Argh! Bedbugs!

I am working my way through my second interaction with bedbugs. The first time I encountered these savage little blood-sucking bastards was way back in 1995 or so. There was no question then that I picked them up on a trip to Thailand. This time, they came back with me from a hotel in Fayetteville, where I stayed for two nights for an agility trial. The trial was in mid-March, so it took a while for them to make their way from the travel crate containing dog bedding in the garage upstairs to the bedroom.

Over a period of three nights, these disgusting pests ravaged my legs and arms. The pustules don't always appear right away so it took that long for the full horror to be exposed. Bedbugs often leave bites in short tracks. And the itch gets worse over several days. I had many dozens of bites on my legs, fewer on my arms. I will definitely have some scars from this.

The solution now is the same as it was in 1995. Wash everything that can be washed, and dry on high heat. Wash it all again just in case. Tear the bedroom apart, moving all the furniture away from the walls. Vacuum, vacuum, vacuum. Empty canister after every vacuuming, carry the trash bag to the can outside, and spray the canister with alcohol.

Then I applied diatomaceous earth. I piled that stuff up along the baseboards, rubbing it into the carpet. I rubbed it into both sides of my futon and all of the bed frame crevices. I let everything sit for a week, vacuumed it up, and repeated. Make sure you wear a mask when using diatomaceous earth (we should all have plenty of masks these days) since breathing those tiny silica particles is not good for you.

After two weeks, I decided to move back into my bedroom. Sadly, I may not be done, since I got a single bite on my knee two nights ago. I will have to move back downstairs tonight, and treat the bedroom again this weekend. But I'm just as persistent as bedbugs, and I will prevail.

Notes From A Pandemic

I was chatting with the director last week. Even before COVID-19 changed everything, we would chat 3 or 4 times a week, and that seems to be a habit in which we continue to indulge. Often, the director describes some proposed change to lab activities, and asks me, on the spot and with no preparation or notes, to riff on what I see as all of the consequences of that change, good and bad. This is not to say that he asks me for advice, as the process is not that direct. He asks me for my perspective. Even so, I know that he has modified his arguments for and against proposed changes based on what I say. I'm just coming up on my tenth month at the lab, and as a supervisor, I'm a relative newbie. But I think that he appreciates that I've been around the block a time or two. And my newness can be beneficial since I look at things with a fresh eye.

While the central topics of these chats are nearly always some administrative or technical process at the lab, we usually spiral out into fairly wide-ranging discussions of politics and science. We tiptoe around religion and similar landmine topics.

We of course talk about how the pandemic has been affecting us personally. With some exceptions, mainly administrative employees who can work from home, all of the technical employees have been coming in to the lab every day. Back in early April, when the stay-at-home measures were being widely implemented, I mentioned to him that it made me anxious to be the only person on my street who was going to work--daily I was driving past all my neighbors who were out walking or gardening or playing with kids. He said, yes, I know, when I get up in the mornings, my house is the only one in my area with lights on inside.

So last week, he mentioned that he had been feeling... he hesitated, so I said, feeling an existential dread? And he said, yes, of course, that (crazy how we both just rolled right past such a huge elephant in the room), but that he'd also been having real trouble focusing on projects that required planning for the future. We decided that the best word to describe this was "viscosity."

I told him that I had been feeling the same thing. There are a bunch of quality management documents that need my attention and even though I have time set aside for that type of activity, I couldn't seem to get to those tasks. It seems easier to focus on small activities of the moment--spending more time examining the biopsy submissions, spending more time reading up on a specific disease I found in a necropsy. We were both feeling dragged down, unable to tackle projects that required us to envision where we wanted the lab to be in six months or six years.

We decided that we shouldn't be too hard on ourselves. If we (we personally, and the royal "we" of the lab) got through this pandemic without making any big mistakes, that would be okay.

Azza Goes To The Vet!

Azza has always been a bit of a problem when it's time to go to the vet. She has to be muzzled, and I restrain her for procedures rather than risking her biting a vet tech. To my knowledge, she hasn't had her temperature taken in years. We have managed to get blood from her though. And vaccinations are routine. I always take treats, but with variable success. Sometimes she is just too stressed to take treats, other times she hoovers them up.

Azza has a protein allergy that cropped up in 2014 or so. I've tried numerous select protein and hydrolyzed diets, but the only one that keeps her gut calm is Royal Canin's Ultamino. Made from chicken and duck feathers, it is the only allergy diet that doesn't contain any protein sourced from animal flesh. It is freaking expensive, too.

I recently learned about Royal Canin's hydrolyzed diet made from soy protein. It is a lot less expensive than Ultamino. A test with a small bag and a few kibbles of SP mixed with her Ultamina seemed to suggest that she tolerated it well, and found it tasty. So I ended up mixing one bag of Ultamino and one bag of the SP diet for a 50/50 mixture.

This was in December. In January, I noticed that she was licking and scratching her inguinal area (the patch of skin between legs and torso that you see when a dog rolls onto its back) until the entire area was red and even bloody, that her inguinal lymph nodes were enlarged, and, more alarming to me, that the caudal-most glands in her mammary chain were enlarged, firm, and sort of lumpy (these would be located on either side of midline in the inguinal area).

Keep in mind that at my job, I see the worst cases of disease in all species. My mind always goes to the absolute worst diagnosis for every case. Fortunately, I've been able to train myself most of the time to take a step back and come up with a more workable differential list. But not this time. This was a problem in my own dog. And I had only one differential: cancer. Lymphoma, mast cell, mammary gland. It was all bad.

I monitored the lumps for a few weeks, and Azza's scratching intensified. I finally made an appointment at my vet. This was back in February before the pandemic was in full swing.

In the exam room at the clinic, I muzzled Azza, and amazingly managed to get her onto her back so Dr. Craig could do a quick physical exam. We got her back on her feet and removed the muzzle. She drifted over to sit next to the vet tech, who I had already schooled in how to behave around Azza. While the tech was petting Azza's head, Dr. Craig said, I see this kind of thing all the time. Like, 15 times a week. I think it's just atopy, basically seasonal allergies.

Whew. Big sigh of relief. Of course, atopy makes more sense than cancer. This is her first spring here, and literally every tree is spewing pollen.

But we couldn't for sure rule out the diet change as a possible contributor. So he recommended I stop feeding the soy diet, and start her on a short course of Apoquel. Apoquel was a real game-changer in vet med when it was introduced. It provides targeted immune suppression that isn't as harsh as giving immune-suppressive doses of steroids. Dogs taking Apoquel typically don't have the excess drinking, urination, and panting that are common side effects of immune-suppressive prednisone.

That weekend, I spent two hours sorting nearly 30 lbs of kibble into piles of SP and Ultamino. The kibbles are roughly the same disc shape but slightly different colors. It was incredibly tedious. I bagged up the SP and gradually mixed it in with the terriers' kibble.

Azza began to improve immediately. I finished the Apoquel, waited a few days, and she blew up again with scratching. So it probably wasn't the soy protein at all, but it was good to eliminate that as a variable. Azza is back on a longer course of Apoquel. Once the heavy pollen season is past us, she may be able to stop taking it until next spring.

Oh, and did you catch that little detail about our vet visit? That Azza let the tech pet her on the head? That was a miracle that I never expected to see. I will never be able to fully let my guard down when I take her to the vet, but this is a big step forward for her. And it also tells me that I chose the right vet for my pets!

Notes From A Pandemic

Don't bother going into Kroger or Wal-Mart here in Little Rock. There's still plenty of panic buying and hoarding going on. I am baffled at their failure to limit the number of "essential" items that someone can buy. All paper goods, most cleaning supplies, eggs, all forms of milk, canned goods, pasta, vitamins and supplements and OTC medications--rows and rows of empty shelves. However, Whole Foods and Trader Joe's still seem to have a decent supply of food, particularly fresh food. Need deodorant? Too bad. Need a nice head of cauliflower? Trader Joe's has big ones for a decent price.

It's interesting how the word "essential" has taken on new, even sinister meanings. In its unavailability, toilet paper has become essential. My job is essential. I am the only person along my street that still goes to work every day. No teleworking is possible for people who do lab-based work. My schedule hasn't really changed all that much. It feels strange to be going through normal daily routines when nobody else around me is doing the same.

At the lab, the number of necropsy and tissue biopsy submissions has dropped off quite a bit. We didn't have a single new small animal necropsy case last week. Still plenty of goats, chickens, and calves, though. Veterinary clinics are generally deemed essential businesses (there's that word again) even in areas where there are more stringent business closure actions than here in Arkansas. But they have to limit the procedures they can perform either by decree or because they have limited PPE and have to ration it out for the critical life-saving procedures.

We wear N95 masks when we do necropsies. We now have to ration them by wearing them for several days in a row. Even so, we are at much lower risk than human health care providers who have to re-use their masks. Sure, our exposure risks include some bacteria and viruses that can kill us, but those cases are rare, relatively predicable (we can identify those high-risk cases early), and we can further mitigate risks by moving the necropsies into a fume hood (if it's a small animal). Nurses and doctors are definitively being exposed to a virus that can kill them--their risk skyrockets with increased exposure. It's a bad situation for them.

Our lab has donated swabs and masks to the Department of Health. And it looks like some state employees who have experience in running PCRs are going to be seconded to the Department of Health. Their regular job may not be essential but their knowledge is.

Stay home if you can. Wear gloves when you have to buy gas. Limit your trips into the grocery store--and wear gloves in there too. No nitrile exam gloves? Use winter gloves and wash them. Alcohol in a spray bottle makes an excellent, clothing-friendly disinfectant. Don't panic. Check on your neighbors. Be polite.

Phone Call

While I don't regularly have to work after-hours or nights or weekends, there are exceptions. On Christmas Eve, I did a necropsy on a police K9. On MLK Day, my colleague and I did a necropsy on a racehorse that collapsed on the track that morning. These are high-profile cases that require us to provide a fairly immediate response. All after-hours cases come in via a dedicated phone that my colleague and I swap between us every few weeks. Right now, I have that phone. Last night, it rang at 2:17am.

I was asleep but jerked awake right away. I fumbled around a bit, and managed to answer the phone in time. It was a guy who told me that his dog had just died. He wanted us to do a necropsy so he could find out what happened.

I always try to manage expectations for these companion animal owners, because necropsies are not magic. Our track record is very good, but we don't always find a cause of death in every case. And for this kind of case, we wouldn't be doing the necropsy until Monday. We briefly talked about a few logistics (we have a dock cooler where companion animals can be dropped off after-hours).

But it turned out that what this guy really wanted was to talk to somebody about his dog. I was that somebody.

So I took a deep breath, sat up and rearranged my pillow and blankets. I spent about 20 minutes on the phone with this guy, talking about sharing our lives with dogs. Talking about seeing our dogs get old. Talking about grief. My eyes kept drifting across my pack--Archie curled up under the covers at my feet, Azza under her own blanket at the other end of the bed, Mimi tucked up next to me, belly in the air, and the cat curled up next to her. I kept this guy on the phone to make sure he heard the words he needed to hear.

Don't misread this. This story isn't about me. It's about being a caring human being. Life lessons.

A Love Letter To My Colleague

I've had a couple of long posts simmering in my brain for quite some time, and I thought I'd give one of them an airing. This post is about my colleague, JX. And no, I'm not really in love with him, but this is definitely a love letter.

JX and his wife, both Han Chinese from Xinjiang (that fact alone prompted me to write more than 1000 words on the current political situation in Xinjiang, which I subsequently deleted, as it's not the point of this post), have been in the US for close to 10+ years. He's got a good applied veterinary job with the state, she's got a good research job with the enormous medical research university here. Between them, they hold many degrees and accreditations.

Now I've got to loop in some old hair-raising tales from our lab. For years, the board-certified veterinary pathologists were stabbing each other in the back. They would sit on cases like they personally owned all data and test results. They would claw and scratch anyone who even dared to ask about the status of a case. They would literally close their office doors and refuse to communicate with lab techs, submitting veterinarians, farm managers, and especially co-workers. Cases would drag on for months.

My colleague JX was hired into this quagmire with the expectation that he would handle all veterinarian-submitted cases that didn't involve tissue or a body. And that's what he did for several years, until that toxic workplace imploded on itself.

I was told by the current lab director that the first time my colleague JX went onto the necropsy floor, the board-certified pathologists wasted no time showing up in the director's office to complain about the "contamination."

And here we are, at the heart of this post. Racism, egotism, white privilege. It all makes me sick to my stomach.

When the implosion occurred, and the racist, egoistic, privileged pathologists quit en masse, my colleague JX was left to hold down the fort in necropsy for months until I showed up in July of last year. Talk about trial by fire. He was certainly qualified but had limited necropsy experience to that point. JX was thrown into the deep end of the pool...and he excelled. He rose to the occasion, and he learned what he needed to learn despite the lack of supervision, guidance, and mentorship.

When I arrived, I met a seasoned gross pathologist, a solid veterinary diagnostician. He freely and generously offered his opinion...but only when asked. He acknowledged that our lab section was in desperate need of supervision...but he didn't want to be the person in charge. When I was made supervisor of our section, he told me, "I have your back. I will support all decisions that you make." How awesome is that? Any supervisor ever would be over the moon to hear that from a high-level report.

And here's the thing. JX might not be in charge, but I don't make very many decisions without consulting with him first. He and I talk about our active cases every day--we discuss what our differentials are, what ancillary tests we might want to run, what results have come in and how they are to be interpreted, and what is important and what is just of "academic" interest. Our discussion are loud, lively, and often involve citing references to each other. Our lab director told me privately that he often has no idea what we are arguing about most of the time, but that he loves overhearing us. In fact, JX and I work so closely that we do necropsies together, and even trade cases between ourselves. This drives Receiving crazy as they want to know "who has this case" but I tell them, JX and I will sort that out later.

JX took in a racehorse today. He texted me to let me know. I replied, "When do you want to do the necropsy?"--it's his case, after all. It's a holiday on Monday and the lab is officially closed and our techs are not available. He said, "Your thinking?" and I replied, "Insured. We shouldn't wait. Tomorrow morning?". He replied, "9am". Perfect. He's in charge, I will be his tech, and it will be a fantastic morning in necropsy with my colleague.

I've had plenty of colleagues and mentors in my checkered career(s). But JX stands out. Professional. No drama. Amazing powers of observation (he found a PDA in a calf, super rare). Thorough but level-headed, so he isn't obsessive. He is kind. He is perfectly happy to indulge in black humor. He thinks outside of the box. He is willing to take risks. But he does not want to be in charge. And here I am, bossy-pants, ready to tell everyone what to do. Match made in heaven.

This is a love letter to my colleague. JX, because of you, I am a better veterinarian, a better gross pathologist, and a better manager.

Some Unusual Production Animal Necropsy Cases

This is the season for beef cows to be calving and sheeps to be lambing, so we are seeing a spike in those animals coming into the lab for necropsy. As a result, I've had four very interesting cases in the past couple of weeks. It's a good thing my professional interests in reproductive pathologies has expanded to include neonatal pathologies!

In case 1, a four-day old beef calf was brought in. Like nearly all of these cases, it was "fine the night before, dead the next morning." The calf had compelling evidence of infection with the bacterium Clostridium. Clostridium species are anaerobic, and live in the soil, so they are everywhere. You already know about two common Clostridium species because they cause botulism and tetanus, diseases that affect both humans and animals. In cattle, other species cause necrosis of skeletal muscle tissue, with a preference for muscle around the thigh and hip joint so the disease is referred to as "black leg." The bacteria also have a preference for heart muscle. In addition to making black patches in muscle, these bacteria produce gas that makes tissues "bubbly" (emphysematous is the doctor word), and they cause gelatinization of fat. Clostridium infections also have a very distinctive "sewer" smell that is usually strong enough to defeat face masks. A lot of the other clinical signs of Clostridial disease are caused by circulation of endotoxins that the bacteria secrete.

So this calf was infected with Clostridium but it wasn't clear at first why. Yes, it died from the clostridial infection and the endotoxemia, but there had to be some precipitating event. Neonatal calves don't have a fully functional rumen yet, and when they nurse, milk bypasses the rumen and goes straight into the abomasum, the glandular chamber of ruminant forestomachs. This calf had huge, greasy, white chunks filling its abomasum, which was itself larger than it should have been. Abomasal bloat has been linked to overgrowth of ... yes, Clostridium bacteria. And Clostridium bacteria have yet another special talent--they cause agglutination of milk proteins. We cultured the same species of Clostridium from the abomasal fluid, from affected skeletal muscle, and from heart muscle. Even though the dam had been vaccinated for Clostridium, a sequence of unfortunate events cascaded through this calf to cause its death.

In case 2, another 2 to 3 day old beef calf was brought in (actually, on the same day as the calf in case 1). This calf had nearly identical clostridial lesions in skeletal muscle and its heart. However, there was no evidence that this calf had ever nursed. The diagnosis in this case was something called failure of passive transfer. When neonatal mammals don't get colostrum from their dams, they become susceptible to many viral and bacterial diseases. This calf never got any antibodies from its dam. Although the first case makes it clear that colostrum is not the only factor for survival (necessary but not sufficient), a complete lack of it is nearly always fatal for these neonates. If it hadn't been Clostridium, it would have been some other virus or bacteria that would have killed this calf.

In case 3, a 10 day old beef calf was brought in. Good necropsy technique means you conduct it in a systematic manner, and try to do it the same way every time, no matter what species you are working on. The actual order of things can vary somewhat, but most pathologists lay the animal on its side, open the abdomen, remove one half of the rib cage, then fully examine all thoracic structures (more or less the lungs, heart, esophagus, trachea, larynx, oral cavity). When we opened the abdomen, it was obvious that the problem was somewhere in there, but I stuck to the program and examined the thorax first. No lesions at all. Everything looked fine.

When you work on the abdomen, you often remove the liver and spleen and kidneys on their own, then examine the intestinal tract from one end to the other. In this calf, the forestomachs looked okay but the small intestines were necrotic and bloody. I was gently tugging on the entire intestinal tract to pull it out to examine it in more detail when suddenly the colon just popped out. I stood there holding a blind sac in my hand for several seconds before it registered what I was seeing. Normally, the colon attaches to the rectum, and normally, you shouldn't be able to "pull out" the colon. This colon did not connect to anything. Normal colons are fairly muscular organs, but this one was distended and flabby. Then I noticed that the muscles lining the pelvic inlet were green and covered with shaggy bits of fibrin. And then I noticed that the two sets of anal sphincter muscles (one is skeletal muscle, the other is smooth muscle) were completely missing. There was no anus or rectum in this animal. There was a hole in the skin below the tail, so on my initial physical exam it looked normal from the outside.

This was an extremely rare and severe case of the congenital abnormality called atresia ani. This abnormality can vary from mild forms in which the anal opening is absent but all of the other organs are present (this can be corrected surgically if it is identified early) to cases like this one in which the colon doesn't reach all the way to the rectum/anus. This case was even more severe because of the additional absence of anal sphincter muscles.

Because the animal couldn't defecate, the intestines became necrotic. Bacteria and dead cell contents leaked out (there may also have been a small rupture, hard to tell when the tissues are so altered), causing septic peritonitis. Circulation of dead cell contents caused septicemia and shock and death. I shared details of this case with a few colleagues and was told that I may never see this rare abnormality in my career again.

The fourth case was a pregnant ewe. Like the calves, she was "fine the day before, dead this morning." I spoke to the owner when he dropped her off, and I learned that she was late term and that he didn't have very good management practices. Sheep and goats that aren't dewormed regularly get a nasty abomasal worm called Haemonchus that makes them anemic and can kill both young and adult animals if not treated. Haemonchus was high on my differential list--present until proven otherwise. But sheep and goats are also quite susceptible to something called pregnancy toxemia, especially if they have multiple fetuses.

This ewe was small, 120 pounds, and extremely overconditioned (fat). A quick physical exam eliminated anemia even before we opened her up. Now Haemonchus was off the list (and in fact, we found no parasites in her intestinal tract). She had three nearly full-term fetuses, all about the same size and without gross defects or evidence of early death. No evidence of viral or bacterial placental infections. Her uterus was enormous, and had squashed her rumen up next to her spine and forward towards her lungs. The papillae that line her rumen were hard and shrunken. Her liver was huge and yellow. All of this, sadly, pointed to pregnancy toxemia.

It affects ewes who are either super skinny or super fat when they are in late gestation, and who have multiple fetuses. The energy demands of those fetuses cause the ewe to first use up her liver glycogen stores, then to begin to use her body fat stores to keep the fetuses alive. In the case of the skinny ewe, there is no body fat and she dies. In the case of the fat ewe, the amount of fat sent to the liver overwhelms it completely, and she begins to pump out ketone bodies and develops rumen acidosis. The papillae respond to the rumen acidosis by becoming keratinized. The liver cells become stuffed with fat and stop working. And she dies.

Pregnancy toxemia is preventable but it requires fairly close monitoring of the ewes before and during pregnancy, and adjustment of their diet to keep them in good condition before they become pregnant. It's also important to identify ewes who have multiple fetuses, usually via ultrasound, so they can be separated and fed separately.

These were not my only cases in the past two weeks (the intake of dog and cat cases is fairly regular), but I thought it was cool that all four of these production animal cases came in so close together. I also appreciated these cases because they really stretched my diagnostic skills.