Always a Lost Cause

Like us, dogs limp for a variety of reasons. Unlike us, dogs can’t tell us what happened or where it hurts using words, leaving us struggling to figure it out for ourselves.

Your most valuable resource for determining the cause of your dog’s limp is your veterinarian. Before calling to make an appointment, however, most of us want to know a little bit about the common causes of limping in dogs, what to expect from a veterinary visit, and when limping is a veterinary emergency.

Gradual Onset vs. Sudden Limping

There are two types of limps: gradual onset and sudden onset. Gradual onset limps happen slowly over time. Sudden limps happen quickly, like their name implies, usually after an injury or trauma. Knowing whether or not your dog’s limp is sudden or gradual can help your veterinarian narrow down the possible causes of your dog’s limp, and can help you determine if your dog’s limp is a veterinary emergency.

In general, gradual onset limps are caused by an underlying, chronic or degenerative condition, such as osteoarthritis or dysplasia. Sudden onset limps, on the other hand, are usually caused by an injury or trauma.

Just because your dog has a gradual limp does not mean you should put off making an appointment. Some causes of gradual limping, such as bone cancer or hip dysplasia, can be treated more effectively if they are caught sooner rather than later.

When to Call the Vet

In general, it is usually better to play it safe and schedule an appointment with a veterinarian for a limp that lasts more than a few minutes, but as with people, dogs seem to have a knack for getting hurt outside of normal office hours. So how do you know when you can wait until the next morning and when you should rush to the emergency room?

Gradual onset limps or sudden onset limps that don’t seem to be bothering your dog too much can usually wait a few hours, and in some cases, may even resolve on their own during the waiting period. In other cases, however, your dog can’t wait.

Broken bones or dislocated joints require immediate care, and nerve damage can be a sign of a more serious neurological condition or spinal injury. You need to get your dog into the veterinarian or veterinary emergency room if your dog shows any of the following signs of an emergency:

Dangling limb (dislocation)

Swelling

Hot limb

Obvious break or unnatural angle

Common Causes of Limping in Dogs

Lameness in dogs is a frequent veterinary complaint, and there is a huge range of possible causes, from chronic conditions to trauma. This may seem overwhelming, but these causes can be broken down into a few categories.

Paw Injury

If you’ve ever stepped on a piece of glass, then you know how it feels to have something sharp lodged in your foot. Foreign bodies, like glass, nails, sticks, thorns, plant matter, or anything else that should not be in your dog’s paw, hurt. They make it uncomfortable to walk and can lead to infection. Insect and animal stings or bites can also cause tenderness and limping, as can lacerations, broken toenails, burns, frostbite, and bruising. A sign that your dog may have something stuck in his paw is that he will lick his paw incessantly.

Joint Disease

Some conditions cause gradual wear and tear on joints and the musculoskeletal system. This leads to limping. Osteoarthritis, hip dysplasia, elbow dysplasia, patellar luxation, ligament disease, intervertebral disk disease, and osteochondritis dissecans (OCD) all can cause limping on any of the affected limbs. Infections like Lyme disease can also cause joint pain and limping, which is just one more reason why it is important to have your dog on an effective tick preventative.

If your dog is diagnosed with arthritis or suffers from dysplasia, your vet will most likely recommend a veterinarian-grade joint supplement of glucosamine and chondroitin. Joint supplements like Glyde Mobility Chews are often used as an early intervention and throughout the progression of osteoarthritis because they are safe for long-term use in most patients. While research is still limited, joint supplements such as Glyde can help reduce symptoms of osteoarthritis and hip dysplasia.

Bone Disease

Some diseases affect the bones in your dog’s legs. Younger dogs, especially large breed puppies, can develop conditions such as hypertrophic osteodystrophy and panosteitis, which make walking painful. Certain cancers, such as osteosarcoma, also affect bones and require prompt diagnosis for the best prognosis.

Injury or Trauma

Injuries and trauma are the most obvious causes of limping in dogs. From car accidents to sports injuries, our dogs are exposed to almost as many types of injuries as we are. Broken bones, fractures, sprains, dislocations, ligament tears, joint trauma, and spinal injuries can all cause moderate to severe limping, and in some cases the dog may not be able to put weight on the affected leg at all. Proper conditioning can help reduce the risk of some sports injuries, but a limping canine athlete should be given plenty of rest until the cause of the limp is identified and treated.

If your dog becomes acutely lame (especially if he’s a puppy), wait for about 15 minutes and try to keep your pup quiet and still. They are like children and will likely yelp and cry for about five minutes. You may find them acting perfectly normal after that time and save yourself a trip to the emergency room.

If, however, they are still lame or non-weight bearing after 15 minutes, you should have them be seen by their veterinarian.

Diagnosing a Limping Dog

Sometimes the cause of your dog’s limp is clear, like a broken bone or a piece of glass in a paw pad. Other times, the cause is a little more elusive.

Your veterinarian may have to run some tests to determine the cause of your dog’s limp. Radiographs can help identify a broken bone, joint disease, and other skeletal abnormalities. Biopsies and joint fluid collection can help identify cancer and other possible causes, and blood testing for infectious diseases like Lyme or immune-related diseases may also be necessary.

Prior to testing, your veterinarian will perform a physical examination of your dog to test for tenderness, pain, and range of motion in his limbs. You can also do your own examination at home before you call the veterinarian. However, without proper training, testing the range of motion and manipulating your dog’s leg is a bad idea and could injure your dog further. You can gently run your hand down your dog’s leg and paw to check for swelling, heat, and to determine where your dog is tender. This information can help your veterinarian determine whether or not your dog can wait for an opening or if he needs to come in on an emergency basis.

Treating a Limping Dog

The treatment for your dog’s lameness will vary depending on the cause. Your dog’s treatment plan could be as simple as a few days of rest, or it could entail surgery, further testing, and a prolonged recovery. While this may sound intimidating, in most cases the sooner you get your dog in to see the veterinarian, the better the prognosis.

While you are waiting for your appointment, try to keep your dog as calm as possible and abstain from exercise or play to avoid making the limp worse, and if necessary, crate your dog in the car to prevent further injury.

For further questions about your dog’s limp, contact your veterinarian and schedule an appointment.

(Read Writing Pain: Pt 1- What it is and How it Works)

Disclaimer: Due to the nature of this post, I will repeat that anything you find on this blog is for informational and writing purposes only. Using this information for anything other than that voids the warranty. I take no responsibility for your use of this information. Read at your own risk.

Let’s start by saying that controlling pain is a pretty big deal- and it’s not always done well, in fiction or in real life. Which is a shame, because multiple studies have concluded that patients with well-controlled acute pain have shorter hospital stays, fewer complications, and a lower rate of chronic pain afterwards than those whose pain is poorly controlled.

Some negative effects of poorly controlled pain include:

Increase in heart rate and blood pressure (which, in addition to increasing risks of stroke and heart attack and increasing the amount of energy expended during the healing process (which is then not available for, well, actual healing), can make bleeding more difficult to control- ask me about my top surgery adventure sometime).

Decrease in movement- no one wants to move while they’re in pain. This includes breathing deeply. Exclusively shallow breathing increases the risk of pneumonia and a kind of collapsed lung called atelectasis, where the small, air-filled sacs of the lung become blocked and can no longer open. This can lead to low oxygen saturation.

Anxiety- either related to movement (person expects worse pain on movement, begins to fear movement), or in general, which further worsens pain (see part one).

Decreased food consumption- who’s thinking about eating during severe pain and accompanying nausea? Causing less energy to be available for healing. 

Suppressed immune function- so an even higher possibility of infection.

Muscle spasms- caused by extreme muscle rigidity (see part one).

Longer healing times- because of all of the above.

Depending on where you’re taking your story, some of these may be what you want to happen. Some things that are barriers to providing pain control include:

Fear of addiction/relapse or dependence on opioids

Fear of loss of control related to opioids

Fear of overdose (hey, they’re already not breathing really well, if we give them this, they might stop breathing altogether…)

Inaccessibility- the person cannot access pain control methods, either because of cost or location

Inability to administer- no one is trained to do certain pain control methods

Side effects of available painkillers are too severe

Pain Control Modalities:

MEDICATIONS:

Pain medications are typically classified as opioid or non-opioid. Drugs used with painkillers to increase their ability to decrease pain are called adjuncts.

Opioid pain medications include morphine, oxycodone, codeine, meperidine, methadone, fentanyl and hydromorphone. Opioids are either made from the opium poppy plant (more specifically called opiates), or are synthetic molecules that are similarly shaped to opium. They work by inhibiting receptors of pain signals in the brain. They are very useful for severe pain, especially surgical pain and pain related to injury.

(Doses on this chart represent similar amounts of analgesia between drugs. Oral means by mouth, parenteral means injected or absorbed.)

Opioids are not available without a prescription, and worldwide distribution of these medications is, unfortunately, pretty horrible. While developed countries have these drugs widely available (and usually very cheaply so), it is estimated that approximately 83% of the world’s population has no access to them (click here to learn prices/availability in specific countries). In many developing countries, costs for these medications may also be extremely prohibitive.

Side effects for opioids include confusion, sedation, hallucinations, euphoria (and, actually, dysphoria), decreased breathing rate, headache, constipation, nausea, vomiting, low blood pressure, and itching. Tolerance, or needing more of the drug over time to get the same effect, is common with opioids. In long-term use, withdrawal is possible. In people who are predisposed, opioids may also pose a risk for addiction.

Non-Opioid painkillers include things like ibuprofen, aspirin, acetaminophen, naproxen, ketamine, adjuncts, and local anesthetics.

Some non-opioids, including ibuprofen, aspirin, naproxen, and acetaminophen, work by blocking the production of chemicals that signal pain in tissue (see part one). Not as much of the chemicals are produced, so not as many signals are sent to the brain, and less pain is felt. These are usually effective for mild to moderate pain (but may be better for headache pain than opioids), but have a “ceiling effect” or a dose beyond which pain control does not improve. Many of these have side effects of bleeding (particularly in the stomach), nausea/vomiting, and rash. Many of these are available over the counter (OTC).

Ketamine works by blocking pain signals in the spinal cord. Many people either think of ketamine as a horse tranquilizer, general anesthetic, or recreational drug, but it is very usable (albeit underused in developed countries) as a painkiller at low doses. It works well for moderate to severe pain and carries fewer side effects than opioids (it may work better in trauma (injury) pain than IV morphine). And is more available worldwide (though still requires a prescription). Side effects it does carry at painkiller doses (which are below recreational and anesthetic doses) include inflammation at injection site, salivation, and insomnia. Tolerance does not occur for about 5-7 months of continuous use. Ketamine can be given in both oral, IM and IV forms.

Adjunct painkillers are drugs take advantage of the fact that a lot of pain has to do with factors other than tissue injury, including exhaustion, strong emotion, nausea, and dehydration, which can make otherwise tolerable pain intolerable. Adjunct drugs do not necessarily decrease pain on their own, but that decrease other symptoms that make pain feel worse. Used with painkillers, they can greatly increase pain control. These include:

Anti-anxiety drugs (for when anxiety is driving up pain)

Muscle relaxant drugs (for when pain is caused by muscle spasms)

Anti-nausea drugs (for when nausea is driving up pain)

IV hydration (to better hydration status)

Anti-seizure drugs (these work well as an adjunct in headache pain by decreasing nerve activity in the brain)

Sedative drugs (for comfort/amnesia during painful procedures)

Combinations of opioid and non-opioid painkillers decrease the amount of any one drug needed for pain control (blocks some pain in tissue, so opioids have to do less work). Pairing acetaminophen with an NSAID like ibuprofen, aspirin or naproxen can also provide better pain control than one drug on its own.

Regional anesthetic nerve blocks- Regional anesthetic blocks inject local anesthetic drugs around a nerve, which stops it from being able to send pain signals. Requires equipment, local anesthetic and training. If there is severe pain, but is is only in one part of the body (broken leg or hand, for example), this is an alternative to full-body medication. These must be done by a physician or other specially trained provider, are typically done under ultrasound guidance, and can last up to two days depending on the anesthetic given and dose. If no ultrasound machine is available, skilled providers can still perform this procedure, but it may be more difficult to correctly place the anesthetic. Other sensation and movement in the area blocked may also be impaired. Good for procedural pain control.

NOTE: There is a public understanding that opioids “just work better at pain control in all areas.” This is not necessarily the case. While they do work well for many types of pain, especially severe pain that other medications can’t work for, they also have prohibitive side effects, and may be less effective than other methods for things like kidney stones, muscle spasm/cramp-related pain, and headaches. In fact, several emergency departments have recently gone entirely (or nearly entirely) opioid free, and had similar, if not better, rates of pain control and patient satisfaction using a combination of non-opioid pain medication, ketamine, adjucts, and anesthetic block procedures.

NON-MEDICATION

RICE- Rest, Ice, Compress, Elevate. Very simple, and can greatly reduce pain and inflammation. Usually used in combination with a painkiller, but can be somewhat effective on its own. If ice is unavailable, using a towel soaked in cool water can provide cooling through evaporation. Compression can be achieved with ace wrap or really anything you can wrap around the injury (your characters should be on the lookout for color changes (white or purple), decreased sensation, and decreased movement below the injury, or additional pain near the injury, and if you want something worse to happen in your story, a complication from this is compartment syndrome). RICE is especially useful for musculoskeletal injuries and soft tissue injuries producing swelling.

Heat or Cold- Heat can relax muscles and improve blood flow to areas. Cold decreases inflammation and slows the movement of pain signals in nerve fibers. These do not completely stop pain, but may help relieve associated symptoms, which will help with pain control.

Bracing/Splinting/Slinging/Casting- immobilization, especially for short periods or times when characters must move to stay alive, helps keep pain from spiking with movement. Changing a person’s position can help with pain as well.

Distraction- Strong focus on something other than pain can decrease how strongly the pain is felt for periods of time. TV, music, doing work that requires intense concentration, or trying to recall a series of (pleasant) memories in detail can shift focus away from pain and make it a lot more tolerable. This works best for mild or moderate pain, or for severe pain with another form of painkiller. Children in pain tend to use this modality automatically. Pleasant touch like massage can also be distracting enough to decrease pain.

Guided imagery/relaxation techniques: These decrease anxiety (which, again, helps decrease how badly pain is felt), and provide some distraction as well.

Placebo Analgesia- People laugh about this one, but there is genuine evidence to suggest that placebo drugs and procedures may be a good tool for pain control in some people. Placebos are procedures or chemicals like starch or vitamin b12 that should not work to help a condition, but that psychologically do have a positive effect on that condition. If the right expectations are created for the “drug”  or “procedure” working (“this drug is really helpful in _____ pain. It will also have ____ and _____ effect”), the brain releases chemicals to meet that expectation. Changes in brain chemistry have been repeatedly noted with placebo use in pain control, depression, migraines, irritable bowel syndrome, and ADHD.

In placebo pain control, the brain releases endogenous (naturally occurring) opioids in response to expectations that the person is getting a painkiller, which chemically reduces the interpretation of pain signals. This unfortunately involves some level of deception, and doesn’t work for everyone, but it was worth mentioning because it can work.

Hypnosis- Hey, if you write whump like I write whump, your characters get desperate pretty quickly. If your characters have nothing else, this might be worth a try to them, and you as a writer can decide whether or not it works for your characters. Because there is such a negative public understanding of the technique, hypnosis works best in a pain control capacity if the person does not know its hypnosis. A provider can describe it as a relaxation technique or distraction technique in order to gain compliance.

Steps for pain-control hypnosis:

Ask that the person focus just on the practitioner’s words. Speak warmly but firmly.

Ask the person to focus on their feet, and imagine them getting heavy and warm. Spend time on this one. Like a whole minute. Make sure those feet are really heavy.

Ask the person to work their way up the body, asking each body part individually, making their whole body feel warm and heavy as they go. This takes some time, go slowly.

Once that’s done and the whole body is warm and heavy, their breathing should even out. If not, start back at step one.

Once breathing is even, ask the person to slow their breathing.

Suggest that the person imagine themself in a pleasant place, feeling no pain, and give a quest or story to act out in that place. Provide an amount of time they should be there for.

Bring the person out of it by telling them to wake up at the count of ten, then count to ten.

The person would not be particularly helpful during this, but if it worked for them, their pain would be manageable. R E F E R E N C E S

Hinkle, J., & Cheever, K. (2014). Brunner & Suddarth’s textbook of medical-surgical nursing (13th ed.). Philadelphia: Lippincott Williams & Wilkins

Iserson, K. V. (2012). Improvised medicine: Providing care in extreme environments. New York: McGraw-Hill Medical.

Stick 'Em Up for the Mugger Crocodile

The mugger crocodile, also known as the marsh crocodile (Crocodylus palustris) is a species of crocodile native to south Asia, including Iran, Pakistan, Nepal, Sri Lanka, and India south of the Himalayan mountain range. They can be found in most freshwater habitats including rivers, lakes, and wetlands; on occasion they may also be sighted in brackish wetlands and estuaries.

Mugger crocodiles average 2 to 3.5 m (6 ft 7 in to 11 ft 6 in) in length and weigh on average 450 kg (990 pounds), with males typically being larger than females. Despite being only medium sized among crocodilians, C. palustris boasts the broadest snout of any crocodile species. Like most crocodiles, they are covered in thick scales which can range from brown to grey to green in color, sometimes with a spotted pattern, which allows them to blend in to the muddy waters in which they hunt.

Like most other crocodiles, marsh crocodiles are ambush predators, lying in wait for prey. However, mugger crocodiles are unique in that they are one of the first recorded reptiles to use tools; in particular, they have been documented using sticks to lure birds into striking distance. They have a wide and varied diet, which can include fish, snakes, turtles, birds, monkeys, otters, and smaller crocodiles; they may also feed opportunistically on carrion. Adults are rarely predated upon, but juveniles and eggs often fall prey to snakes, birds, rodents, and larger crocodiles.

When not hunting, mugger crocodiles spend most of their basking on the shore, as all reptiles do. They will also dug burrows in the mud to hide in when temperatures drop below 5 C (41 F) or exceed 38 C (100 F). Both males and females are territorial, though they may make overland journeys to seek out mates or if their local water body becomes unsuitable.

The mating season begins in November and continues throughout the dry season. Male C. palustris compete for females by slapping their heads against the water and humming. After breeding, the female deposits a clutch of 8-46 eggs in a shallow-dug hole on the bank, and both she and the siring male will protect the nest for the next two months. The ratio of male to female offspring is dependent on the average incubation temperature; cooler temperatures produce more females. After hatching, both parents continue to protect their young, often by carrying them in their mouths, until they reach independence at about 1 year of age. Females reach sexual maturity at 8-10 years old, while males reach maturity at 12-15 years. Adults may live to be well over 30 years old in the wild.

Conservation status: The IUCN has declared the mugger crocodile as Vulnerable. Their primary threat is habitat destruction and conflict with humans. They are also hunted for their skin and meat.

Photos

David Raju

Paul G. Schrijvershof

Today's animal of the day is the Hot Creek Toad (Anaxyrus monfontanus)!

Photo credit: Gary Nafis

This critically endangered species of amphibian is endemic to Nye County, Nevada, in the Hot Creek Mountain Range, hence its name. The marshes that these toads inhabit are fed by hot springs and surrounded by the arid sagebrush steppe, which greatly restricts the toad's native range to just this area. It is believed that the ancestors of this species were able to first arrive in the Hot Creek Mountains by following the White River, which once flowed through the region. However, eventually the river flow changed directions and trapped the toads there.

Photo credit: William Flaxington

For a long time, this species wasn't actually considered to even be a true species, or even a subspecies for that matter. They were originally believed to just be a population of western toads (Anaxyrus boreas). However, recent genetic and morphological analysis showed that many types of toads previously classified as western toads were actually totally separate species! The Hot Creek toad became separated from the western toad in 2020 along with the Railroad Valley toad, and so was the Dixie Valley toad just a few years earlier. Due to it only being recently discovered and it being pretty rare even within its already small range, very little is known about these toads, and scientists have so much more to learn about them.

Photo credit: Gary Nafis

The monito del monte (Dromiciops gliroides) is a tiny enigmatic nocturnal arboreal marsupial native to Argentina and Chile that may be more closely related to Australian marsupials than other South American marsupials…

(read more: Wikipedia)

Spider-Man: Homecoming is the first film in the second reboot; thus, the third Spider-Man franchise our generation got to see in a relatively small amount of time. I remember liking the first Spider-Man and thinking that its sequel in 2004 was one of the best comic-book adaptation films ever made up to that point. Since then, a lot has changed, and most importantly, Marvel making the “Marvel Cinematic Universe” i.e., everything that is wrong with cinema in the last decade. I kind of hate the Marvel films, apart from only a few (I loved the first Ironman, for example). Many of them are unwatchable movies that don’t follow classic forms of storytelling, require you to know all the previous ones in the series, that they heavily reference, and introduce fantastical elements, like mixing and matching aliens with humans, breaking a fundamental law of all sci-fi filmmaking: “One trick at a time.” But this new reboot was heralded as fresh and subversive enough and had some very successful sequels, so I had to see it eventually. Well, the film commits to the same sins mentioned above. It’s fun and fresh, yes, but we never get to see who this hero is. We don’t have an "Act 1". Everything is taken for granted cause... it’s like... you’ve seen it already! Well, no! I haven’t! And because I don’t know what’s going on, I’m not having fun for at least the first 30 minutes. And once I get what’s been going on, I feel robbed again since this character never got to become Spider-Man on his own. He’s like a trainee of Ironman, getting his suit from him and a suit that feels like an Iron-Man suit anyways. It may sound like I’m geeking out, but all I’m saying is that this is a character with a borrowed past and a borrowed present, along with a borrowed costume. So, where’s the arc? Where’s the development every hero needs to have, for us to root for him? There’re some cool scenes, like the Lincoln Memorial, and some fun performances, but this Spider-Man didn’t start on the right foot for me. I hear it gets better in the sequels, until I suspect they again borrowed the premise of Spider-Man: Into the Spider-verse for the last one. What a... Marvel!

C+

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I think people outside the USA severely overestimate how long hospital stays are here.

Like, appendectomy, right? That's maybe 24-36 hours door-to-door if there's no complications. If the appendix actually burst it might be 3 days, but only because they're giving you IV antibiotics and setting up home care to do that at home would take longer than just keeping you in the hospital.

A scheduled surgery like a hysterectomy, cholecystectomy, mastectomy, or anything else they can do laparoscopically (though small "keyhole" incisions)? You're probably not staying overnight at all.

Planned surgeries that need some kind of after care (like bariatric surgery, knee replacements, hip replacements, total vaginal hysterectomies, bladder lifts, etc...) would be usually 1-3 days.

Minor heart attack? 2-3 days.

Fracture and surgical repair of a large bone (like the femur)? About 2-3 days.

What about the exacerbation of a chronic illness like asthma, COPD, heart failure, or hypertension? IF they admit you (not just stabilize and discharge from the emergency department), it will be generally less than about 3-5 days.

Gunshot wound to the abdomen with surgery to repair things? 3-5 days.

And a stroke, sepsis, gunshot wound to the chest, or major heart attack? That would be somewhere in the 5-7 day range.

Severe trauma with multiple severely broken bones and relatively extensive surgery? This might be somewhat longer, but usually for nursing and pain control reasons rather than the surgery or injuries themselves. 1-3 weeks would be usual.

In the hospital for a mental health reason like decompensated schizophrenia or major depression? A little less than a week is normal, though some people stay several weeks if medications aren't working well.

The people who stay in hospitals for weeks or months typically have whole systems that don't work, or are waiting for a major organ transplant. For example, I had a patient once whose entire abdomen was open and couldn't be closed surgically. She was on TPN (IV nutrition) and IV antibiotics and needed massive amounts of wound care done every hour or so because her intestinal contents were spilling out of her open abdomen. She was there for months and ultimately didn't make it.

Are there people who stay longer than these cases? Of course! These are just averages pulled from medicaid data and personal experiences, based on patients who are coming in relatively healthy. Patients who have other significant health problems usually stay longer than patients who come in with a single problem.

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