stumbling block to getting shit done is ‘I’m so tired’, when I am apparently capable of being productive, happy, and energetic for 4 days in a row in a situation that presents many reasons to be tired? (If you’re a parent you’ll likely be thinking - “it’s because you had 4 days without children and dishes!” And you’re probably partially right, but I think there’s more to it.)
This experience has led me to question the narrative of ‘tired.’ I’ve started paying closer attention to what’s really going on when I think I feel tired. Here are the most common things I’ve realised I often incorrectly label as tired:
Bored
Stressed
Anxious (not quite the same as stressed)
Distracted
So the solution is simple right? Just spend all of your time doing stuff that really excites you and that sits in that sweet spot close enough to the edge of your comfort zone, but well-enough within your nature and expertise to put you perfectly into flow, and you’ll never be tired again!
Clearly that’s not possible. The dishes need doing, and AI hasn’t replaced all of the repetitive monotonous tasks of our working lives (yet). Tax returns need filling, and some jobs are well-deserving of the full attention of your sympathetic nervous system. I’m also well aware that any situation like that 4 day high I had at the conference is not long-term sustainable, as evidenced by the total collapse I experience every time the day after I get home. But there are still some lessons here:
If all day every day is filled with ‘tired’ (bored, stressed, anxious, distracted), maybe it’s time for some big life decisions. What are things that put you into that sweet spot? Find a way to do more of that. (Unless you actually are just tired, in which case you only have one thing to fix. Or you just need to hang in there until the children get older - I promise they do eventually start sleeping!)
Correctly identifying other emotions disguised as tired turns out to be very useful. Examples:
A boring task can often be made less boring by a change in location, some music, or even just breaking it into smaller chunks that can be completed before monotony turns into lethargy.
Realising that stress is the driver behind your desire to nap (my favourite form of escapism!) can be the trigger to employ your favourite stress-busting tools. (No, it can’t be ice cream or wine every time!)
Anxiety is trickier, right? Correctly identifying it can help find solutions, and I find just naming it helps to get through it.
Distracted - the scourge of the century. Usually means I just need to put my phone somewhere out of sight!
Much love,
Hugh
PS - Did you know you can leave comments on these in the Substack app or on the home page of this newsletter? I’d love to hear about your favourite ways to combat ‘tired’.
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