"Dr. A Never Met An E. coli That She Didn't Like"

For the great majority of our necropsy cases, we can identify the cause of death right away. There might be a few specifics to sort out, like confirming the specific kind of cancer. But we can usually get most of the diagnosis while on the necropsy floor. 

There are always exceptions. I mentioned in a previous post the handful of cases we were seeing of young dogs with bloody parvo guts that never tested positive for parvovirus. Cultures of tissues from these cases did result in scant to moderate growth of E. coli. Usually, that alone isn't enough to provide a diagnosis.

We culture E. coli and its friends in many of our cases. But not all E. coli are the same. E. coli is everywhere, inside you and outside. It can be considered an environmental contaminant. Animals poop it out, it can live in the soil--you can't get rid of it. But we use sterile techniques to acquire our culture swab samples. So when I get any growth of E. coli, especially from poultry cases, I lean heavily to that as a possible cause of death. 

We've recently had a run of necrotic, hemorrhagic pneumonias in companion animals. Some of them had scant growth of E. coli from lung swabs. But your generic environmental contaminant strain of E. coli doesn't cause that kind of tissue damage. You need a hemolytic strain for this. Our bacteriology group had not been mentioning anything about hemolytic behavior in their reports.

Well. I asked the bacteriology supervisor about this, and it turns out her techs had failed to report the culture results correctly, and the bacteria they cultured were in fact hemolytic. 

I was able to correct the couple of cases that we still had open, but there were half a dozen other cases that were likely hemolytic E. coli infections. But because I've "never met an E. coli that [I] didn't like," according to our pathologist, I had fortunately included a diagnosis of "colibacillosis, suspected" on those cases. 

One of the important aspects of getting a diagnosis is integration. Clinical history, what you see during necropsy, results of tests for viruses and cultures of bacteria, what you see through the microscope when you look at the stained tissue slides, what you learn by reading published literature--all of these disparate types of data get rolled up into a narrative of pathology for each case.

There is one more component of that integration that is much harder to describe. It is a combination of the pathologist's experience, bias, application of the rule that "common diseases present uncommonly" (which means don't go looking for uncommon diseases right off the bat), and a type of gestalt that can develop when you see several similar cases cluster in time (there is definitely a seasonality to some diseases, and some diseases are more common in some species than others). 

The title of this post has complicated subtexts. It is an acknowledgement that I was right in proposing colibacillosis diagnoses for those cases. But it also contains a warning about jumping to diagnostic conclusions without considering all of the differentials. It isn't always E. coli's fault. 

Except when it is.

Lessons From The Past

Early on in the pandemic, I found myself most strongly affected by empty shelves at the grocery store. It was stressful enough to be leaving for work throughout March and April and May when all my neighbors were staying at home. It was stressful to insist back in March that my team at work wear masks when nobody else at the lab was doing so. But seeing large gaps and entire aisles with nothing but stray scraps of paper and dust on the shelves made me the most anxious. Increased my heart rate. I hated going to the store. I stopped my normal weekly trips and stretched out my visits to once every three weeks. 

The weird mass hysteria over toilet paper and paper goods also affected me in an unexpected way. I found myself looking at a paper towel and thinking, well, I've only used this corner of it. I can use it again. And I would carefully set it aside for that purpose.

My grandparents lived through the depression. They are long gone now, but as a kid, I would see them hoard bits of wire and string, re-use a kleenex all day, save tag-ends of soap and cooking grease to accumulate in jars and cans. I distinctly remember thinking at the time that this was odd behavior, but I never really made the connection until now. It's not odd at all when you see those empty store shelves.

I was already thinking a lot about this when I encountered an example of how this pandemic has changed our behavior at work too. 

We use a particular kind of disinfectant to clean the necropsy area at the lab. There are many cleaners that will effectively kill the biological agents that we know are present, but lots of those cleaners are corrosive. We use disinfectant in our boot wash and apply disinfectant solution to many different types of metal, plastic, and ceramic surfaces and tools, and we are ourselves exposed to it. We prefer to use neutral types of disinfectants. 

When we started running low on our stock, we placed an order like we always have. And weeks passed. It wasn't available from that vendor. This vendor might have it, but delivery would be in October or later. Another vendor said, yes, we have it, then the next day said, oops, sorry, no we don't. I started evaluating our options. We could use commercial grade bleach but it really was a choice of last resort. Bleach wasn't available from any vendor either but our bacteriology section had some bottles we could have borrowed. Then our Safety Coordinator came up with a bottle of a very concentrated phenol cleaner that nobody else at the lab wanted to use. Just mixing this stuff up into a solution required full PPE to protect the user. I said, I'll take it! We wear full PPE in necropsy anyway. We could make it work. It wouldn't corrode our boots or our metal tools. If things became dire, we could switch to bleach.

Just a few days later, our shipment of neutral disinfectant arrived. After a brief celebration, I told my team to prepare a purchase requisition for more. The new normal is that we need to order supplies and equipment many weeks in advance. We can no longer wait until we actually need something.

Remember how we started: the pandemic has affected us in subtle ways. I decided that we will reserve our precious neutral disinfectant for important things like tables and equipment. And the phenol cleaner will be used for the boot wash bucket, which is mixed and emptied daily. I told my two technicians, both in their late 20s/early 30s, about my grandparents and the Great Depression, but I am sure they didn't understand how that related to using phenol cleaner for the boot wash.

Hoarding. Choosing less desirable items to preserve things we have decided are more desirable. Using less. Not odd behavior at all.

Disappointing

I like science. I like learning about science of all kinds, and the people involved in making and doing those science things. So last night I decided to watch Radioactive, the Amazon film that was billed as a biopic of the famous physicist Marie Curie.

I didn't quite make it to the 30 minute mark. Marie Curie was presented as a person with the social skills, attention span, and emotional maturity of a 12 year old boy. In fact, the entire POV of the movie felt like it was made through the gaze of that 12 year old boy. Jerky scene cuts. No continuity. No character motivation. The sets were either grey or just too damned dark since the average 12 year old boy could easily confuse dim sets for actual, you know, skill in directing, acting, and editing. Marie Curie was uptight and buttoned up until the gratuitous nudity and sex scenes. All in all, a waste of time for an adult looking for a well-told story about an interesting historical figure.

Whew!

Some random musings.

It's hot here in Little Rock. Like Saudi Arabia hot. I don't miss the baby-powder-fine dust that coats everything in the Eastern Province. But the heat, the humidity, the haze in the air--it feels very much the same, just with trees in the landscape.

I've been to two agility trials recently, both hosted by the same club. They did a fantastic job at redesigning the way that agility trials happen to remove cluster points and to manage the flow of people and dogs. In June, I was voted in as the Agility Trial Director of our local dog training club, and I was so happy to be able to pick the brains of the host club. Our club has a trial on the books for the end of October. Can we hold it safely? I'm not sure, but I'm going to at least work on identifying as many risks as possible and seeing if we can reduce them.

These particular trials were held indoors in a youth soccer facility. The club required everyone to wear masks while in the building, unless you were running in the ring or eating or drinking at your setup. The compliance was astonishingly high. I mentioned this with some surprise to my lab director after the first trial, and he said it might be due to the fact that dog show people are used to following rules. And yes, at dog shows, there are lots of rules. So I think he's probably right.

Two agility trial pet peeves: exhibitors that just let their dogs bark and bark and bark, and exhibitors that cram big dogs into crates that are obviously too small for them. Some handlers have elaborate setups, with arrays of crates, personalized crate covers, color-coordinated everything, a fan for every dog. One guy went to the other end of the spectrum, and didn't even have a chair or ground mat or much of anything except some toys and his dog, and just plopped himself on the floor with his dog in the middle of his chosen crating space. I'm not advocating such a spartan trial experience, but I do think handlers should pay attention to making their dogs comfortable.

At work, our necropsy and biopsy submissions dropped off quite a bit in March and April, but seem to be back to normal levels now. We've had some very interesting necropsy cases in the past few weeks. Our first heat stroke dog came in last week (a French Bulldog). I expect to see more as temperatures are expected to be even higher in the coming 2-3 weeks. We've also been seeing a lot of puppies with horrible bloody enteritis that looks like parvo, quacks like parvo, but isn't parvo. Those are frustrating as those cases often represent a kennel health issue and submitting vets need answers quickly. We do our best.

I had my second case of canine caval syndrome this past week. My colleague has had a few as well. It's associated with chronic heartworm disease. Not all dogs with heartworms get caval syndrome but when it develops, it's very bad. Worm leave the right side of the heart and move UPSTREAM into the large veins. I found an adult heartworm in one of the large veins above its heart, but we've also found them in other cases in the descending caudal vena cava. This dog also had heartworms in the arteries in its lungs; in our exerience, this is a common finding in dogs with heartworms. This dog died of seizures with blood pouring from its mouth and nose. Horrifying. Among the many things that go wrong once this develops, red blood cells get shredded as they try to squeeze past the worms in the veins, and cardiopulmonary collapse is inevitable. Sadly, an entirely preventable death. The take home message is this: get your dogs tested annually for heartworm disease, and give them monthly preventatives to kill larvae in their bloodstream.

I had a very exciting day last week when I got a call from a guy who said, his daughter found a bat in their bathtub, the public health vet told him to get it euthanized and take it to the lab so he was calling the lab to find out how to accomplish that. In just a few seconds of conversation with him, I realized that the most important thing was to get that bat away from this family. Asking him to cart it around to a vet wasn't a good option. At the lab, we don't euthanize animals. I don't have a DEA license and we don't keep euthanasia drugs on site. But all of our commercial poultry submissions are brought in live, and we euthanize those with CO2 gas. I decided that I could use that method on this bat. Quite a bit of capering and hand flapping ensued as my tech and I worked together to come up with a plan to euthanize the bat and keep both of us safe. All turned out okay in the end. Bat was rabies negative.

As an aside, everyone at the lab is required to have a rabies vaccination, and our titers are checked yearly. It doesn't mean there is no risk to us, but we were better positioned to deal with that tiny bat than that guy and his family.

And this week I had to work with a wild cottontail who had neurological signs then died. My god, the list of differentials was a horror show: rabies (unlikely, but it was a mammal so rabies has to be on the list; it's unlikely because small, delicate animals like a rabbit would not likely survive an attack by a rabid animal and thus live long enough to develop symptoms themselves), tularemia (zoonotic and reportable), rabbit hemorrhagic disease (also reportable, may be zoonotic), tick-borne blood parasite Encephalitozoon cuniculi, Baylissascaris worms in the brain (zoonotic, deadly to humans). And heat stress, always on the list for rabbits wild or farmed or kept as pets. Samples had to be obtained and sent to national vet labs and the state health department for testing. We did the necropsy in a fume hood and discarded all of our PPE as soon as we finished. It was nerve wracking to work with this animal. 

Never a dull day at the state vet lab.

Home Repair Fuckwittery

On Friday, I discovered that the GFCI outlet in my bathroom had suddenly stopped working. Pushing test and reset had no effect. I finally got around to working on that little home repair problem this morning.

I started by taking off the face plate and pulling the outlet box out of the wall to make sure all of the wires were properly connected. Everything looked good. Like I am an expert, pssht, but at least there was indeed a ground wire connected to the box, and two white wires were inserted on one side, and two black wires were inserted on the other. Okay, symmetry is good.

I next made a trip to my circuit breaker box, which is stupidly and inconveniently located on the outside of the house. No breakers were tripped.

Now I was facing the possibility of having to replace the GFCI outlet. With home repair, it's always half a dozen steps back before you can take a step forward. I needed to turn off the power to that outlet before I started messing around with it. But none of the fuses in the breaker box were labeled. Why would they be? Are they labeled in your house?

Excluding the large voltage ones which certainly powered the fridge, HVAC unit, and washer and dryer, I had 17 mystery fuses to sort out.

I turned on all the lights in the house and garage, and began systematically working my way through the fuses, filling out a table as I went along and turning off lights once I figured out which fuse controlled them. I had to go back and check a few of my "unknowns" when I realized that half a dozen outlets in the kitchen were not on the same circuit as the one that controlled the overhead lights.

It took me well over an hour of traipsing back and forth. I never figured out which circuit controls those kitchen outlets. But I did find the circuit for the upstairs bathroom--yay! Even better, the process of throwing breakers on and off reset the GFCI--yay again! No replacement needed.

Unfortunately, when I was pushing the box back into the wall, I neglected to remember it was live and gave myself a bit of a shock. Not enough to trip the damned GFCI again, thankfully. But enough for me to call it a fucker, and to make a trip back outside to shut off power to the bathroom.

I finished my day of home care by planting some flowers, and vacuuming the car then driving it to my favorite car wash. I also cleaned the upstairs bathroom, vacuumed the house, and started some black beans in the slow cooker.

It's not much, but it's a start. I rebuilt the rock wall myself.

As a reward for my virtuous activities, I am out on the deck with the entire pack, even the annoying cat, enjoying the beautiful breeze and balmy temperature.

Archie is off patrolling the perimeter.

Non-Stick

The blast from the past in the bedbug post reminded me that I wanted to post this tidbit too.

Back in 1994, I acquired a set of non-stick cookware. It was a big purchase for me at the time. I was extremely proud of my 10-piece set of Circulon pots and pans--not the top of the line but reasonably priced and durable. I can certainly attest to the durability part: I hauled that set of pots and pans and lids all over the U.S. and even the world. Like Harry and Mimi, the set went with me to Saudi Arabia and back.

Circulon, circa 1994.

For decades, I have been diligent about never using metal utensils when cooking. There's plenty of plastic and wood options out there. But even with care, well made things still wear out. The saucepan was the first casualty--even boiled pasta would stick to the bottom. I kept the pan but it got shoved to the back of the cabinet, replaced with a series of cheap pans and lids I picked up here and there. The skillets went next. They became increasingly hard to clean as the non-stick coating was worn away with use.

Out with the old...

So last month, 26 years after that first acquisition, I decided to get a new cookware set. I went with Calphalon this time, another 10-piece set. One less pot, one more lid--but that lid is for the sauce pan! What a luxury!

...in with the new!

Cooking with the new pans has taken some adjustment. They heat up much faster, and more uniformly, than the old ones, so I have to use lower settings on the stove. I had
forgotten how nice non-stick coatings can be to use and to clean.

The old set is boxed up and sitting in the garage. I can't bring myself to throw it away. I have a history with these pots and pans. I could pull out the still-usable pots and donate them, but I can't bring myself to separate them from the rest. Who knew owning a set of cookware was going to be such an emotionally demanding relationship?

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.