Emergency Vet Stories

Over-the-Counter Medications for Pets – Part 2 of 3

This is a continuation of Part 1 which can be found here. Please read that post first. I’m also supposed to tell you that paid links in this post help to support this blog. I also need to buy chocolate, so help a girl out!

Anti-histamines

When it comes to anti-histamines, you have to be very careful to pick the correct product. Many of these drugs are sold in a variety of different combination formulas. You’re going to want to stick with those that only list one active ingredient. Anything that states it’s for congestion, sinuses, multi-sympom relief, or cold and flu probably contains ingredients that are toxic to dog or fatal to cats. If the product has a -D in the name, you can’t give this to your pet (example = Claritin-D).

Benadryl (diphenhydramine)

Benadryl is an anti-histamine medication that is commonly used in dogs and occasionally in cats after having an allergic reaction, for seasonal allergies, for mild sedation, or as part of a treatment protocol for mast cell tumors.

**The two main adult strength Benadryl options.**

Diphenhydramine acts on the histamine receptors in the body to counteract the physiologic response that results in the symptoms of an allergic reaction. Some dogs/cats may experience mild sedation because the drug also affects these receptors in the brain. Uncommonly, some pets will become hyperactive after this drug.

Benadryl is available in liqui-gels and tablets of 25 mg. Children’s Benadryl is also available and comes in both a liquid or a chewable and flavored tablet. The Children’s Benadryl tablets are large and grape-flavored which might make them more challenging to get into your pet.

Topical versions are also on the market, but pets tend to lick these off so they aren’t recommended as frequently in dogs or cats. Make sure to avoid any combination products for congestion and sinus pressure since these contain drugs that might be toxic to your pet.

Many generics and store-brand versions of diphenhydramine are on the market, usually labeled “Allergy Relief” or “Sleep-Aid.” Some of these come in 50 mg sizes, so read the labels carefully.

**Examples of generic diphenhydramine.**

Outside of the United States, Benadryl may contain a different active ingredient than diphenhydramine.

Other Anti-histamines

Since allergies are a common problem in people, numerous other anti-histamines are on the market over-the-counter. Many dogs or cats require prescription-strength medication if they have allergies. Anti-histamines don’t always work well for them. But if your vet does recommend trying them, here are some of the options.

Zyrtec (cetirizine) is available in a 10 mg tablet as well as generics. Claritin (loratadine) comes in a 10 mg tablet or chewable tablet. Children’s Claritin comes in a liquid or a chewable 5 mg tablet. Allegra (fexofenadine) comes in a fairly large 180 mg tablet or a Children’s strength 30 mg tablet. Generics for both Claritin and Allegra are also plentiful.

What other anti-histamines have you used in your patients? Do you think they work as well as the prescriptions like Apoquel? Let me know in the comments.

Part 3 is coming soon!

Over-the-Counter Medications for Pets – Part 1 of 3

My last post discussed pet medications and how to best communicate with your vet about whatever your pet may be taking, especially in an emergency. I had mentioned that it isn’t a good idea to give an over-the-counter medication for people to your pet without speaking to your vet first.

Sometimes your vet WILL tell you to give an over-the-counter drug. This post isn’t intended to take the place of that, but is intended as a resource once your vet has given you that guidance. I wanted to provide some information so that pet owners have more confidence making sure they have purchased the right product and to give some basic information on what these drugs are for.

Names and Labels

One initial point of confusion is that most drugs have more than one name. The actual drug in the product has a chemical or generic name. This is not usually what you will see in big print on the packaging, but rather in smaller print in parentheses. It is also what will be listed under the active ingredients. The brand name or trade name is what the manufacturer has called their version of the drug. You might find several brands of the same drug available over-the-counter.

Paid links help to support this blog, as well as my chocolate habit.

**The active ingredient has to be listed on the packaging. If you aren’t sure that you have identified the correct product, you can look for this section.**

The brand name is outlined in orange above (Benadryl) and the generic name is outlined in green (Diphenhydramine HCl 25 mg). Most doctors are going to just refer to this as diphenhydramine and not include the HCl part. The HCl is a chemical abbreviation and indicates that this is the salt form of the drug and is simply how it has been prepared. The 25 mg in the example above is the dose. This is how much of the diphenhydramine is in each tablet.

Older drugs, like aspirin, may only have one name. Other drugs may have different names in different parts of the world, like acetaminophen/paracetamol.

With any of these over-the-counter products, the dose that your vet recommends may not be the same as that listed for humans. Follow your vet’s advice and double check with them if you have any questions.

Gastrointestinal medications

Pepcid AC (famotidine)

Pepcid AC is an antacid medication that is very commonly recommended by vets for both dogs and cats. The stomach is very acidic to help in digestion of food. However, sometimes that acid causes problems and needs to be suppressed. Famotidine, the active ingredient in Pepcid AC, decreases the acid production in the stomach by interfering with histamine receptors on the cells that produce acid.

Pepcid AC comes in two strengths – regular and maximum strength. You will need to pay attention to what your vet recommended to make sure you pick the correct strength, although this drug is also extremely safe.

**Regular strength is 10 mg in each tablet. Maximum strength is 20 mg in each tablet.**

Pepcid AC does not come in a liquid formulation. Pepcid Complete is not the same product – it contains some extra ingredients so don’t substitute this unless your vet has told you to. Some dogs and cats can stay on Pepcid AC long-term for chronic conditions.

Other common brand names for famotidine include Zantac and dozens of store brand and other generics. These are usually labeled as “Acid Reducer” or simply famotidine.

The generic famotidine tends to also be available in two strengths, 10 or 20 mg tablets.

Prilosec OTC (omeprazole)

Prilosec OTC is a newer antacid medication that is becoming more commonly recommended by vets for both dogs and cats. Omeprazole, the active ingredient in Prilosec OTC, decreases acid production in the stomach by stopping the cells that produce acid from releasing it to the stomach lining.

Prilosec OTC only comes in one strength – 20 mg. This might make it challenging to dose for small dogs or cats. It is not available in a liquid formulation. All of the products containing omeprazole are a delayed-release formulation. Prilosec OTC is a tablet, while other brands may be capsules.

Other common brands of omeprazole include Zegerid OTC and numerous generics and store brands. These are frequently labeled “Acid Reducer” or “Treats Frequent Heartburn.”

Tums (calcium carbonate)

Tums is an antacid that is used more commonly as a calcium supplement in dogs than as an antacid. Nursing mothers and dogs with conditions of the parathyroid gland may require this supplement.

Tums is available is a dizzying number of formulations, flavors, and strengths. It is simplest to look at the basic mint or fruit-flavor options which come in 500 mg (regular strength), 750 mg (extra strength), and 1000 mg (ultra strength) sizes. The active ingredient is calcium carbonate.

Other products that might look similar to Tums but contain extra ingredients include Rolaids or Phazyme. Don’t substitute these for Tums without checking with your vet. A lot of generics are available, usually labeled “Antacid” or “Compare to Tums.”

**Examples of generic Tums (calcium carbonate).**

Are there other gastrointestinal drugs that you might commonly recommend as a vet? Let me know in the comments.

Part 2 coming soon!

What Medications Does He Take?

Have you ever had this conversation as you’re trying to get a history from a client?

“What medications does Rocky take?”
“Oh he’s just on a vitamin.”
“Which vitamin is that?”
“Oh, you know. The one in the brown bottle.”
“Do you know the name of it?”
“It’s… Life Gold. Is that a good one?”
“I have no idea what that is.”
And now the client thinks I’m an idiot.

While this isn’t a daily occurrence, it happens more often when you’re working in an emergency setting and don’t have access to any of the pet’s medical records from it’s regular vet office.

Clients sometimes don’t feel like they need to mention everything a pet is taking. The answer to my question about medications might get them to hand me a bag of pill vials. Or they might swear that Rocky doesn’t take anything only to later tell me how he has Cushing’s disease. When I ask if he’s receiving treatment for that, they suddenly remember that he is on trilostane. Long-term medications don’t always seem to register for them.

When it comes to supplements, I have had clients get offended that I’m not familiar with the exact product they purchased out of thousands of pet supplements on the market. Or they think that I should know what it is from the color of the packaging. I’m sorry – if you tell me the name I can google it, but my focus is keeping up on the latest in emergency medicine and not memorizing the names and packaging of all the supplements out there.

Most of the time I don’t care about the supplements. But in a few cases it can help to elucidate other aspects of the history that the client might not be able to relay correctly. Here is another example:

“Well she takes some pills, doc.”
“Are they a prescription?”
“I don’t know. I order them online.”
“Do you know what they’re for?”
“I think she has a kidney problem.”
“Okay.”
At which point, the client remembers that the pills are in her pocket. She pulls out a package of Denamarin.
“So these pills are usually for the liver. Do you think that maybe Rocky has a liver problem and not a kidney problem?”
“Yeah, that was it!”

I still don’t believe everything a client tells me when they seem this uncertain about their pet’s medical history. But it can help to guide my recommendations for bloodwork or in picking which drugs to use for treatment.

One other thing that happens occasionally is that some people don’t seem to see human over-the-counter drugs as medications.

“Is Rocky taking any medications?”
“No, nothing.”
“And he hurt himself playing in the yard yesterday, right?”
“Yes, he seemed to be in a lot of pain so I gave him an aspirin.”

Umm, aspirin is a medication. And now at worst, I have to worry about whether the dose was enough to put him at risk of stomach ulcers or kidney damage. At best, I have to consider whether I can now prescribe a more appropriate canine NSAID for his pain or not.

So what should you do as a pet owner to help your vet evaluate your pet’s medication in an emergency? Here are some tips:

Make sure not to give any medications for people to your pet without asking a vet first.
Know what prescriptions your pet takes and what they are for. Bonus points if you know the mg strength or bring the bottles.
Know what over-the-counter pet products or supplements you give your pet. Bring the bottles or at least know the correct name. These don’t always have a mg strength on the packaging.
Bringing the medication is good! But don’t bring a bag of every medication that your pet has ever taken.
Be able to tell the vet when the most recent dose of medication was given.
If you aren’t the person who gives your pet the medication, have a way to contact the family member who does so that the vet can confirm any details about medications.

Is there anything else that you have found helpful in your practice when it comes to pet medications? Do you recommend specific supplements or keep certain ones in stock? Let me know in the comments!

Please Stop Calling Poison Control

I wanted to elaborate on some thoughts that I put on Twitter earlier this week. First, here is the incident that prompted this:

I had an 8-month-old, roughly 30 pound dog come into the ER after she ate a lot of raisins about an hour and a half ago. Raisins are toxic to dogs – you can find out more about that over here.

This is a very common type of case for ER docs to see. But as with with many toxin ingestions, the client was told to call poison control. I don’t know who suggested this – sometimes the client is already aware of the service, sometimes our front desk staff tells them to call, or maybe the technician who initiates the triage will suggest it.

For most types of toxins, the standard approach is to induce vomiting for a recent ingestion. Then, other treatments may be performed depending on the dangers of the specific toxin. Often the ER doc will examine the pet, induce vomiting, and speak with the client all somewhat simultaneously.

With this dog, I had spoken with the client while a technician counted the raisins in the vomit. The clients had called poison control which then gives them a case number to relay to the ER vet. I called the hotline for current cases and waited to speak with someone.

And I kept waiting and waiting. After 30 minutes on hold I had to hang up – what a waste of time! I had other patients to attend to. And my raisin eater needed to get started on treatment.

So here’s the thing – poison control is a great resource. There are two places that we call: the ASPCA hotline or Pet Poison Helpline. But for the common toxins that ER vets see on a weekly (or sometimes daily) basis, I don’t need to talk to them. I *know* what raisin toxicity does. I already know the recommended treatment.

Even when my own cat chewed on a lily, I didn’t call poison control. There is a standard treatment for this and I’m quite familiar with it.

Once a poison control case number is generated though (and paid for by the client), I feel obligated to call and receive their guidance. So now I’m in a busy ER, often as the only doctor on, stuck on the phone for information that I don’t need. This just delays care and increases wait times.

Now there are times when I’ll have my technicians place the call and wait while I work on other things. But on many nights, they are just as busy as I am. While I wait, I might be able to do a little other work, like review bloodwork on other patients, type part of a record, or *gasp* eat something.

The situation that particularly irks me is when a client just “knows” their pet was poisoned and calls poison control. Poison control isn’t very helpful when you can’t tell them specifically what the pet ingested. Most of these cases aren’t poisoning and after an exam, this is clear.

When might poison control be helpful then? I think there are three situations when it’s great to call:

Uncommon toxins – This is often human medication that we don’t use in dogs/cats, so the side effects and toxic doses aren’t well-known.
High dose ingestions – If a pet eats something common and I know that this is a massively toxic dose and symptoms/side effects are almost certainly going to occur.
Specific toxins – There are a few toxins where poison control may have detailed information that helps to calculate the dose ingested. The first one that comes to mind is xylitol. Poison control often knows how much is in specific products and can advise different levels of care based on that dose.

So please, please stop calling poison control reflexively for every single ingestion of something that isn’t food.

ER docs, have you had this problem? Or do you love poison control unconditionally? Let me know in the comments.

When the Doctor is Sick

We are halfway through Memorial Day weekend right now and I just finished my last shift: today is the first of four days off in a row. Why do I feel so exhausted?

Emergency work is hard. Doctors and support staff work long days, often several in a row. We put our best in because our patients need us to be there. But sometimes we can’t tough it out and push ourselves any harder.

Last night’s shift was the last of three in a row, which by itself isn’t so bad. But I had gone into those shifts after working five in a row with only two days off afterwards. Those two days off might have been enough to recharge, except I spent all my free time catching up on medical records from the last two weeks. Add in routine home things like grocery shopping, sleep, and laundry, and it certainly didn’t feel like I had a break.

The cases last night weren’t that bad and I saw a lot of easy and quick ones. But then with about two hours left, I started to feel queasy.

There are only three general reasons why I won’t come to work: fever, vomiting, or not being able to stand up (from injury to legs/back/etc.). So when my stomach didn’t feel right, I was worried I was coming down with the dreaded stomach flu.

I finished my cases and asked the front desk to refer any others to the next closest ER. We did have to turn away one dog that still showed up that had ingested chocolate. So I left about 35 minutes early and couldn’t help but feel a little guilty about it.

I never did vomit, but I still don’t feel 100% today. Fortunately I’m not back to work for a while and can get some much needed rest.

How sick do you have to be to call out of work or leave early? Let me know in the comments.

The Schedule of an ER Doc

I’ve been a bit quieter for the past few days, both here and on Twitter. That’s because I just started a run of 5 ER shifts in a row as of today. To make this feasible, I had to make sure I had the rest of my domestic life in order before jumping in for a marathon at work. This takes some physical and mental preparation.

First I have to plan meals, go food shopping, meal prep to at least some extent, make sure my scrubs are all clean, and get the house clean enough that it can survive my inattention for a few days. Then I have to slog through more medical records to keep myself from falling even further behind before I create more work for myself. Somewhere in there, I have to fit in some relaxation and exercise while I can because after some long shifts, I won’t have the energy for much of anything but sleeping, showering, eating, and returning for my next shift.

Why do 5 days in a row of work impact ER doctors like this when the great majority of the working world has a 5-day work week? Well in ER, our shifts aren’t ever 8-hour days. I’ve truly never heard of ER docs that have that schedule. I’m currently working 10-hour days, but most places have a rotating schedule of 12-hour days.

However, by working 10-hour days, I’m only working 4 days a week for my normal schedule. And if I went back to 12 or 13-hour days, I’d only work 3 days a week. So while these long shifts can be very hard, they also have the advantage of long stretches of time off. It’s hard on family life for some people as well.

But for now, I’m just going to hunker down, write some more medical records, and try to get some sleep before I do it again for four more days. What is my trade-off this time? I don’t have to work Memorial Day, so I get a four day weekend!

A Groundhog at the Door

So a random dude picked up an injured groundhog from the side of the road last night. He showed up at the door of our ER with it thrashing in his arms and was upset that we wouldn’t treat it.

First, we don’t treat wildlife. We aren’t legally allowed to do more than stabilize it in any case. Then it has to go to a wildlife rehabilitator which means we have to find one who will take the animal.

If the wild animal is seriously injured, I can humanely euthanize it so it won’t suffer. This guy refused that option. So while I understand wanting to save any animal, there is a practical aspect that wildlife also has to be releasable after care.

If it couldn’t drag itself away from the side of the road or from the guy who scooped it up, this poor groundhog was probably in bad shape.

He told us he’d even pay for care, but I can guarantee you he’d backtrack on that once he found out the real costs. Or he’d stop answering his phone and dump the animal on us. I’ve seen how this plays out in the past.

But the biggest factor in refusing care in this case is that they are all considered “suspect rabid animals” as a species in my state, the same as raccoons. I can’t put my staff at risk like that. Didn’t you learn not to pick up wild animals when you were a kid?

So if you do find an injured wild animal at the side of the road, maybe call us first? Or call Animal Control like we suggested? And if you don’t like those options, then at least don’t show up and shove a bloody groundhog up to the glass of our door until it pisses on you.

You Look Too Young to Be a Doctor

Many veterinary colleges are graduating a new class of doctors this month. I thought I’d relate a few stories about learning to be a doctor and how to find your way among all the new challenges these graduates will soon face.

Something that most newly graduated veterinarians will encounter is that client that turns to you and says, “Wow, you look too young to be a doctor!” Now with COVID curbside protocols, that may not come up as soon when you aren’t seeing your clients face-to-face, but once normality resumes, you need to be ready for that question.

First of all, you AREN’T too young to be a doctor. You put the years into your schooling and you graduated. You are ready for this. I was the youngest person in my class and graduated veterinary school at twenty-three. I skipped a grade in elementary school, finished my undergraduate studies in three years, and got into vet school on my first try. So unless you cut another year out somewhere, you aren’t going to be any younger than I was when I was thrown into a challenging internship.

I was asked, “Aren’t you too young to be a doctor?” or some variation on this ALL THE TIME. Usually I looked away, muttered something embarrassing, and went awkwardly back to what I had been trying to say.

After a few years in emergency practice, I realized that my age was rarely commented upon by clients, despite still being in my mid-twenties. Outside of work, I was occasionally asked what high school I went to (hah!). I wondered what had changed, and the best explanation that I can come up with is that I had developed a subtle confidence in how I spoke with clients. Unfortunately, I don’t think that’s going to be something you can fake with clients as a new grad. You’re going to have to give your communication skills some time to develop.

So what is the alternative?

Think about this ahead of time and have your comebacks ready. If anyone comments on my age now, my go-to is to thank them for the compliment and move on with what I was saying. That likely won’t be as helpful if you aren’t already a seasoned veteran in the field.

I like to think about comments like this from the client’s perspective. Why are they saying this? Are they expressing a lack of confidence in your knowledge or skills? Are they impressed that you are so accomplished at your age? Do you remind them of their own son, niece, or grandchild?

If you know that you look young, you can certainly start by acknowledging that to the client. From there, you could take an honest approach, or maybe a more sarcastic one, depending on your personality and the vibe you are getting from the client.

For the honest approach, saying something like, “Yes, I graduated six months ago and I’m so thankful to be able to finally start helping pets.” Turn any possible doubts from the client into positive thoughts by showing your enthusiasm.

You could take this a step further. “The senior docs here have been wonderful in making sure that I always have someone to talk to about my cases.”

If you choose sarcasm, “Yes, I just finished kindergarten last week,” may suffice.

Lastly, I wanted to relate a story about one case I saw as an intern. I don’t remember the details about the dog, but it was old and very sick. I had no idea what was wrong with it. But I spoke with the clients, recommended some initial diagnostics, and figured that I could think more about it later or ask one of the specialists for advice. I told them that I’d call them later that day with an update.

As I was walking them out, they stopped me in the hallway.

“Doc, we just wanted to tell you that you look very young to be a doctor.”

(Cue self-doubt and anxiety here).

“But, we’re so happy to have you as Max’s doctor today. Our niece just graduated from medical school and you remind us so much of her. So we just wanted to let you know that we’re confident to have Max under your care today. Thank you for helping him.”

So to all the new doctors out there, there will be obstacles out there, but with a little thought you can be ready for this one.

The Hardest Question

One of the hardest questions I get asked by pet owners is, “What would you do if this was your pet, doc?”

Why is it so hard to give a truthful answer to this?

Well, sometimes it isn’t so hard because I’ve been in the same situation with one of my own pets. Or the pet is clearly suffering and euthanasia is the only humane choice.

Other times, I really don’t know what decision I’d make. I may have never been faced with a similar medical condition or prognosis in one of my own. I believe that sometimes there really isn’t a right or wrong answer. For many quality of life decisions, the pet owner is a far better judge of this than I can possibly be in the 20 minutes I’ve known the pet.

The hardest time to answer this question though is for those cases where I know the pet owner won’t want to hear my answer. Let’s say you bring in your geriatric cat who has been losing weight and not eating well for 3 weeks. This cat is extremely thin and has now been vomiting for the past 5 days. At the hospital it is too weak to stand, looks pale, and has obvious jaundice. The prognosis isn’t good, and I don’t know if the cat will even survive the night.

I present the options for advanced hospital care and a big workup, which will be expensive. The client doesn’t have a lot of money they can spend but they really need to save their cat.

“What would you do if this was your cat, doc?”

“I would have brought my cat in for care 2 and a half weeks ago.”

Yeah, I bet that answer wouldn’t be appreciated even if it’s true.

After a Shift Ends, the Paperwork Begins

Emergency veterinarians at most hospitals work a 12-hour shift, give or take a few hours. That time is generally all spent seeing patients, managing in-patients, doing procedures, or working on other doctor-y things, like returning phone calls, calling about patient test results, updating clients about hospitalized pets, or writing hospital discharge instructions.

Once all of the urgent patient care is complete and the doctor is done for the day, there still looms a pile of paperwork to do. For every patient that the doctor sees, medical notes have to entered, either as hand-written notes, or in an electronic medical record system (EMR).

My stack of notes from the past week. All the scribbled shorthand must be transcribed into something readable.

Fortunately, my practice uses EMRs, so I am saved from the ongoing hand cramps of my early career. But that still leaves a lot of work left to do. If I see 15 patients in one shift and each EMR takes 10 minutes to write, that leaves me with 150 minutes, or 2 and a half hours of additional work. For cases that required more complicated discussions, abnormal test results, or any procedures, that chart will take longer than 10 minutes.

For a doctor in general practice, many of the appointments will be for routine preventative care. That’s vaccines, flea and tick prevention, wellness bloodwork, etc. So when most of your patients are going to be normal and need a predictable set of items completed, you can work more from a template and just delete items that don’t apply. These records are easier to write. But in emergency medicine, these types of cases are less common.

Writing a thorough medical record is important. It helps to communicate information to the next veterinarian to see the case, whether it’s a pet in the hospital or the local vet who does the follow-up care.

Your records will also save your butt if you ever have to face a board complaint or lawsuit. I have had one board complaint brought against me in my career and it was thrown out after initial review. My attorney complimented my records and told me he didn’t think there’d be any problem, and he was right. The police report filed against the client probably helped as well (but that’s a story for another day).