So Your Dog Needs a TPLO

Help! My vet told me my dog needs a TPLO! What is that, exactly?

Cranial cruciate ligament (CCL) injury is one of the most common reasons for dogs to have a hind leg limp. The CCL is one of the major ligaments in a dog’s knee, it is the same as the ACL in humans. Its main job is to keep the shin bone (tibia) from sliding forward in relation to the thigh bone (femur). Partial or full tearing of the CCL results in an unstable and painful knee which causes a limp.

Some dogs tear their CCL completely and may suddenly stop putting weight on their injured leg. But the most common story I hear from clients is that the limping comes and goes. Their dog might have been limping off and on for weeks to months (or sometimes years). At the beginning, the limping would get better with rest and pain medications, but the latest episode of limping is worse than before, or didn’t get any better with rest. Worsening of limping often happens when a long-standing partial CCL tear becomes a full CCL tear. Or when dogs with a CCL tear also tear their medial meniscus. The medial meniscus is one of the shock absorbers in the knee. About 50-60% of dogs with full CCL tears and 5-7% of dogs with partial CCL tears will also injure their meniscus.

Diagnosis of a CCL tear is based on finding cranial drawer (instability between the shin bone and the thigh bone) during an orthopedic exam. While most dogs are able to be examined awake, some dogs may be too painful, tense, or anxious to allow a complete exam without sedation.

There are many procedures available to treat CCL tears in dogs. One of the most common CCL surgeries is the TPLO (Tibial Plateau Leveling Osteotomy). The purpose of a TPLO is to change the forces going through the knee so that a dog WITHOUT a CCL can have a stable joint to walk and run on. This is done by making a curved cut in the shin bone (tibial osteotomy). Taking the cut piece of bone, rolling it down the curve that was made, and stabilizing it in the new position with a bone plate and screws. By flattening the top of the shin bone, the thigh bone has a more stable platform to rest on, and other muscles and ligaments are recruited to help keep the knee stable.

Having performed and assisted in over 500 TPLOs, I consider the TPLO to be a very good and very reliable surgery. In the hands of an experienced surgeon, most dogs that have a TPLO have a good to excellent chance for a full recovery with a low likelihood of complications. But, as with most things in life, the TPLO is not perfect and certain individual factors may influence the success of the surgery.

To accurately plan for a TPLO surgery, specifically positioned and calibrated x-rays of the knee and shin bone are taken. Precise measurements of the shin bone are made and our bone cut is planned before surgery. That way I know what size saw blade I will use, where on the shin bone to make my cut, and how far I should rotate the joint surface to achieve a TPLO. Depending on the shape of your dog’s shin bone, whether or not they have torn their meniscus, or if they have other problems in addition to their torn CCL (i.e. a dislocating kneecap), changes may need to be made to the surgery. In some cases, a different procedure may be recommended.

Cost for TPLO surgery can differ (usually based on cost of living where you live, anesthesia protocol used, and whether or not your pet stays overnight after surgery). At Sunstone Veterinary Specialists, a TPLO for one knee will typically cost $3000 plus the cost of the surgical implants (plates and screws). Implant costs will range between $350-500 depending on the size of the dog.* The initial exam and consultation with Dr. Su and any additional diagnostics (such as bloodwork) are not included.

*Extra-large or giant breed dogs (>120lbs) would have extra fees to cover the additional medications, disposables, and resources required. This estimated cost includes the surgical visit (which includes a night in hospital) and routine follow-up (2 and 8-week post-op rechecks).

Lillian Su, DVM, MVSc, CCRP, Diplomate ACVS-SA

Board Certified Small Animal Surgeon

Summer Pet Safety by Jenne!

Keep your fur friends safe during this heat wave. Follow some simple tips to stay safe in the heat:

1. No car rides! Leave the pups at home. Even in the morning time, your car can rapidly heat up, and that cracked window does nothing to keep them cool. A car can overheat in minutes at 70 degrees.

2. Exercise them in the early morning, when the air and pavement are coolest. Hot pavement can easily burn their paws, and exercise in the hot afternoon can lead to heat stroke.

3. Make sure they always have access to cool water. Use ice cubes, give them frozen veggies as snacks (mine love frozen green beans and carrots). You can even make frozen low sodium broth cubes in ice cube trays to encourage hydration.

4. Keep them safe at the river/lakes. Bring potable water with you for them to drink and prevent them from drinking from river/lake. If you wouldn’t drink it, don’t let them drink it. If they are swimming, use a doggy life jacket to keep them safe. Keep an eye out for algae advisories-some locations have toxic algae blooms going on, and this is dangerous for both humans and dogs. Also, watch out for dead fish!! Dogs love to snack on them, but in our area they can get a parasite from eating fish that can make them very ill (commonly known as salmon poisoning, although other dead fish can carry it).

Jenne, BA
Referral Coordinator

Tech Talk – Springtime Safety!

Have a Pet Safe Spring!

What has certainly been a LONG winter will soon be coming to a close. Colorful blossoms and sunny days are more than welcome and hopefully will be here soon. Spring is right around the corner! Unfortunately, parasites and other seasonal risks can put a damper on all the fun. However, you and your furry friend can still look forward to this wonderful time of year by following some of these basic springtime pet safety guidelines.

Road Trips and Outdoor Activities

One of the first things you may want to do as the weather turns warm is travel. This may include a day trip to a beautiful outdoor park or a vacation to a new destination (spring break, anyone?). When traveling with your pet, keep the following safety precautions in mind:

·      Make sure the destination is truly pet-friendly and that your pet is travel-ready. When in doubt, consider a good boarding facility.

·      For road trips, don’t forget your pet’s crate or seatbelt harness. Bring plenty of water and other daily care essentials.

·      If your plans include hiking, avoid a wildlife encounter by keeping your dog leashed, vaccinated, and supervised. Remember, skunks, coyotes, and other animals can transmit deadly diseases.

·      Microchip your pet and keep ID tags updated.

Lawn and Garden Care

Spring is a great time to tackle the yard and clean up the garden. But wait! Many products can be toxic to dogs, cats, and other animals. Before beautifying your backyard, be aware of the following poisonous products:

·      Mulch containing cacao bean hulls

·      Slug and snail bait

·      Rose care products

·      Compost (often contains potentially toxic foods and dangerous molds)

·      Plants such as lilies, sego palms, and crocuses

·      Fleas, Ticks, and Mosquitoes…Oh My!

Although parasites can threaten the health of pets (and people) any time of year, spring can be when most fleas, ticks, and mosquitoes come out in droves. That’s why it’s critical to keep your furry pal on a year-round preventive. Remember, administering an over-the-counter product without consulting your veterinarian can place your pet in harm’s way.

Pet Allergies

Another springtime risk to keep in mind includes protecting your pal against allergies. If you notice your pet itching, losing fur, sneezing, or developing hot spots, please contact your Veterinarian. There are many great treatment options available to ease the discomfort of your pet’s seasonal allergies.

In general, spring means more outdoor time with our pets, which means greater distractions and more risks. If you are in doubt, remember to contact your Vet about any products that could be harmful to your pet.

We hope these tips can help you spend more quality time with your pet and enjoy a much deserved springtime.  Remember awareness and preventative action is everything!

Kat

Surgery Assistant

Tech Talk – The Chronicles of Hank

The Chronicles of Hank!

My husband Cory and I recently adopted a 10 week old Labrador mix puppy! This is our first foray into dog ownership together and his first dog ever. To say that Hank has changed our life for the better is an understatement. While there are challenging moments, (do you have to chew on EVERYTHING??) Hank has enhanced every aspect of our life.

Hank came to us from California. His mom was found as a pregnant stray and was taken in by a foster family down there. She gave birth to 11 puppies (!!) and they all lived in their foster home for about 8 weeks. Some of the pups were adopted in California, and the rest came up here for adoption via the Oregon Dog Rescue. My friend Alysse ended up fostering two of the male puppies for them. She knew we were in the market for a puppy, but that I wanted to adopt one instead of buying from a breeder. So, when we got the text with the adorable photo of the one she thought we would like, we had to go meet him!

We met him one night at her team’s flyball practice. I was surprised at how tiny he was! We fell in love and adopted him 2 days later on a snowy Saturday morning. Since we have brought him home, he has more than doubled in size from 10lbs to over 21 now! He is such a sweet friendly guy who loves people, kids, dogs and cats (though our cats Mama and Zoe are not too sure about him and would prefer that he went back to where he came from.) I am extremely lucky that he gets to come to work with me every day. He was not a fan of being in a kennel, but he is now the Sunstone mascot and lives up front with our referral coordinator, Sarah. Our clients love him and Aunt Sarah even plays him animal videos!

We have been going to Puppy Kindergarten classes at Dog Days NW in Vancouver, WA. At our first class, Hank got put into the “Small and Shy” play group, where he promptly bowled over a little Cavalier King Charles puppy. He now plays in the “Rough and Tumble” group and fits in much better! He loves the obstacle courses they have and has learned sit, down, stay, roll over, shake, and spin! Hank has taken a week-long trip to Trout Lake with my friend Alicia and I where he got to play in his favorite thing – snow! He also had his first beach trip last weekend. He is pretty sure the beach is the best thing ever!

He is now about 99% potty trained and is almost sleeping through the night. Potty training was definitely challenging but with consistency and positive reinforcement, he caught on pretty quick! We will also be happy when he outgrows the “puppy teeth chew on everything phase”, though I know that this phase of life will pass all too quickly. Being a veterinary technician, I work with dogs all day long. I typically see them when they are older and sick so I know all too well how fast the time goes by. Hank makes Cory and I laugh every single day and has brought so much joy to our lives. We are so grateful to everyone involved in bringing us together and also to my work family who loves Hank and puts up with his shenanigans.

This is only the first installment of the Hank Chronicles. Stay tuned for more…..

Katie

Head Technician

Tech Talk – Potty Training Pitfalls

Potty Training Pitfalls

My friends recently got an adorable new puppy who is just the sweetest little girl who caught onto potty training very quickly. She is now about 3 months old; and, as soon as she comes inside from going potty, she’ll go pee on the carpet by their bedroom. Not a lot but it was really starting to annoy them. I received a text recently asking what they should do as they were just about at their wits end and had gone through more carpet cleaner than they’d like to admit. I smiled reading her text as I knew exactly what they were going through all too well, having been there 3 times with my dogs when they were just wee little ones that liked to wee in places they knew they shouldn’t. 

Why, oh, why does she still pee inside?

It sounds as though your pup may not fully have control of her bladder. She is a puppy still, and though she has the basics down, she may not be completely emptying her bladder when outside. So when she goes back inside, she realizes this and just finishes up. Here are some tips to help get you through those piddle situations!

Tip 1: Stay outside a bit longer and see if your pup pees again. If she does, that’s a sign that she doesn’t empty enough the first time. Some pups may do this even 3-4 times given the opportunity. If your puppy pees quickly and then runs off to play in the yard, keep her on leash.

Tip 2: Take her to the same potty area each time. This will help to teach her that when she is taken to this specific spot, pottying is what needs to be done. No playing or other shenanigans in this area.

Tip 3: Don’t be a distraction. If she is outside peeing and you are too fast in praising/rewarding with a treat, you may be interrupting the urine flow. Don’t praise and/or give her a treat until she is completely done peeing and is moving away from the potty spot. And don’t walk away while she is peeing! Stay stationary as she may stop mid stream to try to follow you. 

 Tip 4: If she is treat motivated, and knows which hand/pocket/bag/etc they are in, she may not finish up doing her business completely because she wants that treat. And, at this point, reward her only when you are headed inside and you are sure that she has completely emptied her bladder.

Basically, your pup peeing inside after you’ve recently been outside is COMPLETELY NORMAL and just means her body is still learning, growing, and may need a bit more time outside (with some modifications). 

On occasion, some pups may develop a bladder infection causing them to piddle inside more. If you believe this may be the case, please consult your regular veterinarian.

Happy potty training!

Erika

Cardiology Assistant

Tech Talk – Why Ultrasound?

Why Ultrasound?

One of the most common things I hear from clients calling to schedule with Dr. Elliott, the internal medicine specialist here at Sunstone, is that their primary care vet is recommending an ultrasound as the next step for their pet. Indeed, the ultrasound is one of our most valuable tools for diagnosing the pets we see, but many people are surprised to hear that it is an option and may not know why it can be so useful.

There are several different options for imaging when a pet gets sick. The most common is the X-Ray, which most veterinary practices have located right in their clinic for easy use. Less common are ultrasound, CT and MRI. CT and MRI are considered more advanced imaging and are usually only found in a few specialty practices. Ultrasound machines are more common than CT and MRI, but not every veterinarian is trained to use the machine or feels comfortable interpreting the images, so they may refer their patient to a specialist like Dr. Elliott.

The key to deciding which form of imaging a pet needs lies in where the doctor is trying to look. X-Rays work by sending a beam of radiation through the body at undeveloped film for a very brief moment to create a single image. These pictures are very useful for evaluating bones, lungs and giving a general view of soft tissue structures within the body. Ultrasound, on the other hand, uses sound waves to create images. Very similarly to the echolocation used by bats, the ultrasound machine can interpret how the sound waves bounce back, forming a picture. Air and dense structures like bones bounce back the sound waves, while soft tissue structures like the liver and kidneys let some bounce back and some pass through. Because bones and air don’t let waves through at all, ultrasound is not a good tool for looking at/behind bones or within air-filled areas, like the lungs. However, it is excellent for looking within the abdomen.

One of the biggest differences between these types of imaging equipment is that ultrasound produces a live video stream of images as the doctor moves the probe around. This lets the doctor see organs from many different angles, which gives them a lot of detailed information. Sometimes there are visible changes, and being able to see those changes gives us a diagnosis. However, in many cases these changes could happen for a variety of reasons and the only way to tell the cause is to look at the tissue on a cellular level. For these times, Dr. Elliott can use the ultrasound as a guide to take a small sample of the organ in question, which is then looked at with a microscope.

In my two and a half years with Dr. Elliott, I have probably helped with somewhere between 1-2000 ultrasounds, so I have seen firsthand how much information can be gathered with this tool. I have also seen when the answer was found with an X-Ray, or a blood test, or a stethoscope. These are all important tools, with their own strengths and weaknesses, for gathering information to piece together the puzzle of what is happening inside each pet.

Colleen

Internal Medicine Assistant

Tech Talk – Emergency Pet Preparedness

Emergency Pet Preparedness

“Prior planning prevents poor performance.” This is a quote my father has told my siblings and I growing up, and still tells us to this day. It’s a quote that you can apply to many areas of your life and goes well with the topic I am about to discuss.

For the past few years, we’ve been hearing about this massive earthquake that can hit the PNW at any time and that there’s an impending disaster coming this way.

Question is, are you prepared for whatever is headed our way? Better yet, are you prepared for your animals? The best way to protect your household from the effects of a disaster is to have a disaster plan. And if you are a pet owner, that plan must include your pets. Being prepared can save their lives.

In the event of a disaster, if you must evacuate, the most important thing you can do to protect your pet is to evacuate them too. If it’s not safe for you to stay behind, then it’s not safe to leave pets behind either.

I’m going to go over a few things you can do to be more prepared for your animal in case of a disaster.

First, if you don’t already have one, you should start putting together a pet emergency preparedness kit. This could include the following: Medications and medical records (stored in a waterproof container), first aid kit (animal specific), sturdy leashes, harnesses, crates/carriers, current photos of your pet and even a picture of you and your pet together. A collar with an ID tag, enough food and water for several days, bowls, cat litter/pans, manual can opener, small poop bags, trash bags. Other sanitation necessitates like paper towels, household chlorine bleach (it can be used as a disinfectant if diluted correctly) and newspaper. Don’t forget bedding, towels, treats, and their favorite toys if easily transportable. It would also be a good idea to have information on feeding schedules, medical conditions, behavioral problems, and the name and number of your veterinarian in case you have to foster or board your pets. Keep all of this in a storage container so you can just grab and go when needed. There are some pet emergency checklists out there that you can use to guide you that I will include at the end of this article.

Second, know a safe place to take your pet. Never assume that you would be allowed to bring your pet to an emergency shelter. Contact hotels and motels outside your local area to check their policies on accepting pets and restrictions on number, size, and species. I would also ask if “no pet” policies can be waived in an emergency. Keep a list of “pet friendly” places, including phone numbers, with your disaster supplies. You can also ask friends/relatives outside the affected area whether they can shelter your animal. Make a list of boarding facilities and veterinary offices that might be able to shelter animals in disaster emergencies (include their 24-hour telephone number). Check with your local animal shelter. Some shelters may be able to provide foster care or shelter for pets in an emergency. Just keep in mind that shelters have limited resources and are likely to be stretched thin during a local emergency.

Another important tidbit to keep in mind; in case you’re away during a disaster or evacuation order, make arrangements well in advance for someone you trust to take your pets and meet you at a specified location. Make sure you show them where your pets are likely to be if they hide when they’re nervous or scared and show them where your disaster supplies are kept. Go over their feeding schedule, and medications if they’re on any.

Third, make sure your pet(s) have current ID. Double check that their tags are up to date and securely fastened to your pet’s collar. I would also consider microchipping your pets. You’ll increase the chance of being reunited with pets who may get lost by having them microchipped; make sure the microchip is registered and up to date, and that it’s in your name.

I would like to reiterate, if you evacuate your home, do not leave your pets behind!!! Pets most likely cannot survive on their own and if by some chance they do, you may not be able to find them when you return.

We don’t know when the “big one” is going to hit and it’s not pleasant to think about but we need to. So, remember the five p’s; Prior Planning Prevents Poor Performance. Take action now so you know how to best care for your furry friends when the unexpected occurs.

For help identifying pet-friendly lodging, check out these websites:

Bringfido.com

Dogfriendly.com

Doginmysuitcae.com

Pet-friendly-hotels.net

Pets-allowed-hotel.com

Petswelcome.com

Tripswithpets.com

Here are two websites you can use as a guideline for making your checklists and being prepared:

https://www.fema.gov/media-library/assets/documents/90944

https://www.cdc.gov/features/petsanddisasters/

 

Alicia, AA, AAS, LVT

Surgery Technician

Tech Talk – Who is Your Vet Tech?

Who is your Veterinary Technician?

The Veterinary Technician is an indispensable part of your pets medical team yet it seems that many people outside of the veterinary world have no idea what we do. Do we simply hold animals for the doctors we work for? Do we snuggle puppies and kittens all day long? (No, though that doesn’t sound bad…) Are we similar to human nurses? Have we gone to school? Are we licensed or registered? How are we different than Veterinary Assistants? This blog post is here to dispel all these myths and to hopefully answer your questions!

A Registered Veterinary Technician (or Certified or Licensed depended on what state you live in) is a technician who has passed the VTNE, the Veterinary Technician National Exam. They will also have satisfied the additional requirements their particular state and/or province may have. The VTNE is a rigorous examination encompassing both small and large animal medicine. Most states and all provinces require that VTNE candidates be graduates of a Veterinary Technology program accredited by the American or Canadian Veterinary Medical Association. There are a few states left that allow technicians to “grandfather” in, meaning they can use on the job experience in order to qualify to take the test however, this is going out of favor.

Most RVT’s have graduated from either a 2 year or a 4 year Veterinary Technology program where they studied everything from anatomy and physiology, pharmacology, surgical nursing, anesthesia, radiology, parasitology, medical math and more. During these programs students typically complete externships where they gain on the job experience and many students work at veterinary practices too. Upon graduation and successful passing of the VTNE, a person can be lucky enough to call themselves a Registered Veterinary Technician. There are many different avenues a technician may choose to go into such as working with laboratory animals, food animals, zoo animals, equine medicine, small animal general practice or emergency practice, specialty medicine and more!

There is another level of expertise that Registered Veterinary Technicians can pursue and that is to obtain their Veterinary Technician Specialty certification. There are a variety of specialties a technician may pursue such as Small Animal Internal Medicine, Emergency and Critical Care, Anesthesia, Dentistry, and more. This is an extremely demanding process that requires many hours of experience in their specific field (3 years or 6000 hours as an example), letters of recommendation, continuing education, case logs and case reports, as well as passing another rigorous examination. There are only about 700 VTS’s in North America. Becoming a VTS is a great way for technicians to advance in the veterinary field and to gain advanced skills and knowledge.

So, now that you know about the education level of RVT’s, lets delve into what they do all day at work. A technician will likely wear many hats during the course of a typical day. Legally, we are not allowed to perform surgery, prescribe medications or diagnose a disease or illness. These are tasks left to the Veterinarian. Aside from these, we perform the majority of patient care tasks. One of the biggest things that RVT’s do is induce, maintain and recover patients from anesthesia. When your pet has a dental cleaning, surgery, endoscopy, or any other anesthetized procedure, the anesthesia is likely done by an RVT. A technician will also be taking radiographs (x-rays), drawing blood, placing IV catheters, placing urinary catheters, performing dental cleanings, running laboratory tests, giving medications, educating clients,

assisting the veterinarian, and many more tasks. A RVT is similar to a human nurse and there is a push in our field to start calling all licensed or registered veterinary technicians, Veterinary Nurses. We will see if this change comes about.

A Veterinary Assistant does many similar tasks that a Veterinary Technician may do however, they have not completed a Veterinary Technology program or passed the VTNE. Legally there will be a few things that they cannot do, such as induce anesthesia, give rabies vaccines, give IV injections without an IV catheter, etc. Many Veterinary Assistants are very knowledgeable and experienced. I know that I could not live without the assistant on my team! They are equally as indispensable as Veterinary Technicians, but they do not share the same title or credentials.

I hope that this blog post has cleared up a little bit about what a Registered Veterinary Technician is and does. Next time you see the technician at your pet’s veterinary office, make sure to give them a big hug and a thank you for all of the personal care they provide to your beloved pet!

Winter Wonderland!

Winter Wonderland!

My littlest fur baby (Jensen a 1.5 year old Red Heeler) experienced his first snow last week, and it was one of the funniest things I have ever seen. After running in and out of the room 3 times trying to get my attention, I finally got up to see what it was that he wanted. He ran to the living room and stood there growling in front of the bay doors that lead into the backyard. Curious, I got down to his level to see what he was growling at, there was nothing but giant snowflakes falling from the sky. I opened the door and he darted onto the patio, threw his head back, and howled! After a dramatic pause, he bowed to his new found toy, barked, and began to jump and snap at the air to catch these mysterious white flakes falling from the sky. I must have been laughing so hard because Jensen would pause to look at me, ears like satellites, head tilted to the side in wonderment at my silly noise making. His sisters, Sadie and Lola, joined him after a few minutes. They all continued frolicking around the yard making puppy angels, tossing the icy flakes around with their noses, and playing chase while bouncing around like little foxes in the snow.

As I played with my dogs in our little PNW winter storm, and after having to trick Jensen into going inside before he turned into a little pupcicle, I began to think about all of the things I needed to do to keep my dogs safe while playing outside in the cold/snow:

WATCH OUT FOR ICE! 

Here in the PNW we tend to get snow, then that all so lovely freezing rain. Be on the look out for ice patches when your pooch is outside as dogs can easily slip and break their bones or strain a joint just as people can. Also, be careful when walking your dog on a leash because when they slip on ice, you both may fall!

NO SNOW CONES FOR FIDO

As much as your dog may love eating the snow or catching flying snowballs, like my Jensen likes to do, this can prove to be unsafe for your pet. Antifreeze can smell sweet and taste even better to animals, but it is HIGHY TOXIC. Rock salt, while not toxic to your pet, can easily get mixed in with the snow and can cause an upset stomach. Lastly, eating large amounts of it can also dramatically lower your pooch’s core temperature and trigger hypothermia.

PROTECT THEIR PAWS

Some dogs are made for colder weather (i.e Huskies have thicker pads as well has coarser hair); however, if your dog is not designed for this, limit their time outside and be sure to dry their paws when they come inside. Treat any cracked pads with a moisturizer specifically made for your pooch’s pretty paws, or try a cream made for cow udders to sooth their pads. 

CLEAR SOME SNOW!

To make potty time quicker and easier, shovel an area where your dog likes to do their business so they know where to go (and your house stays piddle free). If they do have an accident in the house, try taking them out more often and rewarding them when they come back inside (essentially you will be potty training your dog again as this crazy white stuff falling from the sky is a new situation for them, which requires a new routine). 

GET MOVING!

If your pups are like mine, they require a ton of exercise! It can be difficult to get out and get moving with your dog when it is cold out; but, staying inside may lead to pent-up energy which can potentially lead to destructive or nervous behaviors! Once my dogs were acclimated to the cold and they were used to wearing their fancy new winter coats, we started back up on our regular walks and they have been spending more time outside each time they go out. When it snowed, I built Jensen a little obstacle course which he just loves and his sisters tried to destroy! If it is just too cold for your dog, try puzzle feeders, peanut butter or other treat filled Kongs, or simply playing hide and seek in your house; anything to keep them busy and entertained on these cold days!

There really is nothing more heartwarming than watching your dog play in the snow! Best of luck with our up coming winter storm! 

Stay toasty!

Erika S. 

Cardiology Assistant