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Post by Jeremy & Browney on Nov 12, 2017 7:08:20 GMT -7
☆ 1 Browney weighs 17lbs, he started on medication 11/10/17. He also takes medication for congestive heart failure. I will list the disc problem meds first, then the Heart meds. For disc problem 12.5mg Tramadol twice daily 12.5mg Rimadyl twice daily 62.5mg Methocarbamol twice daily For heart problem 2.5mg in am/1.25mg in pm Vetmedin 10mg in am/5mp in pm Furosemide 2.5mg Enalapril twice daily [Moderator's note: please do not edit 17 lbs. Rimadyl as of 11/10: 12.5 mg 2x/day for 7 days, should then be a test for pain stop Tramadol 12.5 mg 2x/day Methocarbamol 62.5 mg 2x/day Vetmedin 2.5mg in am/1.25mg in pm Furosemide 10mg in am/5mp in pm Enalapril 2.5mg 2x/day]☆ 2 My dog's name is Browney and he is a 12.5 year old Miniature Dachshund with Congestive Heart Failure.☆ 3 The vet said he has a herniated, or bulging disc. They only took xrays, and told us to crate rest him for 5 days. I do not believe they specialize in this, but they do call in others when needed. They have helped us with all of his heart problems. ☆ 4 We started strict crate rest yesterday morning. (11/11/17). He slept in the bed with us the previous night as the vet told us it was ok as long as he didn't move around a lot. We know better now. ☆ 5 He shivers a little, but isn't yelping at all on the meds. ☆ 7 He can walk, but one of his back leg drags. He wags his tail a lot still. ☆ 8 We have not found wet bedding. He has not urinated at this point for about 10 hours though which is uncommon for him. When he last went it was like normal, other than he could not lift a leg to pee. ☆ 9 He is eating a little less, but drinking the same amount of water. Has not pooped since 11/10 in the afternoon. My concerns at this point are my lack of knowledge with the meds and the amount he is taking. I am also concerned that I will miss an important step and make something worse. The vet telling us to rest him like this for only 5 days concerns me as well. I am very glad I found this place, and thank you in advance for any help. *EDIT* Here is a picture of his Xrays.
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Marjorie
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Post by Marjorie on Nov 12, 2017 7:33:09 GMT -7
Welcome to Dodgerslist. My name's Marjorie - what's yours? Shivering is a sign of pain. Browney is on a very low dose of Tramadol, almost like nothing at all. Tramadol has a short half life and works most efficiently when given consistently every 8 hours. We've seen dogs of Browney's weight taking 50 mg of Tramadol 3x/day. Tramadol 3 to 5 mg/kg (0.5 to 2.5 mg/lb) every 8 hrs to QID (up to 6 times daily at lower dose) Anecdotal reports include 10 mg/kg QID for more severe pain vasg.org/t_drugs.htm#TRAMMethocarbamol also has a short half life, working best when given 3x/day (every 8 hours). Please speak to the vet ASAP about adjusting Browney's pain meds so he can rest comfortably. Have no patience with pain as pain does hinder healing. The vet has room to adjust the meds and also Gabapentin can be added to the mix. Eating less may be a sign that a side effect of Rimadyl is beginning. Please speak to the vet about adding a stomach protector, possibly Sucralfate, to protect against the side effects of Rimadyl. We usually recommend Pepcid AC; however, since Browney has a heart problem, that may not be the best choice. Side effects of Rimadyl are not eating, vomit, diarrhea, bleeding ulcers. For how long a period of time has Rimadyl been prescribed for? Kudos to you for reading up on IVDD and questioning the crate rest of 5 days. It does take a full 8 weeks of strict 100% 24/7 crate rest to heal a damaged disc. Let us know you are on the same page about crate rest. The hallmark component of conservative treatment is the crate rest part. With little blood supply discs are much slower to form good scar tissue than it takes a blood rich broken bone to heal. That 6 weeks of a cast for a broken arm to heal is similar to the recovery suite being a kind of cast for the disc. 100% STRICT crate rest 24/7 for 8 weeks provides limited movement to allow good strong scar tissue to form. Super tried and true tips for setting up the recovery suite: www.dodgerslist.com/literature/CrateRRP.htmSTRICT means: - no laps - no couches - no baths - no sleeping with you - no chiro therapy - no dragging or meandering at potty times. Carry to and from the recovery suite to the potty place and then allow a very few limited footsteps. Using a sling (long winter scarf, ace bandage, belt) will save your back and help to keep a wobbly dog's back aligned and butt from tipping over. A harness and 6 foot leash is to control speed and keep footsteps to minimum as you stand in one spot. An ex-pen in the grass is an excellent alternative to minimizing footsteps with the physical and visual to indicate there will be no sniff festing going on! www.dodgerslist.com/literature/slingwalk.jpgQuestion everything and read so you become the most important part of your dog's health care team. Good place to start your self education: www.dodgerslist.com/healingindex.htmPlease let us know what the vets says after speaking to them. Healing prayers for Browney.
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Post by Jeremy & Browney on Nov 12, 2017 7:43:39 GMT -7
Thank you for your help. I will not be able to speak to the vet for about 24 hours. Is this ok, or should I call an emergency type clinic? Also the Rimadyl is twice a day for 7 days, then once a day for 7 more days. My name is Jeremy btw. I couldn't figure out where to fix that in my profile.
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PaulaM
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Post by PaulaM on Nov 12, 2017 8:06:03 GMT -7
Jeremy, you know Browney best. Shaking can be anxious, being cold and it can be pain. Often if you see another sign of pain that helps to confirm pain. IF there is indeed pain, then waiting 24 hours is like a life time of torture. Pain also impedes healing...so you would then want to see an ER vet to get immediate help for Browney.
◻︎shivering-trembling ◻︎yelping when picked up or moved ◻︎slow to move ◻︎tight tense tummy ◻︎arched back, ears pinned back ◻︎ head held high or nose to the ground. ◻︎ restless, can't find a comfortable position ◻︎slow or reluctant to move much in crate such as shift positions ◻︎looks up with just eyes and does not move head and neck easily. ◻︎ not eating due to painful chewing or in too much overall pain ◻︎ holds front or back leg flamingo style not wanting to bear weight ◻︎not their normal perky selves
Because of the CHF, you will need a vet to discuss if pain meds can be brought more to the normal aggressive mgs and frequency IF, if you are indeed seeing pain. And also what acid suppression can be used with CHF if Pepcid AC (famotidine) can't be used.
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Post by Jeremy & Browney on Nov 12, 2017 8:09:58 GMT -7
His stomach is tight, but not as much as it was a few days ago. He is shivering, but not all the time, only part of the time.
I think I am going to be patient until tomorrow morning to see what they say. He seems to be mostly laying down and sleeping. He does toss and turn a little at times, but not a lot.
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PaulaM
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Post by PaulaM on Nov 12, 2017 8:27:33 GMT -7
If you are seeing shivering and/or tight tummy nearing the next dose of tramadol or methocarbamol that is telling you those meds are wearing off too soon. If you are seeing shivering, tense tummy when having to move to change position or go potty that is telling you the pain meds are too light and are not properly covering pain. Browney is on an exceptionally light dose and frequency for both tramadol and methocarbamol than what is used for a disc episode. Not eating is a BIG RED FLAG to us that stress and Rimadyl is doing damage to the GI tract. Both cause extra stomach acids. Browney has enough to deal with he certainly does not need bleeding ulcers as one more problem. An acid suppressor is a must when on Rimadyl! If not because of heart issue Pepcid AC (famotidine) then sucralfate, omeprazole...you need to discuss this with a vet, we are not vet and do not know about CHF and meds. Never have any patience with pain. When meds are correct he can get comfortable in an hour and it stays that way dose to dose. Bookmark a thread to receive an email alert when someone has replied 1. Go to your Profile> Profile Edit > Notifications: checkmark BOOKMARKS 2. Go to the Conservative Board: checkmark your dog's thread, then use the ACTIONS button to select bookmark
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Post by Jeremy & Browney on Nov 12, 2017 8:41:02 GMT -7
I just gave him boiled chicken and plain rice and he ate it like he had never had food before. Maybe he just wanted something other than his normal dry food. As for me discussing his meds with a vet, I fully intend to do so tomorrow morning. I am hesitant to call an emergency place that does not now anything about him.
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Post by Jeremy & Browney on Nov 13, 2017 5:02:16 GMT -7
Ok, I plan to call the vet today so I wanted to run my questions and concerns by you all first to see if there's anything I am missing. I appreciate all of your help, we love this dog like a child, so it is a very tough time for us.
1)Can we increase the pain meds (Tramadol)? I gave him an extra one in between doses yesterday (37.5mg total yesterday) and he appeared to be feeling better. Can I increase this for every day? Can we give him Tramadol and Methocarbamol 3 times daily instead of 2 as they have a short half life?
2)He is not eating much dry food if I give it to him alone, but if I mix it with chicken and rice he eats the bowl clean.
3)He has not had a bowel movement since Friday afternoon.
4)Can we give him something to protect from the side effects of the Rimadyl on his stomach and GI tract? Pepcid/Famotidine, or maybe Sucralfate?
5)Why was the recommendation for him to only be in a crate for 5 days as opposed to longer? (the answer to this will not change what we do, we are going the full 8 weeks regardless. I just want to hear her reasoning.)
6)How will we know when he no longer needs meds?
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Marjorie
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Post by Marjorie on Nov 13, 2017 6:20:25 GMT -7
Those are all good questions for the vet, Jeremy. You can also ask her why she feels the Rimadyl needs to be weaned instead of just stopped. Rimadyl is a NSAID and does not need to be tapered. At the end of the 7 days, it can just be stopped, along with all pain meds, so a test for pain can be made. If there is still pain, then there is still a need for all meds as there is still swelling pressing on the nerves of the spine. If there is no pain, then all meds can be stopped. You don't want Browney on these meds for any longer than absolutely necessary. More on that here: dodgerslist.com/literature/healingsweling.htmIf she doesn't want to adjust the Tramadol and/or Methocarbamol (possibly because of Browney's heart condition), ask her if Gabapentin can be added to the mix. If she doesn't want to increase the pain meds, be sure the reason is due to Browney's heart condition and not because she doesn't want to use aggressive pain meds. IVDD does sometimes require the use of aggressive pain meds. The meds can sometimes cause constipation. Pumpkin can help firm up stools OR it can help to loosen stools. The amount of water in the diet makes all the difference. To loosen the stool, add equal parts water to each kibble meal along with a teaspoon of plain canned pureed pumpkin 1x a day. To firm up the stool, add 1 teaspoon pumpkin to kibble and no extra water 1x a day. Note alternatives for constipation: really ripe mashed fresh pear, just take off the peel; microwaved and mashed peeled sweet potato. It's always best not to adjust Browney's meds on your own, especially in light of his heart condition and the other meds that he's on. Please do let us know what the vet says after speaking to her this morning.
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Post by Jeremy & Browney on Nov 13, 2017 6:49:25 GMT -7
So this morning I got him up and carried him to the potty pad. He did not go to the bathroom, but was a little wet underneath. I checked his bedding and didn't find any accidents. Then I put him in his cage and gave him some food and his meds. After he was done I went back to take him to potty. He yelped when I tried to pick him up. This is the first time he's done that. I tried again but a different way, but he wouldn't even let me get him off the ground. I am being very cautious to support his entire length while lifting him.
When he wouldn't be picked up I had him walk very slowly about 3 steps to the tile where I put a potty pad down for him. He did not go to the bathroom. We rebuilt his cage in the kitchen with a potty pad on the end thinking he would just go from pillow to pad. Once we got him in there he pooped and peed on the pillow. This is not normal for him, and has me concerned.
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PaulaM
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Member since 2007: surgery, conservative . Montana, USA
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Post by PaulaM on Nov 13, 2017 7:03:07 GMT -7
Jeremy, I'm glad you will be calling your own vet asap this am to see about getting the correct meds on board to deal with thiis disc episode. With a dog in pain you can't care for him without hurting him and the dog can't begin to heal. Pain actually hinders the healing process.
Since 11/11 there has been no anti-inflammatory on board to bring down swelling/inflammation. Swollen tissue puts more pressure on the spinal cord. Pressure causes pain and enough pressure can cause death of nerve cells. We observe death as loss of function.
As damage to the spinal cord increases, there is a predictable stepwise deterioration of functions. When nerve healing begins, often it follows the reverse order. 1. √Pain caused by the tearing disc & inflammation in the spinal cord other back leg: 2. _?_Wobbly walking, legs cross 3. _?_ Nails/toes scuffing floor 4. _?_ Paw knuckle 5. √Weak/little one back leg movement, drags leg, can't move up into a stand 6. Legs do not work at all (paralysis, dog is down) 7. Bladder control is lost 8. Tail wagging with joy is lost 9. Deep pain sensation, the last neuro function, a critical indicator for nerves to be able to self heal after surgery or with conservative treatment.
Let us know what changes to the med list your vet makes this morning
Because your vet has not seen him for this issue, likely you are going to have to transport Browney. Any time out of the recovery suite can be a danger of too much movement to the vertebrae pushing on the weak disc. Pad out the crate with a rolled up blanket/towel to prevent Browney's body from shifing when you take a corner or brake.
Oh and it would be best to provide new information in a new post. Once moderators have boldfaced a post for important points we may miss the new information you add.
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Marjorie
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Post by Marjorie on Nov 13, 2017 7:25:35 GMT -7
Jeremy, could you explain a bit about what you mean when you say you "rebuilt his cage in the kitchen"? Do you have Browney in a secure crate or ex-pen? It's not a good idea to add room for a pee pad as that could allow Browney to move around too much. The recovery suite should only be large enough for him to stand up, turn around and lie down with his legs extended comfortably. More info on setting up a secure, safe recovery suite: www.dodgerslist.com/literature/cratesupplies.htmI do hope the vet will be able to get Browney's pain completely under control today. Getting the correct meds on board can make all the difference.
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Post by Jeremy & Browney on Nov 13, 2017 7:31:34 GMT -7
He is in a pen and we realize that he should not have too much space. We have built a pen and a few different rooms so that we can have him near us as it seems to calm him. The one in the kitchen I made it bigger by unfolding some of the extra sides and put a potty pad next to his bed because he would not let me pick him up so I was concerned about that. I realize I should not give him that much room but I was worried they're picking him up was worse for him then allowing him to have somewhere to step to to pee. I apologize if anything I'm doing or saying doesn't make sense this is all very new to us and to be honest I am a wreck.
Hi, sorry if this post is a little screwy I am posting from my phone. I run a construction company so I had to get out of the house to go get things started and then I plan to go back as soon as possible. My wife is there with the dog. I don't know what you mean about the vet has not seen him for this issue? I took him to the vet last Friday 11/10. also you say he does not have anti-inflammatory but I thought the Rimadyl was an anti-inflammatory?
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PaulaM
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Member since 2007: surgery, conservative . Montana, USA
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Post by PaulaM on Nov 13, 2017 7:44:58 GMT -7
Jeremy, my appologies for mis reading the med list. Brownie DOES have an anti-inflammatory (RIMADYL) on board. I may take 7-30 days to get all the swelling down. In the meantime pain relievers are given at a more aggressive dose than the meager Tramadol 12.5 mg 2x/day and Methocarbamol 62.5 mg 2x/day for a 17 lbs dog. Since we are not vets you would need to discuss if a more aggressive pain med approach can be used with CHF. AND also about getting Pepcid AC on board.
If your normal general DVM vet has already seen Browney, then getting meds change should NOT involve a risky to the disc transport. Med adjustments are normally done over the phone to avoid moving the dog.
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Post by Jeremy & Browney on Nov 13, 2017 8:20:36 GMT -7
Can you tell me what you think a normal dosage of the Methocarbamol would be? I read above for the Tramadol that it should be up to 50 mg 3 times per day. I did not see anyone mention anything about the methocarbamol. I do not intend to change this on my own without talking to my vet but I would like to at least have an idea of what I should be shooting for. I appreciate all of the help from all of you here you guys are awesome.
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Marjorie
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Post by Marjorie on Nov 13, 2017 8:28:04 GMT -7
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Post by Jeremy & Browney on Nov 13, 2017 9:35:20 GMT -7
Ok, heres a double update. 1)He has wet the bed twice more since I left the house.
2)I just spoke with the vet. She has allowed a medication increase to the following. ▲Tramadol 25mg/3 times a day ▲Methocarbamol 125mg/3 times a day ✚Famotidine 5mg once daily before all other meds
[Moderator's note: please do not modify 17 lbs. Rimadyl as of 11/10: 12.5 mg 2x/day for 7 days, then 11/17 test for pain stop Tramadol ▲25 mg ▲3x/day Methocarbamol ▲125mg ▲3x/day ✚famotidine 5mgs 1x/day Vetmedin 2.5mg in am/1.25mg in pm Furosemide 10mg in am/5mp in pm Enalapril 2.5mg 2x/day]
She wants to send him to the neurologist because he is urinating in his bed. She is calling to check their thoughts this morning and will let me know. I am very nervous about that and moving him. I really do not want to get surgery if there is any way we can a void it.
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PaulaM
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Member since 2007: surgery, conservative . Montana, USA
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Post by PaulaM on Nov 13, 2017 10:50:23 GMT -7
Jeremy, good work on getting the pain meds adjusted and a stomach protector on board.
Before bladder control is lost the dog would have to loose use of both back legs. Scroll back up for the order of neuro function loss in the post I made this morning.
Within an hour IF, the pain meds are correct, then you would be able to care for Browner without causing him pain to lift and carry to the potty place. The proof of whether a dog has bladder control is the sniff and pee test.
SNIFF and PEE TEST The only way for us humans to know if there is bladder control is with the sniff and pee test. Carry outdoors, set on an old pee spot to sniff it. See if urine is then released. Make sure the sling or your hands are not on the tummy area as that can press on the bladder. If urine comes out after sniffing at the spot that is proof of bladder control
QUESTIONS: Has Browney lost use of both back legs. If not which leg is dragging? Within the hour are all signs of pain gone? Let us know what was observed with the "sniff and pee" test. Did your vet say Tramadol could not go to 50 mgs 3x/day do to CHF?
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Post by Jeremy & Browney on Nov 13, 2017 12:01:30 GMT -7
The vet said according to her literature the max for him was 38mg 3x daily for the Tramadol and that she was being cautious due to the CHF. I gave him 1 dose of Tramadol and one of Methocarbamol , at the new dose, when I got back home at 9am. This is 4 hours after his last dose, but they were the much smaller doses that the vet originally prescribed. About 30 minutes after this I was able to pick him up and move him without any yelp. His left rear leg is the one that was bad. He is still able to walk, just that leg does not seem to do what he expects it to. I keep my hand next to his left rear while he goes potty to help him balance. I have not tried the pee test, but will try it later when I take him out to potty. I have not been taking him outside, but rather a potty pad on a tile area of our house. He is trained to go there, or outside, but I figured the risk was less there. Here is a picture of him in his cage.
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PaulaM
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Post by PaulaM on Nov 13, 2017 12:24:36 GMT -7
Jeremy, can he move that back left leg at all? Can he bear weight on it...does the paw knuckle under? Or does it completely drag behing him (paralyzed)?
If the vet is being cautious about CHF that is a different matter about the dose of tramadol for a 17lbs/7.71kg dog Way too much room in the recovery suite. Only enough to stretch out the legs fully when lying down and easily turn around to change positions. Maybe half of the space and you could still get in a smaller area for the pee pad?
If he will sniff on old urine piece of pee pad you put on a new pee pad adjacent to the crate and then choose to release urine, he has bladder control. He may not have wanted to move so peed in his suite because he was in too much pain earlier. Let us know what you observe now that there has been an adjustment to the pain meds.
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Post by Jeremy & Browney on Nov 13, 2017 12:34:40 GMT -7
He can move his back leg and can stand up still. If you turn the paw over he won't turn it back.
He is very relaxed now and hanging out in his cage. The vet just called back after she spoke with the nuerologist. They want me to stop giving him Methocarbamol and start Gabapentin. I will update with the dose this afternoon once I pick it up. As for way too much space, I think scale is messing with that image. When he stretches out flat with his legs out he is the length of both pillows, and if he tries to lay the other way it is not wide enough.
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PaulaM
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Member since 2007: surgery, conservative . Montana, USA
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Post by PaulaM on Nov 13, 2017 12:42:07 GMT -7
Jeremy, as long as there is one position that he would be able to fully stretch out the legs, that is good.
Good news, then that the left back leg is NOT paralyzed. By definition he must then also have bladder control!
As damage to the spinal cord increases, there is a predictable stepwise deterioration of functions. When nerve healing begins, often it follows the reverse order. 1. Pain caused by the tearing disc & inflammation in the spinal cord 2. Wobbly walking, legs cross 3. Nails/toes scuffing floor 4. LEFT backPaw knuckles, RIGHT back leg normal function 5. Weak/little leg movement, can't move up into a stand 6. Legs do not work at all (paralysis, dog is down) 7. Bladder control is lost 8. Tail wagging with joy is lost 9. Deep pain sensation, the last neuro function
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Post by Jeremy & Browney on Nov 13, 2017 12:46:35 GMT -7
After talking with the vet, she suggested that he might have peed in the cage also because of so many different medicines. The pain part makes sense as well. With that said, he just peed in there again. Not sure how we are going to deal with this. I have put plastic under the cage, then we put pillows wrapped in trash bags, then pillowcases over them so he has something to lay on that isn't plastic. Hopefully this is just a side effect of the drugs. All of this can be so overwhelming.
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PaulaM
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Member since 2007: surgery, conservative . Montana, USA
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Post by PaulaM on Nov 13, 2017 13:14:15 GMT -7
Jeremy from our supplies list www.dodgerslist.com/literature/cratesupplies.htm the tip on using 100% synthetic fleece is a good one. Fleece (no cotton) will wick away moisture from skin.. Fleece can be by the yard at any fabric shop like JoAnn's. Grocery stores, Wallmart sell very inexpensive fleece throws (around $10) you can cut with scissors to size needed to tuck in all around the mattress just like a bottom sheet of sorts. Often you can get two fleece sheets out of one throw. Layer in this order Mattress enclosed in trash bag > pee pad next > Use 100% synthetic fleece sheet to tuck in all around the mattress to hold the pee pad in place. Having a couple of fleece sheets make changing easy. They wash and dry very quickly.
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Post by Jeremy & Browney on Nov 13, 2017 13:17:23 GMT -7
Thank you. that sounds like a better way than we are doing.
He peed again in there, but this time when I moved him to clean it, I tried to turn his toes under on his left back leg out of curiosity, and he turned them right back. I know that isn't much, but it gave me hope. The last time that was tried was last Friday 11/10 by the vet.
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Marjorie
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Post by Marjorie on Nov 13, 2017 14:40:19 GMT -7
One other tip that I found helpful when my Jeremy was on crate rest was making an attachable crate bowl hanger for his food/water dishes to prevent spillage in the crate. Just be sure to fill in any extra room in the crate where the dishes used to be with rolled up towels/blankets. www.dodgerslist.com/literature/cratesupplies/bowlHLDR.jpgI do hope to hear an update soon that Browney's pain is completely under control and that he's been able to pass a sniff and pee test and is now going on a pee pad outside of the crate. I all too well known how stressful it is to care for a dog who's having accidents in his crate. Hang in there - hopefully things will improve soon.
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Post by Jeremy & Browney on Nov 13, 2017 17:09:44 GMT -7
Thank you for all of the suggestions. You ladies are amazing.
One question. The filling in gaps in the crate with blankets or towels, is that to prevent the crate from having different "levels"?
Ok, so no more Methocarbamol and now ✚Gabapentin 100mg 2x daily.
[Moderator's note: please do not edit 17 lbs. Rimadyl as of 11/10: 12.5 mg 2x/day for 7 days, should then be a test for pain stop Tramadol 12.5 mg 2x/day ✚Gabapentin 100 mg 2x/day - started 11/13 Vetmedin 2.5mg in am/1.25mg in pm Furosemide 10mg in am/5mp in pm Enalapril 2.5mg 2x/day]
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Marjorie
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Post by Marjorie on Nov 13, 2017 17:09:50 GMT -7
Actually, I was thinking more of rolling up towels or blankets to above her pillow level so she doesn't have that area to move in. Any extra area that she doesn't need to lie down comfortably with her legs extended should be filled in with rolled up towels/blankets to block off that area. If she doesn't need all of the two pillows to lie down on, then block off part of one pillow. Think of the crate as a cast for the spine. She should only have room to stand up and re-position herself and then lie down comfortably with her legs extended. With conservative care, the less movement, the better.
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Post by Jeremy & Browney on Nov 13, 2017 17:10:51 GMT -7
Ok, I get what you are saying. Browney is a He also.
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Marjorie
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Post by Marjorie on Nov 13, 2017 17:15:11 GMT -7
Have you started Brownie on the Gabapentin yet today? His pain should be completely under control within one hour of giving the new course of meds. Please note that Gabapentin is another med that has a short half life and works best when given consistently 3x/day (every 8 hours) so if the new meds are not covering the pain completely, please speak to the vet about giving the Gabapentin every 8 hours. Yes, I know he's a boy and what a handsome boy he is!
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