The Vet Vault 3.2.1.

Hotspots, disappearing airways, neck pain that isn’t a neck problem, and unreasonable expectations.

Hubert Hiemstra

Jul 11, 2024

Who’s coming to Science Week on 25-27 July?

Some of the topics I’m excited about digging into with the speakers:

The interface between medical conditions, pain, and behaviour.
Stemming the flow: management of canine incontinence. (Surgery)
Surgical Timing: When to Cut? A review on when to cut certain cases
The Latest & Greatest in Wound Care. Leeches, anyone?
Management of concurrent thyroid and kidney disease in cats
ER controversies: C-Reactive Protein in the Emergency Room

…and about a hundred more. (The FOMO is real!)

3 Clinical Pearls.

1. Hotspots: Yes for steroids, nope for AB’s

From episode 165 on the medicine feed. With Dr Nellie Choi.

Our dermatology lecturer at uni tried hard to encourage us not just to reach for the pred for every skin case. And if bacteria was involved, then the preference was definitely to go with antibiotics, and hold off on the steroids. In my head, a wet smelly hot spot is the epitome of a bacterial skin disease that needs antibiotics. But dermatologist Dr Nellie Choi had this to say:

The accurate name for a 'hotspot' is acute pyo-traumatic dermatitis. They happen because of self-trauma, which is the real cause for all of that bleeding and pus.
Usually, all you need is something to stop the discomfort, and steroids are best for this.
Systemic antibiotics are usually NOT indicated initially, unless it’s a very large area with very severe signs.
Plan: steroids, topical antibacterial, like chlorhexidine. Follow up in 2 - 3 days. If it’s not much better, THEN start the antibiotics.
“In my experience, 80% of patients will improve with steroids alone.”

2. Don’t stuff around with upper airway issues.

From episode 137 on the ECC feed. With Dr Simon Lemin.

A case from last week was a scary reminder of something Dr Simon Lemin explained in this episode on emergency tracheostomies. (Which my patient very nearly had to have!):

Brachycephalic staffy (you know those boofhead ones) with a previous history of needing treatment for acute upper respiratory issues after running around like a.., well, like a boofhead staffy, on a hot day. Because of the history, the owner responded very quickly this time when he saw loud URT sounds with some increased breathing effort, so my patient presented pink and happy - just a bit noisy. “Bit of Dex and sedation will sort him out quick-sharp”, I said with confidence. Luckily I admitted him, because 20 mins later he was COMPLETELY blocked, very blue, and 2 minutes away from dead, despite a nice level of sedation and dex.

My question to Dr Simon was: How do these patients go from ‘normal’ to dying so quickly? Here’s why:

Decreasing the diameter of a tubular structure does not just cause a linear increase in resistance in the tube. If you want to get nerdy, it’s based on the Hagen-Poiseuille equation, which states that, for laminar flow of fluid in a tubular structure, resistance is inversely proportional to the fourth power of the diameter. This doesn’t apply exactly to turbulent air flow, but what it practically translates to is:
A small decrease in the diameter of a tube leads to an outsized increase in resistance to flow. (This is also why even a slightly bigger IV catheter is much preferable if you need to give fast fluid rates.)
Of course, increased resistance to air flow in the upper airways leads to more vibration of those sensitive airway mucosa, which causes it to swell, which leads to a further decrease in diameter, which ramps up the resistance… and the cycle continues. Hero to zero in minutes, not hours.
Take away: The upper airway patient with the potential for decompensating (think post-op BOAS surgery) should not be out of your sight at all until they are completely back to normal.

3. When neck pain isn’t a neck problem.

From episode 160 on the surgery feed. With Dr Liesel van der Merwe.

Quick pearl from this great conversation on how to work up the neck pain patient:

Once you’ve identified neck pain on clinical exam, leave the neck behind and flex the carpus to look for pain. Why?
Because every vertebra has little synovial joints on it, and all of these little joints love being affected by immune mediated polyarthritis - just like the carpi. So IMPA can present as neck pain.
REMEMBER: IMPA is not that uncommon, and moving it higher up your DD list for the neck pain patient early on in the process could point you in the right diagnostic direction. (Joint taps, vs MRI and CSF taps!)

2 Other things

“Listen to the nurses.You might not necessarily 100 percent agree with what they say, but unless it’s something that is dangerous or goes completely against any advice, in most cases, just rely on the nurses. You don't have to prove anything.”
- Some fantastic advice for locums (and good life advice in general!) from Dr Wolfgang Dohne in our most recent episode.
“Old George Orwell got it backward. Big Brother isn’t watching. He’s singing and dancing. He’s pulling rabbits out of a hat. Big Brother’s busy holding your attention every moment you’re awake. He’s making sure you’re always distracted. He’s making sure you’re fully absorbed. He’s making sure your imagination withers. Until it’s as useful as your appendix. He’s making sure your attention is always filled. And this being fed, it’s worse than being watched. With the world always filling you, no one has to worry about what’s in your mind. With everyone’s imagination atrophied, no one will ever be a threat to the world.”
- Chuck Palahniuk

1 Thing to think about.

Back when we lived in the UK, the TV show Little Britain was one of our favourite distractions. My favourite gag was this series of skits about a customer in one business or another with a ridiculous series of increasingly unmeetable demands.

Each skit would start with ‘Somewhere in a shop in England a man is looking for a…

Birthday card… “I’m looking for a birthday card. For a man. Who is 60… 5. He likes the sea (C)… word. (That’s ok, I can just write it in.) Do you have any cards that just say ‘Happy 65th birthday… (shopkeeper optimistically starts reaching for a card) …Michael Fillipedes… “

Somewhere in a video rental shop in England a man wants to rent a movie: “I’d like to rent a film starring Chevy Chase and Rick Morales as cops who go under cover and pose as rappers in order to foil a drug deal. PG 15.” Shopkeeper: “I don’t know that one. I don’t think that movie’s been made.” Customer: “That’s ok. I’ll wait…”

It’s funny because it’s preposterous. Nobody really acts like that, right?

—

Somewhere in a vet clinic in New Zealand a man brings a sick cat to the vet…. “I’d like you to tell me what’s wrong with my cat. Without doing any tests. I can’t do that treatment. There’s no way I can keep him inside. Do you have any treatments that don’t contain any chemicals? Yes I’d like you to do the surgery. No, I can’t pay.”

—

So why aren’t we laughing when this happens to us? Why do we tie ourselves in knots trying to meet preposterous expectations, and then feel guilty when we can’t?

Sorry, that movie hasn’t been made. We don’t stock that card.

Much love,

Hugh