Animal life summer08


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Animal life summer08

  1. 1. KANSAS STATE UNIVERSITY SUMMER 2008 LIFE Animal V E T E R I N A R Y M E D I C A L T E A C H I N G H O S P I T A L Inside Student’s Hard Work Saves Draft Horse Brown Cow has Purple Knee Speaker Foam Saves Dog Afghanistan is Special to Specialist W
  2. 2. SUMMER 2008 Contents Pg. 2 AnimaLIFE Editor’s column The two words “animal” and “life” share the “L” because— just like our pets—they are a seamless part of our lives. Pg. 4 VMTH Director’s column S h a p i n g t h e f u t u re o f t h e h o s p i t a l h a p p e n s e v e r y d a y. A Father’s Gift Pg. 5 Dr. Amy Rankin Dr. Amy Rankin Pg. 6 Pulling Through A senior student I remember a wonderful summer day when I was about 6 years old. It was late afternoon didn’t originally s h a re s h i s a c c o u n t when my Dad parked the station wagon in front of our two-story home in Kansas City. As envision a career in of a draft horse veterinary medicine. that pulled through we got out, a police cruiser stopped in the street. The officer said, "Little girl, do you like Now she’s an despite enormous puppies? I only have one left." He lifted the tiny creature up and handed it to me. She ophthalmologist. medical challenges. immediately snuggled her nose to my neck. I flashed my Dad a look with pleading eyes that begged, "Can we?" Dad smiled. I darted into the house with excitement and announced that we had a puppy. We named the seventh female of the house, Officer Squad Car Macan. Dogs were important members of my family growing up. People often talk Pg. 10 How Now Brown Pg. 12 Road to Recovery about the animals they love, but we Cow? Dog’s life depends seldom talk about the people who C o w re c e i v e s on a vacuum, taught us to love and care for them. w o r l d ’s f i r s t speaker foam and a For me, that person was my Dad. artificial ligament, veterinary surgeon known as the who works well My amazing father passed away this Wildcat Power under pressure. Patrice Scott, “AnimaLIFE” editor, with Clyde. winter. For those who wondered if C o rd . Right: Dad with my sister Rita and Officer. they’d missed the fall/winter edition, you now know why one was not produced. It touched me deeply that many readers cared enough about AnimaLIFE to contact me and Pg. 15 Referring Vet Pg. 16 Kabul-ing it inquire. If you appreciate the way the articles Together Honesty is the are crafted in the magazine, my Dad has touched your life. I simply could best policy for Afghanistan comes not write them the way I do without the life foundation I was blessed with. Loved ones – Dr. Rober t Johnson. a l i v e i n D r. D a v i d animals and people – are gifts. H o d g s o n ’s r i v e t i n g account about Thank you for indulging me in my story. As always, please contact me if you have a story teaching veterinary you'd like to share. I'd love to hear from you. W students in the All the best, w a r - t o r n c o u n t r y. About the Cover After a lengthy stay at the KSU-VMTH, 11-year-old Dachshund, Little Pup (LP) is back Patrice Scott home with his owners, Bill and Dee Wills. Marketing and Development Officer Veterinary Medical Teaching Hospital Editor Photography Publisher All rights reserved. 1700 Denison Ave., 103 Trotter Hall Patrice Scott Digital Instruction, Support and AnimaLIFE is published by the Manhattan, KS 66506-5601 1700 Denison Ave. Creative Services Veterinary Medical Teaching 103 Trotter Hall College of Veterinary Medicine Hospital at Kansas State Contents of this Phone: 785.532.4046 magazine may not be reproduced Manhattan, KS 66506-5601 Kansas State University University, Manhattan, KS 66506. E-mail: 785.532.4046 Dave Adams For advertising information in any manner without the written Patrice Scott contact Patrice Scott at consent of the publisher. Personal family photos 785.532.4046. AnimaLIFE / pg. 2 AnimaLIFE / pg. 3
  3. 3. Faculty Profile Dr. Amy Rankin Shaping the Future... Eye Know-How Story by Patrice Scott Photo by Joe Montgomery TODAY D r. Amy Rankin, assistant professor of ophthalmology, didn’t production. I felt so relieved that we finally knew what was wrong. We just apply the prescribed originally envision a career in ointment to her eye daily and veterinary medicine let alone she’s perfect.” G reetings from the Veterinary Medical Teaching Hospital at Kansas State becoming a veterinary University. I hope your summer was fulfilling and that you had an opportunity to Dr. Rankin advises clients to be specialist. All that changed when enjoy family and friends. We are excited to share more wonderful stories about alert to possible signs that their she applied to veterinary school our patients and clients as well as some of the hospital’s successes and challenges. We pet is experiencing eye (vision) her junior year in college. Before are pleased to get AnimaLIFE back to you after a short hiatus! problems. If, for example, a pet long, her long-range plan is squinting, rubbing at the eyes, The Pet Health Center renovation was completed recently. The new area better included becoming an producing extra tearing/ accommodates the heavy traffic flow in the busy local practice area of our hospital. With ophthalmologist. watering; if the eyes have a new cabinets, countertops, exam lights and LCD monitor for the microscope, the space “After three years of general cloudy or bluish cast or the white is more efficient and addresses the needs of the doctors, students, technicians and practice, I decided I was ready area turns red, it may be time to patients. It is an excellent learning environment. for a new challenge,” Dr. Rankin see an ophthalmologist. If a Our equine clients will be happy to know that we will soon begin construction on an says. “I love ophthalmology horse is spooked when equine lameness center that will be located on the east side of the hospital. The equine because I get to work with every approached from one side but faculty will have a dedicated and enclosed space designed for diagnosing lameness. species. Ophthalmologists not the other, this may be a sign manage eye problems in cats, of a vision problem. We are quite hopeful that our small animal surgery suite can be renovated within three dogs, horses and exotic years. Currently we have four operating rooms and the suite has remained much the The great opportunity here is that animals. For me, it’s the best of same since the hospital was built in 1977. Tentative plans call for a total infrastructure so much can be done. all worlds wrapped into one upgrade and the addition of one operating room. The floor plan will be modified so that Many corrective microsurgical specialty,” she says. “Every critical services are unified. For example, the anesthesia induction area and patient procedures are available to help animal has two eyes.” recovery will be co-located near ICU to increase efficiency and optimize patient care. patients suffering from diseases Dr. Rankin finds it doubly or degeneration of the eye. We would appreciate your help in making these plans become reality. Some of our needs gratifying to help clients and Dr. Rankin tells of a VMTH patient propel our visions; others help patients today. Recently, our linear accelerator became patients because many of them that was completely blind from inoperable. Then we learned that it was irreparable. This is an extremely important piece have never heard of a veterinary cataracts. “His cataract was so of equipment in our fight to help animals with cancer. Oncologists use the linear ophthalmologist until they need complete I couldn’t see his accelerator to deliver targeted beams of radiation to kill cancerous tumors. If you are one. “So many people don’t retina. So, if I can’t see in, he interested in learning more about the many ways you can help our hospital help animals, know that this specialty exists,” can’t see out.” She surgically please call Patrice Scott, marketing and development officer, at 785.532.4046 or e-mail she says. What I want our clients broke apart the cataract and was her at to know is that we’re happy to able to restore the patient’s Thank you for supporting our hospital, and thank you for caring about animals. W help them, and we’re happy to vision to nearly normal of 20/70. work with their veterinarians.” Warm Regards, More help is on the way for small VMTH client Medina Roynon is a Dr. Amy Rankin at home with husband, Dr. David Rankin, and twin daugh- and large animals thanks to her typical client who was unaware ters, Mary Frances and Eleanor. The family adopted Sugar when she research. Dr. Rankin is currently of the specialty until her puppy, failed her eye examination during the service dog certification process. assessing different models of Pebbles, needed advanced care. inflammation inside the eyes of Pebbles’ breeder told Medina that the puppy’s left eye was scratched by cats to determine which medications can be used clinically to reduce Roger B. Fingland, DVM, MBA, DACVS a littermate. When problems persisted, she took Pebbles to a inflammation. She’s also conducting a corneal sensitivity project with Associate Dean, Clinical Programs veterinarian who treated her for an eye infection. “She kept blinking and alpacas. Director, Veterinary Medical Teaching Hospital her eye seemed to irritate her,” Medina says. A friend suggested that Dr. Rankin comes to the VMTH from a busy ophthalmology practice near she make an appointment at the teaching hospital to see an Milwaukee, Wis. She earned her DVM from the University of Wisconsin ophthalmologist. Surprised by the existence of the specialty and hopeful, and her master’s degree from Purdue University. Medina quickly made an appointment. “I guess it was something I never thought of because I’ve never had a dog with an eye problem.” Dr. Rankin’s husband, Dr. David Rankin, is an anesthesiologist at the VMTH. They live in Manhattan with twin daughters, Eleanor and Mary Pebbles, at 5 months, came to the VMTH. “Dr. Rankin thoroughly Frances, 4. The family has three cats, Frank, Herb and Myrtle; a dog, examined Pebbles then shared her diagnosis,” Medina says. “Pebbles Sugar; and two birds, Hector and Speedy. W was born with a congenital eye defect – her left eye had no tear AnimaLIFE / pg. 4 AnimaLIFE / pg. 5
  4. 4. . n Monday.. Editor’s note: An ”I me t Wilma o . tensified.. incredible group of y tremors in top priorit ...The made Wilma her Dr. Beard people were brought rk. ent to wo With that, we w together thanks to it takes.” their unwavering “Whatever ma that as up. n so bus y with Wil ks with her w I had bee y two wee commitment to realized m I suddenly smates, o my clas ilma animals. The ith one e- mail t s with W W er two week ured anoth I had sec following article was ith Wilma originally written as I reache d d ay 2 8 w the hospit al. r 38 days in home afte an essay by senior friend and W ilma went her best orgotten, Wilma, le ft, with ack at ho me. ot soon be f r, Betty, b you will n rtne t, Wilma, veterinary student pulling pa s All the be Elliot Stevens about if ever. his experience with W ilma, a 23-year-old Belgian mare, arrived through the stethoscope. Her respiratory rate had been Sunday, Aug. 26, 2007, at the KSU-VMTH 16 breaths per minute before the penicillin; afterward it Wilma, an equine Edited by Patrice Scott with several swollen areas on the left side of was 80. I realized Wilma’s clinical signs were consistent her neck and with a cough, which had been treated with with an allergic reaction to the penicillin. Dr. Beard patient. He wrote the an antibiotic without response. Accompanying Wilma was confirmed the diagnosis. her best friend and pulling partner, Betty. I could not have Wilma’s owners, Stephanie and Keith Guthrie, have 70 ‘I met Wilma imagined the events that would transpire during her detailed piece when horses and a few cats and dogs. Stephanie is best hospital stay or the diligent efforts of a wonderful owner. defined by a line from the Emma Lazarus poem “The I met Wilma on Monday, the first day of my two-week New Colossus” that describes the Statue of Liberty. The he was nominated for equine medicine rotation. After completing a physical poem ends with the statue herself speaking: “Give me exam, I placed a catheter and drew and submitted blood your tired, your poor, your huddled masses yearning to the Radar Mullet for a complete blood count and chemistry panel. We breathe free, the wretched refuse of your teeming shore. Scholarship for Clinical Excellence by on Monday... started Wilma on two antibiotics, penicillin and gentamicin, that provide broad coverage against many bacteria associated with respiratory disease. After infusing a very small amount of penicillin, Wilma became restless and began having intense muscle tremors. I immediately stopped infusing the penicillin and watched Send these, the homeless, tempts tossed, to me: I lift my lamp beside the golden door.” Stephanie would do without for the benefit of her animals. Her doorstep and pastures in Inman, Kan., have eased suffering and provided happy days for many animals. We explained to Stephanie that a medical intervention her for a few seconds. The tremors intensified, and Dr. Beth Davis, This is an edited account of Wilma’s 38-day hospital stay. It Wilma began circling in her stall with a maniacal unease. I was necessary and outlined the costs. She said, “Whatever it takes.” With that, we went to work. Wilma notified the intern, Dr. Tami Karges, and she monitored associate professor is also an extraordinary firsthand look at a senior student’s Wilma as I ran to find the senior clinician, Dr. Laurie started to grind her teeth, often a sign of extreme pain. One hour after administering the penicillin, Wilma’s urine Beard. Dr. Beard made Wilma her top priority. and equine section true responsibilities. turned red in color. This was the result of an immune Wilma’s circling ceased within five minutes, and I mediated hemolytic event, which culminated in her by Elliot Stevens, DVM—Kansas State University 2008 proceeded with a brief physical exam. Her heart rate that immune system destroying her red blood cells. All cells head. morning had been 36 beats per minute and was difficult are important, but the loss of red blood cells that carry to hear given her large size. Following the penicillin oxygen to her body amplified the critical situation. Pieces administration, the heart rate increased to 130 beats per of the now-destroyed red blood cells lodged in her minute and sounded like someone knocking on a door kidneys and caused a pigment nephropathy that can AnimaLIFE / pg. 6 AnimaLIFE / pg. 7
  5. 5. progress to renal We continued fluid administration in an attempt to prevent classmates, I had secured another two weeks with Over the next few days, we increased outside time from failure. We were kidney failure from the hemolytic process. We also Wilma. Deep down I hoped I would not need that much a half-hour to an hour, three times a day. She loved being managing a severe needed to account for the fluid that had refluxed from her time before sending her home. outside, and it was great to see her so happy after all allergic reaction to nasogastric tube. That meant Wilma would need 118 (92 she had been through. Since she was doing well, we Monday, Sept. 15, the first day of the supplemental penicillin, + 26) liters of fluids. Additional reflux must also be turned our attention to Wilma’s problem at presentation; rotation, marked Wilma’s 15th day in the hospital. monitoring the replaced. Unfortunately, she continued to reflux: 90 liters the swellings on the side of her neck. We evaluated the She was stable in the morning but that all changed in the destruction of the that day. It was virtually impossible to meet her fluid swellings with an ultrasound and aspirated them using a afternoon. She laid down in her stall and was groaning. red blood cells, demand, but we gave her as much as we could. Over the 3-inch spinal needle. The cytology was consistent with a Her heart rate and breathing increased. We gave her pain and trying to next two days, Wilma refluxed 75 to 80 liters each day. seroma. There was a small amount of drainage seeping medication and monitored her closely. A rectal prevent kidney The good news was that her hematocrit was stable, and from one of the swellings, so we talked with Stephanie examination revealed that her cecum was distended with failure. she stopped producing red urine. We were beyond the about opening it to allow it to drain properly. We gas. We talked with Stephanie about surgery. Our plan allergic response and the immune mediated red blood explained this would extend Wilma’s hospital stay, and It was important was to monitor Wilma closely and be prepared to take cell destruction. We now focused on managing the ileus. Stephanie told us she would have it no other way: She to begin her to surgery if necessary. wanted Wilma to have the best care. Again, “Whatever it aggressive fluid After being on fluids for four days, we had two Wilma was treated with fluids and pain medication and takes,” was the answer. rie. therapy to major problems! We needed to get Wilma’s Keith Guth received vigilant monitoring. Over the next 24 hours, she ner y with ow protect Wilma’s gastrointestinal system moving, and she needed proper I reached day 28 with Wilma, and it was time for me a and Bett did not lay down, but her condition did not improve. We Wilm kidneys. She weighed 1,700 nutrition. We addressed the first situation with lidocaine. decided very early Monday morning to start Wilma on the to move on to surgery so I transferred Wilma to another pounds and needed 46 liters (12 gallons) of fluids to (Lidocaine is typically used to block pain for short surgical student who is a good friend. I continued to visit Wilma drug, yohimbine, a pro-motility drug. It required all the meet her daily requirements. However, we needed Wilma procedures, but it is also used as a pro-motility drug.) for our daily conversations, to groom her (even though yohimbine in the hospital to give her just one dose. to produce more urine than normal to prevent the lodging Wilma required 52, 100-ml bottles of lidocaine she didn’t need it), and to take her outside whenever I ‘I met of the destroyed red blood cells, so we administered IV administered intravenously each day of treatment. The Following administration of yohimbine, her gastrointestinal motility improved, and she appeared to be much less was free. Wilma went home after 38 days in the fluids at the rate of 92 liters every 24 hours, twice her first day on lidocaine, Wilma’s reflux decreased to 45 hospital. I was not able to be there when she left, but Wilma daily need. liters and normal GI motility sounds were auscultated. painful. Thankfully, surgery would not be necessary. We offered her small amounts of food and water, which she maybe it was better that way. Wilma’s condition improved and lidocaine therapy was on Wilma’s hematocrit, a measurement of red blood cells, was 16 percent at 5 p.m., which meant she needed a discontinued after four days. accepted without hesitation. Over the next few days, we challenged Wilma’s digestive system by increasing her As I conclude this writing, I am looking out the window thinking about Wilma and Betty standing side by side on a Monday... blood transfusion. I could feel Stephanie’s unease as she was nervous about Wilma’s condition. I reassured her we Wilma’s body was converting fat into energy because she had not eaten solid food in four days. We talked with fluid and food intake until she was no longer refluxing. It was her 22nd day in the hospital and she appeared pasture under the vast, open, starry Kansas night sky. All the best, Wilma, you will not soon be forgotten, if ever. W were going to do everything we could to get Wilma Stephanie about placing Wilma on total parenteral to be doing very well. through this event. Given that Wilma’s immune system nutrition (TPN) to be certain Wilma’s nutritional needs was destroying her red blood cells, we closely monitored were being met. We explained the expense with the TPN, all physical parameters that might indicate an allergic and once again, Stephanie said, “Whatever it takes.” reaction to the blood being transfused. We recorded Wilma was on TPN for three days. This “stray” was the beginning of a friendship Wilma’s heart rate and breathing pattern every On day 11, despite having been through an allergic and scholarship five minutes for 5 ½ hours until the transfusion was reaction, an immune mediated hemolytic event and ileus, complete. It was a late night, but when I checked Wilma’s adar was a stray hematocrit before going home, it was 22 percent. We were going in the right direction! Wilma appeared stable so we decided to allow her to eat small amounts. I fed Wilma one handful of pelleted feed R who adopted his “mama,” Lavonne every four hours and added brome hay to her ration. I Mullet, when he was The next morning, Wilma seemed uncomfortable, and was also able to do something I had never done before: I between the ages of 6 we were concerned that a blood clot may have lodged in took Wilma and Betty outside for a walk and grazing. The and 8. Their six years the arteries or veins that supply blood to her future was looking bright. together were marked gastrointestinal system. If it wasn’t a clot, her reduced I had been so busy with Wilma that I suddenly with constant red blood cell numbers may not have been able to realized my two weeks with her was up. It was hard companionship and provide oxygen to her gastrointestinal system. The to leave Wilma since we had been through so many late Lavonne Mullet and happy times. Lavonne outcome of either scenario may have resulted in the nights, early mornings and full days. I knew so much Radar and Radar were failure of part of her gastrointestinal system. We about her that I could never adequately tell the next referred to the performed an ultrasound of her gastrointestinal system Photo by Dave Adams student what she liked and what she didn’t like. For teaching hospital when Radar was and found that her small intestine and stomach were fluid From left to right: Keith and Stephanie Guthrie, Wilma’s owners; instance, Wilma likes to be groomed every morning diagnosed with kidney disease. In a letter distended. In the horse, a fluid distended stomach can be Lavonne Mullet, VMTH grateful client and philanthropist; senior starting at the back and working forward; she likes you to posted on the hospital’s Web site, Lavonne life threatening because horses cannot vomit. We student Elliot Stevens and wife Sheila; and Dr. Beth Davis who scratch her behind the jaw; and she likes you to stand in writes: “Thanks to your incredible staff, we immediately passed a nasogastric tube and refluxed 26 nominated Elliot for the scholarship. The group gathered at the the stall with her. There was just so much about her that I were able to manage his kidney disease, liters of fluid. This was more bad news for Wilma and her annual senior honors banquet where Elliot was announced the could never transfer on a piece of paper or in a brief and I had another wonderful year with my owners. We called Stephanie and told her that we were winner of the Radar Mullet Scholarship for Clinical Excellence. conversation. precious little dog.” (To read Radar’s story, concerned that Wilma had developed ileus, decreased go to, click on Teaching motility of her gastrointestinal system. She told us, Luckily, I was scheduled for a supplemental equine Hospital, then ‘Why We Do What We Do.’) “Whatever it takes.” Again, we went to work. rotation and might be able to stay with Wilma if a student would switch rotations with me. With one e-mail to my Lavonne was so impressed with their experience she decided to honor Radar’s veterinary students by establishing a scholarship that memorialized Radar and recognized veterinary students with exceptional communication skills and academic achievement. Thus was born the Radar Mullet Scholarship for Clinical Excellence. W AnimaLIFE / pg. 8 AnimaLIFE / pg. 9
  6. 6. Dr. Anderson replaced Wilhelmina’s torn ligament with the artificial one, dubbed the ‘Wildcat Power Cord.’ ortunately, Wilhelmina’s owner recognized the value of saving continued to experiment with a variety of materials until he discovered F her. Mike Frey is the son of Dr. Russ Frey, a legend at the College of Veterinary Medicine. “She’s owned by the son of an important faculty member in our college’s history,” Dr. Anderson says. an unusual form of nylon monofilament, a solid material about the diameter of a coffee straw. But the question remained: Could this man- made material replace the natural ligament of a 1,500 pound animal? “It’s wonderful that there is a On Jan. 17, Dr. Anderson replaced connection to Dr. Frey with this Wilhelmina’s torn ligament with the case and that Mike understands the artificial one, dubbed the “Wildcat teaching value.” Power Cord.” Dr. Anderson’s Mike says he was happy to be part surgery team included surgery of an effort that could help animals, residents Drs. Kara Schulz and producers and students. “I was Jose Bras, intern Dr. Manuel always under the assumption that Chamorro, along with an animal with this problem was anesthesiologists, veterinary going to be heading down the students and technicians. road,” he says. “If they could The next day, the Jersey cow was perfect this so that a cow could be led across the hospital’s video kept in production, that would be synchronization pressure mat to worth quite a bit.” determine her level of lameness. Story by Patrice Scott Dr. Anderson explains that the “Her stride length had increased 30 Photos by Dave Adams cruciate ligament is a dense tissue percent, and she bore 25 percent that connects the bones in the knee more weight on her operated leg,” joint. Injuring it can be career- Dr. Anderson says. “To have that n 8-year-old Jersey dairy cow is back at her ending and often life-ending – until much improvement is spectacular.” now. The three published surgical (His long-term goal was to develop Manhattan, Kan., farm thanks to a decade of techniques for anterior cruciate a replacement ligament strong rupture in large animals have a enough for bulls. Lab tests revealed research and an experimental surgery performed failure rate of approximately 50 that the Wildcat Power Cord could percent, Dr. Anderson says. This Shelby Reinstein and Nichole DeBellis were the senior veterinary withstand up to 12,000 newtons of at the Veterinary Medical Teaching Hospital. fact caused him and surgery students who named Wilhelmina. pressure – roughly 50 percent colleagues Drs. Guy St-Jean and more than an adult bull requires.) The cow, named Wilhelmina Jolene by the Andre Desrochers to investigate alternatives in the 1990s. The team Wilhelmina retuned home and was kept in a box stall for a week or so, designed a cruciate ligament using braided polyester; however, the Mike says. After that, she had the run of the free stall. “We had a tough veterinary students assigned to her case, material was not strong enough for heavy cattle. Dr. Anderson winter with all of the snow and ice,” he says. “I didn’t think she’d get around as well as she did.” sustained a breeding injury in December 2007 Nichole DeBellis and Shelby Reinstein were the senior veterinary when the cruciate ligament in her right knee students who named Wilhelmina. They appreciated the vast learning opportunities this case presented, especially those relative to anatomy ruptured. Dr. David Anderson, professor and head of the stifle and monitoring Wilhelmina for specific conditions dairy cows are at risk for developing. These include inflammation of the udder of agricultural practices, replaced the ligament (mastitis) or of the uterus (metritis), a metabolic imbalance (ketosis), ulcers and displacement of the abomasum, the fourth compartment of using synthetic material called monofilament a ruminant’s stomach. “We worked really hard for her and spent long hours at the hospital, but nylon. The procedure’s success will have it was definitely worth it after seeing how well she did post-op,” Shelby says. “I love being part of the discovery aspect of veterinary medicine, enormous implications for breeding quality cows and it is always really rewarding to try something you’re not sure about and have it work. And, my parents were quite impressed that I could and bulls with the same injury. milk a cow!” Since operating on Wilhelmina (above), Dr. Anderson has successfully Wilhelmina continues to do well today thanks to the efforts of the implanted the Wildcat Power Cord in two adult bulls. The surgery is hospital’s faculty, staff and students. So the next time you hear the now offered routinely at the Veterinary Medical Teaching Hospital. phrase “how now brown cow,” you’ll know she’s fantastic. W AnimaLIFE / pg. 10 AnimaLIFE / pg. 11