Vet Talk

Tincture of Time: Watchful Waiting

Our propensity is to link unrelated events

March 13, 2017 (published) | March 13, 2017 (revised)

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I used to think I could control ducks with my mind but it turns out ducks and I just have very similar ideas about what stuff ducks should do.” —Jacy Catlin 

Humans have this little quirk in their brains: when two things occur at nearly the same time we tend to think they are related, that one caused the other. Many times they really are: if you eat a sandwich that’s been sitting out in the sun all day and you get sick, blame the sandwich. That sandwich wanted you dead, man.

But if you wave your hand above your head in a big figure eight, say “peanuts and sausages” three times and then win the lottery, there’s no way that stuff is related. It may look like it is, and our brains really want to make it seem like your little ritual led to the big money win, but you know logically that these events are totally unrelated. Our propensity to link unrelated events like this (described by the Latin phrase post hoc, ergo propter hoc – afterwards, therefore because of) is the cause of much human misery and suffering, but is a byproduct of our big brains. It usually serves us pretty well by helping us avoid things like the sandwich of doom the next time. The scientific phrase that describes the mindset needed to avoid falling prey to this is correlation is not causation: just because two things happened together, or in quick succession, doesn’t necessarily mean they are linked.

This phenomenon is behind many of the crises facing modern medicine (of the human and veterinary variety) and also behind many of the irrational things that we humans do. The placebo effect, the adherence of many people to ideas and therapies that have been proved useless or false, the utterly unshakable belief that many have that a patient with a fever MUST always have antibiotics – all arise because of this tendency we have to link unlinked events. Many people have been led to the sometimes false conclusion that fevers go away due to antibiotics, not the body’s innate ability to heal itself, by the fact that the fever resolved after the course of antibiotics began. Every fever doesn't need antibiotics because antibiotics only work on bacteria, and there are many causes for fever that aren't caused by bacteria, such as viruses, cancer, immune disease, etc.

Many pet owners raise an eyebrow when I suggest waiting and watching to see if a subtle, non-specific symptom, such as a fever, goes away on its own instead of running a battery of tests or prescribing antibiotics. If we have a stable, comfortable patient, sometimes - not every time - waiting to see if either the condition goes away or elaborates into something we can more easily figure out is a reasonable option. If there’s anything in the picture that’s alarming, say a fever accompanied by abdominal pain, or history of diabetes, then further workup makes sense and is warranted. Also, some pet owners aren’t content to wait. For those, some form of action is helpful for them (not necessarily the patient), so in those cases I try to pick interventions and tests that don’t make things worse and may shed some light on what’s going on. But in many cases, my preference often is to wait and see.

Watchful waiting is the term that’s been applied to this tactic, and I think it’s served my patients well but may have confused the occasional pet owner. Watchful waiting can’t be applied in all instances and across all situations, though. In some cases, the effect of waiting can be disastrous, and to use it properly, clinicians have to have enough experience and intuition to have a feeling for how diseases and patients generally work. It requires a sense for what state the patient is in, how able the owners are to judge their pet for signs of worsening, and their ability to come in for follow-up care if needed. The one-year-old indoor cat with a runny nose who’s still eating and has smart owners who’ll come back within a day if things get worse will be offered watchful waiting; the one who lives 90 minutes away probably won’t.

The next time your vet talks to you about waiting to see if things will go away on their own, give it consideration. If your pet is not in a crisis, is still eating, active and not in pain, it might be a reasonable course of action.

22 Comments

Colleen Whillans
August 15, 2020

My cat will be 13 in September. He was diagnosed with diabetes in March 2017. It took from then to July 2018 to get the right dosage of insulin. From July 2018 til July 23rd we had the right dosage. He is on Prozinc, Diabetic dry vet food. He was 14 pounds when diagnosed. Now he is 17.7lbs. So didn’t gain much. So after taking my cat to the vet to have his yearly check up they noticed his Blood Glucose level was 16.6. So they adjusted his insulin. So he went from 4 ml in the morning and 3.5 ml at night to both 4 ml morning & night. Was out camping August Long weekend and did his blood count July 28th. It was low 3.5. So called the vet and they dropped his dosage to 3.5 morning & night. I took it again July 31. One was 2.9 and the other was 4.3 two hours later. So vet knocked it down to 3 ml morning & night. Did another count August 11th and it was still low. So vet told me to drop dosage to 2.5 ml morning & night. I am hoping we can get his insulin stablized again. He still acts like a kitten. But he does have A little bit of cataracts but I am hoping to keep him around longer then 13 years.


Jackie
August 14, 2020

My Maltese is eight years old. I have been trying to keep the glucose at a balance level but it’s a little hard to do that today I took a glucose it was 112 how much insulin should be given for that level in the 100’s.


Robert
August 8, 2020

Liked the article.  It was informative. I have an elderly cat that just turned 17.  She's been diagnosed diabetic going on 4 years, and tolerated the insuln well. Two weeks ago she went in for annual visit and her Doctor discovered low b/g levels and recommended taking her off insulin. A week ago, I noticed she wasn't able to stand or walk on her own.  Took her to the hospital and she had b/g levels of 345.  Gave her 2 units and 1 unit later that night.  In addition to a 250 ml IV drip.  Seen the next day and b/g levels were 74.  Continued the IV fluids with no insulin until morning, and b/g levels swung back to 174.  It's gone like that for six days running.  Her blood glucose levels won't stabilize.  Have fed her slurry with syringe all week and her appetite is coming back slowly.  She is rehydrated as well.  Still not strong enough to stand or walk on her own.  But she's alert and responsive to her surroundings.  Any thoughts?


Angela G.
June 30, 2020

My sweet beautiful cat was on Vetsulin for 5 years. I could not monitor her blood sugar. It was too stressful for her and me, so my vet put her on 2.5 units 2x day. She was doing great every day I never saw any symptoms and then OUT OF THE BLUE she had a Hypoglycemic episode where her sugar went down to 20. I rushed her to the vet and they got it under control. She was doing so well but the morning I went to pick her up she had another one and no one was at my vets office overnight to save her. They tried but too much damage had been done and she didn’t make it. I am devastated by this. I’m waiting for my vet to call to give me some answers.  How could another episode happen So suddenly when she was doing so well again?


Beth DeVinney
June 15, 2020

Great news for pet parents of diabetic dogs! Free style libre!  We have been monitoring our dog Gracie since last November and it is fantastic.    She was diagnosed after going blind over night from cataracts. Purdue University allowed us to use the libre monitor and she is in a study there for her eyes As well.  She gets shots twice a day and it works really well she is 95% regulates.


Fran Munschauer
May 30, 2020

Suzie 10 lb chihuahua on insulin 3 years and has OPPOSITE of "Dawn phenomenon" as in humans. BG 500 at dinner...250+ IN AM..SHE REMAINS ASYMPTOMATIC BUT has had ERRATIC BG LEVELS ON Vetsulin,especially at dinner time...doesn't last 12 hours OR may suddenly work overtime with AM BG 80??? NPH didn't last..Lantus was good except I never slept worrying about 4 am hypoglycemia...I wanted to try a HUMAN insukin (Novolin 70/30) hoping it was better FDA regulated but no DVM uses it. Suzie has had her first medical issue-refused to eat- but resolved next day and chem panel was fine except Hct 24. DVM suspects stomach issue??? My main question is WHY would her BG be 500+ at dinner but 300 or so in AM? Suzie's spreadsheethttps://docs.google.com/spreadsheets/d/1O1YNDHz-t4REns_tbAN6D_M3AYT6_kgqbHE7JWo6kSM/edit#gid=811447094:


Hilary Rockwell
May 25, 2020

My mom has a 13 year chihuahua that has diabetes and the vet has him on 4 units of insulin in the morning and 3 in the evening but his sugar is still 350 to 400 and they can't get it down :(


Christy Corp-Minamiji. DVM
March 22, 2020

Hi Charlene,  I'm so sorry you're having this struggle. Managing diabetes can be such a pain!  Unfortunately, the only way to get a handle on it will be to work closely with your veterinarian. 


Charlene Kendrick
March 22, 2020

My Buchon is 14. For the past three years we have been giving her insulin twice a day! She started off with a 4 then a five! But since I check morning and night I usually give 5 in the morning and if necessary 6 at night! I have dropped down to 4 if she is low! Tonight she was HI. I guess that means as high as she can go! I do not know anything else to do! They can change her insulin but they said it would cost a lot! Help!


Jennifer
March 6, 2020

My 10 year old terrier was diagnosed 7 weeks ago, is on Vetsulin. He started at 3ml and has been increased to 9ml. He is still not regulated, with very high levels in the morning (~650) before his shot and levels around 350-450 in the afternoon. When he was first increased this last time, he had levels in the 100's, but it only lasted a day. I was told by some folks on the Facebook support page that because my Vet increased more than 0.5ml at a time - she increased 1.5ml (from 6.5 to 8) one week and 1ml (from 8ml to 9ml) the next week, that the optimal dose could have been "missed," as though there's a rebound affect. Is this true? I sent my Vet glucose curves, and I believe she increased based on the fact that the lowest levels were still very high. I've read about the Somogyi affect, but I don't think it applies here since the levels never went lower than normal and then spiked up within a day. I do believe that the Dawn affect may apply, but what I really want to know is whether there's some sweet spot number that when missed (increased beyond that number), will cause a dog to stop responding to the insulin altogether.  Thank you!!


Holly
January 18, 2020

Great info! I want to share for other diabetic pet parents. Ask your vet to write you a script for the Style Libre. Our dog has been wearing it for 16 days (second sensor now). It is non surgical and can be applied in about 10 min. You can download the app or buy the coordinating reader at the pharmacy. You can then scan the sensor AND GET AN ACCURATE READING. Our dog has no issues with it. He sleeps wearing it, can be bathed etc. it is amazing. We are able to check his sugars anytime we want and no need to prick him. Without insurance it’s $60 ish dollars for 14 days of tracking. Also, if you are having trouble with using an alpha tracker here is the way to get the blood you need. Insert the lancet into the one thing. Take the cover off lancet. Expose needle tip. Very gently PULL THE LANCET OUT a little bit. (This allows the needle to actually prick the dogs ear!) put the cap back into the pen. Warm up your dogs ear with a warm rag. Massage ear gently. Once the ear looks a little pink, then hold the ear gently against the pen and click the button for the lancet to come out. Flip that ear back and give it a few seconds. You should get enough blood to test. If not gently squeeze ear for blood to bubble.


Christy Corp-Minamiji, DVM
November 26, 2019

Flash glucose monitoring devices such as the Freestyle Libre device mentioned by Z are fairly new.  Here is a link to an article on our sister site Veterinary Partner that explains more about these devices. https://veterinarypartner.vin.com/default.aspx?pid=19239&id=9150771 


Z
November 24, 2019

My doc implanted a temp (lasts 14 days) glucose monitor in the back of my pup's neck. It interfaces with an iphone app called FreeStyle LibreLink. Try it out. It's more convenient than dropping off at the vet. Saved tons of money, but the app is still buggy. Works 90% of the time.


Tani
October 27, 2019

My dog was diagnosed 4+years ago. She is practically blind. We have managed to control her levels most of the time. The last few days her levels have been around 7 and too low to give insulin. Will this be damaging to her not to have insulin.


Michelle Massotti
October 22, 2019

I'm a new mom to a diabetic dog. I purchased an alpha tracker and had a miserable/anxiety day of err codes all day. 10 Lancers and 6 strips with not one reading. I cant afford $107 at the vet for a curve.(we just saved her from ketoacidosis and wiped us out) will the dosage I'm giving her now ever be reduced? (which seems gr8, cause she's eating and drinking and urinating normally) I'm giving exact food and insulin at exact times to help from any fluctuations. 


Christy Corp-Minamiji, DVM
September 11, 2019

Hi Diana, Unfortunately, diabetes can be challenging to control for many patients.  Also,there are so many factors at play that no one other than a veterinarian who is working with you and your dog is going to be able to assist.  We recommend making an appointment to go through all of your records and concerns with your veterinarian.  I'm sorry you're having such a rough time getting her blood glucose under control. 


Diana Gibbs
September 10, 2019

My dog was diagnosed in Feb this year. We have been doing blood test on her every 2 hours and her blood is so unpredictable. Our vet keeps changing us on her doses and I have been keeping very good records on her. with a higher dose she goes too low and with a lighter dose she is too high. Please help !


Deb Domurat
February 15, 2019

So if your cat's level has been in the mid to high 300's for several checks he should be a insulin?  I knew when my other cat needed it it was over 500, but this cat is up and down :-(


Gus Ray
May 30, 2018

Great article, also of note is A1C for cats and dogs is now available as a test to veterinarians


Tania
April 14, 2017

Thanks for the great article. My sentiments exactly (albeit phrased in a more eloquent way). However, not so good when your boss tells you that you're not giving enough injections.


Julia Dahlke
March 23, 2017

One of most oft-prescribed treatments:  "tincture of time".  It's been around a long time but very effective.  Thanks for the article!


Kate McDuffee
March 23, 2017

A mentor of mine, regarding watchful waiting or benign neglect, used to say, "Don't just do something. Stand there!"



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