Facultative rabies

(Facultative: capable of adapting to different environmental conditions)

Well, this past week can be taken out back and shot, as far as I'm concerned.

Isadora had been sick with kidney disease and an upper-respiratory infection for a little while, but we thought we had it under control. She was getting fluids intravenously, and we had a plan for when she resumed eating, and how we would manage her kidney disease--the prognosis seemed good.

Since our vet clinic is not an emergency facility, and no doctor is present on the weekend, I got a call from the vet Friday a week ago, suggesting I take her home and provide hands-on care Saturday and Sunday--syringe feeding and subcutaneous fluids--and then bring her in Monday to restart the IV. Sounded like a plan--I was going to attend the Western Washington Wildlife Rehabilitators conference at the UW Saturday, but I could be a little late to that, np--so that's how we proceeded. I picked up Izzy, subq-fluided her, and then left for the conference. When I got back that evening, we did the same routine plus a syringe feeding.

Sunday, same deal. That's when she decided she'd had enough of this crap, and bit me in the right index finger knuckle, HARD! I think I'm going to have a scar from it.

By Monday morning, it was red, hot, and so swollen it had that Botox look: no natural wrinkles anymore; half of the back of my hand was almost perfectly flat and fluid-filled. And it hurt like a bastard! We're uninsured at the moment, due to unemployment, so I don't routinely go to the doctor, but I wasn't about to let this infection go systemic, either, so it was off to the emergency room for me.

I dropped Izzy off at the vet's on the way to the ER, and warned them about her biting me. We actually have observed this behavior, called "The Cobra", in the past: when she feels bad and over-interfered with, she bites swiftly and hard, without warning, compared to the absolute lovecat she always is when she feels better. Since she gives no warning, I didn't want anyone else taken by surprise.

The visit to the Overlake ER was the best it could be, given the circumstances--it's an ER, after all, nobody's idea of a good time (I hope!). But the staff was competent and kind, and since no gunshot wounds or anything like that were coming in, I was able to be seen right away. The nurse practitioner who saw me was friendly and patient, and willing to answer questions. She thought it was a Bordetella infection, and although penicillin is the first line against that infection, the almost-fact that I am allergic to penicillin made doxycycline the recommended way to go.



Figure 1: Image of Bordetella bronchiseptica from http://upload.wikimedia.org/wikipedia/commons/thumb/1/1d/Bordetella_bronchiseptica_02.jpg/240px-Bordetella_bronchiseptica_02.jpg



Figure 2: Doxycycline, related to tetracycline

With a sling to immobilize my dominant hand (to remind me not to use it anymore than necessary), and a container of antibiotics, I headed home. I had just gotten settled in when the phone rang. It was the vet, and she asked me some questions about the bite. Then she said she had some bad news, and I knew before she told me that Isadora had died.

We're all shocked--we thought she was getting over this upper respiratory thing, and would go on to have her kidney disease successfully managed. She thought so, I thought so, Iain thought so--but whatever it was she had, it was too much for her.

Well, that was bad enough. But wait, there's more!

It turns out that King County has a "rabies protocol" that automatically kicks in when an animal bites a human, and then dies shortly after. She had to report it to the public health department, and was waiting to hear back from them whether they needed to get Izzy's head to test the brain for rabies.

She did the right thing in invoking the protocol, even though I'm (almost) sure we're in the clear. I'm just neurotic enough to worry about the tiny possibility of it, even though we agree she showed no signs of rabies either here or at the clinic, and her staggering was plausibly due to her weakness in not eating for so long, rather than the neurological degeneration of rabies. Her "flu-like symptoms" are more consistent with an upper-respiratory-tract infection than the symptoms Wikipedia's entry on rabies describes, and the bite was far from unprovoked. I was bugging her with syringes and needles, and "The Cobra" goes back for years now.

It looks like the public health department is going to agree with us, and not insist on testing. So that's that, except for the next couple of years, in my more paranoid moments, I guess I'll be interpreting every little sneeze or shiver as the onset of my own personal rabies case.

I told a conservationist friend, and said that, just in case, I was preparing a list of people to bite </oldjoke>. "Facultative rabies", she proposed. I like that.

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Good kitty Isadora

Il pleure dans mon coeur
Comme il pleut sur la ville

(by Paul Verlaine)

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3 rules for infection control, applied

Son of a bitch, Isadora, that hurt! Twice--once when I was on the receiving end of a deep bite after fluids/feeding, and again when I poured alcohol over it.

Fortunately, I'm current on my tetanus booster shots, given how often I get bitten, scratched, or otherwise punctured around here.

Yesterday, I saw Dr. John Huckabee's talk on infection control at the WARA conference; I thought, though, I'd have a few more days before actually applying them.

Rule 1--Don't be a fomite! Fomites are inanimate objects that can transmit infection, so reusing needles or gloves that can carry germs, or not cleaning telephones, keyboards, or doorknobs that are handled frequently can pass on infection. By "don't be a fomite", he means take care to clean and disinfect your clothing, instruments, and environment in such a way that their potential for passing on infection is minimized.

Rule 2--Wash your hands! I'm pretty good on this one, actually; I wash my hands frequently, especially after handling the cats, or going to the bathroom, and before handling food.

Rule 3--Clean first, then disinfect. This is the one that I've been the sloppiest about in the past, partly because I've never thought too much about the difference between cleaning and disinfection. As Huckabee clarified yesterday, cleaning uses friction to remove microbes from the environment, while disinfection is the use of agents that actually kill microbes (I am deliberately not linking to Wikipedia in this instance because their article confuses the two; I am not the expert who needs to clean it up, but they conflate cleaning and disinfection).

What I've done in the past is pour alcohol over the bite, thinking I was cleaning and disinfecting simultaneously. Wrong! The presence of organic material reduces disinfectant activity; that's what Huckabee means by "clean first, then disinfect". So this time, I washed the wound well, scrubbing and rinsing for an entire minute, before pouring alcohol on it, and then drying it, applying Neosporin, and bandaging.

UPDATE: Ooops, hit "Post" too fast--I meant to say that I hope the fact that Isadora has the strength to deliver a bite like that means she's feeling better, at least a little...

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Mood: impish

Yesterday I attended the Washington Wildlife Rehabilitation Association's Fifth Annual Washington Wildlife Rehabilitation Conference. While not an wildlife rehabber myself, I am very interested in the community--they have a wealth of good experience and knowledge, and they are definitely on the side of the angels in their work to help wildlife. I want to direct a significant part of my future anatomy informatics research toward developing tools for them to be able to share, organize, and find that information as seamlessly as possible.

The program was crammed full of good information, and I have a lot of biomedical and behavioral information to process into usable form, and many new contacts to follow up on. They ended on a fun and useful note, with a workshop on raptor imping, or feather repair for Washington birds of prey, such as hawks and owls. It's kind of like a hair transplant for avians, but it's much more practical than cosmetic--it can make a lot of difference in flight stability, which itself can be a decisive factor in deciding whether or not a bird is ready for re-release into the wild.




I hasten to reassure Washington hawks, owls, pelagic birds, and others that I have no intention of actually practicing on real birds any time in the near future! For me, it was an opportunity to learn some non-mammalian anatomy, and--more important--to get a hands-on opportunity to see how wildlife rehabbers gain, process, and share new information with applied (clinical) relevance, in order to incorporate those observations into some future way of information-sharing. I appreciate Mike's (the instructor) taking his time and materials to provide the instruction and practice, and WWRA for providing the venue and opportunity to take the workshop.



In real life, of course, you'd be carrying out this procedure on a live bird in rehabilitation; we practiced on isolated feathers instead. As good an idea as that sounds in theory, you'll also see its wisdom borne out in practice as the workshop unfolded. Below, in the bottom right quadrant of the photo, you see my broken feather (a left #10 primary from a barred owl, to be precise) on the left, and a replacement left #10 primary feather from a different barred owl on the right.



By the time I had taken this photo, I had already separated the calamus of the broken feather (left) from its vane (center). If this were a real-life situation, the calamus would still be attached in the follicle of the feather in the bird, who would be restrained or anesthetized, lying there while the procedure is carried out. The replacement feather (right) has not yet had the calamus separated from the vane, which will be the next step.

That's where the tea candles you see in the picture come in--if you take the time to heat the scalpel blades thoroughly in the flame, then there's no slicing or sawing through the shaft. The warm blade cuts through the quill like butter.

Fortunately, Mike stepped us through it patiently, because at a conceptual level, I was not sure I understood what had to happen to what in what order. There seemed to be a similar concern elsewhere in the room--I heard people doubting whether they could do this. After all, the animal's welfare is the primary concern, and they (and I) do not want to screw that up. But the people in the room, other than me, carry out other difficult procedures to help injured and recovering wildlife every day, and I had no doubt that the rehabbers who want to go on in imping will do so successfully, after some practice.

Below the calamus has been separated from the vane in both feathers, and in the left of the field, the calamus of the broken feather (still embedded in the follicle of the live bird, remember!) is roughly lined up with the vane of the replacement feather. Notice how I've been moving the calamus around in the photos to get a comfortable alignment for me--in real life, that poor bird would not need to be rotated so much and so often; part of this skill, I think, must be learning where things need to be, and setting them up that way at the start.

The calamus of the replacement feather and the vane of the broken feather are at right, and can be discarded, except I am going to try to use the shaft of the broken feather as the bridge for my imping.



Success! Or, at least, half-success; I still have to do the same thing for the calamus.

The bridge slides in to the shaft of the vane, and fits snugly--there is no looseness or rattling around, which will have an adverse effect on the success of the imping.



At this point, I am feeling rather pleased with myself, although I am concerned about how long it is taking me, with my "patient" either restrained or under anesthetic. Birds, after all, stress out very easily; I think that developing skillful speed must be an important component of this.

Other people in the room are having similar concerns; from somewhere, I hear the following exchange:

"Oh, no; we took too long--the patient just died!"

"Well, check and see whether he's a feather donor."

My bridge to the calamus was not quite as successful as to the vane; it was a little floppy. But the workshop was winding up, so I didn't have time to start a whole new bridge. For the sake of practice, I went with this one, and now that the bridges were in place, it was time to bind them permanently.

We had had a discussion at the beginning of properties of glue; epoxy actually seems to be the best choice, although sea water can cause some kinds to lose their integrity. The choice of glue is a non-trivial question, in other words, but for the sake of a practice workshop, Mike chose SuperGlue because it's cheap and fast.



I already had a certain amount of doubt about the safety of birds, blades, and flames around my motor skills; accidentally SuperGluing a bird's wing together seemed to me like a real risk to be avoided, and I promptly proved the point by SuperGluing my right ring finger and pinky into kind of a mirror-image "OK" sign (or "Arschloch" sign, if you're a German-speaker.) Ironically, if I were a pterosaur, I would have just totally subverted the entire imping procedure, since while bats fly on their fingers, and birds fly on their arms, in pterosaurs, "the ring finger is the wing finger" (I'll attribute that quote if I can find where I heard it), so I had just taken out my entire wing.

"Help", I said softly to Mike, who sized up the situation, pulled my hand up over my head like the referee does a boxing champ, and announced, "Can I have everyone's attention, please? Don't do this." (waving my hand). Fortunately, one of the rehabbers was also an experienced mom, who has obviously lived the SuperGluing fingers together scenario before. With warm water, a pen to gradually work the fingers apart, and a minimum of drama, we got it under control.



My results, while not perfect, were actually not bad for a first attempt, although as said above, it took a very long time. Below are pictures of my imped feather.





I did not get to keep my imped feather, as this is an area where Federal law, tribal law, endangered species, and freedom of religion all intersect, sometimes quite contentiously, and there is a lot of paperwork involved to make sure that everyone is cleaner than Caesar's wife about the use of raptor feathers. Mike and WWRA have the required permits, and can put on the workshop, but to transfer the feathers to us, who do not all have those permits, is a ton of effort, accounting, and documentation that we did not go to.

I totally had a blast, I learned something about avian anatomy, and more about the rehab community and how they gain, share, and use clinical information. All in all, a day very well-spent.

These are very good people, and they do important work to help animals. I invite you to support your local wildlife rehabber, as well as local and national wildlife rehab organizations: the National Wildlife Rehabilitators Association and the International Wildlife Rehabilitation Council. Locally, I am going to donate my time and money to WWRA, and I invite my readers (both of you! :) to do likewise.

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Cat nurse

Isadora is doing a little better. She came home for the weekend, since our vet is not a 24/7 emergency clinic, and the vet wanted her to get hands-on care Saturday and Sunday. She's been receiving intravenous fluids, which I'm not qualified to administer, but I can give her subcutaneous fluids twice a day for two days, as well as syringe-feeding her, before I take her back in Monday.

Yesterday, she was quite passive; today, as big a pain in the ass as it it, I'm glad to see her resisting the fluids and syringe, as it means she has more strength than she did have. I got 15cc of cat food slurry (warm A/D dissolved in water) down her yesterday, and 20cc this morning. Additionally, she had 300mL Ringer's lactate yesterday, 150mL this morning, and I'm planning another 150ml tonight and once again early in the morning before taking her back in to resume the IV.

Her creatinine, while still sucky, is trending the right direction (down--it's now 3 times what it should be instead of 6 times); we think the BUN is probably doing so as well, but it's still so high it's out of range of the clinic's machine, so we can't know for sure. The vet thinks that if she can shake this upper-respiratory infection, then she's got a good prognosis for managing her kidney disease. We've got to get her through this crisis first, though, and while I do see a little progress, Isadora's still got a long way to go.

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One foot in front of the other

I'm kind of numb right now.

I need to go back and check the dates, but since about June 2008, we've been through the following feline emergencies:

• Isadora had her external ear (pinna or auricle) amputated, due to chronic infections.
  
  
• Cleo almost starved to death due to inability to eat; removing half her teeth gave her her life back.
  
  
• Simon (aka Caspian) got really skinny, which turned out to be due to kidney disease; we gained a few months by treating him, but lost him in November.
  
  
• Cleo lost her appetite again in January; this time, it turned out to be liver disease of some kind. Putting her through a liver biopsy to determine exactly what disease she had didn't seem indicated, given that she's such a poor surgical risk that we wouldn't operate anyway, so we treated her conservatively. I syringe-fed her, forced pills down her throat, and administered fluids subcutaneously through the skin on the back of her neck. That bought us a little time, but it ultimately wasn't enough; we lost her at the end of January.
  
  
• Isadora's had a cold for about a week now, but until yesterday, seemed pretty much herself, just sneezier. Yesterday morning, though, she was totally sacked out when we left in the morning, and when we returned in the afternoon, she hadn't moved. That's kind of odd for Isadora, who likes to strut around like she owns the place, and I picked her up to see if she's ok. While not skinny (and certainly no longer Isadora the Hutt of old), she definitely seems to have lost weight. We thought it might be due to our changing their kibble, so I got out some canned food as a treat to get her to eat. She was very interested in the food, but somehow couldn't or wouldn't manage to eat it, and as she walked away from it, she staggered. It looked very much like Cleo toward the end of her liver disease, so I got her into the vet first thing this morning.
  
  

We lost a human friend (a real mensch) very recently, too, but I don't feel ready to talk about that, and mixing it with a discussion of cat emergencies doesn't feel productive right now, so we can just stipulate that I've pretty much been mainlining cortisol for a few months now and leave it there.

Anyway, the vet called me, and I thought we were going to talk about the cold. It turns out Isadora is a lot sicker than I realized--it's her kidney disease, which has been kind of low-grade since March 2007, flaring up again with a vengeance. We don't know why--maybe the cold, or something else, got her to stop drinking water for a while, she got dehydrated, and then the other symptoms spiked up, hard and fast.

The good news is, she's not as sick as Simon was, and the doctor thinks she can be successfully treated for some time to come. What surprised me was that she asked me if I wanted to do so, having just gone through it with Simon (who, to be fair, HATED his treatment, and made it clear it was an ordeal to get fluids or pills).

I dread going through this routine again. But of course, I am going to do so; there is no question about it. The fact that Simon just went through it doesn't change anything; it's not like there's just one chance at life for a kidney cat in our household and it's Izzy's bad luck that Simon got there first.

I do appreciate her asking me that; it was considerate, and I know she loves Izzy and is an advocate for her. At the same time, I am sure that if Izzy had only a poor chance at some quality time, or were likely to suffer from treatment as much as Simon did, she would tell me so honestly. She's a good vet, and having access to her to care for our cats makes this, if not exactly good, way less sucky than it *could* be.

But at the same time, it is stressful as well. I was feeling like a real Angel of Death there for a while, and when Izzy got yesterday this morning, I was beating myself up about changing her food, about what in our house could, unbeknownst to us, be poisoning all our cats one by one, and so forth. As the vet and I talked, though, it became clear that this is just the statistical cluster from Hell, though--our cats are stratifying into two groups, the older/sick ones and the younger/robust ones.

None of the younger ones have been to the vet in at least two years, and none are showing any signs of any illness. We've just got two broad groups of cats, and the circle of life is being played out. The clustering, though, is stressing me out; I'm sure that if they did a CAT scan of my head right now, they'd see the outline of the skull, lined by a thin layer of gray and white matter, and most of the image would be one huge cortisol-induced ventricle right in the middle.

Of course I am going to give Isadora her chance, and treat her kidney disease. But as to how to carry it out, I think it's not going to be conscious thought so much as just keeping going: one foot after the other....

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