Is length the most important thing? (Day -160)

Quality vs Quantity of life in dogs

I’ve recently spent some time within some of the top oncology (cancer) referral vets within the UK and been in consults with people who have to be told that the biopsy says it is cancer. One of the most difficult questions that pet guardians will then ask is how long a loved pet has left – this is an awful question that has to be answered so carefully because we just do not know.

We try to use evidence based studies looking at different treatments when discussing the options – however these studies over use statistics to give averages. Unfortunately within veterinary research many studies only have a small amount of patients which is caused by the way the veterinary industry works. This means that when looking at a study with average life duration from start of treatment of 3 months that some dogs may have died at 1 week whilst others lived until 9 months or a year. I am personally starting to believe that statistics should be limited to use only in sample sizes over a defined minimum limit to improve reliability (I wrote about statistics here).

However what is missing from most of these studies is perhaps even more important and is the second question that most pet guardians ask. That is what the quality of life is like. It is something that may sound strange however it is much easier to quantify quantity of life (i.e. days) than it is quality (i.e. happiness) of a pet.

This is still something in it’s infancy within veterinary medicine – with humans we can explain that it will hurt now but it will mean that they are good later. The first time I saw this discussed was within surgery decision making in the AWSELVA journal in 2014 (J. Yeates & S. Corr) to evaluate treatment options based on the amount of painful time vs the amount of pain free time.

This is something that is difficult though as we need to define how we recognise the quality of life. For example if we consider movement as an indicator as recently there have been studies using accelerometers (step counters) to monitor the activity of an animal. A study just published used this to measure the physical activity in dogs receiving chemotherapy as an oncology treatment which may be acceptable.

However if we look at dogs with neurological problems that may have abnormal circling or pedalling movements then activity may not be the best quality of life. Here is where other techniques may come into play with things such as a seizure diary being kept to record frequency and duration of seizures to allow comparison of good time vs bad time.

Hopefully soon we will have better measures for the quality of life – and be able to apply these when making decisions that may impact animal welfare.

Outcome based veterinary medicine… (Day -278)

Outcome based veterinary medicine

In nature animal behaviour is driven by need. They balance their energy expenditure to the expected reward received. Yet it is proven psychologically that sometimes people do stuff just because the people before them did it. Check out the video here:

So yeah, all those people started to do that just because someone else did. When asked why they did it they didn’t know. Unfortunately this also happens in veterinary medicine as well as human medicine as well as other professions.

A good example is the air port on an infusion giving set – many people just open it even with collapsible plastic bags/bottles because they always have. This is something that is used with fixed volume glass bottles to let air in to replace the liquid that is lost.

It is often easy to do what you always have as you feel safe, yet it does not always reflect what is correct or best. The worst case is when you have been shown to do something, yet do not understand why you are doing it. The best case is when you understand why you are doing what you are doing.

Now yesterday I spoke about evidence based medicine and the problem with statistics in research papers. Today I want to talk about another type of medicine that I have read about recently – it is called outcome based medicine.

So instead of doing stuff because that is the way it is always you decide what you want the outcome to be, and you take the steps to get to that outcome. The perfect example is that of fluid therapy. There are loads of guidelines and refinements to fluid therapy are happening all the time. However it is always about the amount, the speed, and type of fluid.

Traditionally though there was guidelines on the quantity, some on the speed of administration. However the thing that was undefined was that of when to stop even though the measurement of fluid deficit is subjective.

Now with outcome based medicine you are looking at what you want to achieve in a measurable way. With fluid therapy we have things such as the heart rate, blood pressure, capillary refill time that we can use with well-defined normal ranges. So if you want to get to these normal parameters you can give smaller boluses of fluids over a shorter time. Reassess these clinical parameters; if it is normal then you can stop, if not then you repeat the bolus until it is normal.

This way you know what your outcome is, why you are doing something, and you know how to measure it. For me when I think about surgery this is logical, I always try to have a plan of what I will do when I operate. I will know what my expected outcome will be.  I will then have backup plans with their expected outcomes. And then I will have plans on what needs to be done post operatively as well.

So taking this approach of outcome based medicine and applying it within internal medicine takes some of the guesswork away. And in combination with properly reviewed articles from evidence based medicine will I think this will form a lot of the future of veterinary medicine. In surgery especially we are already looking at computer models to predict the outcome of surgery on a patient by patient basis.

Forgotten in a stye (Day -291)

Vet Student Pig Medicine

I’ve started my training on pigs, in total from the 4 year course it consists of just 4 weeks teaching. It started with a lecture this week and during this I had a sudden realisation. It’s taken me a few days to get my thoughts straight before I write this.

Pig medicine is all about one thing, and that is increasing its growth so that you can kill the pig sooner for meat.

I realised that no one really keeps pigs as pets. There is no discussion of individual health instead just consideration of the production unit. This is the first time I am actively questioning whether I should be eating meat from pigs. There are so many pork based products that I enjoy – I take great pleasure coming back to England for my English breakfast – the bacon, the pork sausages.

I have gone through so much education, and one of the things I hold dear is the ability to draw my own judgements from my own experience and education. It is something that has often caused me problems – as the famous saying goes about stories…

There are 3 sides to every story, their side, the other side, and the truth.

Whilst the start of pig medicine has confused me – I have resolved that I should go through it with an open mind. And at the end I will make my own decision.