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Jessica R. Kinsey, DVM, DACVS, 220 Mount Laurel Road, Moorestown, NJ (2024)

05/13/2023

Starting June 11, antibiotics and pharmaceuticals previously obtained over the counter, will require veterinary prescription. This means that clients administering treatments and patients receiving them most have a valid veterinary-client-patient relationship (VCPR). This transition has not been well received on all fronts, but will he beneficial for all involved.

Veterinary and human medicine alike are not about the products you buy; they’re about knowing how to use them appropriately. If your pet has prostatitis and baytril is prescribed, you’re not paying for baytril, you’re paying for the 8-12 years of advanced education that guided your vet through diagnostics to determine the issue, choose the antibiotic, determine the dose and route so that optimal concentrations accumulate in the region if interest. You’re paying for them to make sure the antibiotic is used responsibly so your pet or family member doesn’t develop untreatable MDR infections, to ensure antibiotics remain efficacious, and ensure no one (pets or humans) involved suffers from adverse effects. Because all these things are 100% necessary, it’s never been appropriate or smart to just guess and obtain a random antibiotic through a cheaper source.

There are SO MANY adverse effects when meds are not used properly. Micotil, an antibiotic used to treat respiratory infections in cattle became super popular because it’s a macrolide class antibiotic and when it first came out, many infections were sensitive to it. Many farmers have been using it without direct veterinary supervision for a couple decades. It’s deadly if injected IV (cardiotoxic with no antidote) and over the years, multiple farmers have died from accidental injection. Amikacin, another strong antibiotic people can sometimes get otc, causes renal failure. When we use it in clinical situations, we test the kidneys every three days to ensure they’re not sloughing tubules. If someone just gives it to their pet otc, they can easily kill their dog’s kidneys in a week. Again, damage is irreversible. Danger to humans and danger to pets are good reasons not to allow meds that should be RX to be obtained OTC.

Baytril, another antibiotic that can be obtained OTC, was a very strong and effective antibiotic when I graduated vet school (Spartans Will 2008). It’s been massively overused and now many of our infections are resistant to it. It also only kills one class of bacteria, so veterinarians who use it judiciously reserve it for infections where it is appropriate. Those who don’t know what bacteria they are likely treating use it because it worked well for something in the past. The infection doesn’t get treated and resistance develops. Most bad pseudomas and staph infections are now resistant. Drug resistance is dangerous to animals; this is also dangerous to humans as flora are shared among zoonotic infections. Progression of antibiotic resistant by improper use of medications is a valid reason to make antibiotics available OTC prescription only.

Many parvo cases we see owned by clients got vaccinated with otc vaccines. These vaccines were in affective because they were likely not appropriately handled or stored. Yes tsc vaccines are cheaper, but vaccines at a vet are less than $100; parvo treatment is thousands of dollars. When people treat pyelonephritis or pyometra with OTC antibiotics instead of getting necessary care, treatment efficacy is decreased. Decreased efficacy is another reason that prescription meds should not be available OTC.

As a whole, the new restrictions on OTC pharmaceuticals are a long time coming and a good step in the right direction for human and veterinary medicine.

Costs are of concern for everyone; financial assessments and consideration of associated expenses are imperative before getting a pet. Costs of care must be considered above costs of pet purchase or as part of the expenses in running a livestock operation. When applicable, insurance is a wise investment.

Veterinarians are not oblivious to the concerns associated with the costs of pet care, but their cost of education and costs of operations are continuously increasing and they cannot shoulder the burden of the luxuries of pet ownership or business expenses.

$A few months back, I repaired a humeral fracture for a kitten owned by a rescue. The adolescent kitten had been acquire...$

11/16/2021

A few months back, I repaired a humeral fracture for a kitten owned by a rescue. The adolescent kitten had been acquired with a somewhat chronic humeral fracture. The fracture had started to heal. Options for amputation and repair were discussed. The rescue wanted to attempt repair.

One of the important factors to consider before repairing a humeral fracture is to assess for nerve damage. In cats, the median nerve and brachial artery pass through the supracondylar foramen; the radial nerve and medial nerve are pretty close to the distal humerus. Nerve damage is more common in these fractures than with most other fractures. Prior to surgery, we assessed all three cutaneous zones to ensure sensation was intact. We also assessed the kitten in motion to ensure that motor function was present.

The kitten was taken to surgery; the humeral fracture was repaired; because the fracture was chronic, the ends of the bone were covered in callous. The radial nerve had to be peeled off the callous; the other nerves were not visualized. The calloused ends were drilled to ensure good blood flow to the fracture ends. The fracture was repaired with a plate-rod construct. Xenograft (because I don't have feline allograft) was placed at the fracture site.

The kitten was ultimately fostered by one of my ICU technicians.
Unfortunately, the kitten did not use her leg post-operatively. While the cutaneous zones appeared unchanged, she didn't use the leg at all for about 3 weeks. At 3 weeks, she started to have some function of the carpus; she didn't walk on the leg, but batted water and toys. By five weeks, she used the leg normally during motion.

Radiographs at 8 weeks revealed complete healed; the kitten is now normal.

*****

Humeral fractures are always an indication for open reduction and internal fixation (ORIF); they should almost never be conservatively managed as the joints above and below cannot be stabilized.

They are typically referral cases. A few specific types are addressed with divergent pins, pins and screws, and interlocking nails. Most diaphyseal fractures require plating or placement of a plate-rod construct. The plates can be placed medially, laterally, or cranially. I usually place the cranially or laterally.

In papers assessing the prognosis for humeral fractures treated with ORIF, the prognosis is regarded as "good" but most of the papers include dogs and cats and a variety of fractures. In a series of dogs/cats, the complication rate was higher with articular fractures (condylar/T-Y fractures) OR fractures not repaired with plates. In a paper describing fractures addressed in cats, 75% of fractures had a functional recovery, but 6% were not addressed surgically (not recommended), some were addressed with ESFs (not really recommended), and the appropriateness of the mode of repair was not assessed.

For our patient, the plate rod construct was chosen because the fracture ends did not interdigital (therefore, the cortex was not 100% reconstructed).

Nerve damage can be seen with humeral fractures, especially chronic fractures. There are three recognized forms or nerve damage and the prognosis varies based on the form encountered. The three types are neurapraxia, axonotmesis, and neurotmesis.

In neurapraxia, the nerve remains intact, but transient functional loss is observed. In axonotmesis, the axon is completely disrupted but the myelin, perineurium, and epineurium is preserved. In neurotmesis, the nerve is completely disconnected/severed. Neuropraxia often resolves over a 2-8 week period. The other forms are unlikely to resolve.

For this reason, the recommendation is typically to give patients with nerve damage up to 8 weeks to respond. That was easy in this case as the patient had sensation the entire time and didn't appear painful. In brachial plexus injuries, I tend to be more aggressive in the amputation of deep pain negative patients because these patients often have complete avulsion.

In our patient, I was hopeful that, while I peeled the nerve off the callous, minimal damage occurred. I was hopeful that no additional damage had occurred, but also intermittently considered pre-existing brachial plexus damage I couldn't identify. Luckily our patient was able to regain function.

This patient likely went from not using the leg to using the leg well because her fabulous foster mom did range of motion exercises diligently throughout her recovery.

10/16/2021

Tomorrow marks the beginning of veterinary technician week. The last 18 months have been very hard for the veterinary community. It started with fear, shut downs, layoffs, and donations of PPE, oxygen, and ventilators to our human counterparts. After a short time, it transitioned to a situation where everyone made a coordinated effort to utilize modified client and patient interactions in effort to continue to perform standard of care services with limited resources. Finally, we transitioned into a situation where we were universally understaffed, had more patients in need than ever before, and worked to provide exemplary service while keeping clients and employees safe.

While some days run smoothly, some days have been a straight up battle as we fight to provide for the needs of our patients, clients, and each other. We have been tested in ways we were never tested before, and, while it doesn’t always seem like it, we have continued to succeed — every day we have made a difference — whether it’s saving a patient, providing comfort and understanding to a client who’s pet we can’t save, supporting a coworker who’s ready to throw in the towel, or just surviving to fight the good fight for another day.

Thank you to all those who continue to work day in and day out to provide for our patients and clients! Thank you to all those who go above and beyond at every turn! Thank you to all those who offer words of comfort and encouragement when the rest of us are feeling down or not acting as our best selves!

Thank you to our awesome anesthesia nurses who strive to keep our patients safe and give them the best chance regardless of the situation! Thank you to our mini-surgeons (scrub nurses) who see the best and the worst of surgeons and patients and continue to strive to save patients by their own hands on the daily. Thank you to our scrub nurses who go the extra mile to prepare the ORs so we have the best tools to provide care when time is limited. Thank you to our icu and wards nurses who care for our patients when they’re often at their worst; your care allows many of our more critical patients to recover well when they may not without you. Thank you to our ER nurses that care for our patients overnight, but also, sometimes get dragged into some of the worst surgeries I’ve ever seen and —yet — continue to fight to optimize care.

Thank you to nurses that fill our meds, admit our patients, help obtain and run diagnostics. Thank you for our financial staff that often have the difficult conversations; thank you to our reception staff who work on the front line, handle an immense amount of incoming calls, and manage many of our clients when they are at their absolute worst.

Posted below are some of our pandemic cases- some pets we’ve treated over the last year and a half. When you look through them, please remember how YOUR LOVE, SKILL, EDUCATION, and EFFORT made a difference for them. Please know most of them are here today because, despite everything — YOU REFUSED to GIVE UP!!! Thank you — you are appreciated !!!! ❤️🐶🐱

09/13/2021

About 2 weeks ago, one of my colleagues performed a C-section on a Pitt Bull.

One of the pups had an omphalocele, a congenital defect in which a hole in the abdominal wall is present and intestines, liver, or other organs exist outside the abdominal wall. They are typically covered in peritoneum, but the peritoneum can rupture at any time. This condition has been recognized in small and large animals and humans.

In humans, diagnosis and treatment is well defined, but it’s not always correctable. Many patients have multiple congenital abnormalities and many cases require revision of the abdominal wall structure (fascial releasing incisions) to allow correction. In horses and cows, organ resection and abdominal closure has been described in treatment. In dogs and cats, there are minimal case reports of correction.

This is the first case I've seen where I thought correction might be possible; the pups were fairly large (this one was 500 g) and the abdominal wall defect was fairly small, so it seemed reasonable to try.

With the help of an amazing anesthesiologist, and some very dedicated technicians, this pup was anesthetized. I was able to quickly prep and drape the abdomen, open the linea at the level of the defect, explore the abdomen (which had mild presence of blood clots, tiny organs, and no other significant abnormalities), lavage the abdomen copiously, culture the omentum, and close the abdomen in 2 layers. Closure was not significantly tighter with all organs in the abdomen than it had been with external organs. Bupivicaine (standard release) was placed at closure.

Post-operatively, an attempt was made to get the pup to nurse colostrum, but the bitch had no milk availability. Oral (tube fed) and subcutaneous fresh frozen plasma were administered. The pup was treated with gabapentin and clavamox. She was tube fed milk replacer initially and then started drinking from a bottle. While she's not out of the woods yet, making it to her suture removal has been a huge step in the right direction.

The culture was negative.

I am hopeful that treatment of these dogs like incisional dehiscences/septic abdomens may give pups that would otherwise not have a shot at life an option.

I am hoping to be able to treat more of these dogs in the future. Loss of domain is often an issue because organs initially sat outside of the abdomen and return of the organs to the abdomen may increase intraabdominal pressure and the organs may not fit. Furthermore, in many of these cases, the absent abdominal wall may create a situation in which the abdominal circumference is lessened when the abdominal wall in closed. While it was not necessary in this case, fasciotomies may allow closure and minimize increase in intraabdominal pressure.

02/21/2021

There have intermittently been some requests for pictures of anatomy during spay, so I decided to do a post on a pyometra I recently did surgery on.

At our current practice, I typically only cut pyometra cases that are high risk OR, occasionally, random cases because our ER doctors are extremely busy. The high risk cases are always crazy -- the most recent high risk cases were an 18 year old dog with significant cardiac disease, renal insufficiency, and proteinuria AND a 3 year old dog that presented as a pyometra/DKA.

In both cases, my anesthesia nurse had a considerably harder job than I did. I think this is true is most pyometra surgeries as the actual surgery is a spay, but we're performing it on a sick dog that we'd deny elective surgery if we had the option.

Our cases are typically diagnosed via ER doctor-performed FAST scan or internist-performed abdominal ultrasound. Pre-operative diagnostics include CBC and chemistry/electrolytes +/- manual differential +/- coagulation profile. The DKA also had a vaginal cytology because a lot of the symptoms from DKA and pyometra overlap and we wanted to be sure that the dog truly needed surgery.

Stabilization includes aggressive bolus resuscitation (20 ml/kg boluses until blood pressure has stabilized), unasyn +/- baytril (I typically give baytril in azotemic cases), and GI meds as needed. There is no publication looking at efficacy of culture when pre-operative antibiotics are given to pyometra, but the study assessing pre-operative antibiotics with cystotomies concludes tissue cultures post antibiotic therapy are accurate. In practice, after >10 years of culturing every pyometra, I rarely have a negative result. E. coli is the primary isolate, both in reseach and in practice. Over 95% of cases are sensitive to unasyn/clavamox. The remaining 5% are typically sensitive to baytril. I've had 2-5 cases with MDR bacteria; these are typically merepenem or amikacin sensitive.

Surgery is 2 part -- an explore AND a spay. The explore part is essential. I will say, I base how aggressive I am on the pre-op blood work. For dogs with liver enzyme elevations/bilirubin elevations, I biopsy the liver and check the gallbladder. I've found so many incidental splenic and adrenal masses; I've removed a few gallbladders due to TE and concurrent cholecystitis. Many things I look at but don't touch (adrenals, etc.); I'm currently planning a partial cystectomy for a bladder mass noted by a GP at a pyometra surgery.

I make a point to look at the uterus and ovaries; I have seen a lot of ovarian tumors and, in many cases, infundibulae are open. If the infundibulae are open, there is technically communication between the peritoneum and open abdomen. I lavage these cases like septic abdomens and use perioperative baytril in addition to the unasyn. For overt rupture, I also place a JP drain.

As an intern/early resident, I did hundreds of these surgeries with electrocautery and hand-ties. As a surgeon, I use a LigaSure device. This is not 100% because I'm now a diva; it's faster and bloodless, and by using the LigaSure on the ovarian pedicle, there's no foreign material left behind to get infected. The uterus has to be tied with suture.

Whenever I spay a dog, I visualize the ureters by the bladder and tract them to the kidneys. In can usually feel them but not see them medial to the kidneys. The ovarian pedicle is caudolateral to the kidneys. Attached below are some pictures.

I also sample the bladder (urinalysis and urine for culture); to minimize cost, I culture the urine and the uterine tissue together as a tissue culture.

Lots of lavage (~100 ml/kg or more) and routine closure. Most sick patients need 24-48 hours of postop fluids and hospitalization to be recovered well enough for me to comfortably send them home.

*****

12/22/2020

A couple weeks ago, I did a RIGHT forelimb digit V amputation on an older Golden Retriever. This sweet girl had some lameness and a toe mass for about 2 weeks prior to presentation.

Pre-operative radiographs of the RIGHT forelimb revealed an aggressive lesion on the RIGHT digit V P3 with regional soft tissue swelling. Radiographs of the thorax revealed a questionable nodule visible only on the LEFT lateral view. Axillary and prescapular lymph nodes aspirated as normal/reactive. Preoperative blood work was normal.

Options for incisional and excisional biopsy were discussed, but excisional biopsy/toe amputation was recommended.

The toe amputation was performed with the aid of a ring block (in addition to general anesthesia).

The patient was positioned with the digit of interest up (LEFT lateral in this case) and the limb was draped routinely; a loose tourniquet (made with a penrose and hemostat) was placed around the RIGHT carpus.

The tourniquet was tightened. An inverted Y incision was made over the lateral aspect of MC V and P1/P2 digit V; the incision was continued around the toe and to the lateral aspect of digit IV. A fairly wide margin was obtained around the suspected tumor site (P3) -- all grossly abnormal skin was excised with a 1-2 cm margin. The vessels were taken down using the LigaSure device. The soft tissue was removed. The ligamentous structures around the lateral/dorsal MC-P joint of digit V were incised, the joint was disarticulated, and the digit was removed. The tourniquet was released. No bleeding occurred.

Surgeon regloved and changed instruments. The site was aggressively lavaged with warm saline. The ligamentous tissue was apposed to cover the end of the exposed MC digit V using 3-0 PDS (SI). The subcutaneous and cutaneous tissue was then apposed using 3-0 monocryl; the closure was reinforced with glostitch (SI).

A modified RJB was placed post-op.

*****

Whenever we see a mass associated with a digit, the majority (55%) are malignancies. Of these malignancies, about 50% are squamous cell carcinoma; melanoma (20%), soft tissue sarcoma (13%), mast cell tumor (9%), and OSA (5%) are also commonly seen.

When we see lysis of P3 or another bone, this is marker for malignancy.

While, aspirates and incisional/excisional biopsy are all choices, I typically recommend excisional biopsy and culture in cases of bone lysis because once the bone is damaged by the lysis, treatment of any condition (cancer or infection) without removal of the bone would be unlikely.

*****

12/16/2020

About 4 weeks ago, I did a late night surgery to address one of the worst intussusceptions (in terms of involvement) I have ever seen.

The patient was an 11 year old Pitty who had never been formally vetted before. He'd always been a healthy dog, but he had received no preventative care.

He had eaten carpet a couple weeks prior to presentation; he vomited shortly after the ingestion and had waxing and waning vomiting and inappetence for several days. Then he appeared to pass the carpet. Shortly after this, he started having severe diarrhea. He became progressively depressed and started regurgitating.

Pre-operative blood work revealed significantly electrolyte derangements and low protein/albumin. The albumin was 1.4 g/dL. An ultrasound revealed an intussusception. A parvo test was negative. F***l testing was negative.

Exploratory confirmed this abnormality. The entire colon was filled with intussuscepted jejunum, ileum, colon, and cecum. There was a large volume of non-inflammatory fluid in the abdomen. Luckily, the majority of the intussuscepted intestines (intussusceptum) were able to be removed from the colon (intussuscipiens). There was a lot of fibrinous change to the intestines, but most of the intussusception could be reduced. Also, fortunately, the portion of the intestine that was compromised was about 6 cm orad to the ICJ.

A side-to-side stapled anastomosis was performed. The abdomen was copiously lavaged. The anastomosis was wrapped in an omental patch. Post-operatively, an NG tube was placed. A canine albumin transfusion was administered.

Our sweet little patient made a full recovery; when we saw him for his two week check, he had gained 7 pounds since he left the hospital. He was dewormed and started on maintenance heartworm/internal parasite prevention. Biopsy revealed no evidence of cancer or IBD.

******

Underlying factors that contribute to intussusception include internal parasites, severe acute enteritis (ie parvovirus), intestinal foreign bodies, chronic enteritis (ie IBD or GI LSA), and focal neoplasia. Our patient presented an interesting circumstances because, all of these factors could be present. Ultimately, a complete work-up revealed no overt underlying cause aside from a previous foreign body. The patient was dewormed to address any underlying parasitism.

Risks of treatment of intussusception treated with IRA include intestinal dehiscence, recurrence, anesthetic risk, poor outcome due to underlying disease, and persistent enteritis/colitis.

Risk factors for dehiscence are well reported in the literature. Published risk factors include low pre-operative albumin (

10/26/2020

A couple weeks ago, this sweet little pup was presented for acute head trauma - she was bit by her much larger housemate. She had an overt proptosis, retrobulbar hematoma, and swollen face. She was a little dull.

Surgeons at our practice do not usually perform enucleations, however, since the patient was a tiny (1 kg) and young (~ 6 weeks) and had recent trauma, a surgeon was requested. The pup had been surrendered by her original owners and picked up by a rescue, so funds were limited. The decision was made for my fellow and I to fix her together.

Initially, things went smoothly with our transpalpebral enucleation, however, when the remnant bits of globe were dissected free of the orbit, it became obvious that, there was more significant hemorrhage than typical and the orbit/zygomatic arch were fractured. After the enucleation, the hemorrhage was stopped; the fragments of orbit and arch were removed to prevent deformity with age.

The site was cultured and closed over a hand-made active suction drain.

Puppers received a blood transfusion post-operatively (10 ml - ridiculous). She made a full recovery.

She's already up for adoption.

*****

The most common source of hemorrhage associated with enucleation is optic artery bleeding. This pup also had bleeding from fractured bone and damaged musculature.

Because the wound is a bite wound, drainage is recommended. Active drainage is preferred (by me not as a universal statement) because there is no drainage over the repair site/face and cosmesis is optimized and because there is minimal contamination and prompt drainage.

The drain works quite well; a butterfly catheter is modified so the syringe end is removed, defects are made in tube that sits in the patient (in the orbit here), and the drain is exited through the skin and secured to a no-additive vacutainer tube. This creates suction to remove up to 2-5 ml of fluid (depending on the tube); we typically change this every 4 hours.

*****

10/26/2020

A few weeks ago, we had two male dogs came in with bilateral perineal hernias. Both dogs were dachshund mixes. Both had straining to urinate/defecate as their primary signs.

Only the colon was herniated in both cases. Both cases had prostatomegaly. They were corrected within 1-2 days of diagnosis, but not as an emergency.

In both cases, bilateral hernia repair was performed using an obturator flap. In one case, the patient was castrated simultaneously. In the other, the dog had been neutered about 2 weeks prior to the hernia repair.

Both cases healed without complication.

*****

- Perineal hernias are commonly seen in intact male dogs. The pelvic diaphragm is weakened by testosterone. Straining associated with prostatic enlargement may also contribute to herniation.

- Intestines (large and small) and the urinary bladder are the most common the herniate. Just like any other hernia, herniated contents can become entrapped or strangulated. Herniation of the bladder AND entrapment/strangulation are considered surgical emergencies.

- To treat herniation, there are two treatment options - these are performed separately in multiple sessions or as a single session procedure.
- 1 ) the hernia can be closed - either primarily or with the aid of a flap or mesh placement
- 2 ) the herniated organs can be secured via pexy
- In cases in which there is entrapment or strangulation, I typically explore the abdomen and pexy first. A herniorrhaphy can be performed immediately afterward (or within a couple weeks).
- In cases in which there is no entrapment or strangulation, I typically reduce from the perineal approach and close the defect that way.

- While herniation can occur in 6 locations, most commonly, the levator or coccygeal musculature weakens to precipitate herniation. The muscles can typically be closed dorsally. A flap can be made from the internal obturator and this can close the defect ventrally.

- Because testosterone is a common precipitating factor for failure and reported failure rates are 10-46%, for intact male dogs, neuter should be performed at the time of hernia correction.

- In cases where non-intact males herniate, I typically recommend ultrasound to ensure that there is no testosterone source to cause the herniation.

*****

10/11/2020

Tomorrow marks the start of national veterinary technician week.

Throughout my career, I've been surrounded by a number of veterinary technicians and other veterinary professionals who not only excel in their field, but are also fabulous human beings.

During the COVID-19 crisis, our hospital staff has been subjected to new responsibilities, persistent challenges, and even personal risks that have made their jobs even more challenging now than ever.

While there is no doubt that they feel the increased stress load and, sometimes, shear exhaustion, day in and day out, they continue to make massive contributions toward maintaining optimal client communication and patient care.

To the quiet heros who schedule our appointments, admit our patients for appointments and procedures, fill our medications, run our pre-operative diagnostics, safely anesthetize our patients for surgery, tenderly recover our patients from surgery, and lovingly help them to get back to their former function - THANK YOU FOR YOUR CONTINUED SERVICE. Our patients are better because you WON'T STOP CARING and this doesn't go unnoticed.

Attached are photos of some of the many patients we have helped recently. As you remember their unique stories, please remember that you made a difference in the life of someone's family member. I'm so honored to work with you all !!!

Jessica R. Kinsey, DVM, DACVS

05/13/2023

11/16/2021

10/16/2021

09/13/2021

02/21/2021

12/22/2020

12/16/2020

10/26/2020

10/26/2020

10/11/2020

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