Dr. Deer: Welcome back to the 2 a.m. podcast. This is Dr. Deere, and I am here today with Dr. James Cellini, a board certified veterinary neurologist at Ocean State Veterinary Specialist. Dr. Cellini earned his DVM from the University of Georgia before completing advanced neurology and neurosurgery training through internships in Florida and Texas and a residency in New Mexico. In addition to his clinical work, he's passionate about veterinary education. Sharing practical neurology concepts with veterinarians, students, technicians, and pet owners through his educational platforms. And today he's gonna be talking to us all about neurology and give us some really, really great pearls of wisdom today. So I'll hand the floor over to you. jim: thank you for having me, Dr. Deere. I appreciate it very much. I'm very happy to be here. when you came to me, and by that I mean DM'd me on Instagram about doing this podcast. I thought probably the best thing to cover overnight ER neuro neuro problems is just to do like a grab bag of like all these little hacks that I've learned and picked up and just very quick little pearls to help you because you're not gonna be thinking about pathways and things like that or any detailed neuroanatomy when you're like by yourself and somebody you know, stat calls a vestibular dog straight through the door. That all goes out the window. So you need to like just reflexively know what to do and what to look for. So that's kind of like my thought process when I present neuro talks to like new interns and overnight doctors and or just ER doctors in general. So that's kind of like the gist of what we're gonna do today is like a list of real quick like hacks and things that you'll see very commonly. These little hacks will help you very commonly. That's kind of my goal. All right. Cool. so I wrote a few down here before we got started and these have been I've been thinking about these for a couple days. So we're gonna kind of group these three things into like what category one is gonna be seizure stuff. All things having to do with seizures, since that's probably the most common thing, neurologic disease you will see on the ER floor, I would say. y you would agree with that, right? Okay. I think it's every Dr. Deer: Yep, absolutely. Yes, yes. jim: day. Do you think you think you see a seizure dog like literally every day? Dr. Deer: I would say at least every other day. And then jim: Okay. Dr. Deer: I am in Frenchyl, so I do see a lot of IVD as well. Yeah. jim: Yeah. I'm sure you do. So okay. So kind of a a tangential kinda kind of just like an intracranial thing. We'll start there and then we'll move into actual seizures. So I'm gonna I'm gonna ask you, like I'm gonna I'm gonna kinda pretend like you're the resident or the intern I'm talking to. Is that okay? Okay. All Dr. Deer: yeah, for sure. jim: right, cool. So so let's say we have a a stat call up front and the receptionist is freaking out. And she says stat immediately. The tech runs up there, brings the dog back, and the dog is in a coma, like literally non Dr. Deer: Mm. jim: responsive. one of the first questions that you would ask yourself would be the most common things you wonder is like, is does this dog have a structural brain problem causing this, like a brain tumor or a bleed or meningitis, something like that? Or has this dog been poisoned? And Dr. Deer: Mm-hmm. jim: these are two totally different things. And do you know like the the number one fastest little exam part part of the neuro exam that you can do to try to figure out which one of those categories are happening right then and there? Dr. Deer: Ooh. I feel like I I know I like to reach for like the Glasgow coma scale, but that's not just like one finding, that's like a a culmination of findings. Would it be like a like a pain response, like a a something like pinching the toes? jim: That's a that's a good one because if they don't have a pain response, they're in a coma. All Dr. Deer: Right, yeah. jim: right. But let's just assume they are in a coma. They just got a completely non-responsive dog. the first thing you do, just like they do in the movies and TV shows, is you shine a light in their eye and look at their PLRs. Because if a dog's in a coma and they have a something structural taking up space inside their brain, causing a coma. Their PLR pathway is probably going to be affected by that. They are probably going to have some version of either pinpoint or really fixed dilated pupils. And their PLRs are not going to be behaving normally, nor will their pupils. Because it's just hard to get to a coma and also spare that circuitry. Okay. Dr. Deer: Mm. jim: So if you shine a light in a dog's eyes and their pupils are they start off normal, they constrict the way they should. The PLR pathway is all normal, but you have a comatose dog. That tells you all that anatomy is working normally. And so nothing's probably taking up space and pushing on it and knocking it around. So you're probably dealing with more of a metabolic or toxin sort of a situation. Okay. Pro Dr. Deer: Okay. jim: it's not 100%. And the main there's an except there's a toxin exception to this rule, and that would be ivermectin toxicity because it'll destroy your retinas. So that's the one kind of asterisk to the rule. It's not a hundred percent rule, but. There's a reason why like you go to the human ER and every human ER medical based show has got an ER doctor consulting on it. They're always they're immediately flashing a light in your eye to try to tell that when somebody's coming in with like an altered mental state. So that's that's buried in the Dell Hunter book. I've been using that for like sixteen years now. Whenever I get called to like do a consult on like a tablecase or something like that, to this day, Dr. Deer: Mm-hmm. jim: first thing I do, give me your PLRs and we go from there. So not a lot of people know that. Everybody s everybody skips over that from like vet school and and whatever. But it's very simple, very fast way to just know which path to maybe start going down with your with your differentials and whatnot. So very cool. did you think that was cool? Okay, good. All right, good. Dr. Deer: I did, yeah, because I I love tests that save owners money too. And so if jim: Yeah. Dr. Deer: I can out the bat do something that costs zero dollars, that's part of my physical exam and give them a much better like narrow down what disease I'm working up or or where my thought process is and what questions to ask for my history, like that's invaluable. jim: Yeah. Yes. I the reason I love Neuro so much is because you can get so close to all the information you need with just an exam. You can't get all the way there a lot of the time. I mean sometimes you can, but you get you get so far into it with just an exam. It's really amazing. all right, cool. So moving on to the second thing I wrote down. I'll kind of move it around my list here. I'll kind of branch in that. So A lot of people with cases of like head trauma and concerns for intracranial hemorrhage and whatnot, there's always there's this lingering zeitgeist out there that like giving Manitol is dangerous because it will leak out and like suck fluid into the like brain interstitial space or something like that if there's a ruptured blood vessel. but I've never seen that actually like demonstrated anywhere. And There's a line in the Dewey clinical neuroanatomy textbook that I always go back to, but he says this concern is unfounded and should be ignored. Like it's literally a sentence written in that book. And what I can tell, from what I've looked into this, I've never seen this as an actual problem. So I think this is one of those like theoretical concerns that just got propagated amidst the entire industry. But I would just give Manitol. Like if you suspect you know. You need you need to treat intracranial pressure, but you're kind of holding back on it because you think it might make things worse from a active hemorrhage or something like that. I I I would not be too worried. I would just give them manitol. So have you ever heard of that concern and like take pause before? Yeah, I've seen I've seen people, Dr. Deer: No, no. No, I know jim: yeah, it comes up every now and then. Yeah. Dr. Deer: Yeah, I think usually when we're deciding between like manitol and hypertonic, we're more worried about like like electrolyte abnormalities or if we feel like that patient needs IV fluids jim: Mm-hmm. Dr. Deer: and thus like should you give Manitol if the pet needs it's it's more of like that discussion. I hadn't heard about the the leakage jim: Yeah. Dr. Deer: before. jim: Yeah, I would say like one out of every ten interns kind of brings that up. 'Cause we get about twelve new interns a year where I work, and like one out of every ten or twelve, I I kind of will mention that. They're like, Yeah, I've heard people say that before. So it's out there still. So all right, cool. So moving on to let's talk about like if a dog comes in or a cat comes in with let's do first time seizures. Okay. What the first two seizure drugs that you would start a drug naive cat or a dog on? What's the f like the main two that you're kind of debating? Dr. Deer: Yeah, I think in ER we usually do pheno or kepra because they're injectable. so jim: Yeah. Yeah. Dr. Deer: it's a lot easier to to get on board. and then you can load them right away. jim: Yeah, yeah. That's pretty much the discussion with like any patient first time seizure. So yeah. do you well like what scenarios would you, Dr. Deer, give one versus the other? Just I I'm just genuinely curious, like how you think. Dr. Deer: Yeah, I think man, there's that's always the discussion I have with the owners about like if there's cost concerns to where having to check phenol levels, if they've got like a history of elevated liver values, if they have valley fever, so they're already on fluconazole, tend to stay away from like a phenobarbital. But I do tell them that like Kepra, as you know, the side effects being less theoretically does seem like it has a honeymoon period. it can be three times a day depending on the size of the pet. So you're kind of playing that delicate balance between are you worried about the liver? Are you worried it like where are you worried the seizure is coming from? And what like the whole picture of the pet is. jim: Yeah. All totally fair. And the Valley Fever aspect of that is not something I would have ever thought of because I don't live anywhere near you. So no, that's that's smart. Dr. Deer: Yeah. We every every pet gets tested for valley fever. If anything weird happens to them and it it it y they'll probably have it. Yeah, it is. Yeah, they say desert dog profile. Does it have valley fever? Yeah. jim: Yeah, it's like yeah, it's like minimum database for you guys over there, right? Yeah. Yeah, yeah. I've heard of that. it's interesting. I did my residency in just north of Albuquerque and we never saw I think I saw one case and it came from southern Arizona, but we never saw Dr. Deer: Mm-hmm. Yep. jim: it out there. It's like it's it it is very limited. Dr. Deer: Mm-hmm. jim: but okay, so one thing I I would just maybe throw out there is like the age of the patient too. In dictating which drug to start. So if you've got like a 14-year-old dog who just had their first seizure, there's probably a p an underlying pathology, like a macroscopic or structural, gross, whatever word you want to use, brain lesion, whether it be a tumor or stroke, or even just like, you know, mm doggy dementia starting to cause some problems and an epileptic brain. You might want to air towards Kepra in those older pets first, just because the side effects of phenobarbital the first two to three weeks can mimic what a progressive brain lesion is gonna do during those next couple of weeks, too. And it can just make it really hard to say if it's the pheno or if it's the primary problem getting worse. And then you've got an owner who's like making quality of life decisions, maybe on a transient problem. Or just like at a on a Dr. Deer: Mm-hmm. jim: problem that can be cured with a dose adjustment sort of a thing with phenobarbital. So Dr. Deer: Mm-hmm. jim: in an older dog with first time seizures, I found myself lately, I didn't always do this, but I found myself lately reaching for Kepra first versus younger dogs, especially those like epileptic breeds, like herding breeds and huskies and whatnot. so younger dogs, I tend to blast them with phenobarb right off the bat. If it's like a tr like a cluster seizure presentation or, you know, I I really think it's it's like a home run diagnosis of epilepsy. but older dogs I tend to be a little more gentle and still give them something just to make sure that they don't, you know, that that they can handle it a a little bit better and they avoid side effects. I'm little more side effect averse, I guess, with with that one. Dr. Deer: Yeah, and that's kind of an interesting point because I know that in the ER we have this, I don't want to call it like a theory, but if you are phenoloting a patient and they are like profoundly sedate from the pheno, everyone's like, it's a brain tumor. jim: Right. Dr. Deer: And I don't know if there's any credence to that or if it's just every dog's different and some of them just, you know, it hits them hard. jim: Yeah, I mean you're being loaded with a barbiturate. Like what do you want to do? Dr. Deer: Mm-hmm. jim: You know? Dr. Deer: Some of them you would have no idea. They stare at you like that's all you got. And some of jim: Correct. Dr. Deer: them you're like, is is it breathing? jim: Do you find that cats usually absorb a phenobolus just fine? Dr. Deer: Yeah, but cats are so weird. jim: And they don't really react much to it? No. Dr. Deer: Cats are so weird. They're either, I mean, y I feel like any rules don't apply to them. They do whatever they want. jim: That is correct. I've never seen a cat with a liver problem from phenobarb ever in my career. Never seen a Dr. Deer: really? Good to know. jim: hepatotoxicity. Ever. Dr. Deer: And with your phenol loading, I know that that's also like another kind of discussion. Is it four MIGs per kig Q four hours for four total doses? I've heard neurologists say just hit the sixteen MIGs per kig in one go, because otherwise they're gonna keep seizing. Do you have like a hard and fast rule or do you kind of play the same game where it's like they're clustering, just hit it? jim: I'm I'm pretty Yeah, I mean every situation's different, but I am my default setting is the you know twelve to sixteen Migs per cake all at once IV bolus. I've never seen a dog need to be on the vent after that. I mean, yes, they'll be sleepy and they they may not want to get up and just take a long nap, but I've never seen one need respiratory support after that. I don't know if you have either. But so I don't think that's a very common concern at all as far as that goes. and if they're coming to an ER with like cust cluster seizures, they need a spike in pheno immediately. Like their brain needs to stop doing that. Cause the more it does that, the more likely they're gonna extend their hospital stay and need more drugs. And it's this gravity well of just meds and intervention if you don't get on top of it. So Dr. Deer: Mm-hmm. jim: I tend to slug them. Because the fur you give them four minutes for kid IV and you wait four hours for the next dose, it's like a subtherapeutic amount in their bloodstream the whole time. I Dr. Deer: Yeah, that's true. jim: mean, nothing's really doing anything. So I tend to go towards the latter short answer. Yeah. Unless there's some clinical reason. Dr. Deer: Yeah. jim: so that's a good segue. what would you so let's say you have a dog come in who's on phenobarb. This is the the gets a little harder. Dog that's on phenobarb and he's having cluster seizures and let's say he's on phenobarb and kepra, just and he's maxed out on Kepra, so you can't just you can't you're out of that step too. and his last pheno level was eighteen mics per mil. And you and you look and it was like done three weeks ago. And you look in Dr. Deer: Mm. jim: the in the records and it was eighteen, but the The primary vet didn't touch it 'cause the dog was fine at the time. Do you know how much you would bolus this dog? Or if you would, would you bolus Dr. Deer: Ooh. jim: the dog IV? Dr. Deer: I I I think I would. I know I have even on dogs that are maxed out in Kepra, if they haven't had their Kepra like within the last few hours, do like another like sixty MIG per kig. but I feel like maybe like a four jim: W what about Fino? Dr. Deer: to a six. a pheno, yeah. I think I'd probably do like a four to a six mig per kig of like a little pheno, just like bump and see what happens. Or just like a Madazzlam CRI or something, if if they're going. jim: Okay. Do you know how much you could give if the dog's level was eighteen? Dr. Deer: no. jim: You could give twelve minutes per k to I V. Dr. Deer: okay. jim: Okay. So now I got I gotta have a huge disclaimer on this one. I was taught this by Dr. Deer: Yes. jim: a a neurologist who has since retired, but he was a very successful neurologist for 40 years in one of the top four largest cities in America. And for 30 of those forty years, he was the only guy in the entire city serving about ten million people. So Dr. Deer: Well. jim: I cannot find the old pharmaceutical or pharbic kinetic data To back this up, but his guidelines for this have always worked perfectly for me. So if a dog what you do is you take the difference between 30 and the dog's serum level, because 30 Dr. Deer: Mm-hmm. jim: is the top end of the drug level for phenabar, right? So you subtract in this case, the dog's level is 18. So you subtract 18 from 30, you get 12. If you give that as a mig per kig, you'll get the dog's drug level back to. To about maxed, right at thirty. Dr. Deer: Wow, that's easy math too. jim: So if it if the dog's drug level is 18, you've got a lot of room left to go. If the dr if the dog's drug level is 25, I would give five minutes per kig. Right. now if the dog's drug level was like 15, would I give 16 megs per kig? I don't know. I'd probably top out of like 10 megs kig, IV or something like that. But if you do that and you track the drug level with a corresponding increase, you know, in in the drug afterwards of like twenty-five percent or fifty percent in that case. You'll get up to like maxed pretty quick and you'll be right at about thirty, somewhere in that neighborhood. So that's a really quick way to know how much you can give these dogs. Like you can give these dogs more phenobar than you think based on the Dr. Deer: Mm-hmm. jim: especially those drug levels that are below twenty, twenty two. You just slug again Dr. Deer: Yeah. jim: and they'll take it. Dr. Deer: What if they don't have that? Like you know, they say, yeah, they did it recently and then they hand you an invoice, and they're like, See, but jim: Right. Dr. Deer: you don't have like the actual number. is do you jim: Yeah, I mean then Dr. Deer: just kind of just guess? jim: Yeah. No, then you don't know. So because Dr. Deer: Yeah. jim: you don't know if the dog's walking around with like a a drug level of thirty three. Dr. Deer: Yeah. jim: You know? So I don't know if I would tinker with it at that point. Dr. Deer: Mm-hmm. jim: I would as soon as you can. Do you have like in house phenol level where you worked? Dr. Deer: I didn't know that was a thing and then Dr. Gibson told me about it and I jim: Yeah. Dr. Deer: emailed like the two clinics I work at and was like, yo, where w we need this. 'Cause it's just a slide, jim: Yeah. Dr. Deer: right? jim: Yeah, it may not be perfect because when you compare it to IDEX, shout out to IDEX, but when you compare it to IDEX and like other like you know, labs, it's it sometimes can be a little off, although that might be like timing of the sample too. So I'm not really sure. But it's close enough. Like I've I've never seen it be so far off that I'm like, you know, affected by it, you know, with my decision making. So yeah, if you don't have one. I guess that would be topic number five is definitely get like an in house phenol level cartridge or or whatever the term would be. 'cause they're Dr. Deer: Yeah. jim: super helpful and they they allow you to do things right on the spot and make decisions like So so yeah, if the you you subtract so just to review, you subtract the dogs or cats drug level from thirty and you give that number as a mid-procured IV bolus. You'll be right there. Dr. Deer: And then do you put back on like Q twelve hours from there, as long as they're seizure free. jim: Yeah, I I would so like so like if a dog's level was eighteen and they were on sixty milligrams B I D, so one sixty Dr. Deer: Mm-hmm. jim: one sixty milligram tablet every twelve hours, that was their dose. If you increase that dose by fifty percent, that's ninety milligrams BID, and fifty percent more of eighteen mites per mil will be twenty seven mites per mil. So you give them that slug that bolus, and then you make their drug, their dose fifty percent higher. Dr. Deer: Perfect. jim: And you'll be pretty much maxed by that. Dr. Deer: Okay. jim: Now, a month later when they come in for more seizures, I don't know what to tell you at that point. I mean, you know, you can you do bromide and zonesomide and all that, but then you're done. but yeah, that's that's my phenobarb hack that's made my life a lot easier many, many times. Shout out Dr. Podell. Dr. Deer: That's a good one. I feel like that's gonna be the one that people are gonna be like writing down, like, I need that one. It's gonna go up on the like jim: Yeah. Dr. Deer: you should know board in the clinic. jim: Yeah, I gotta be careful because like I said, I cannot find the pharmacokinetic source for this. And I Dr. Deer: Mm-hmm. jim: I've tried to dig it in dig into the to the like the the numbers and and even AI can't find it for me. So take it with a grain of salt, but I do it all the time. I will say that. All right, cool. let's see. here you go. Here's here's one. So if a dog's on bromide, what what IV fluids should you not give? Dr. Deer: you worry about like the chloride displacing the bromide, right? Yeah. jim: Yeah. So you don't want to give like regular strength saline or things close to that Dr. Deer: Mm-hmm. jim: in terms of their chloride content. So ideally I just have these dogs not on IV fluids if they're awake and eating and drinking, which is like a weird sight. but if they're stable and they're eating and drinking and they just had a seizure, you know, forty five minutes ago, then I don't have Dr. Deer: Mm-hmm. jim: them on anything. They're just, you know, they're hanging out for a little bit and going home in twelve hours. But if you gotta put them on something, I would like half strength saline or something similar where there's not as much chloride. In it. and I've navigated that like so we've had dogs get like foreign body surgeries and stuff like that on bromide. I'm sure there's like an elegant way to do this, but what I've usually done is just try to work with the criticalist about like giving them the least amount of chloride as humanly possible while during their surgery and whatnot. Dr. Deer: Mm-hmm. jim: I'll check their I'll submit their level like right before when they come in. And then I'll do like serial level checks while they're in the hospital. And I may like if the next level comes back low, I may just like bump the dose and give them a few extra of their doses while they're in the hospital. It's kind of subjective, but I'm trying to just track it a little bit that way, not let it Dr. Deer: And you're talking bromide levels, right? Not like chloride jim: tank. Bromide. Dr. Deer: electrolytes. Okay. jim: No, I'm talking bromide level. Yeah. Dr. Deer: Okay, yeah. jim: Some people have asked me if the chloride number on a chemistry analyzer correlates to bromide level, and as far as I know, it does not. I think it's kind of like all over the place. So one more thing with seizures. don't fear ketamine. So if you're having a hard time keeping a dog under control with like a medazolum C R I and whatnot, phenobolises, the wrong bro, da da. give them ketamine. there's a paper by Patrick Reynard and Curtis Dewey that came out a few years ago, but that it'll tell you the protocol. But I believe it's it's a five mig per kid IV bolus followed by like a mig per kid per hour CRI. it's a lot, but don't be afraid to give ketamine. It's like an underutilized drug for seizures for sure. Dr. Deer: Do they know do you know the mechanism? Is it something about like the excitation of of like i the brain or Yeah. jim: Yeah, an inhibit in it's basically like an inhib it's it it's an NMDA antagonist, so it's going to Dr. Deer: Mm-hmm. jim: just basically prevent more action potentials from firing is the idea. Like it's cyotoxicity and all that. and they they talk about it in the paper and they theorize it. But I've used it, it works perfectly. So all right, cool. And then debate I can Dr. Deer: With seizures, one thing that I see sometimes is people start gabapentin for a first-time seizure. I I haven't really ever seen a neurologist recommend that. jim: I don't know where that comes from, to be honest with you. I use as like drug number five in cases. But like regular gabapentin, it it's just not effective. It does it doesn't I don't know if there's even been a study that's even looked at it in dogs. but no, I would not recommend gabapentin as a as a like a sole agent for epilepsy. The pre-gabelin we give, I forget the dose. I'd have to look it up because I prescribe it like once every three years. But it's it's it causes a lot of sedation and ataxia. Like it really will make a dog a zombie dog. Like more so than bromide, Dr. Deer: Mm. Okay. jim: I feel like. So that's why we kind of reserve it. And you have to give so much of of gabapentin to do this sort of thing that like nobody even gets close to that dose. Dr. Deer: Yeah. jim: all right, cool. So that's a good like seizure summary for overnight stuff. Dr. Deer: Mm-hmm. jim: Do you as an ER doctor have any seizure questions that you're always wondering about? Dr. Deer: I yeah, I think the biggest argument is always sending home like medazam for patients. And jim: yeah. Dr. Deer: if you can put in syringes, I've heard people say that they'll send the injectable kepra home to give rectally. So kind of those like who who ER, it's hard because we don't see the same people over and over again. And, you know, you have that should I send home a, you know, this medication of people I've never met before. But as a neurologist, kind of what are your criteria for sending home the rescue drugs? And how how do you send them? Do you just write a prescription or? jim: we so I send home so my at home rescue protocol is I do medazoliam at zero point five Mixford kid intranasal as soon as a dog or cat starts having the seizure. Not don't I've seen people say like wait a minute to give it and stuff like that. I wouldn't Dr. Deer: Mm. jim: do that. Give it as soon as possible. Even if they're having like an aura and you know a seizure's coming, I would just give it then. Okay. Excuse me. we sent it home in syringes in like a little darkened bag. there's a pharmacokinetics study that I've seen before, and I want to say it was published in the late 90s. but I don't believe medazolam absorbs into plastic the way diazepam does. study. I did not come armed with all my references for you, just to let you know, but People watching this, feel free to cross reference me on this, but I I can look I'm trying to look it up right now, but I'm not going to because it's gonna pause the podcast. But yeah, I I send it home in syringes. and I do I usually do like three doses at a time. So my protocol that I write for people is when you have a seizure, give them a dazzlam intranasal. Then as soon as the dog or cat can swallow. and recovered, give them one extra dose of everything they're on. Basically, Dr. Deer: okay. jim: is what it is. So whether it's and yes, if you give them an extra dose of bromide, it's not gonna do much, but give it anyway is is my thought process. Just try to keep you out of the hospital is what I'm trying to do. Dr. Deer: Mm-hmm. jim: so even if that seizure is like three minutes before when they were due for another drug, I would double them up. Just again, Dr. Deer: Mm. jim: we're just trying to keep you home and out of the hospital and stop having any more. the next 24 hours. And then on top of that, I do chlorazepate oral at about a half to one MIG for kid orally every eight hours for 48 hours after a seizure. if they have a second seizure, repeat the midazolam, intranasal, and give another extra oral dose of everything. And if they have a third seizure, do the intranasal medazolam and then just come to the yard. Dr. Deer: Perfect. And for that chlorazepate, jim: That's pretty much my program. Dr. Deer: is that something like they can fill at a human pharmacy or do they have to get it like compounded somewhere? Cool. Good. Okay. jim: That you can. Yeah, that's just an oral benzo. So, that you can get at C V S. I send that to C V S all the time. I find it's a lot cheaper there. Injectable Medazolam. Turns out you can't just get that at CVS. So you have to you have to get that from us. Dr. Deer: Someone told me that they they take the Bordatella like intranasal cannula thing to send home with their intranasal med Yeah, okay. Yeah. jim: No, yeah, atomizers. Yeah, I I left that part out. We sent them home with atomizers on the end of the syringe. Good good catch. Dr. Deer: Yeah. And if you if you're in a pinch, what's a good alternative if you don't have atomizers? jim: I would just take the syringe and just plug it into their nose and squirt it as hard as you can. As far as I know. Because I think that the mo I think Dr. Deer: Yeah. Yeah. jim: if you put force into it like that, you'll probably like aerosolize it anyway. Dr. Deer: Fair. Mm-hmm. jim: I've heard people say ideally you would split the dose up between both nostrils, but I think you're just taking too long to try to figure that out. I think you'll you'll probably Dr. Deer: Mm. jim: lose some and not get it into the nose if you try that. So I say just blast it. cool. All right. So do you want to move on to let's do vestibular and we'll do IVDD last so people stick around because IVDD is like what everybody sees. Yeah. Dr. Deer: The hot topic. Yeah. jim: It's been a hot topic for my entire career, IVDD. All Dr. Deer: Yes. jim: right. So we'll do a brief talk about vestibular stuff here. Okay, so a vestibular pet comes in to see you. And your first question is, is this a central or a peripheral located lesion causing this, you know, vestibular dysfunction, let's call it. Do you know the most predictive and important part of the neuro exam to determine central versus peripheral? Dr. Deer: Is it the direction of the Nystagmus versus the direction of the Torticollis if they have it? That's usually how I do it. Okay. jim: No. Okay. It's postural reaction deficits or CP deficits, depending on who you trained under. But yeah. So those are the things those are the most sensitive and specific determinants of like does this dog have a brainstem or cerebellar lesion, basically. And whatever side those are on, that's the side of the lesion. So you can ignore the head tilt, the nystagmus, all that stuff. If you're getting like, let's say a know, dogs falling to the right, right head tilt, everything's right. let's say his eyes are stuck to the right. Okay. So and they're Dr. Deer: Mm-hmm. jim: not moving. Then that's not gonna happen. But if everything is to the right, but they have CP deficits on the left, it's on the left. It's a left side lesion. That's probably Dr. Deer: Okay. jim: a paradoxical lesion, but it's on the left. right. one cool paper that came out a couple of years ago and and I think J V I was looking at so in people when they present to the ER with vertigo, one thing that they'll have done to them is they'll they'll be asked to fix your gaze on something to try to reduce the speed of your n of your nystagmus and Dr. Deer: Mm-hmm. jim: determine that helps with localizing. So apparently. So in Dodge, you can't ask him to do that. So the closest we can do to that is like cover one eye and see what happens to their nystagmus, because that we think that might help with them kind of like just eliminating half of their field of view. So a paper came out that looked at if you do that and you notice their beat frequency increases in a vestibular pet, then that's way more likely to be a peripheral lesion. So that's another kind of like newer thing that just came out a couple years ago. So a beat frequency increase can can kind of clue you in. And they've got like a 90 90 something specificity sensitivity from that. So Dr. Deer: Wow. jim: it's pretty wild. so that's another thing you can do. So between those two things, you should be pretty good in trying to localize in central versus peripheral. a lot of people wonder like dog comes in with a head tilt. And nystagmus, plus or minus facial paralysis. And everybody wonders, okay, yeah, it's a peripheral locating vestibular dysfunction. Is it otitis or is this idiopathic vestibular dysfunction? And one paper that's called Clinical Reasoning in vestibular dysfunction, and it and it looked at this in dogs and cats. And it found that the presence of Horner syndrome was associated with otitis media more often. and had like I'd have to pull it up again, but it was associated with otitis media is the bottom line. So of all the things that you would look for in your exam, if they have a Horner syndrome with these things, that's Dr. Deer: Mm-hmm. jim: gonna point to otitis media a little more often. It's not a hundred percent like anything else, but you can look for that. Okay. So small pupil tosis. elevated third eyelid, that that stuff. scleral injection, the vet the blood vessels dilate. Don't forget that. That's a sign of a s of sympathetic loss too. So that's another part of it. so that's that's a good little kind of clinical trick. And then you know, these days an MRI costs like four to five thousand dollars if you add in everything, Dr. Deer: Yeah. jim: you know, and all the the anesthesia and all the admission stuff and hospitalization stuff, blood work, da da da. so people are like, no, I can't do an MRI. That's absurd. I hear that like all the time. And I say, okay. the biggest thing that's going to tell you what happened to your vestibular dog is time. Because if your dog's vestibular dysfunction came on really suddenly, And if it stays the same or slowly improves over the course of a month or so after that, then as time goes on, and that holds true, you're probably dealing with a stroke or vestibu or or idiopathic vestibular dysfunction. So if you had to graph it, you gr the symptoms go up really bad, and then as time goes on, they trickle down and they slowly improve. That sort of graph is gonna be what stroke or idiopathic is gonna do. So I tell people. You know, they're super upset because their dog can't move from vertigo. And they're like, Well, what do I do? I say, Well, the next few weeks are gonna tell you if this is gonna be okay or not. And if everything stays the same and he starts getting better and we're not doing any specific treatment to your pet, then we're probably dealing with one of those two things, which are self limiting in many cases. Okay, st yes, strokes can be caused by underlying issues and there may be more strokes, da da da. But most of the time we don't find a cause for a stroke in a dog. And they just happen as one off things and you know, you they just recover from it. whereas stuff like a tumor, once it starts and creates a s a problem, it can, but it's usually not as a as a paracute onset and dramatic sort of problem vestibular wise as strokes and idiopathic Dr. Deer: Mm-hmm. jim: dysfunction. So you're gonna see s usually a little bit more gradual onset, but it's never gonna get better. It's not gonna resolve once it starts. Yes, it could wax and wane. So there might be like a little wave of form to the graph as time goes on, but the trend of the graph is gonna be worsening over time. Okay. Same with meningitis. Okay. Dr. Deer: Mm, mm-hmm. jim: otitis, that's probably gonna do something around the same thing, but the bottom line is it's not gonna get better over time. Something's gonna keep happening and You're probably not going to return to normal once otitis has reached your inner ear. Okay. so again, those are just things to say like, look, if there's no MRI, we don't have a diagnosis, just give it time, help them along the way. and we'll see what happens. I'll see you in three weeks and we'll see how things are going then. a lot of people see a really severe vestibular dog and think that. Because the symptoms and the quality of the vestibular dysfunction is really severe, it must be a severe problem. But the most severe vestibular dysfunction is often caused by idiopathic disease. I mean, dog dogs will be spinning and completely incapacitated from that. Dr. Deer: Yeah. jim: Or like cerebellar infarcts would be a you know another one. And those both of those things can oftentimes get better with time. So just because it's really Really bad, you don't know what the next three weeks are gonna hold for the dog. And then being a bad say severe vestibular dysfunction does not mean like your life is threatened, I guess is is the best way to put it. Dr. Deer: Right. jim: Yeah. that's all I had with vestibular dysfunction. Those are the those are the big ones. I got one more. Dr. Deer: Yeah. Do you ever do is it called the balsalva maneuver where you is that what it's called, where you like they do it in people with vertigo? I may be calling it the wrong thing. jim: the it's called the I know what you're talking about. It's where you're trying to get the Otoliths to resume Dr. Deer: Yeah. jim: their normal position. Yeah Dr. Deer: The Epley maneuver. the Epley maneuver. I I figured it probably cause it human vertigos for different reasons. jim: Yes. Yeah. As far as we know that the odoliths migrating and being in abnormal positions and I as far as we know, that doesn't happen in dogs. it I guess I suppose it very well could. there is a paper in human medicine that looked at people with vertigo of that cause getting acupuncture in the ER. And it Dr. Deer: Mm. jim: I believe it was blinded and placebo controlled. And it showed that acupuncture actually shortened their recovery time a little bit. Dr. Deer: interesting. jim: So I don't think it's unreasonable cons to consider something like acupuncture for the most one way street sensory nerve in your entire body. Like, you know, like if you're gonna choose acupuncture, it's good that's gonna be the nerve, I would think, Dr. Deer: Yeah. jim: would be a good one to to try it on. So, so yeah, just to kind of throw that out there too. And then a lot of times ER doctors will come to me with a vestibular dog. I'll do an in-house consult. You know, owners are not gonna scan, they don't wanna do much. like All in diagnostics. So there's like a a trio or a a foresome of diagnostic test that I would say short of an MRI that makes sense. It's gonna be your blood work, a thyroid, a blood pressure, and a urinalysis with a UPC reflex. Because you're looking for low thyroid, you're looking for protinuria, and you're looking for, you know, regular blood work stuff, and then you're looking for at their blood pressure. Those are like your major problems that you could pick up that could predispose a dog to a stroke. Dr. Deer: Mm-hmm, mm-hmm. jim: So hypertension being a big one. in a cat, you'll probably hit something on one of those. And especially in like older cats who present with like acute onset vestibular dysfunction, there's a decent chance you'll pick up something there amidst all that. So those are like your main staging, or not staging, but I guess like minimum database for a vestibular pet. all right, and then let's you want to move on to IBDD now? Dr. Deer: Yeah, for sure. jim: Okay. Dr. Cellini, should I do an NSAID or should I do prednisone for this down dog? I know. I still get Dr. Deer: The number one question. jim: it's it's I've been so I started vet school in 2005 and I remember people saying this. it really doesn't matter. I mean, yes, there's a paper that showed that steroids have more side effects, but like the side effects were like GI upset and some diarrhea, and they got Dex SP. So it's Dr. Deer: Mm, mm-hmm. jim: you know. I I I don't really think it matters that much. In my experience, they're already on one of them already by the time they come to see me. So I never make this decision to begin with. Like somebody's seen this dog before I've touched it and they've started started it on something. So I don't think it matters. My my one caveat would be if you know for a fact this owner is never going to do an MRI or a CT ever, I would just do Pred to cover you in the 1% chance that it's not a herniated disc for the other stuff. Dr. Deer: Mm, mm-hmm. jim: Like if it's meningitis or something weird. just do pred to cover you, but I would say pick whatever one. And you know, I've been using prednisone more and more lately just because I honestly feel like it's pretty good anti inflammatory for these purposes. And I don't know, I I got a little bit I got a little bit swayed because I felt like I was giving carprofen sub Q and and seeing a bunch of GI ulcers and these horrible diarrhea cases with my UCATs in. So I started switching the other way. recently. Dr. Deer: Mm-hmm. jim: But I'd say either one is fine. Short answer. what is let me ask you, Dr. Deere, what is the most important prognostic factor in a dog who is paraplegic? Dr. Deer: I I'd say like if they've got deep pain or not, superficial pain. Yeah. jim: Yeah. Yeah. That's it. That's it. So if if a dog has deep pain and they've been paralyzed for like ten days, okay, the prognosis like you say you do you find a discernation, you take it out, you decompress them, and there's nothing crazy on MRI, right? Their prognosis should be pretty good for walking again. Like it may take longer, but if you follow that dog out to like twelve weeks, it's probably gonna be walking. So, If the dog has deep pain, the odds are good they'll walk, period. one time I get a little bit worried is the dog who's like suddenly was walked in this morning and it's bam paraplegic in like an instant. And you do its MRI and you find like not too much spinal cord compression, but like a huge bruise in its spinal spinal Dr. Deer: Mm. jim: cord bright and swollen. You can't do anything about the brightness and the swelling that that that Think of it as like a concussion to the spinal cord. You can't Dr. Deer: Mm-hmm. jim: do anything for that. Surgery is just to take the disc out and decompress the spinal cord. That's it. So there's not much of that to do. I get a little worried because we've gone from normal dog to one step below the worst possible scenario instantly. And we're like close to that already. So we might be on the path to the next 12 to 24 hours actually turning into a deep pain negative dog. And this is our evolution, and we caught it so early. So Dr. Deer: Mm-hmm. jim: You gotta be aware when dogs go down very, very quickly and you're there catching them in the first hour or two of this happening. You don't know if, like in a normal case, this would have happened at 11 p.m. And then 10 hours later, the owner gets home from work or something, and then you see it, and then it's D pay negative. So you gotta kind of Dr. Deer: Mm-hmm. jim: think about like where you are in the timeline of these things, too. and that extrapolates to what you tell the owner. Like that's a different conversation versus a dog who's been down for twenty four hours, you kind of know where his neurostatus is kind of nadired at. You know? Does Dr. Deer: Mm-hmm. jim: that make sense? I try to get that point across Dr. Deer: Yeah. jim: sometimes. It's kind of a hard one to to get across. Dr. Deer: Yeah, I I think if you think of it like like dog bite wounds where they need some time to declare themselves, that's seems like it's jim: Not the thing I would have thought of, but okay. Sure. Dr. Deer: I mean, that's the discussion we always have with owners is that like, you know, sometimes it takes a bit before we see how bad they actually are and it's the same kind of theory. It's an injury with bruising and you don't immediately see it. So I I I think that does jim: Right. Dr. Deer: like make sense. jim: Yeah. It's almost like skin myelomalacia. Yeah, Dr. Deer: Yeah. jim: it starts to slough and get all necrotic and you don't know that's gonna happen yet. That's interesting. Dr. Deer: Mm-hmm. And it was a puncture wound yesterday and now it's like, jim: Right. Dr. Deer: good. Yeah. jim: Now it's a horror movie. Yeah. Dr. Deer: Yes, exactly. jim: I was an ER doctor for two years. I don't I don't miss that stuff, I'll tell you that. Dr. Deer: Yeah. jim: so yeah, so the most important prognostic factor is just having deep pain or no susception, as we call it. And speaking to that, when you assess this, are you are you able to put up videos and stuff as we talk and like clips and stuff Dr. Deer: yeah. jim: in the after production? So on Dr. Deer: Sure. jim: my Instagram is a is a reel of me doing a deep pain like a a toe pinch on a cat. So you might want to this is a good one. I can give you another one too. if you wanted to use that like a good example. But when you pinch a dog's toe and you're looking for deep pain, you're looking for a conscious response. Okay, you're looking for that information to get from their foot to their brain to say, Hey, something is crushing my foot right now. Okay. And they're they need to consciously do something. Even if it's just a pupil dilation or some sort of like behavioral, like I'm kind of uncomfortable. Dr. Deer: Mm-hmm. jim: the easy ones are when they turn around and try to scream at you instantly. Okay, because you Dr. Deer: Mm. jim: know something's gonna. But you need to look for that. You getting a a withdrawal on the limb and a and a reflexive pullback is not the same thing. That's a different circuitry, and that circuitry stays at the level of the limbs. Okay. that doesn't ascend and go up to the brain. So if you see a a reflex that means something, it's not good or bad in many most cases. But if you're talking about determining the prognosis and if there's no susception or deep pain, you need a conscious response. And so the video Dr. Deer: Mm-hmm. jim: I'm gonna probably have you put up here is me pinching the dog's toe and you see that this dog is not reacting. whatsoever. Like there is the the dog's not consciously aware that I'm pinching its toe right now. Dr. Deer: Mm-hmm. jim: And then in this video, I'm also going to probably right about now touch his front leg with with a very gentle pinch, and you'll see this dog strongly react and because his front legs are transmitting that information just fine because his neck is Dr. Deer: Mm-hmm. jim: intact. So there's a huge difference here. This is the difference in the in the behavioral response. So one is loss of deep pain and one is normal. So hippopotamus, I'll send you a little clip of a black and white bulldog puppy that had a Dr. Deer: Yeah. jim: un unknown cause staphylococc resistance staph in Pyema and an eight month old puppy. Yeah, out of nowhere. Dr. Deer: Dang. I had a jim: Weird case. Dr. Deer: coccidia in the brain that was a eight week old puppy. we found out a necropsy, sadly, and it was like the same. jim: Not so not Cotsidioides, Cotsidia the GI parasite? wow. I've never heard of that. Dr. Deer: Yeah. Yeah. Yeah. I went from like testing it for parvo because it was vomiting diarrhea to like not breathing in the oxygen kennel, like obtunded. And that's it said it had necrotizing pancreatitis and coccidia in the brain. And we were like, What? Didn't know that could happen. jim: Wow. That's insane. Whoa. Okay. Dr. Deer: Yeah. jim: wild. Yeah, what was the other thing I was gonna say? Yeah, no, I think that's that's pretty much the most important thing about like IV D Dr. Deer: Mm-hmm. jim: is just knowing how they present and how they could like where you are in the timeline of things and then just having deep pain or not. Those are like b the biggest two messages I wanted to or try to impart on people. I guess the final thing with IVD would be lately there is a push to do less surgery on these dogs. Because these dogs Dr. Deer: Yeah. jim: don't do as poorly without surgery as you might think. And we're starting to realize like the the way that costs are getting out of control, less and less people can do this stuff. And not all of them are just like auto-euthanizing their dog because they're like, you know, but I'm Dr. Deer: Mm-hmm. jim: just gonna have my dog as a handicapped pet, right? And we're finding that oftentimes they are like walking within six weeks after this. And you, you know, they came in paralyzed. A deep pain negative dog probably won't, but a deep pain positive dog's got a decent chance. I mean, you're at like a even if you're paraplegic and you do medical management, you're at like a I want to say almost like a 60% chance of walking again in six weeks. So I've been stressed I stress to people too, like don't don't just give up on these dogs because you can't do an MRI. You know? Like just give it time and just see what happens and if You know, if they're not walking within like two months, let's call it from their injury, and you can't really care for them and it's a lot for everybody and they're struggling with UTIs and stuff like that, sure. But many times they these little docs and whatnot will get up and start walking again. It's the most amazing Dr. Deer: Mm-hmm. jim: thing. I think that is all I can think of. Dr. Deer: I guess if I were to transfer a case to you, so say I had an owner and the dog's deep pain, negative or positive, the owner jim: Okay. Dr. Deer: is open for surgery. I've talked to them about like the recovery, you know, ascending, descending, myelomala. Is there are there like little particular things that you want discussion wise to the owners before they they even, you know, cross your desk? Like things that you need to make sure as a GPE are you're you're saying to these people? jim: I mean, you're asking in some ways the wrong person. And the reason I say that is because I mean I'm the right person to be asking this, but I'm a little bit different because I don't feel like I need an owner to be prepped in many ways. Like I'm happy to just go over that with them when they come to see me. And I don't I'm of the opinion that like as a GP You you don't need to have like every neurofactoid like ready to go and perfectly lined up before you can prep somebody to see a person like me. Like that's kind of why I exist. So I think all you need to do is just tell people, like, yeah, this is how much it's gonna cost. Okay, sure. I but honestly, I don't even need you to do that. But like if you want to, most people are gonna require that. Dr. Deer: Yeah. jim: and just be like, look, like your dog's paralyzed. Brief localization. He's got a spinal cord problem. He's probably got a herniated disc. You want to throw out like a his prognosis should be good with surgery, or maybe it's guarded, or maybe it's, you know, poor without caveat, asterisks, whatever the neurologist tells you is going to override what I say, you know, default to them. Dr. Deer: Mm-hmm. jim: But these sorts of cases, like I don't, I don't know if it necessarily falls on the non-neurologist or non-surgeon to like, prep somebody for every little aspect of like what they need. It's kinda like my job, is it not? Dr. Deer: I think that's very fair. Yeah. Yeah. jim: Okay. Thank you. So yeah, I'm I'm a little bit different than most. Like I I really like I try to see like down dogs like initially I just take off the whiteboard a lot. Like if I see a down dog back leg not working on our whiteboard and our ER is slammed, like I don't need I I I could do that. Like I can just start talking Dr. Deer: Mm-hmm. jim: to them and just taking the case and just be like if you know I don't need to know that they're gonna do an MRI and surgery to see the case necessarily. So to answer your question, I think the big things would be like, yes, if they're going to do an MRI and surgery, they should probably know it's gonna be eight to ten thousand dollars to do all that and not think it's fifteen hundred bucks fair. Dr. Deer: Mm-hmm. Right. jim: Okay. they need to know that their doctor has a spinal cord lesion and they're seeing a neurologist and then they'll talk to you about that. This is what you think, but you don't need to get into too much detail. Well, I don't think. And you know, tell me if you disagree, but like I I don't I looked at the human model of like human primary care and emergency. I've never been to an emergency, like an urgent care or anything like that that would give anywhere near the level of neurologic detail as vet ERs and GPs are expected to give people. And when I say expected, I mean like expected by people like me. Dr. Deer: Mm-hmm. jim: To like filter all this stuff before it even gets to me. So I'm very anti that. I'm very just like, just give me the case and let me deal with this. That's kind of my philosophy. And that's why I'm the wrong person to ask that question to Dr. Deer: Yeah. No, I think that's fair because even if I think about when I'm taking cases from GPs and they say, like, I have a hemoabdomen that needs a splenectomy, and I say, That's fantastic. Just financially prepare them and just make sure that they, you know, they know that this this is not an easy, straightforward, you know, we just remove the spleen, that's the end of it. But I anticipate that I'm having that discussion with them as well, jim: Yeah. Dr. Deer: like when they get there, just to reiterate, because even if they've already heard it. hearing it a second time sometimes is what it needs to stick. jim: Yeah. Like, do you think, like, if God forbid, if my child had a head trauma, okay, do you think I'm gonna ask my pediatrician all the details about like her intracranial procedures that she's gonna have? And like all Dr. Deer: Yeah. jim: the No. They're just gonna say, they're gonna put their hands up and say, I'm not even remotely touching this. You're going to a pediatric neurologist, right? So, Dr. Deer: Yeah. Uh-huh. jim: you know, I I I think this is you're actually getting into one soapbox of mine. we stumbled into a soapbox Dr. Deer: Yeah. jim: here. But I do think like tertiary care could do a lot better by just saying, okay, and just seeing cases and not trying to like have everything set up on a silver platter quite as much. Dr. Deer: Mm-hmm. jim: That's that's a big soapbox of mine. Dr. Deer: Yeah. Yeah. I think as long as they're financially prepared, I'm not I'm not too offended if people show up and end up euthanizing because they hear a detail that they missed the first time. Like I it's not you know, I I feel bad if they traveled like hours in order for that to be the outcome. But like I'm not mad at the general practitioner for that. It's not their fault, you know. jim: Yeah, maybe for you, because you've got a dog who's systemically like about to pass, like and they need to be taken care of, right? For me, I've got a paralyzed Dr. Deer: Yeah. Yeah. jim: dog who's systemically stable. It's not gonna die Dr. Deer: Mm-hmm. jim: from what I'm seeing most of the if we're talking down dogs, right? Generalities here. Dr. Deer: Mm-hmm. Yeah, yeah. jim: So I personally, because of that, I don't if if people want to just come see me and they're not prepared to do an MRI, I'm fine to do a consult if I have a consult space open. We totally fine. Dr. Deer: Mm-hmm. jim: And I'm also comfortable, like if it's not neuro, I can kind of like navigate, you know, what's your vitals? What's your blood work? You Dr. Deer: Mm-hmm. jim: know, I had a great Dane come in with a grapefruit size tumor on his femur a coup a coup about a year ago. And he came in to see me for like a back problem. And I was like, I think we should just take an X ray of your dog's leg, and he had a, you know, massive osteosarcoma on it. I Dr. Deer: Mm. jim: could do that. I can I can order a a leg x-ray, you know. So Like it's I don't need to be filtered all that much, I guess is what I'm trying to say. Yeah. Dr. Deer: Yeah, no, that's fair. And then on the referral topic again, if I were to send you a case and I gave it, is there like a pain protocol that you prefer? I know some of our local neurologists prefer like fentanyl so that it's shorter acting. They still get that pain control, but they can do their own neuro exam. I don't know if that's something that you care too deeply about or if you're like, jim: I would probably I mean that makes sense. Like you want something short acting that's gone by the time they get to see you. But I can't remember a time where like a drug really inhibited like a paralyzed dog's assessment by me. Dr. Deer: Mm, mm-hmm. jim: it's I guess it can like make it harder to see a robust, like deep pain response that you're looking for. But even in the times where it's been kind of like, I'm not sure, I just tell people like, look, there's an opioid on board. This may or may not be real, what I'm seeing. And I would go into all this thinking we're doing our best and there's a little bit of limited information here. Okay. Fine. Like that's you know, Dr. Deer: Mm-hmm. jim: have having an o a a longer lasting opioid on board versus a short one is not going to be the difference maker that people make to say, okay, I'm going to MRI or You know what mean? So Dr. Deer: Mm-hmm. jim: I th I used to, you know, get caught up in stuff like that and and be like, what are you doing? You know, but it doesn't matter. It really doesn't. You know, you just work around stuff like that. but if you had to pick one, sure, it makes sense to give like a shorter acting drug. Yeah. I'm not gonna go totally against my neurologist colleagues that you are referencing with that with the fentanyl concern. Dr. Deer: No, I I I get it. I mean, and when you were saying carprofen versus prednisone, I always say that that you know, there are two neurologists in the valley. One wants pred, the other one wants carprofen. If you're gonna go to this one, I'll give you this one. If you're gonna go to this one, I'll give you this one. If you're gonna go to neither of them, I'm gonna see if your liver and kidneys look okay and make an adjustment from there. jim: You know what you should do, Dr. Deere? You should do whatever you think is best. How about that? You've been in you've been a veterinarian Dr. Deer: Yeah, yeah. jim: for many years. And if a neurologist sees a dog on pred and they wanted it on an NSAID and now they're all up in arms Dr. Deer: Mm-hmm. jim: about it, you know what? Let them deal with that. That that's just that's just neurologists being difficult. Just just do whatever you Dr. Deer: Yeah. jim: think is best is my is my advice to people. Like just Dr. Deer: Yeah. jim: it's fine. Dr. Deer: I will say though that Dr. Lanscove, she personally has IVDD and she says that prednisone is like a miracle drug when she's having a flair. So I've, you know, kind of kept that in mind too when I'm making my assessments. Is like, well, let's let me see if I feel like I get 'cause I always do callbacks like the next day or the day after if I'm in clinics just to be like, Hey, how they doing? Like, do you need anything? Like, did there any questions you thought of? and for my own, because I want to know this if I'm trying a new treatment protocol or if I'm adjusting things, is it working or not? Because we don't get jim: Yeah. Dr. Deer: follow up in the ER. We just don't. jim: Right. No, our our our ER gets pretty good follow up because like we have like every specialist pretty much in our hospital. So they just like they see, Dr. Deer: Yeah, that's nice. jim: you know, the everything stays there. Like it nothing really goes anywhere else. So Dr. Deer: Mm-hmm. jim: unless our MRI goes down and I have to send it somewhere else. Not that I'm Dr. Deer: Who? jim: not that that's on my mind or anything. Dr. Deer: Ha ha. Well, these were some really great tips. I mean, I I feel like I was like making little mental notes like when I go through, I'm gonna write some of these down and and maybe mail them out to like our our interns and our mentees because some of these are these are really great pearls. jim: I'm glad that you got value and I hope your audience gets value out of it as well. Yeah. Dr. Deer: Yeah. And if anyone wants to see some of these videos that you talked about, you know, learn a little bit more about neurology, how can they find you? jim: Instagram at DVMCellini would be the the way to find me. I deleted my TikTok account because it was poisoning my mind as I Dr. Deer: That's very fair. jim: Yes. but yeah, Instagram would be the main one. And I used to do YouTube videos, but I haven't done one in like eight months. So I may or Dr. Deer: Mm. jim: may not start doing them again. But I like doing little Instagram things. Those are like nice and easy. So that'd be the main account. Dr. Deer: Mm-hmm. Yeah. Well, thanks so much for coming on. We really appreciate it. And maybe we'll have you on again in the future for something else, Nero. jim: I'm happy to talk about anything you want anytime. Dr. Deer: All right, awesome.