Good evening, everybody, and welcome to tonight's webinar. My name is Bruce Stevenson, and I will be chairing this evening's webinar. A big thank you to our sponsor, Smart Vet AI.
Without their generous sponsorship, we would not be able to bring you this webinar for free, and, we really do appreciate their sponsorship. A Little bit of housekeeping before we move on to the main event. For those of you that haven't joined us before, we are recording all the sessions, and the recorded version will be up on the website, the webinarvet website, in the next 24 or 36 hours.
And you can, go back there and watch and rewind and fast forward and relook at slides, which during the presentation tonight is not going to be possible. So bear that in mind. You won't miss anything, you can always go back to the recording.
Also, if you have any questions, if you just move your mouse over the screen, the control bar, which is normally a little black bar, pops up at the bottom normally, and you'll see there's a Q&A box on that. If you just click on that and, type your questions in there, we will hold all of those over to the end, and we will get through as many as what we can this evening. So it is now my pleasure to welcome to the webinar vet, Doctor Jamie Ley.
She's a practising veterinarian and entrepreneur with over 14 years of clinical experience. She is the founder of Wonder Vet Mobile Veterinary Service, an in-home veterinary practise based in North Carolina, as well as Smart Vet AI, a clinical decision support tool designed to support veterinarians in interpreting lab work, generating differential diagnoses, and improving client communications. Doctor Leyty previously built and led a fear-free and AAHA accredited hospital that grew into a multi-doctor 67 days a week practise with emergency capabilities.
The hospital was later recognised as the AAHA Hospital of the Year, reflecting her commitment to clinical excellence and high-quality patient care. Jamie's work is driven by a passion for supporting veterinarians in the real-world challenges of practise, particularly in the moments of uncertainty where clinical decision-making is most complex. Jamie, welcome to the webinar, vet, and it's over to you.
Bruce, thank you so much for having me and thank you guys for being here. We are going to do a topic today that is near and dear to my heart, and it's blood work that still trips me up, and it is real-world interpretation for practising vets. So this is me.
I'm Doctor Jamie Laty. I have been practising. I'm still practising for 14 years.
I started my career doing an internship at a busy 24 hour private practise and stayed on as an associate. I later became the intern coordinator there. So I helped raise a lot of baby doctors in that time.
And as Bruce said, I started, built, and sold a six-doctor practise, and it's currently the recognised Aha Hospital of the Year. And then after I had kids, I decided I wanted something a little bit different in terms of the pace and schedule, and so I started a mobile practise and that's what I do now. I love it.
It's fantastic. I highly recommend it. And last year, I started a side project, trying to help develop a programme that, helps us with our, our workload.
We have a lot of cognitive responsibility, a, a lot of cognitive overload in our, in our profession, and I wanted a tool to just help with some of that. So, we'll talk about that in a little bit, but just wanted to let you know, I am in the trenches with you guys. I am practising.
It's not easy stuff, and just because I've been doing this for a while doesn't mean that, I have all the answers. It, you know, hopefully, over time, you just learn what to slow down for. So let's get into it.
All right. So, the gap that we're gonna talk about today is textbook versus real life. And, you know, we're in vet school, everything comes to you in a very clean pattern.
It's just one disease at a time. It's pretty easy interpretation. You don't have a lot of things competing for your attention, and, you know, that's important because you're learning new things, but then you get thrown out into the real world, and it's a totally different animal.
You know, you're, you've got messy overlapping results, you've got clients waiting for you, 10 minutes in between appointments, patients with comorbidities, and often, if you're anything like me, you're sitting there wondering, well, am I overreacting to this? Am I missing something? What do I do next?
What kind of decision do I make? How do I talk to this owner about that? And so this presentation is a lot about closing that gap and then just giving us support and confidence in how we, we manage the real life of veterinary medicine, because the textbook stuff is hard enough, but real life is, even messier.
Quick roadmap, what we're gonna cover in 45 minutes. We're gonna talk about some common lab patterns that might be a little bit tricky. We're going to help avoid some cognitive traps, build a triage framework just like you would if you were triaging an emergency.
And And then also feeling more confident explaining uncertainty to clients. I think this is a big piece, and probably where if you're anything like me, a lot of us feel, maybe a little bit sheepish when we're not sure the answer, how do we get a client to make a decision. So, let's get into this, big picture stuff.
The 4-question triage framework that I use when I'm looking at blood work, it's gonna be the same thing every time. And so, these 4 questions are, is it real? Is it primary, secondary, or incidental?
Is this acute or chronic? And does this pattern match my patient? To me, I think that's probably the most important.
They're all important questions, but it, does this match the patient in front of me, I think is super important. And just remember that just because something as, is labelled as abnormal, doesn't always mean that it is important. So we have to talk about the blood work pattern and the clinical signs.
So you need context for, for both of these. All right. So let's dive into this a little bit more.
My mental checklist, if we're talking about something real versus artefact, we all know that there are things that can, influence our blood work, hemolysis, lipemia, clumping. As a mobile practitioner, the delayed processing is big for me. I'm not always right at a centrifuge when, when I'm drawing blood, so, And, a lot of times as I'm interpreting, I'm having to look at, some changes there.
Is this change of primary, secondary, or noise an easy thing to think about, you know, your ALP, we all know that that can be affected by lots of different things. So is it, is it a primary problem? Is it reacting to something?
Is this acute or chronic? Classic example, a, a PCV, you know, a PCV of 22 could be a dog with a hemo abdomen. That you need to address right now, or it could be a cat that's been walking around for 8 months with, you know, chronic disease.
So knowing where that number sits in comparison to, you know, last week, the week before last month, is important. And then again, does this pattern fit my patient, without context. Looking at blood work in a vacuum is, is dangerous.
You should never do that. There are different things that can change based on age, based on breed. Are they on medications?
Are they intact or not? What diets are they on? And so all of this has to be taken into consideration, and you guys know this.
This isn't anything new or different, but, you know, as we're just trying to, organise our minds, remember that that's an important, thing to, to look at. OK, so I put this slide here, mostly to get your attention, and it says that reference intervals are lying to you. And that's, that's not true, but I'm hoping that you're paying attention now.
The important thing to know here is that reference intervals are statistical, they're not clinical. I think we all know that, but we don't always internalise it. So it's, it's just a starting point.
It's not a diagnosis. So by definition, 5% of your patients are going to be, abnormal. 2.5% will be higher, 2.5% will be lower.
Again, it's just statistics. So, and that's just for one value. And if you have a panel of 20 values, you know, statistically, that increases your odds that something's going to be flagged abnormal that isn't.
Your breed exceptions are important. We know that cavaliers are gonna have big fat platelets. We know that greyhounds are gonna be wonky, adjust for your life stage, your, your puppies are going to have a high ALP.
That doesn't necessarily mean that they've got a shunt, they're growing. Your adult dogs or your senior dogs, can have muscle loss, and so that can affect things. At the end of the day, we're looking at trends, right?
So things that are Normally inside the reference range and they're still normal, but they're moving towards the boundary, that is just as valuable information as something that's outside of the reference range. So again, just remember, reference ranges are statistical. So when we talk about evaluating our blood work, we can't do this in a vacuum.
I've already said that once. This is, you guys already know this. We have to look at clinical signs and the magnitude of the abnormality, right?
And this is trying to help us make a decision on what to do next cause veterinary medicine is not just about knowing the answers, it's about making decisions on how, how to manage it. So, let, let's talk about, an ALP of 220. And a dog with no clinical signs, like, I'm not really excited about that.
Imagine most people aren't. But in a dog that's drinking more and peeing more, that 222 maybe is a little bit more significant. On the flip side, if you have a dog with an ALP of 800, and it's not Got any clinical signs.
I'm still going to be paying attention to that and I want to know more. But if you've got a dog with an ALP of 800 and it's PUPD, OK, we've, we're going somewhere else now. .
So, just remember that you have to, to interpret both sides of things. A quick pattern recognition cheat sheet. A lot of these, patterns, you know, were, are drilled into our brains as we're in vet school, and they're not necessarily easy to remember, and some of these things we don't see that often.
I think about, like, for me in practise, how many times do I see Addison's? Not that often. I know it's out there.
Absolutely. Have I seen it before? Yes.
Does it always try and sneak up and grab me? Yes. But it, it's not something that you see that often.
And so, sometimes you forget to look for it. You know, your globulins being elevated, that's something that I often don't always think of as a pattern, but it's a, a marker of chronic inflammation. So, Your cheat sheet here, if you memorise these, it makes it easier, but again, we're looking for, for patterns, not individual values.
OK. Before we get into the meat and potatoes of this talk, I'm just going to do a quick plug for Smart Bed AI. This is the programme that I built, and it is a clinical support tool.
And what it does is it helps interpret blood. Work in context of your physical exam findings, and this is not intended to replace you or replace me or my thought process. What, the way I use this is to pressure test my differentials, you know, I'm seeing a case in front of me and I've already got an idea of what I, where I think this is heading, and this is a tool that I use to just make sure I'm not missing something.
If I'm feeling a moment of uncertainty, it helps me, Get through that and turn it into a plan. And also it's a, a great tool to help me communicate more clearly with clients and, and that's another side of things that can be tricky. So I use it to challenge my blind spots, to reinforce good instincts, and at the end of the day, to make better decisions faster.
And that to me is probably the, the most important part of this. All right, so that was my plug. Here we go.
If you're anything like me, your 4 p.m. On a Friday, case is going to hit differently than, earlier in the day.
And so, this is a tool that just helps support when your cognitive load is high. All right. Let's get into the cases.
This is what, what we're really here for, right? So the 5 cases that made me pause, these are real patients that I've been seeing, on my mobile practise in the last year, year and a half. We will walk through them together.
I'll talk to you about what, tripped me up or what made me second-guess something. And, And then how we worked through that. OK.
So our first case, this is a 10 week old male Bishapu puppy, so Bishan poodle, that is, was a purpose bred puppy. So it's a breeder that I work for. And, this little puppy is about 1/3 of the size of its litter mates.
So, it is thriving, it's eating, active, no abnormal clinical signs aside from the fact that it is smaller than the litter mates. If, if you've been around the block, of course, you're looking at that puppy right there thinking, OK, that, that looks like a liver shunt if I've ever seen one. Me too, the breeder too, so that's, that's kind of what we're looking for here.
On exam, quiet but interactive, mentally appropriate, had a little tiny, heart murmur, not super exciting for me at this stage, and did have, medial patella luxation. No one's shocked by that. And so what we decided to do with this guy is a CBC, chem, and faecal.
And we're trying again to figure out what is going on with him that he is so tiny. And Here are his blood work results. So I'll let you guys look at this for a second.
Take it in. But we did do a faecal, float on him and, it's just an OMP and he was, negative for parasites. We have some changes on the CBC for sure.
Our chemistry is not super duper exciting there. On the chemistry, or sorry, on CBC we've got, regenerative anaemia. It is, a microcytic hypochromic regenerative anaemia.
And we've also got, a little bit of a neutrophilia with a monocytosis. So, some things happening here. So again, we're, that little puppy, I'm looking for a shunt.
And this is what I've got on my blood work. So let's talk about anaemia for a second and how we work that up. We'll talk about the mechanism first.
We have loss, slices, decreased production, and sequestration, and different things on your, CBC will help guide you. I guess CBC and chemistry will help guide you as to, what the mechanism is. So when we talk about blood loss, you know, you expect the bone marrow to regenerate, so you'd expect some reticulocytes.
You are, you would also expect protein loss. So, in this puppy, the proteins were normal. So less suspicious of, a haemorrhage situation.
He did have a regenerative anaemia. Lysis, you know, we're, we're really thinking IMHA in a pup, a 10 week old pup, probably unlikely, but when we're looking for, a lysis mechanism, you think a regenerative anaemia, an elevated Tbili, and spherocytes on your smear. Again, low on my priority list for this pup.
Decreased production. This is your bone marrow failure, and this is typically a non-regenerative anaemia. And iron deficiency falls into this, but it's a little bit tricky.
It kind of crosses over between loss and decreased production because iron deficiency is from a chronic blood loss. So, a little bit of a, a double dip there. And then splenic trapping, that is sequestration.
Again, unlikely in this little tiny puppy, but it's like, not likely to be a regenerative anaemia. So, non-regenerative anaemia. So we've got our mechanism here.
And then the characteristics of the blood cells help narrow it. So this is a microcytic hypochromic regenerative anaemia. So that narrows us down.
We're looking at an iron deficiency. We're still looking at shunt, some hepatic insufficiency, and breed variant which does not fit with this pup. All right, so the conclusion on this little guy, and we'll get into this resolution here.
So it wasn't actually a runt. This is, he had an iron deficiency anaemia and probably from chronic GI loss. And so what made me pause here was, again, is this, is this anaemia something that is, he's just a young pup and he needs time to, for his bone marrow to get going, or do we have something going on here?
So he's a case that I threw into Smart Vet and it flagged as an iron deficient anaemia. And it recommended empiric deworming and iron supplementation, which sounded good to me. So, Just remember that a negative faecal isn't always the, the, the real answer here.
So, recommended deworming. And we started an empiric treatment for him. Started with some panicurfebendazole and rechecked him in 4 weeks and his anaemia was resolved.
He was gaining weight and not as big as his litter mates, but certainly catching up. So, when we go back to our framework of questions that we're looking at, the question that solved this is, is this real? And I'm talking about the faecal result here.
It said a negative faecal. But our anaemia pattern challenged it, challenged us to, to think differently. So, when you have a conflict between your test and a pattern, you really should be looking at the one that explains the whole patient.
You know, you got a 10 week old puppy here with an anaemia. Think worms, for sure. I mean, I also have other things on your list, but, dewormed him and he did great.
So, this was a really easy case, just easing you into it. Let's get into one that is a little bit more real life. .
So this is Sophie. She is a dog that I've been seeing for over 10 years. She is a 12-year-old female spayed German Shepherd.
About 2 years ago, I diagnosed her with Cushing's. About 8 months after that, diagnosed her with transitional cell carcinoma of her bladder. And then about 6 months ago, she developed a squamous cell carcinoma of her nose.
So, this poor girl has had, quite the, the rundown of things. So, I am seeing her for her annual exam. Just checking in on her.
So, again, she's got a history of Cushing's. This one is an adrenal tumour. So, already, she's not in the, the normal.
So she's had that for a year. She's been managed on Verol. She has a history of transitional cell carcinoma.
She was treated with radiation through the oncologist. And then recently diagnosed with, squamous cell of her nose. They have declined to, pursue that further.
She, also excitingly has thrombolic events every so often and will have stroke-like, signs on one side of her body. She has arthritis, of course, she does. She's 12.
She has chronic recurrent UTIs partly because of her recessed vulva and also her bladder cancer. So she's currently on Verol, gabapentin, Galaprent, and a low dose of aspirin for her thrombolic events. So she's kind of a train wreck, but a beautiful train wreck.
So on exam, kind of, what you expect for a 12 year old Shepherd. She has some changes in her eyes, some dental disease. She's got arthritis.
She's got a pendulous abdomen from her Cushing's, some muscle atrophy, and she has a recessed vulva. So all of that fairly unexciting, normal for her. It is her annual blood work, so we're doing a CBC, chem, urinalysis, T4, faecal, and, heart when check 40X.
OK. This is Sophie's blood work. Lots of red hair, lots of things abnormal, out of the reference range.
We'll kind of work through this. Our CBC, actually, probably one of the better spots of her blood here. Her platelets are a little bit elevated.
We can explain that with Cushing's. If you jump over to her chemistry, you can see on the right-hand side, what her values were, a year prior or 6 months prior. And you can see some changes there for sure.
So, we've got some, kidney things going on. We've got some electrolyte things going on. You've got her ALP which is pretty stable from where it was, cholesterol amylase lipase, and then if you jump down to her urinalysis, definitely some stuff happening there.
We've got isosphyuria, of course, she's cushionnoid, protein in her urine. She's got blood, she's got bacteria. Again, remember, she's got bladder cancer, and Yes.
So this one, you look at this and go, OK, what do we do here? So, Sophie has everything. So the question isn't what's wrong?
It's, what am I gonna do today? We're talking about decision making here as a vet. So, what do I need to do with this information?
So, the things that we expect to be abnormal, we just move to the side. Not today. So she's got Cushing's, so we're, that's not today's problem.
Her, cholesterol, her ALP, not worried about it. Her UTIs, . Are, are pretty on course for her.
So we're paying attention to that. But also what's new today is her kidney disease. So she has, CKD and she also has a metabolic acidosis.
So that's new. So she is, in a spot where she needs treatment. So we recommended, urine culture.
We need to stage this, and we need a blood pressure. Certainly not gonna do a, talk on chronic kidney disease management today cause that could be a whole another hour of talking. But just remember that when you are managing kidney disease, you're not just rechecking your creatinine and your BUN each time.
There are other things to pay attention to. You guys know this. Watch for her and watch for anaemia.
Hers was good if you remember. Her phosphorus was normal. Her electrolytes were abnormal.
And also we need to be managing our blood pressure. That's an easy one to forget, but try not to. And then UTIs.
And the, the new recommendation, or I guess it's not that new, but the recommendation is if they have, bacteria in their urine, we're only supposed to be treating if there are signs of, Upper urinary tract signs. And in this case, she does in fact have that. So we cultured her urine as well.
So, when we wrap this all up into our case, questions or framework, the question that we were asking that solved it today is primary, secondary, or incidental. You know, we're looking at this blood work going, What in the world do we need to do today? And figuring out what's the important thing, for today.
That's what your goal is. And so when you've got a medically complex patient, not all the time, but most commonly, the most dangerous abnormality is the one that's the newest. So that's the one that you need to, prioritise today.
All right. So our next case, this is Brody. He's another one of my long-term patients.
I've been seeing him for over 10 years. Brody is a cute little chihuahua. He's 11 1/2, male neutered.
He has a long history of seasonal adipe, so it's not uncommon for his hair to be, different and changed and wonky. He has a history of immune immune-mediated polyarthritis. He does not have any medications currently.
He's well-managed. This is a client who is very in tune to her dogs and does everything by the book. And she noticed that he's been more clingy than usual.
And that was her main concern. Also has been drinking a little bit more, intermittently, and he has been dribbling urine a little bit. And so he's been wearing a belly band off and on.
Owner also notes hair thinning, and she feels like that's more than his normal pattern. So on exam, pretty healthy little guy, pretty good teeth for his age. He did have a little bit of bradycardia for a Chihuahua, I think 65 feels a little bit low, but no murmurs, no arrhythmias.
His abdomen was soft. His coat was still pretty thick, a little bit of thinning of the undercoat. And had a little bit of arthritis, some changes in his joints.
And again, this is a yearly, so we plan a CBC, chem, urinalysis, thyroid, faecal, and because the owner, wanted to, we also planned for an abdominal ultrasound and an echo, to work up his bradycardia. So, This is Brodie's blood work. Just like his exam, pretty good for an older guy, not too bad.
We look at his CBC. I would, I have no, no problems there. His chemistry, I look at that and go, OK, that's not so bad.
An ALP of 229. I'm not really excited by that. I don't know about you guys, but not super exciting to me.
His urinalysis, he, his specific gravity is a little bit lower than what I would like to see, but not a, not Iouric, so, you know, I'm not really super impressed with any of this. I guess I am impressed. I'm not worried about any of this.
Ultrasound came back normal, and his echo came back, clean as well. So Brodie ends up having Cushing's. So, the, ALP of 229, again, wasn't really exciting to me, but the clinical signs of him drinking more and peeing more, that was enough to dig a little bit deeper.
So what I ended up doing, I threw his, blood work in through Smart Vet and it recommended digging a little bit deeper and So we did. I sent, sent out a urine, cortisol creatinine ratio, and it came back elevated. And so then we did a low-dose DEX and he came back, consistent with Cushing's.
So, Cushing's. This is one of those diseases that I love to be the hero and fix them. I do not love working them up.
I, I find them very frustrating to work up because they never follow the textbook. It's always, you know, not a slam dunk. So, and Birdie is one of those cases where he's just not a perfect slam dunk.
So, when we talk about working it up, one of the tests that I really like is the urine cortisol to creatinine ratio. I like to just call my lab and ask them to add it on if I'm concerned for something. And it's a good rule out test.
If it comes back normal, you have a pretty good idea to say that Cushing's is not likely here. If it comes back abnormal, if it comes back positive, it does not mean you have Cushing's. It means, it means you need to keep looking.
So Brodis came back positive. So we went digging a little bit deeper and we did a low dose DX suppression test and found out that he had pituitary dependent hyperadrenal corticism. So, Again, you have screening tests, you have confirmatory tests, and then you also need to differentiate.
That's why we like the low dose deck over the ACH STEM. The STEM is, I find, easier in practise because it's just quick and it's an hour. However, you don't get your differentiation.
All right. So the resolution with him, he is, happy and on Bearil, doing great. His hair came back.
His, ALP of 229 is now normal. So, you know, in this case, his blood work was not really very impressive, but the history is, is where the, the interesting stuff was. So when we ask, when we go back to our framework, what question solved it, it is, does this fit the patient?
And just remember that the, the lab values tell you what. It's just a number, but the patient is going to tell you how much it matters. So that was Brodie All right, this is Will.
Will is a 1315 year old male neutered domestic longhair. Whose owners have noticed that he's been urinating inappropriately and losing weight. So, he, for the past couple of months, he's been urinating outside of the box.
It is a large amount, not a lot of odour, pretty dilute urine for the owners. They say that he is eating them out of house and home. He is not vomiting.
He's not having any diarrhoea. And he has lost almost 5 pounds over 2.5 years.
And in the last 6 months, he's lost 2 pounds. So a pretty significant change here. On exam, he has some iris atrophy.
He has some dental disease. He definitely has some muscle wasting, not surprising given his, his weight loss. His heart sounds fine.
His abdomen is soft. And if you are anything like me, you are looking at this cat going, great, this is a thyroid cat, this is slam dunk. Easy peasy.
Let's do some blood work and confirm. All right, so we do a CBC, a chem, a T4, a faecal, and a UA on Mr. Will.
And this is what we've got. So we've got a little bit of a non-regenerative anaemia. Our kidney values don't look too exciting.
A little bit of an elevated SDMA but nothing else jumping out at the moment. Our specific gravity, we've got an isostonuria, so that's relevant. No UTI.
His crea CK that's abnormal. And he's got a little bit of elevation of his probMP. And his T4 is 2.8.
I was expecting it to be off the charts. I don't know about you guys, but I was unimpressed with his T4 of 2.8.
So, again, this is one of those cases where I'm sitting there going, OK, well, am I missing something? Am I overreacting? What's going on here?
So, this is a case of two diseases masking each other. I think that everybody probably knows that thyroid disease can mask kidney disease. I don't always think about it going the other way as well.
So This is one where he had, he had both. He has chronic kidney disease and hyperthyroid. Again, look at this blood work, neither of those values jump out.
But we have to ask, does this pattern match the patient? And let's talk about thyroid workup and a geriatric kitty. So, obviously, if your T4 is elevated, you're gonna treat that with, when they have clinical signs.
If it's high normal, so it's within reference range or on the higher end of reference range, and they're sick, you, you should be suspicious. If the T4 is low, remember the, the syndrome sicky thyroid, you know, if you, if the body is sick, it can draw down your T4. So, a cat that has all the clinical signs of thyroid disease, but the T4 is normal, can be A cat with sticky thyroid.
So, in this cat, his hyperthyroidism increased his, GFR and so that made his kidney values look better than they were. And his kidney disease made him sick to thyroid, making his thyroid look normal, so it masked on both sides. So, We did a free T4, confirmed that he was hyperthyroid and has kidney disease.
So we started him on management for both. And so in this case, The diagnosis was hiding inside the blood work. And again, the question that we have to go back to is, does this fit the patient?
And that blood work before did not fit my patient. So, you have to, really look into, to all sides of that. And, and a normal T4 in an older cat that's sick, that's not reassuring.
You should be suspicious of that. So if you have a high normal T4, keep, keep digging. All right, so this is our last case that we're going to tackle.
This is Bonita. She is a 10-year-old female spayed domestic shorthair, and it was my first time seeing her. She is an indoor outdoor garage cat that they've had for 10 years.
And in the last 2 days, she has been a little bit more lethargic. She has not been eating well. She vomited once this morning.
She's had diarrhoea for two days. And they say that this is, the, the eating is pretty abnormal for her. She's usually a pretty predictable eater.
So, on exam, Bonita was a big girl weighing in at 15 pounds, but she had a body condition of, so she, big girl, body condition of 8, but she had a significant amount of muscle atrophy. That is not normal. She had dental disease.
Her belly didn't feel super uncomfortable. She, sounded fine on auscultation, maybe a little bit quiet, reserved, mentation, a little bit dehydrated, but otherwise, nothing that was jumping out, as crazy abnormal. To me, the biggest thing with Bonita that had My spidey senses tingling, was that she had muscle loss, a significant amount of muscle loss.
When I think about a cat that's only been sick for 2 days, reportedly, you know, she's only been clinical for 2 days, you would not expect to see muscle loss the way that we did with Bonita. So, I think, I think that's important. My plan was to do, CBC, chem and the T4.
I could not get pee on her, and we sent off a faecal. Again, she's an indoor outdoor cat, so faecal is important. .
And she was sick, so we did some symptomatic and supportive care while we were waiting. I treated her with some subcu fluids and Cerenia while we were just waiting for, the results to come back. Again, she looks like a sick cat.
Big, big girl. OK, so for her blood work, it comes back and Let you look at it for a second. I'm not super excited by Bonita's blood work results.
Her CBC. Not super crazy, a little bit of a stress lucogram going on there. Kidneys look pretty good.
Now, again, I don't have urine. I can't, I can't tell you the concentration. I did not get urine, was unable to get it on her, But everything else on her chemistry looks pretty uninspiring to me.
Her thyroid was normal. He probianP was normal. Her faecal was negative.
OK. Well, now I've got this. Big chunky sick cat who's not feeling so good, and what do we do?
So, this is one that, again, I'm questioning myself, am I missing something? What's going on here? So we did, I, I did put this into Smart Vet and it pointed out the proteins.
So I'm gonna go back here for a second. And the albumin within reference range was 2.8, towards the low end, but still normal within the range, and the globulins were normal, but But the, the ratio of the albumin to globulin ratio, was starting to be a little bit inverted here.
So, when I put it into Smart Vet, it says, Check for chronic inflammation. So, we did an ultrasound on her, and it was suggestive of inflammatory bowel disease, even though she hadn't been sick chronically. Her, her body condition said otherwise.
So remember, when you're looking at blood work and you're talking about pattern recognition, it's not always just about what's flagged as abnormal. You should also be thinking about what should be there and isn't. So, you know, normal-ish blood work in a, in a sick patient, that's still a finding, that's still significant.
So, when we work up hypoproteinemia, a couple of different things that we look at. So, if we're looking at only a decrease in albumin and the globulins are normal, think about, you know, your liver disease or losing albumin through your kidneys. Very early PLE you can see that.
If both of your, proteins are low, you have a hypoproteinemia, protein protein losing and neuropathy all day long. You're losing both of those. And then if you have the inversion where your albumin is down and your globulins are up, and you've got an inverted ratio, think about chronic inflammation.
So, infection, FIP, that's something that, you know, at least I don't know over there, but we see it a lot here. Ehrlichia, fungal disease, lymphoma, multiple myeloma. Those are all things to think of when you start to see an inverted, albumin to globulin ratio.
So, in, in cats. You know, specifically when we're talking about diseases of the GI tract, inflammatory bowel disease and small cell, lymphoma are hard to distinguish, you know, you really need histo for that. But it's important to know the difference and typically, they both can carry a, a decent prognosis.
So in this one, the resolution. She, we, we started empiric treatment for inflammatory bowel disease and she improved dramatically. Her blood work continued to be good after that, and, her signs resolved, diarrhoea improved, appetite came back, and now she is starting to recover some of that muscle loss.
It's not Dramatically improved, but we're, we're getting there. So, the question that solved this is, is it primary, secondary, or incidental? So this, this was a chemistry panel that was not glaringly obvious, but the body condition and her muscle loss, that was what really made me pause here.
So, the takeaway here is that pattern recognition isn't always just about what's flagged, it's, it's also what should be there and isn't. OK, so let's talk about why do we miss things, and the issue with With veterinary medicine and with veterinarians, it, it's not that we don't know the medicine, we do. It's just that practise, the, the conditions in which we practise make it really easy to miss things that we know.
So it's not a, a knowledge problem, it's a workflow problem. We've got, time pressure, you know, we're, we're seeing appointments every 20 to 30 minutes. There's interruptions, people are calling you, your assistants need something.
Your, your attention is fractured all the time. Pattern decay, this is big for me. You know, I've been practising for 14 years, and if I don't see something regularly, my brain doesn't always remember to think about it.
So, uncommon patterns are, are rare because they're uncommon. So you don't stay sharp on things that you don't see often. This is a big thing, you know, it's, it's easy to miss something that you don't, you're not accustomed to seeing.
And then the other thing is decision fatigue. I don't know about you guys, but making decisions all the time, small decisions that impact a lot of different things, there's a lot of weight that we carry that, it, it just weighs you down, and sometimes it makes me feel a little bit foggy. So by the 18th case of the day, I don't have as much bandwidth to give as what I did on the 1st and 2nd case of the day.
And so it's, It's easy for me to get dismissive of things that really do probably require my attention. Let's also talk about client communication here, because that's another big part of what we do, you know, as veterinarians, we have to speak two different languages. We speak the language of doctors, which is very technically heavy, you know, we have to be able to talk about a microcytic hyperchromic regenerative anaemia, and then we also need to be able to translate that into a language that's easy for clients to understand and talk about an iron deficiency anaemia and what that means.
. So client com client communication is a really big part of that. And what I want you guys to remember is that you don't need to be sure to sound confident or to be confident. And that uncertainty named is uncertainty managed.
If, if you can tell them, that you're feeling unsure and also have a clear next step, that builds client trust and you guys are doing this together. It's not just on you to figure out what's going on here. And so when you're talking to clients, instead of saying things like, I don't know what's going on, which I'll be honest, I say that all the time.
a better way to, to phrase that is there's, I've got two possibilities, and, and here's how we're gonna tell them apart. Instead of saying this blood work is abnormal, well, this is outside of the expected range, and that's what this could tell us. Well, let's run more tests to be safe.
Instead of saying that, well, here's a test that is going to change our plan. And as you start to, To, to think that way, what is going to make a difference in how we move forward and what decisions we're gonna make, I think that that makes a huge difference in how you practise. .
Saying it's mild or it's probably nothing, it's mild today, but that can mean different things. Here's what I wanna check next, and just remember that, you know, clients don't expect you to know everything, but they are looking to you to lead them through it, to guide them through it. And so uncertainty named is uncertainty managed and then also have a clear next step.
So client communication, this is an important part of. Of, of blood work interpretation. We said this a little bit earlier that the patient that you see on case 20 deserves the same brain as the patient that you saw on case 2.
And that is what I built Smart Vet AI for. It's decision support. It's helping, you when you're maybe not at your clearest.
I'm gonna talk about the evolution of me as a veterinarian, what has changed for me. I don't, I can't tell you that the blood work has just gotten easier magically, but I do think that my, my, my thinking got clearer, got better. Instead of looking for things outside the reference range or looking for abnormalities, you know, I'm looking more for patterns.
. And I'm trusting trends instead of chasing the answer and needing to know what to do with every abnormality. What I'm really asking is what next decision is best. So chasing the decision, not the answer.
And instead of being afraid that I'm missing something, figuring out how to prioritise, . And, and the last one is instead of carrying everything alone, use, use tools and colleagues to, to help and, you know, now I'm a solo practitioner, and so I don't always have the benefit of, colleagues around me to bounce ideas off of and so that's where, Smart Vet has been helpful for me, . Better interpretation comes from better thinking, not better memorization.
And the longer that I practise, the less I ask, what is the diagnosis and what, and instead, what is the next best decision? So, before you go, I think we're wrapping this up here. If you guys are interested in trying Smart Vet, this is again, a second pair of eyes.
Everybody can have a 7-day free trial, but, my, all the webinar attendees, can have a coupon for 30 days for free, and you use the code webinar vet, go to www.smartvetAI.com and type in the code webinar vet, and it will give you 30 days for free.
Throw in, you know, one of your complicated cases from this week and just see what comes back. You can also reach out to me. My email address is [email protected].
But happy for you guys to try it. I would love your feedback. Let me know how you feel about it.
And thank you for being here and taking the time and for doing what you do. This is hard work. It's hard being a vet and I just appreciate you guys being here and staying curious.
Amy, thank you so much. There is a lot of, thought-provoking comments and that in there, and I love your phraseology that you've changed over the years. It, it's subtle, but it's hugely impactful.
So thank you for sharing all of that with us. Absolutely, thank you. Jamie, before we start getting to questions, and we have had a few, I wanted to ask you to just elaborate.
You say you run a case through Smart Vet AI. What does that mean? Are you, are you scanning stuff in?
Are you, What are you doing? You are putting in your case history, so you can copy and paste from your PIs, history and exam findings, and then you upload a copy of your blood work. And honestly, my assistant does this for me.
I just say run that through Smart Vet and it generates a report for me. So it's taking the blood work that we already have, and it's taking the clinical context of the physical and the exam findings and It is prioritising a list of differentials, treatment recommendations, and next diagnostic steps, and that's all in the doctor's report, and then it also makes a second report for clients that is a simplified version of all of that. So something that's easy for them to understand, and help, help manage, you know, that side of things.
Excellent. So it's a, it's a simple, as your, as your phraseology suggested, just run it through. Run it through, yeah, and, and have your assistant do it.
It doesn't need to be something that you are adding on to your day. It, it literally takes 2 minutes, and they can do it while you're doing something else, and it just generates a report, and it is, it's a website. It's standalone.
It's Penz agnostic. It doesn't matter what programme you use. All you need is a PDF from your blood work to put it through.
Fantastic Right, let's get to some of the questions that have been coming through. There's loads and loads of praise and thank yous coming in for an amazing presentation. So you, you guys, if, I remember many years ago, Anthony always used to say, if we were in an auditorium now, you would be getting a round of thunderous applause.
You're too kind. Thank you. No, it's just me in my bedroom with my, my computer.
Well, your first experience has been a good one, so that's always positive. Thank you. It means we can get you back again.
Oh, fantastic. I would love it. Paul asked, in your IBD case, what was the treatment that you gave the kitty?
Yeah, fantastic. Hey, Paul, thanks for listening. So for this kitty, I started on a low dose of prednisone, just because it was quick and easy, something that I could get an immediate result from.
I typically do a 0.5 mg per kg dose of pred first for about 5 to 7 days, and then I drop it down and see how low I can get it and manage the signs. There's also budesonide that you can use, And I have used it plenty before and like it as well.
In this case, it was just something I could get quickly. Yeah, yeah. And it's, the, the prednisolone versus budesonide is, is really about, confidence and, and convenience.
When you get to the pharmacy shelf, the hand goes to the prednisolone. Yes, and also price point, you know, something quick and easy. Yeah, yeah.
Jun asked a very interesting question. It says you are talking a lot about patterns and pattern recognition. Is there any recommendation of references or reading that one can use to develop that skill?
That is a really good question. I, you know, pattern recognition, I think it, it comes from seeing it over and over and over again. And if you're, sometimes I think that, blood work sees me and I missed the pattern, right?
Like I'm seeing it completely, just, just missed it. So I, I think that, Where something like, like AI is really excellent at is. It, it is not a thinking entity.
It is a pattern recognition. That is all it does. And it does so, I would say with a better success rate than what my brain can do, because I don't see all the patterns all the time.
And so I, I really like AI for that, because it kind of keeps me honest. But in terms of, you know, what other What other, tools you can use for pattern recognition. I think a good old textbook or even then something like that, but it's hard to organise it all in one spot, which again, I, I, I trust AI for pattern recognition just simply for the repetitiveness of it.
. But again, don't always blindly trust AI. You should always use your brain. You should always question everything.
But It does a good job of recognising patterns. Yeah, well, that that's the whole thing is that it's, it's a tool, it's not a replacement, as you yourself said right in the beginning. You know, the, the, the idea that AI is gonna take over being a vet is ludicrous, but it's certainly there to help you.
You know, it, it's interesting because every generation has new technology that can, can be scary, that makes us worry, like, are we, are, are we taking ourselves out? But I think that understanding how to use it judiciously and how to support you, is important and it, it does not replace you. You still have to be the expert in the room, but I do think that it can help with that cognitive load.
That we, we carry a lot, guys, like, we are doing the most here and I think that's why burnout is so common in our profession is that it's, it's just hard to, to balance it all. And so, using a tool that just helps support you, I think, I don't think it's a cop-out. I think it just helps you be a better clinician and to be a happier clinician.
Yeah, exactly. And, you know, with what you explained just now, you, you have to put your clinical findings together with your blood work into a Smart Vet, which means that you have to do a clinical examination and record it. So, that goes back to being, you know, your, your clinician to start with, and you're just helping your brain by case number 20 to, to give that, sort of consistent, non-tiring AI backup, as it were.
Absolutely. Yeah. Crystal asks, in case number 2, there was amylase and lipase that were elevated as well.
Would you consider that there was pancreatitis likely associated with the Cushing's and kidney disease in that baby? That's a great question. And I think, all right, so this is probably gonna show a little bit of my age and background here, but, I am really picky about how I interpret amylase and lipase, personally.
I was always taught that those values aren't super helpful. And that they can be mess, they, they, they can be abnormal with any blow of the wind. And so, when I'm personally diagnosing pancreatitis, I want an ultrasound.
I want to see an inflamed pancreas on an ultrasound before I call it. Now, with that said, I think that if you put 10 of us in a room and we have a, a dog that has GI signs, and You know, elevated amylase and lipase on blood work, we're probably all going to treat it to resolution, and one of us might call it gastroenteritis and one of us might call it pancreatitis. I think that's all semantics.
Could that dog have pancreatitis? Sure. She didn't have any vomiting or diarrhoea.
So I think more than likely, she's got an adrenal tumour that's bothering her pancreas by proximity and she might have some inflammation there. Absolutely, or she could have eaten right before I came to see her. Yeah, yeah.
Yeah, it's one of those tricky ones is pancreatitis. It's, it's not easy. I don't even think AI would get that one right most of the time.
No, and I think that, OK, this will also bring it all back into this presentation. You have to look at the clinical context. In a dog who is not vomiting or diarrhoea or having any sort of GI signs, if they have an amylase and lipase that's elevated on blood work.
That's no clinical signs and An abnormality present, I'm not paying a whole lot of attention to it. I'm, I'm waiting for, for the dog to tell me that it's an issue. Yes, as you said before, you know, bring it back to what the patient is telling you.
Yeah, yeah. Folks, I just want to make a comment. There are, some very specific, requests for information and guidance on cases.
We are not able to discuss specific cases on the webinar, but here's a thought, why don't you go and, download Smart Vet. And use your webinar vet code and run it through there. It gives you a chance to play with this lovely new toy that we have available to us.
And if you're still having problems, I'm gonna go out on a limb here and say that if you drop Jamie an email, she would be happy to guide you. I would love to. Absolutely.
Yeah, but, but try out, try out the Smart Vet. That's what it's there for. You've done your clinical, you've, you've got information.
Put it into Smart Vet and then you can experience it for yourself, and you get, you get some answers and as well as experience with this new tool. Jamie, I am afraid to say we are running short of time, but I would like to just tell you that there are amazing comments coming through here of how fantastic this has been, how informative. Great presentation.
Thank you so much. What a webinar. That's excellent.
Thank you so much for the presentation, and they go on and on and on. So thank you for your time. We really do appreciate it.
Thank you. I appreciate all you guys tuning in. Thank you.
And for your generous sponsorship of the Smart Vet, AI for sponsoring tonight, we also thank you for that. To all the people who attended tonight, thank you for your time. We really appreciate you being with us, and I hope that you have enjoyed this as much as I have.
Last but not least, Amelia, my controller in the background, making everything run smoothly. Thank you so much and thank you for giving us the heads up when we, not paying attention. I do appreciate that.
And for everybody, I wish you a good evening. From myself, Bruce Stevenson, it's good night.
