And So it Ended…Goodbye Belize. Adios.

Things had been a little more quiet at work for a few weeks.  I was not complaining about ending my time at Saga Humane Society on a less hectic note.  However, now that the final days were winding down, it was like they could smell that I was leaving.  Everyone was in a panic to see the vet before she left the island for good.

CAUTION, SOME MILDLY GRAPHIC PHOTOS

On Thursday we lined up a nice final snip day.  Thursday is when we did the majority of our free spays and neuters.  Secretly, this was one of my favorite days.  Not because it was all surgery, but because it was mostly human-free.  Merari in reception knows that unless your dog has a leg hanging off or an eye falling out, Thursday is not for appointments.  I could have a break from the regular stress most vets face in dealing with a variety of clients, questions, and personalities.  On this Thursday one of the staff went out into the community to do some errands and to look for any additional animals that might need spay/neuter.  She returned with an owned dog that was already neutered, but clearly was having trouble walking.  I took a look and thought, “What in the H#@*!??”  This dog had a tumor that I had never seen the likes of before.

Foot Mass

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I wasn’t really in the market for new challenges, but as a solo vet you don’t always get to pick and choose. I decided to try using the cautery machine (one of the items purchased for Saga with my fundraiser before I  moved to Belize) to help me to remove it, then suture it closed.

Mass Removed from Paw

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What a relief for this dog!

We also had a fun goodbye lunch that day at one of the beach resorts.  Sitting out looking over the ocean with the whole staff and a few friends.  We never usually had the opportunity for time like this and I cherished it.

Lunch Out

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Friday was my last full day at Saga.  Twenty animals would be looking for medical care (not a record by any means but enough to keep us on our toes). Eight of these needed an exam with deworming and vaccination, simple enough.  One was an anal gland abscess, yes, this is as horrifyingly gross as it sounds, thank you vet gods for deeming this necessary on my second to last day.  We rechecked a recent adoption with a little hair loss and a lot of itch, performing a skin scrape to identify demodex mange and get him on the road to better health.  One dog was losing weight with a good appetite and we sent off some blood work to Belize City on the airplane.  We tested another with one of our quick snap tests to diagnose him with both heartworm and ehrlichia (tick fever) and start some treatment.  I diagnosed one dog with neck pain and sent home medications and strict instructions, while another complained of bloody diarrhea with muscle wasting.  I rechecked a healing leg wound (doing great) and a broken toenail (needed heavy sedation for full removal and cleaning).  The staff brought in an underweight dog that members of the public had been complaining about due to it’s thin appearance.  A very large dog that was rescued from our sister island of Caye Caulker a month prior came in for a recheck.  Although it was amazing that she had gained significant weight, I also noted that her mammary glands looked huge.  We had no way of knowing previously if she was spayed and really she was not an ideal candidate for surgery at the time.  Now it was obvious that she would need surgery the next morning before I left.  As it turned out, which I suspected when I felt her belly, she was in fact NOT pregnant.  She was having pseudopregnancy (where a dog’s body thinks they’re pregnant and makes milk), so once spayed she went on to do well.  We also picked up a really cute friendly tomcat with a swollen leg.  We got him neutered and on medications so that eventually he could go back to ruling his neighborhood (without  making more kittens!).

So, that leaves just one more case.  A dog who had been in a fight with another dog in it’s home a few days earlier.  The owner thought it was more fresh, but after shaving down the neck I would have had to disagree.  The dog had a thick coat and so a wound could easily go unnoticed for awhile.  I suspect the odor eventually gave it away.  Under sedation we shaved some of her face and most of her neck.  There were some old tooth puncture wounds and just a lot of skin infection, like a big bad hot spot.  She went home looking like a mess but I knew that in a few days it would be a lot better.

Friday night I went home.  It was bittersweet knowing that Saturday morning would be my last regular trip to Saga for work, by lunch I would be done.  I put on my pyjamas, got myself a treat, and sat down on the couch.  Then the phone rang.  Sigh.  It was of course Ingrid, it was an emergency.  She told me hesitantly that it was the same dog, bitten again.  The same dog I just fixed up that same day.  I put on a scrub top and biked back to work alone.  There she was, an even bigger mess than before.  The owners looking embarrassed and exasperated.  Although they had gone home and separated them, the other dog had grabbed her through the small slats in the fence.  I let them know how much I didn’t appreciate fixing up the same dog twice in the same day, but they already knew that there would need to be a change at home.  I took the dog and sent them away for the night.  The wound was in the same area and even though there was a lot of blood, it looked small.  A  tear on the back of her neck.

Dog Bite Wound Surrounded by Skin Infection

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It would have been easier with help, but I didn’t really want any.  I just wanted to do it alone.  Once she was under anesthesia it was strangely peaceful.  Just me and the dog.  I needed to shave a little more fur, and not having any sharp clipper available left I tried to channel my inner Ingrid and get it done with a straight blade.  I flushed and explored the wound and found it to be huge under the skin compared to the small tooth hole visible from the outside.  I carefully opened up the whole thing.  Even some of the neck muscles were torn apart.  After flushing and flushing and flushing to clean it, I finally put it all back together like a jigsaw puzzle. Placing dozens and dozens of sutures in multiple layers, finally getting to the skin.  Trying to learn from the results of previous cases, I also immediately placed a drain, hoping that all of the tissues would survive and that no abscess would form.  I gave her pain meds and antibiotics and carried her to a cage to tuck her in so I could go home.  I was tired out when I got back on my bike and pedalled home.

Neck Wound Sutured with Drain

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The next morning would be my last.  I would stay on call for multiple days of emergency but I would not go through my regular work routine again.  I came to Saga and spayed the Great Dane with the milk in her mammary glands from the previous day.  The surgery on this giant breed dog went off without a hitch.  My neck wound dog looked great and was up and about.  I tended to a few appointments and that was it.  At noon I said goodbye, I hugged the staff that had made all this possible, I tried to hold back the tears, and I rode away.  I knew how thankful I was to have had this year in Belize.  How almost no one in my profession would ever get to experience the type of year I just had as a real part of the community of San Pedro.

So many people have thanked me so many times, but it is I who was the lucky one.

 

“Doctora, You Have an Emergency.” A Year of Waiting for the Phone to Ring.

The voice on the other end of the phone was always calm.  Sometimes too calm.  I often couldn’t tell based on the tone whether she meant that someone had called about a broken toenail, or whether a dog had been run over and now it’s skull was hanging out of it’s scalp.  Honestly it could go either way.

How many times could it happen?  During almost ten years as a veterinarian in Florida I had not spent even 1 minute on call.  I moved to Belize and started a year of being on call 100% of the time.  Only when I left the island was I potentially safe, otherwise all bets were off.  Sometimes I was already at Saga in my time off (bonus, no travel time) but often I was in the shower, on the couch in my pyjamas, scuba diving, running, on my bike, or in the gym.  Sometimes I was asleep in bed. Many times I was eating breakfast at Estels Dine by the Sea on a Sunday morning and once ended up pulling bones out of the business end of a dog then saving a chihuahua from hypoglycemia (low blood sugar) back to back while my visiting friends packed my pancakes into a takeout container.

When I look back, I was pretty lucky.  When I got called out on a weekday night it was rare and usually serious.  Most people (and their pets) let me go about my evenings in peace.  It was much more likely to get called in on my days off, between Saturday at noon and Monday evening.  It was also likely to be a dog, as I saw only six cats and one parrot for an after hours emergency.  I looked back at my log to see how the year panned out.  Some of the cases I will never ever forget, others I could barely recall even seeing it on paper.

Types of After Hours Emergency Visits

C-section (the very first emergency, of course!): 1

Dog Bite (never ending): 11

Intussusception (telescoping intestines requiring major surgery): 1 – Hi Mango!

Sick Young Puppy (many reasons): 6

Abdominal Exploratory (oh Ingrid): 1

Injured Parrot (sore leg): 1

Lame/pain (musculoskeletal including spine, legs, etc.): 12

Fractured Limb (some amputated): 3

Post Surgical Complication (don’t act wild after your neuter): 1

Health Certificate for Travel (the best non-emergency emergency): 3

Distemper (not good): 1

Hypoglycemia: 2

Vomiting +/- diarrhea (includes parvovirus): 11

Acutse Allergic Reaction (can you save hives?!): 1

Dead on Arrival (respiratory, very sad): 1

Euthanasia Requested: 4

Urinary Tract Infection: 1

Decreased Appetite (without much other excitement): 2

Hit by Car: 2

Toxin (don’t let your dog eat marijuana, topical medications like creams, plus some unknowns): 4

Bones stuck in the colon/rectum: 1

Gun Shot (drama): 2

Eye Concern (always emergent): 3

Collapse with Fever: 2

Cough: 1

Needed Injections (after hours): 5

Ruined Bandage (I said keep dry): 1

Cat Bite (to the butt of course): 1

Broken Nail: 1

Pyometra (uterus infection – please spay your females): 1

Liver disease (and yellow): 1

As you can see, some were short and easy, some were terribly complicated and took hours.  Most of these types of cases also came up during our regular clinic hours as well.  In the early days the technician attended all the emergencies with me.  As I got more comfortable in the clinic I would try my best to let her stay home, but not only did Ingrid field almost every call, I often needed her help for surgical cases.  There were cases where her teenage daughter ran for towels and opened my suture, and others where I instructed my boyfriend Mick on how to hold off for me to place an IV catheter.  I could never have gotten through all those cases without periodic help.  I remember recently being alone with an owner and her small dog who had been recently attacked by a large dog.  As I started my exam and pain meds she started looking a little faint and I told her, “Ma’am, deep breath, you’re going to have to hold it together because right now it’s just you and me!”

Some concerns were very popular, like dog bites, others thankfully were more rare.  Only four of my emergency cases ended in euthanasia when it was not the original intention of the owner bringing it in (ie. I had to recommend it).  Three died while I tried to save them (1 uterus infection, 1 gunshot, and 1 toxin).  Of course those are the types I never forget.  Some are very satisfying, like sending a momma dog home alive to her nine puppies after a C-section was done to remove her one deceased puppy.  Others are heartbreaking, like staying up all night and having the dog die despite me.

I will say, that when coming in after hours most people are in a more vulnerable position.  They are often panicked at the condition of their dog.  Sometimes the fix was easy and so it felt good to alleviate their fears and send the dog home for what would likely be an easy recovery.  Other times their severe concern was warranted and I knew it would be touch and go.  Some wounds started as a three hour procedure, but then required a month of aftercare to finally resolve.  Either way, clients were always thankful, grateful, and respectful.  Every single person who hauled me out of bed late at night apologized, even though they didn’t have to.  It was appreciated.

Various After Hours Wounds

Foot pad laceration from yard, machete wound sutured, gunshot to abdomen (did not survive), gunshot to head and neck (partially healed), left front leg amputation due to dog bite.

It always feels good to see these pets feeling good with happy owners later on down the road and know that for some of them, we literally saved their lives.

So, to answer the question of how many times could it happen…ninety-one.  I attended ninety-one after hours emergencies.  It was great experience and honestly was much smoother and less scary than I had envisioned before my arrival.  I learned a lot.  I stretched my abilities.

Who needs sleep and free time anyways?

The Wild Wild West

It started on a quiet Saturday night.  I attended a dinner with the staff to say goodbye to one of our own.  We enjoyed food, drinks, and laughs.  I went home smiling and soon put on my PJ’s and headed to bed.  I awoke at 1:30 am and I was already on the phone.  Somehow I had answered while still asleep.  I quickly recognised those most familiar words, “Doctora, you have an emergency.”  It of course, was Ingrid.  She sounded far too chipper, and I soon found out that she was still awake, having not yet been to bed.  Within five minutes she was at my door, picking me up in the golf cart to drive me to work.  Biking around in the middle of the night would not likely be perceived as “safe”, even by me.

As we arrived I immediately recognized the male owner.  He is a well known local that makes one of my favorite unique island drinks.  He and his wife had returned home from a late night shift to find their small friendly dog having difficulty using its hind legs.  After a thorough exam, I gave an injection as well as some medications and home care instructions and we were all headed home once again.  By 2:30 am I was putting my head back on my pillow, having difficulty falling asleep after all of the excitement.

CAUTION: Some bite wound photos.

At 6:20 am the phone was ringing again, this time I looked at the screen before I answered, a number was listed with no name that my phone recognized.  As I said hello, the voice at the other end sounded panicked.  I knew her right away.  She quickly explained that her neighbor’s dog had been attacked by another larger dog.  I instructed her to send them to the clinic and rolled out of bed.  Pulling a scrub top over my head and exercising my self imposed special right to wear flip flops after hours, I hopped sleepily onto my bike and headed to town.  The owner met me minutes later with a small fluffy dog having bite wounds on both sides of her abdomen.  All I knew was that the dog who bit her dog was not her own.  I quickly realized that I would need help, and so as I sent the owner home, I called for assistance.  The dog was soon under anesthesia in order to clean and better assess her wounds.

Bite Wounds on Right Side

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When it comes to bite wounds there is often more than meets the eye.  On both sides although it appeared like small punctures, they connected to each other with extensive damage to the underlying tissues.  This needed to be opened up and flushed out before being sutured closed.  After a few hours we had everything squared away.  The dog was resting quietly in a cage and I was heading home by 10 am.

Closed Wounds on Left Side

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I stopped on the way to pick up a few groceries, and as I stood in front of the freezer trying to find affordable bacon, the phone began to ring.  I searched my bag and glanced at the screen, Ingrid.  Sigh.  I answered jokingly, wondering what could possibly be wrong now.  “Gunshot”, she explained sounding concerned, “The other dog involved in this morning’s dog bite has been shot.”  I quickly paid my bill and headed back to the clinic.

I arrived back at Saga to evaluate this large dog.  By all reports from all peoples I met, the shooter was yet a third party, but of course that was for the police to sort out, not me. Unfortunately, many hours had passed since she had been injured and no one had noticed until now.  She had been given an injection for pain and we now started emergency IV fluids.  Her heart was racing and she was covered in blood.  We began washing her down to find the location of her wound and soon found a single bullet hole entering her abdomen from the side.

Bullet Hole into Abdomen

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This was obviously not an ideal situation even in the most advanced of clinics.  This was a dog who desperately needed a blood transfusion and surgery and  was not likely stable enough for anesthesia.  We got her to a point where we thought it was best to open her up and explore her wounds.  As I cut her belly open from the midline I was greeted by a sea of blood.  Not having any suction here we began to use sterile towels and gauze to find the source.  Quickly I identified a dramatic hole in her small intestine, but could still hear air escaping and smell a foul odor.  Eventually I found a second area with multiple holes where the small intestine meets the colon at the area of the cecum (a small organ that dogs don’t have much use for now through evolution, but animals like horses and rabbits need for digestion).  This meant that mixed in with the blood in her abdomen was feces.  I took a moment to evaluate the entire situation in my mind.  I took off my gloves and asked for the phone.  I explained to her owner the extent of her injuries and my recommendation for euthanasia.  As he agreed with me to go ahead and let her go, sadly, she died on her own.  Although my decision was vindicated, I felt saddened at what she had been through.  What we had all been through.

Finally I arrived back home after 2 pm and put myself back to bed.  Over the next week the fluffy dog with the bites returned to the clinic for a recheck and although her right side was healing perfectly her left side was forming a draining abscess due to the bacteria in the dog’s mouth that bit her.  Despite antibiotics right from the start there was infection and some of the skin was dying.  We decided to hospitalize her for care, using additional antibiotics and honey bandages as well as removing dead tissues as we went along.

Healed on right, Infected on Left

I continued this type of treatment for a week until I felt that I could again make an effort to close the wound.  Soon we went back to surgery and I opened up any remaining pocket, placed a drain to allow the fluid to escape, and closed her up again.

Wound Closed Again, Now With Drain

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After five more days of maintaining the drain we were able to remove it.  Eventually her stitches were also taken out, but frustratingly a small area in the middle of the wound was open. I started honey bandages yet again to encourage it to heal in on it’s own.  It had been three weeks since the bite happened.

Wound Almost Healed

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Finally She Can Go Home!

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In the end, two dogs survived that day of emergencies, one did not.  As I conferred later on with one of the ladies involved on that fateful morning, she said to me in reference to the day’s events, “It’s like the wild west.”  Indeed.

Oh Belize, It’s Almost that Time

It’s hard to know even where to start, but my time in Belize is coming to an end.  My year of crazy adventures and even crazier medicine and surgery has almost come full circle.  Working for a non profit shelter in what is technically a third world country does not take care of things like student loans and retirement, and so I knew that this ride would not last forever.  It’s hard not to get emotional, because despite the lows, there have been immeasurable highs.  Despite the sweating, the muddy feet, the endless stream of dogs who can’t seem to keep their bandages clean and dry no matter how many times that I swear their leg will fall off and I pull out my hair and….I digress.  Like I said, it’s going to be hard to say goodbye.

Belize is this tiny country that has taught me so much.  The things I have learned have ranged from medical, to language, to cultural/local, to so much about myself.

Medical

When I think back I’m not even sure what I thought this would be like.  I knew what I would have to extend myself medically and be pushed to my limits.  As it turned out, after a short time, I was left as the only vet on an island of 13,000+ people for the next six months.  If I couldn’t do it, it wouldn’t get done.  So I tried.  Hard.  I learned how to spay dogs much more efficiently than I had ever before and got good at this.  I learned how to remove legs and toes without wanting to run and hide (almost).  Over time I realized that tick fever (ehrlichia) has about twenty different and unrelated presentations (note, when Ingrid whispers tick fever, listen).  I started to recognize ringworm from across the room.  I attempted to perfect my physical exam, as many times it was the only “test” available.  I learned how to do house calls, how best to perform home euthanasias, and did the first of many after hours emergencies of my career.  I figured out how to heal bite wounds, hit by golf cart wounds, gunshot wounds, run over by taxi wounds, machete wounds, and unknown wounds.  I bandaged and sutured and bandaged and sutured through work days and evenings and weekends.  I learned to “make do” times a million and to never waste even a single gauze square.

Language

The short version is that those of us that only speak 1 or 2 languages basically suck.  I would strongly advise all children of the world  be exposed to multiple languages, because we North Americans are sheltered and deficient in our multi-lingual skills. Officially Belize is an English speaking country.  This used to be a British dependency.  Most born and bred Belizeans will speak Criol to family and friends and are fluent in English and many speak Spanish.  Some know Garifuna and Mayan languages as well.  Many islanders, however, are first or second generation immigrants from other nearby latin countries, all of whom speak Spanish.  I grew up speaking English and French.  I started to learn the basics of Spanish online before I arrived, and I mean very basic.  I quickly realized that at least eighty percent of my clientele would prefer to, or only could, communicate in this language.  I got Ingrid to start teaching me, we made a list of three words or phrases on the clinic white board right next to the list of patients and who needed their bandages changed.  Once I had mastered them we changed the list.  I listened carefully every time clients and staff were talking to each other, and I started trying to use my new words intermixed with English words in sentences until I could start to string multiple words together.  I got laughed at, I laughed at myself, I made lots of mistakes.  But people noticed, they smiled, they appreciated my efforts and encouraged me to continue. By month eight I was able to travel through Central America with my non-spanish speaking sister and get by.  Learning a new language as an adult is hard, my grammar is terrible, but I feel proud for trying.

Cultural/Local

Things in Belize happen in their own time.  I had to let go of my frantic need to be on time.  One of the most common phrases here is, “Right now.” This actually translates to, “I’ll do it in a few minutes when I have a chance but not immediately.”  Life got easier when I figured that out.  It turned out that the world does not spontaneously combust when things happen in a more relaxed timeframe.  Many things have to be done by hand or in person, and that means waiting.  Get used to it.

Belizeans are friendly, you just have to try.  In my experience the people who live here are more reserved and private at first,  but always extremely respectful of the doctor.  After a few visits once clients got to know me, they got more relaxed, saying hello and joking with me.  I learned while on many outdoor morning runs that if I smiled, they smiled.  If I said good morning, I got lots of kind responses.  At my Crossfit gym I soon felt like one of the group.  It just took a little time.

Buying food here is not a one stop shop.  It can take visits to 3-5 stores to finish buying eggs, bananas, meat, vegetables, and dry goods, depending on what you need.  I also learned not to often go out looking for a specific fresh item, it’s better to keep an open mind and buy what looks good.  Living on an island means that sometimes nothing looks good.  I have eaten more wrinkled vegetables than I can count.  Things that I would have thrown out in the past are mostly fair game.  Expired items mean half price, and that’s like finding gold!

My favorite Belizean food is conch ceviche. Conch is the big pink shell that you place to your ear to hear the ocean…and it’s delicious mixed raw with lime juice, tomato, onion, cilantro and spices, scooped up on a tortilla chip.  I’m going to miss rum punch too.

I can go anywhere and do anything on a bicycle.  Enough said.

Myself

Hmmm, I think this will take more reflection once my time here is done.  I know I can be a lot braver than I thought.  I can live in a tropical climate with no a/c.  I can easily go without real shopping, fast food, going to movies, and buying “stuff” for months on end.  I learned to appreciate side trips to Mexico.  I can get a chain back on a bike and bathe without running water as needed.  Perhaps I have more skills in areas both veterinary and otherwise that I never gave myself credit for.

I think as vets, most of us can be pretty hard on ourselves.  Wondering if we are making the right decisions or doing a good enough job.  For me, being left to my own devices for a year with close to no input on thousands of cases was a challenge.  Ten years of experience came in very handy.  I am so thankful to my colleagues back home who answered my pleas for help from time to time.  It also turned out that emergency on call was not as awful as I supposed it might be and I could survive it.  The positive feedback from the community fueled my  energy to continue on.

So, I know that I will look back on my year in Belize with fondness and amazement and laughs.  My blog has been a way to keep track of many stories and events, much like a diary.  I have a few more blogs to write and post in my remaining time here, and then I will take a break.  I plan to visit my homeland of Canada for the upcoming holidays, and then I will move on to my next opportunity as a small animal vet in Doha, Qatar, a tiny oil rich country in the Middle East.  I have had a few people ask me to continue on writing even after I leave Belize, so I will see where things take me.  I am so grateful for those who have taken the time to follow along.

 

resumepic

Saying Goodbye

I am often reminded that I am a part of a profession which so many people desired to do when they were young.  I have had hundreds of clients, friends, and acquaintances over the years tell me that they “always wanted to be a vet”.  To be a vet is often to be a trusted and kindly regarded professional member of a community.  This sentiment makes me proud.  Often though, the comment above is then followed by  “But I could never put the animals to sleep”.  Oddly enough, “Can you put animals to sleep?” was not a qualifying question on any test, assignment, or interview to get into or pass 8 years of university. It is unlikely the whole reason why a person did not pursue this profession.  Someone once told me, when faced with this comment, that they respond “Yes, I’m a cold blooded killer.” but somehow I’ve never had the guts to try it out.

Euthanasia is one of the most  misunderstood parts of this job. It is by far NOT the worst part of my job.  There are vets and support staff that work in places where high numbers of healthy pets must be put down (ex. overcrowded shelters) and that can definitely be emotionally taxing and damaging.  For me, the worst is not being able to fix a twelve week old puppy run over by it’s own owner by accident, the worst is seeing a three year old dog dumped at the shelter because it has bad skin, the worst is opening the crate of a cat that hasn’t urinated in three days only to find it already died in the waiting room.  Even worse is having an owner repeatedly refuse euthanasia, preferring to allow the pet to suffer to death.

For most veterinarians euthanasia is reserved for those at the end of their natural lifespan or who are in pain and are suffering. If I allowed myself to become emotionally involved every time, well, I would have burnt out and walked away long long ago.  There are times, especially around the holidays, that I have been asked to euthanize up to five animals in just one day.  Other times that I have not done it for weeks.  That’s not to say I don’t care.  I care very much.  I have empathy for almost every client who comes for euthanasia.  I try to remember that although this is a normal day for me, this is often one of the worst days of an owner’s life.  Likely a day that they will literally remember until they die.  They will remember what I say, what I do, how I act.  I try very hard to make these memories a little easier.  Of course there are those where I get emotional, sometimes a pet I have fought long and hard to save, sometimes one that I have failed to save despite great effort, sometimes an owner that just pulls at my heartstrings.  It’s ok to be sad, just not to be sad every day.  It’s my job to be strong, to be in control, to provide reassurance.

Here in Belize I have had my fair share, some old, some young, some stray, some owned.  It puts me at ease knowing that when the injuries are too severe, or the disease has won, that I have this option to end their suffering. The culture of dog ownership here is different than in north america, but it is also changing. Many pets are loved and cared for but still have a job to do, such as protecting the house and property.  Even owners that try to act tough are still moved emotionally when it’s time to let go.  Most people here choose not to stay, they say goodbye and let us look after the rest.  I’ve learned over the years not to judge.  You can stay, you can go, everyone chooses for their own reasons.

Many here (especially expats, but not all) have asked for home euthanasia, something I had never done.  This had me on edge at first because it puts me in unfamiliar surroundings, but for many it is an easier emotional or logistical option.  I’ve kneeled in the dirt, sat on porches, crouched on kitchen floors, and perched myself in front windows with tropical breezes off the ocean all to let owners say their final goodbyes at home.  It’s become a regular part of my job here.

It is always hard to decide to say goodbye to a pet.  We are often guilty of waiting too long because we love them so much.  We have concerns of not knowing when is the right time.  We have sadness about letting go.  I know, I had all these feelings when my own cat Gator was dying of kidney failure at the age of ten.  He was my first real pet as an adult.  I feared what all clients fear.  But when the day came, I was thankful that I was able to let him go.  He deserved at least that.

Gator

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So, to answer the question “I just don’t know how you do it?” I do it out of compassion, it’s my job.

A Touch of Honey

So if you know me, or are getting to know me, you’ll quickly realize that my style of vet medicine does not include too much in the way of “natural” remedies.  I’m more about scientific proof than word of mouth.  So, it may seem odd to some that I have used honey more times in the past 6 months than in the previous 10 years combined!

CAUTION GRAPHIC PHOTOS AND SOME NAMES HAVE BEEN CHANGED.

What, you will ask, have I been using all this honey for?  Is she feeding dogs sweetened hot tea?  The answer is….wound care.  There are records of honey being used for this purpose as early as 2000 B.C.  It has been used for years in human medicine.  Although there are a variety of topical products and medications that are used in bandages for open wound management, honey is something that is relatively cheap and easily accessible here in Belize!  Granulated sugar is also an option, but we are lucky to have real home grown honey from the mainland right here.

Belizean Honey

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Honey has antibacterial properties with no signs of bacterial resistance, it decreases swelling, helps tissues granulate (heal in) faster, and makes dead tissue fall off quicker.  In this blog I will go over three cases where honey played an integral part in successful wound treatment.  All were very satisfying but the third case is perhaps my favorite as I grew an attachment to this patient and it ends in typical Belizean fashion.

Olaf

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Olaf actually made it into an early blog, he had been brought in by his owner’s children having been run over by a golf cart.  He was ridden with ticks and had wounds on both front legs.  On the right side the tendons by his wrist (carpus) were showing.  This was my first case of serious open wound here at Saga Humane Society.  As I contemplated what to do, I asked my boyfriend to run to the store to look for honey.

Olaf’s Worst Wound

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After multiple days of medications and applying bandages full of honey, the wound was no longer infected and the tissue was healthy enough to be closed surgically.

Olaf’s Healed Wound

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Sophy

 

Sophy was brought in by her family.  She had been wounded a week prior and they had been trying to get her to heal at home.  I could see the telltale  yellow stains of iodine on her fur.

Sophy’s Hind Foot

Under deep sedation Ingrid clipped and cleaned the wound and found it to be very infected.  Her fifth metatarsal bone (these are the bones between the ankle and the toes) was also broken and sticking out.  I removed the piece of fractured bone knowing she’d be fine without it.  I started her on antibiotics and anti-inflammatories by mouth and applied a honey bandage.  I knew that there was not enough loose extra skin to for me to ever close this wound with surgery.  Every couple of days we would check the wound and I would trim the tissues, I also put in some temporary tension sutures to encourage the wound to come together.  It started to look much healthier.

After a Few Honey Bandages

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Sophy stayed at Saga during this time so she could not get into trouble!  As the wound got much smaller we finally removed the bandage to let it air out.  After 2.5 weeks of treatment, she was ready to head home.

Sophy Healed

Blackie

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Blackie is a senior dog.  I first saw him when I was in the community doing  spay/neuter with a large volunteer vet group in the San Mateo area.  The clinic was closed that day so his owner brought him to see me in the field.  He was worried as Blackie had run away for five days and come back with some punctures and swelling on his left chest.  I evaluated the wounds, which were infected and draining, and gave the dog antibiotics and anti-inflammatories.  As requested, he came to Saga to follow up days later, at that time the hair was beginning to fall out, but Blackie was doing well and we continued the medications.  I did not have the foresight to know what was to come.

A week later, Blackie came in for his scheduled recheck.  His owner was smiling and was still giving the medications, although Blackie had gotten loose and left home for awhile once again.  I could not yet see how it was doing.  He said the wound had gotten a little bigger so he was a little worried, he was still smiling.  That’s why my jaw dropped when I actually saw what had happened.

Blackie’s Left Chest Wound

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I was a little lost for words at first.  The overlying skin had all died and sloughed off.  The wound was over 18 cm long. I knew Blackie would need hospitalization so I could sedate him, clean the wound, and do regular honey bandages.  I applied honey to the wound and then wrapped the bandage around his chest to keep it in place.

Bandaged and Tshirt

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As much as I grew to love Blackie, he was never my biggest fan.  He tolerated me but I could only talk to him, never pet him.  Still, that old man face, I just couldn’t resist.  Over the course of a week the wound looked much healthier.

After Honey Bandages

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Finally I decided it was time to try surgery.  There was a lot of tissue with a weird cobblestone consistency that needed to be removed.  I only wanted healthy tissue left behind after closure.  I then sent him home.

Wound Closed

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Blackie was a little late coming in for his suture removal.  He had been at home during this time and I anxiously awaited the results.  The owner had not called with any concerns.  When he finally showed up again his wound was doing well but was not perfect.

Two Weeks After Surgery

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I removed the remaining sutures and added some more oral antibiotics and a topical cream.  I sent him home with instructions to return in a week, sooner if needed.  I knew that this was unlikely to happen, but I felt fairly confident that the wound would finish healing.  A week passed, then two.  I was sad that I had lost Blackie to follow up.  I would not get to see the final result, having worked so hard to achieve a good outcome.

Then, last Monday it happened.  It had been a few weeks since I’d seen Blackie.  It was my day off and I decided after the gym that I would ride my bike up north a for awhile.  To get there I have to pass through town.  As I biked alone down the north end of middle street, I approached a thin tall boxer mix from behind.  He was sauntering along alone on my left, a little stiff with arthritis.  Somehow I knew in an instant.  I passed him and slowed, I looked back at his face…Blackie!  I jumped off my bike, he didn’t run, but he didn’t slow down either.  I tried to talk to him softly by name as I grappled with my bike while frantically trying to get my phone out of my bag.  I followed him up a side street.  I’m sure the local ladies going about their morning business thought I was a lunatic.  Finally I got him to stop briefly.  Again, we have a “I don’t touch you without a muzzle or sedation” kind of relationship.  I got a good look from a few feet back and was satisfied that his wounds were gone.  The honey bandages had played a huge role in this success.

Blackie Out and About

As he walked away briskly I smiled to myself.  Blackie was on the lam once again.

 

A Toxic Sleepover

It was a Thursday morning, I was tying the last sutures of a dog neuter just a few minutes before noon.  Ingrid was answering the phone and I was only half hearing what she was saying in the hallway.   Then she walked in and turned the phone to speaker, the lady on the other end was clearly an American and from the south.  She was in the midst of spelling a word I had never heard and explaining that her dog had eaten some of this cream.  Yelling through my surgical mask in the direction of the phone I asked her a few basic questions.  She explained the cream was for her husband’s skin and now the dog had vomited three times.  Ingrid smartly asked when the dog had done this, the answer came as 7:30-8 am.  We then came to learn that by boat and then taxi they lived thirty minutes from the clinic.  Ingrid asked them to come in at 1 pm, less than an hour away, and I raced home for lunch.  Little did I know that this patient was going to stay with me forever.

I arrived back at Saga and was quickly followed by Missy and her two owners, a retired husband and wife who have lived here for many years.  She was a 2 year old, chocolate colored, female spayed spaniel mix.

Missy

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Missy was fairly quiet with a normal examination.  That morning she had gotten up onto the back of the couch then on to a table to steal a tube of medical cream.  She had chewed on about 1/8 of the tube and eaten an unknown amount.  This was the very first time the owner had ever used the product. The product was Efudex (fluorouracil) 5% topical.  It is in a class of drugs called anti-metabolites.  It is a very expensive cream used topically (on the skin) for cancerous and precancerous growths in people and works by blocking the growth of abnormal cells.  I had never heard the brand name and had never had a dog eat it.  I quickly sat down to find out what it was and to search the Veterinary Information Network (VIN) to figure out what to do.

Efudex

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It looked like from my research that the drug would initially cause vomiting and diarrhea, if enough was consumed (and it doesn’t take much) then next would be seizures, if the dog survived that then days later the bone marrow could be suppressed leaving the animal prone to infections.  I read a few postings that stated that if it was bad, the dog would likely be very ill within the first hour.  This gave me hope, Missy had vomited three times about three hours into the ordeal and at this point, six hours later, she had no seizures.  I quickly wrote down a treatment plan.  We started some fluids, anti-nausea medication, and stomach protectants and had her sit in another room with her owner for observation.  She sat there all afternoon and nothing happened.  Eventually I let her go home with a number of medications from antacids to antibiotics.

Minutes after leaving Missy’s owners called.  They had stopped in town and she had had a weird episode of collapse.  They came right back.  It was about 4:30 pm.  She returned to the clinic and I could tell she was off.  What they described was seizure-like and so I gave her some IV valium, which is often used to treat an active seizure.  I knew that I would not have enough of this drug for a dog with repetitive seizures.  I made a quick call to a local MD and he generously agreed to sell me some more.  I wrote down the prescription on a sticky note and sent the gentleman owner off to pick it up.

As I was preparing to put in an IV she seized.  It didn’t last long and she recovered on her own.  I gave her some more valium, but instead of becoming sedate she was hyper and whining.  This was constant.  I spoke to her owners and advised them that at this point I’d need to hospitalize Missy  overnight.  In my mind I wasn’t sure yet how I would do that, but I knew I’d just have to make it work.  I sent them to a local hotel for the night so they would be close by.  Ingrid helped me get her IV fluids going and closed up the clinic.

Missy On IV Fluids

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My boyfriend was kind enough to bring me food and pyjamas, a dear friend Sandie came by with the fanciest air mattress I have even seen!

Getting Ready for Overnight

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Missy continued to bark and cry, she was very upset.  I assumed this was due to being in a crate and her parents leaving.  I read up more on this toxicity.  I have limited drugs to choose from and limited equipment by which to give them.  I decided to give her just a touch of sedation so she could rest.  She slept silently for over an hour, but then it all started again.  I pilled her with oral medications, and she seized briefly each time from the stimulation, always recovering.  I realized over time that valium had no effect. Around midnight I fell asleep.  At 1 am I awoke to Missy barking/whining loudly.  I did more research.  I lacked the correct injectable medications and pumps to potentially block her seizures.  I decided to do it orally instead and gave her a high dose of phenobarbitol, with the pills she seized, then recovered.  Later in the night she seized again trying wildly to bite me in her confusion, and ruined her IV.  I decided to leave it until morning.  I sedated her once again.  I realized that the whining and barking was actually part of the poisoning, fluorouracil can cause not only seizures but hysteria as well.

At 5 am I awoke to silence.  I knew it had been long enough that the sedation would have worn off.  I prepared myself for the worst, but indeed Missy was still alive.  She was clearly looking quite drugged, as the phenobarbitol had now been digested.  But even with a little stimulation she started to cry, and then rest again.  She did not seize.  I knew from my research that it was a time game.  Most cases would have seizures for 1-3 days and then spontaneously would be ok.  Most, however, were in a drug induced coma for this duration of time and this is something I could not achieve here.  If she lived through the seizures then we could deal with the bone marrow issues if they arose.  At 7:30 am Ingrid arrived to take my place.  I gave her a briefing and then quickly took off for home to shower and eat my breakfast.  I had already updated her worried owners.  I was exhausted.

As I stood in my bedroom leaning over the dresser, trying to apply makeup and soak up the last bits of coolness from the overnight a/c the phone rang, it was Ingrid.  There it was,  twenty-five hours after she ate a small amount of Efudex cream Missy was dead.  She had seized and passed at 8:31 am.  And I did what I rarely ever allow myself to do over a patient.  I cried.  I cried because I knew how much they loved her, I cried because I tried so hard, I cried because I knew the guilt that would ensue.  I was mad because I had not yet given up, not yet decided to let her go.  I was reminded that I don’t always get to decide.

I got back on my bike and rode back to work to start the next day.

I wrote this story with Missy’s owners permission.  I did so because many people know the classic dog poisons (chocolate, rat bait, garlic, Advil, lillies) but they may not know some of the others (xylitol sweetener in gum and peanut butter, raisins, grapes) and certainly don’t often think of human topical medications as being a danger.  The drug that this dog ate is horribly dangerous if eaten/licked by a pet.  The owner was given no warning by their doctor.

Other common topicals like over the counter steroid and antibiotic creams can cause stomach upset if licked or eaten.  Prescription hormonal topicals like estrogen creams can be dangerous to pets when they eat them or even rub against the owner who is using them on their arms etc.  Pets often like the taste of things like NSAID (non steroidal anti-inflammatory) creams that owners use for pain and swelling, these include drugs like Voltaren (diclofenac) and  flurbiprofen, pets may lick them off the owner or eat the tube.  These can absolutely cause death. There are others such a zinc creams for diaper rash and vitamin D creams for psoriasis that cause severe side effects if consumed.

I realize in retrospect that once the seizures started I could never have saved Missy.  The dogs that present for eating this product die at a rate of 95-100%.  Those that live are usually in a drug induced coma for days.  Investigating this toxin and treating her, though, taught me a lot.  Missy’s case will help me in the future.  I will certainly never forget it.  I’m glad that I was naive enough to try.

Happy Missy

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Please alway use caution and keep all medications far out of reach.  Do not allow dogs or cats to rub on or lick areas where you have applied a topical medication to yourself.