Playing Doctor

It was a lovely sunny day at the VBB hospital. The trees were getting some new green as the spring rolled in and there was the slight scent of wet earth that remained from an early morning shower. My day was ticking by, surgery in the morning, followed by afternoon appointments, when suddenly a gaunt figure in a large flowered hat careened into the front lobby.

By large flowered hat, I mean it was a hat with HUGE fuzzy flowers on it, worn by the famous "hat lady" in our little town in recognition of the first official day of spring. This particular lady had hats for all sorts of occasions, all worn as a partial jest and partial personality tic of the wearer.

On this day, the normally sunny countenance of Hat Lady was marred by a look of horror. She was holding an equally flowered handkerchief wound around her wrist. As I walked into the reception area, I could hear her demanding to know the rabies vaccination status of one of our patients. I explained that we were not allowed to release that information to her since she was the owner. However, after looking at the record and seeing that the patient, Teeth, had his last rabies vaccination within the year, I felt pretty comfortable telling her that I didn't think she had anything to worry about with regards to rabies. I advised her to go to the doctor to have the wound looked at and maybe a tetanus shot.

It was at this point that the Hat Lady started yelling that I had to give her a rabies vaccination. I told her that A) I didn't have vaccines for humans and B) I was not licensed to give a vaccine to a human. She kept saying that a rabies vaccine is a rabies vaccine and that she "demanded" that I give her one. When I told her that she would need to talk with her doctor and animal control about that, she got super dooper mad. She threatened to call my boss...I offered to dial the number for her. She threatened to call the board...again, I offered to dial the number for her.

When the police showed up (she had called them about the dog bite), both the officer and I were finally able to get her to calm down. As the dog in question was current on vaccines, he was quarantined for 10 days in the home of his owner and the Hat Lady never required a rabies vaccine (at least not yet).

This brings up some important things: One, a vaccine approved for dogs, cats, goats, cows, horses, etc is not necessarily approved for humans. In fact, I am struggling to think of one off of the top of my head. Two, most vets would rather you call the vet board because they refused to work on you rather than to have a board report for working on you. Hell, the vet at my undergrad even refused to pull a splinter out of the hand of a fellow student because he didn't want to get in trouble for working on a human.

The last thing to let everyone know is that rabies vaccines are important. It is against the law to not have your dogs and cats vaccinated and it is a bad idea to not vaccinate other animals. In the US, there are not large numbers of animals identified as being rabid nor are there large amounts of people dying from rabies. However, in places like China and India, those numbers increase exponentially. We can thank our relatively low rabies incidence to the efforts of the public health departments and veterinarians. That does not mean that we can relax our attitudes towards rabies. We have global travel of animals, including the adoption and importation of animals from places in the middle east, where soldiers are falling for homeless animals and trying to help them. Some of these animals can come to the US with rabies. So, thinking that you can extend the time between rabies vaccines beyond the scope of the vaccine is both illegal and dangerous.

A family in Florida just found this out. Their dog came in contact with a raccoon. The dog had not been vaccinated for rabies within the allotted time. Most rabies vaccines are either considered to be effective for 1 year or for 3 years. This dog had been vaccinated 7 years prior to the incident. Because of the lack of protection from the rabies vaccination and the contact with a raccoon, this dog contracted rabies. Rabies is diagnosed post mortem (after death) via a certain test on the brain cells. Once this dog was diagnosed with rabies, the humans in the household had to be vaccinated and the other family dogs were euthanized. In reality, after the unvaccinated dog came into contact with a raccoon, an animal species known to harbor rabies, the dog should have been euthanized or at the very least quarantined for 6 months or so. Rabies viral particles have to travel up the nerves from the site of the bite/contact into the brain, which can take a long time. Thus an animal can be infected, but not start showing signs or being able to transmit rabies for weeks to months, depending on the site of the bite.

As for the 1 year versus 3 year protocol, I am split on this. For animals that are likely to come into contact with wild life regularly, I would stick with the yearly protocol. I have read a report of a dog that contracted rabies in spite of being within the 3 year interval per his rabies vaccine. For those patients that are less likely to see hot wild life action (like my indoor, couch potato old lady dog), I would go with an extended, 3 year protocol. And just because your cat does not go outside, do not assume it is safe. There are enough people that find random bats in the house...and a bat bite often goes unnoticed, even when they bite a human. So, obey the law....and use some common sense. Some of my colleagues might disagree and they are welcome to do that. However, a classmate of mine told me that they just had a dog diagnosed with rabies in Virginia and there was also a recent report of a horse that was diagnosed with rabies in Tennessee.

Musings

So today I’m feeling a bit sad and reflective. I have to do something I am NOT looking forward to for a number of reasons. But it does give me the opportunity to look back and realize that I am reaching a milestone in my career as a “Family Practitioner” Veterinarian. It’s almost as if my career is reaching real maturity.

Eleven years ago I graduated from Vet school, feeling proud, hopeful, excited, and yes, even a little relieved that I’d managed to get through it. I had an incredible stroke of luck and found an amazing family in a small town who took me and the Hubs in as one of their own immediately. They were looking for an associate Veterinarian for their small-town practice. The practice and the family hiring were such a perfect fit we flew back to VBB College Town, loaded up our meager possessions into a Ryder truck and drove across the country on the biggest adventure of our lives.

I was getting settled into being a Vet quite nicely the day about 10 years ago when I met the Andersons. They are a great couple, about my age. Joe is probably the biggest guy I’ve ever met….the size of a redwood practically. But he’s gentle, quiet, reserved, and when he speaks he has something to say. His questions are probing and thoughtful. He listens carefully to my answer, mulls it over, and GETS it. Rita is sweet and caring, the family worrier, but also keenly intelligent. She’s funny and friendly and dramatic at times (in a good way). I love to see them on my schedule; it makes my day knowing I get to see them.

That first appointment was to see the new addition to the couples’ lives, Ike and Ivan. They were brothers, Labrador mixes- with what, who knows? But they both have pensive, wrinkly, adorable hound dog faces and long, droopy ears. At the time they were about 6-7 weeks old, and there was NO predicting they’d each top 100 pounds when fully-grown. They were each small enough to fit in one hand! Ike was nearly white-blonde, and Ivan black with white on his feet. New puppies have always been my favorite type of appointment. I take my time- nearly an hour usually to meet the family and puppy, do a physical exam, and talk about all the things it takes to raise a healthy, happy, social, well-behaved family member. Our puppies visit every week or two as they grow up so we can love on them and bond- I’d say 95% of my canine patients drag their owners into the clinic from the parking lot. Ike and Ivan are no exception. Ivan has always been a bit more shy than his brother…he comes in, hides a bit behind Mom, and peeks around her legs.  Ike is the brave one….in my face schnuffling on me the moment I enter the room. Then Ivan sidles up and says hi while he thinks my attention is on Ike. Funny boys. They ALWAYS visit together, even if only one of them needs to see me.

Over the years, I’ve seen the brothers welcome two baby boys into the family (the two-legged kind). Brendan is the baby- a bit young for me to really get to know yet, but Joey is about 7-8 years old now. He’s a perfect mix of his parents. He’s friendly and funny like Rita, and he asks great questions and listens like Joe. He’s got a round cherub face and a mass of mahogany colored curls. I think he’d be a great Vet. One time he brought in a plastic dinosaur (he was about 5) and explained to me some medical problem it had and his treatment plan for it. I don't usually enjoy kids…..THIS is a kid I LIKE. I could hang out with him and have fun.

Ivan and Ike are like all dogs with the best families- medical disasters! I don’t think there is a problem common to labs that at least ONE of them hasn’t had in the last 10 years. They’ve both been to see specialists multiple times. Ivan has had both knees re-built. Ike once ate an ENTIRE tin of popcorn on Christmas Eve morning (you know, those HUGE tins with the Christmas scenes on the outside and three flavors of popcorn inside?) I usually see appointments until noon on December 24th, but somehow I’d gotten REALLY lucky and nobody needed to come in. I was planning to stay home, but I got a call from the office- Rita had called in a panic, thinking Ike would rupture his gut from the popcorn! I went in to examine him, he was stable, happy, tail wagging, face grinning, belly HUGE! He belched NOT so softly as I palpated his belly…..he felt like a plastic trash bag STUFFED full of popcorn! Rita felt so bad about calling me in on Christmas Eve she brought coffee AND Starbuck’s gift cards.

Ivan and Ike survived the popcorn and various similar disasters over the past decade…and there was NEVER any question from Joe & Rita that they were going to choose the best recommended tests and treatment every time. But they are also 10 year old BIG dogs. They’ve really started to show their age the past couple of years.

Ivan has always had some lameness issues from his bad knees, but then Ike started having trouble with arthritis in one of his shoulders. We’ve tried a number of therapies, all of which are either ineffective or they make him ill. He can barely get up and down the stairs now, and the loss of the muscle tone of that leg is obvious from yards away. He simply can’t use the leg any more.

Then about a week and a half ago Ivan was on my appointment schedule. He wasn’t eating, seemed really lethargic. Rita brought in Ivan (Ike waiting in the truck this time) and Joey. As I bent over to say hello to Ivan my heart sank. I stroked him under the chin, only to find the lymph nodes there were the size of large eggs. Moving down along his neck I found more enlarged lymph nodes in front of his shoulderblades, and again in his calf muscles in his rear legs. “Rita,” I said…”You guys fish a lot, right? Could he have possibly eaten any raw salmon or trout?” (I knew the answer was no…Joe and Rita have learned over the years NOT to let the dogs have anything out of the ordinary because Ike has a particularly sensitive stomach). She confirmed that, though they’d been fishing, there was no way the dogs had eaten any fish… Damn. Not salmon poisoning.

I looked up at her, "All his lymph nodes are enlarged. This worries me. I am NOT happy to find this.” I could see her start to mist. She’d known. She sent Joey out of the room to sit in the lobby. He protested- he’s always well-behaved and has NEVER had to leave the room before. But she asked him again quietly, and he nodded, and left the room. I think he knew, too…even at 8. I told her my fear was that this was lymphoma. I needed to take some samples to send to the lab to confirm it…then we talked about cancer. If I HAD to pick a kind of cancer for my dog, it would probably be lymphoma- chemotherapy protocols these days can do amazing things…remission is common and many times you can get good quality of life for years. Then she dropped the bombshell. She asked if it would be wrong, and could I do it if she asked, to put the boys to sleep together. Ike hasn’t been doing well, and now Ivan is really uncomfortable and not eating. They’ve NEVER been apart. There was crying. And talking. Lots of talking. We decided to wait for lab results, then we’d take it from there.

Unfortunately (as I’m sure all the DVM readers have already guessed) the lab confirmed small cell lymphosarcoma. Ivan did ok during the weekend while we awaited the results, but his appetite was down again Monday. I spoke with Joe and Rita probably four or five times on the phone last week…deciding whether to go see the internist for a consultation, then deciding whether to give prednisone a try, then deciding when it’s time….

It’s time. Today. This afternoon. Ivan is not doing well- won’t eat, won’t play. Ike is plugging along but in constant pain from his shoulder. I imagine the whole family will be there. There will be tears. There will be hugs. They want the boys cremated together, their ashes mingled in a single container. It will be hard. But I will do it, because I love them and they are my friends and I have the privilege of sparing them from a horrible end. So is the life of a family Vet.

There’s a poem called “The Rainbow Bridge” we send to clients at the loss of a pet. It’s quite lovely, a nice sentiment….Heaven for animals, essentially. I’m glad it gives people solace. At times I wish I could believe in those things. But I am a naturalist, realist, scientist, atheist. I believe that the end is, well…the end. Now, before you go feeling all sorry for me, or disappointed, take a moment to think about what that can mean:

We have this life, and ONLY this life. Enjoy it. Make the world better for yourself and the others around you. Heaven is not some mystical reward to be given to you in the afterlife. It’s an ideal, a dream, a goal. It’s something we all need to work together to MAKE for OURSELVES. Love well, love deeply, love many. Find humor. Find beauty. Find joy. SHARE it. Share your defeats and tragedies as well, for without sorrow there is no joy, and pain shared is pain halved. Smile, laugh, cry, dance. Live.

I can't haz bloggie :(

Well, thanks so much, but, we were beaten by that other animal blog - I Can Haz Cheezburger. I suppose it's kinda crazy we were even in the same category. Maybe 2013 will be our year? Vote early and often! Ha ha.

In other news, I've been taking care of a family member's pet lately. As previously discussed, I hate, loathe, and detest this type of situation. That said, so far, it's going ok (fingers crossed, ptui ptui ptui, salt over shoulder, etc etc). The kitty in question has fatty liver disease, and his liver enzymes have decreased by half in 3 weeks, and he's maintained his weight and hydration status nicely. It's an interesting situation, because without going into too much detail there is a somewhat complicated backstory on both the kitty side and the human owner side. Here's hoping he continues to do well.

Post-Vegas re-entry kind of sucked. That's probably why it's a little quiet here at VBB central. Jet lag, wishing I were back in Fantasyland, you know how it is.

Today when I walked the puppy, she picked up a dead snake on the sidewalk and tried to give it to me. I've pretty much stayed in that kind of mood all day.

Voicemail of the Day

"Uh, hi. I'm calling because - well, I got a 20-dog hoarding situation here in [place 500 miles from World's Best Animal Hospital]. Basically I'm calling all the vets I can find, just hoping to find someone who can, you know, donate some supplies and stuff to help my dogs. If you can help, please call me back at [number]."

Clients behaving badly

I think this behavior is a little over the top. Your dog dies so you beat up your veterinarian? Really?

I remember when I was in school, we had a dog in our ICU who was hanging on by a thread pretty much during my entire ICU rotation. I don't recall specifically what was wrong with him, just that I had to check his vitals every 15 minutes all night for several nights in a row, and they were never good, and I frequently had to page my resident, which is never fun, and it didn't at the time seem to me that this dog had any real chance of going home.

At some point toward the end of my rotation, this dog started actively trying to die again. This time, for whatever reason, the owner of the dog got mad. Having received yet again a phone call from the supervising veterinarian asking him if he wanted full resuscitation or if we should euthanize or let the dog go, he apparently hung up the phone without answering, and arrived at the building moments later (he must have been on his way in for a visit or something). He stormed past the security desk and headed into the ICU and just started pushing and shoving and yelling and knocking over IV poles and basically clearing a path to the dog - in whose cage I was sitting, because I was bagging him at the time. Luckily the security team was right behind him and they had him out of there pretty fast, because all I could think at the time was how upset my mom was going to be if I was killed by some maniac client before I even graduated.

Anyone else ever find themselves on the wrong side of a client's fists? Officer Cynical, I'm not talking to you here :) (though I'm sure you can share plenty of fun stories) (and you should feel free to do so)

Taking a Break

Tomorrow is a half day for me, and then I have the entire weekend off. Off meaning not working, and not answering the phone, and trying really hard not to have even one thought relating to my hospital slip inside my head, for two entire days. So of course, I have a bandage that runs nearly from wrist to elbow. This one supplants the one I took off this morning from the other arm, which replaced the one on this arm that I needed last week. 

I work with dogs and cats, and each comes fully equipped with teeth and toenails, weapons designed to help them capture and kill prey, and also to defend their very lives from others of their species, and those bigger ones who would kill and eat them. They are born willing and able to use these weapons. Yet I can go weeks without so much as a nick on my precious skin. That’s the norm for me, and I’m proud of it. Decades of this work, dedication to making my patients comfortable in an uncomfortable situation, and lessons learned from all those mistakes have taught me how to stay healthy in this work. So yeah, I can expect to go weeks without getting injured. Until I take some time off. That is my Achilles heel. 

The bite and scratch gods lay in wait for me to plan a day off. Their eyes light up at the prospect. And they turn loose upon me the nasty dogs, the evil cats, and those resoundingly clueless people that were somehow placed on this earth with no higher calling than to let their animals maul me.

It is no one’s fault that I chose a circumstance that mandates long hours and dedication to folks and their pets. I picked this deal at a tender age, and I rarely regret the decision. But after a few months of 60 hour weeks, I crave some time away. I recharge in really nice places, mountains and deserts and seashores, places of beauty, solitude, and quiet and fresh air. I look forward to these moments of respite, away from the pathos and tragedy that is the inevitable dark side to the work I love. And when these places have done their work on me, I return to my calling renewed, happy, and frankly a lot more effective. 

But something happens as I approach these moments away from my work. I change somehow. And the bite and scratch gods sense this, and they make me pay. Maybe after working myself ragged, my reflexes just aren’t up to the challenge. Or maybe that negative side of me, that I’m-not-perfect-and-thus-deserve-punishment side just folds and lets the harm happen. I don’t know… maybe I’m just tired.

This time it was the 7 month old puppy that never read the directions, the directions that state that puppies should love everybody and kiss the world. And this tyke lives with people who expect it to snarl, bark, and maul pretty much everyone it comes into contact with, so they yelled at me when their dog tore me apart.

This time it was the man with a career in education, the man with the geranium IQ, and the life skills of a four year old, who brought in the 108 pound dog wearing the harness. Every veterinarian knows that the dog wearing a harness will bite you, for the harness is the owner’s concession that the dog need never mind. The bite missed, but the claws have left their scars forever on my arm.

And this time it was the cat that reminds us that cats are only semi-domesticated animals, and he lived up to that potential.

So I’m going to leave tomorrow wearing a bandage again. But the coast beckons, and I will nap and read and write and relax, and the only thing that might go wrong is the other same thing that happens whenever I take a day off. It will probably rain.

Who are the people in your neighborhood?

I took my puppy out for a walk this morning, as one does, you know. We were walking up the hill, stopping to sniff around and check things out, the way a puppy does when walking somewhere new, when I noticed up ahead there was a dog straining to urinate on his front lawn. It caught my eye really only because the dog was maintaining that position for so long. He seemed uncomfortable, stressed out, and oddly postured. Hmmm.

As we approached, I noticed the dog, whom I knew to be the type of dog who typically runs up and jumps on everything that approaches him, was on a tether, but that the tether was long enough that the dog could easily reach our spot on the sidewalk. Still, the dog did not move from his spot. He kept straining. My puppy sat on the sidewalk next to me, head cocked, looking at the dog. I stood there and wondered what to do.

Luckily, seconds later the dog's owner came outside and stood in his driveway. "Oh hey there!" he said. "That must be your new puppy! What a cutie!"

I smiled and thanked him and before I could even say anything else he said "Yeah, Brashly isn't doing so hot you know. He's had a kidney thing for a while, I think this might be it." I said "oh, you're aware. Good. I was worried about him and had actually been standing here thinking about whether I should knock on your door because it sure seems like he's having trouble urinating. He looks very uncomfortable to me." "Oh - trouble urinating? well, we had him at the vet last year because he was peeing small amounts all over, you know? and the vet said it might be stones and maybe we could fix it with diet change or maybe surgery - but also he said it might be a tumor, or even something else. He wanted to do an xray, but, you know - Brashly's eleven years old. We ended up taking him home to think about it and then just forgot about it for a while, it was kind of inconvenient all the walks but it didn't seem like that big a deal, but now you know we have to leave him tethered out here all day because he just drips urine now and then and never really actually pees. And a couple of days ago he pretty much stopped eating, so - I think we'll get him to the vet soon, but, I'm not sure he'll come home. See how he's standing there with that look on his face? He does that all the time. He'll stay like that for hours."

Readers with a medical background can probably feel my blood pressure rising through their keyboards at this point. This poor dog has been suffering progressive urinary tract disease for a YEAR, and is now at the point where he literally can not pee more than a couple of drops even when he stands there and strains FOR HOURS, and he's dying in front of them slowly and painfully and - here's what really blows my mind - IT IS COMPLETELY DUE TO IGNORANCE (with a small side of average intelligence).

I *know* these people. They have a child the same age as one of my children. That child desperately wants to be good friends with my child, but my child isn't so interested because "that kid is really kind of boring." Oh well, you know, kids. But these people are friendly, charitable, service-minded, professional people. I see them at local charity functions, doing volunteer work at the library, all kinds of things like that. They definitely love their dog and have expressed their feelings of love for the dog to me on more than one occasion.

I spent about five minutes standing there, with a smile and look of concern on my face, telling this dog's owner that regardless of the cause of the obstruction, at this point, their dog is suffering, and he needs to go to the veterinarian TODAY. He asked me if they should have done the recommended xrays last year and maybe this wouldn't be happening and I told him the truth - if diagnostics had, for example, revealed stones in the bladder and they had been surgically removed and the dog maintained on an appropriate diet, then hey, maybe it would be fine today. But, I have no retrospectoscope nor do I have a crystal ball, so I can't say for sure what would have or will happen. Regardless, as soon as I finished talking to him, he whipped out his cell phone and made an appointment for later this morning with his dog's veterinarian. So, there is that.

Gun Control

Now, I am sure that people can debate whether or not private citizens should own firearms all day long, but that is not the kind of gun control I am talking about. I am talking about not leaving your loaded shot gun leaning up against the wall in your house. It could lead to something getting shot off...like the nose of your dog.

I had a couple carrying a profusely bleeding pit bull careen into the hospital. The dog was sneezing and snorting blood everywhere, but the tail was wagging a mile a minute. The owners were both crying and generally freaking out. I took a quick look at the dog and determined that the damage was not too bad: the dog was a young healthy dog that was apparently happy and stable in spite of his injuries. The owners kept freaking out and I had a hard time getting sense out of them. I finally grabbed the husband by the shoulders and looked into his eyes and said, "It's not that bad...I should be able to put that back together." The both settled down and relayed the story.

Apparently, they had left a loaded shot gun leaning against the wall....not locked up, not in a gun rack, just leaning against the wall. The happy dog's overactive tail knocked the gun over. When the husband picked up the gun, the dog was investigating the hubbub when the gun went off, catching his nose. Given the (relative) lack of damage, it looked like most of what got the nose was scatter. It was bleeding like crazy, but there was enough tissue that I could get it all back together.

After I fixed the dog, I ascertained that there were no children in the house. As nice as the owners seemed, if they had kids, I would have reported the accident. While I would shake my head and be a little down trodden if I heard about another animal in the house getting accidentally shot, I would have had a hard time living with myself if a child had been involved. This may not be completely legal per se, but if it isn't, it is a clear example of what is right versus what is legal. Human physicians don't really have this quandary: they are required to report gun shots.

A couple of weeks later, I got a thank you letter with pictures from the owner. There was a picture of a dog happily grinning at the camera as well as a close up of the healed nose.

Things we learned in Vegas (open thread)

1. One can walk down the Strip at any hour, bwak-ing like a chicken pretty loudly, and no one will even look at you funny in any way.

2. Loudly saying "pus-filled uterus" at dinner probably gets you written up on the Busboys Behaving Badly blog.

3. Champagne cocktails TID would make the average workday a lot more tolerable.

4. There are a lot of people who don't own mirrors or have any true friends to stop them from being seen in public looking like that.

5. If you're gonna boldly wear that micro-micro-minidress without any panties, do us all a favor & get a bikini wax first.

Tell us, esteemed colleague: what are your lessons from Vegas?

Someone seems confused around here

Now, I don't know if it's just me - but, I thought that given our blog title, and the general tenor of our posts thus far, the subject of our blog was pretty clear. I don't know too much about how Google's back-end works with respect to their search algorithms or anything, so maybe that's why this is coming as such a surprise to me, but - well, take a look at these search terms used to find our friendly little blog:

Seriously, people? SERIOUSLY?

Just in case you can't read that last one - some poor misguided soul ended up here after searching for "pissing in vagina." PISSING IN VAGINA! I really do not think that the subject of "pissing in vagina" has been under discussion here at VBB central, so I suppose the poor soul in question left disappointed. I'd like to try to remedy that.

Assuming that the searcher was actually interested in finding out about pissing THROUGH the vagina, rather than some type of sex-play involving pissing IN someone ELSE'S vagina (which, now that I think about it, could totally be what he or she was going for in which case EW, OMG, please pass the brain bleach!), then this person would have been better off googling "female urogenital fistula," or "vesicovaginal fistula." These are real conditions. You may, if you were an Oprah fan like my mom, even have seen an episode of Oprah about poor women in Africa with these problems and gone around for the next six weeks grossing everyone out by bringing up the subject while they were trying to eat.  Anyway, in case our poor searching person comes back here looking for information about it, suffice it to say - sometimes, for a variety of causes including botched surgery, problems with pregnancy/labor/delivery, malnutrition, etc, a tunnel of sorts opens up between the urinary bladder and the vagina (or sometimes the uterus or cervix) resulting in uncontrolled leakage of urine out through the vagina. Affected women are incontinent and often malodorous.

Please see the informative article here: http://emedicine.medscape.com/article/267943-overview for additional information on this unfortunate malady.

Thus endeth today's VBB foray into medical problems in the one species we are not licensed to diagnose or treat. Please don't report us to the medical board for practicing without a license. Thanks for stopping by!

How to Save Money on Vet Bills

You can find a lot of articles online about how to save money on your pet care bills, like by buying Old Ranch Genuine By-Products dog food or getting your pets’ vaccines at the feed store or cornering your neighbor veterinarian in her garden rather than taking your pet to her office. I’m here to say: Don’t do any of those. Instead, if you want to save money on pet care, keep your pet healthy by using common sense and following these rules:

• Keep your dog on a leash (with the other end of the leash attached to your person) or in a fenced yard.
• Keep your cat indoors.
• Spay or neuter your pets, preferably by one year of age. This reduces or eliminates the risk of many health problems (breast tumors, uterine infections, testicular tumors, prostate infections, etc.), prevents pregnancy complications, and reduces the urge to wander. Think of unspayed/ unneutered pets as teenagers with raging hormones but without even the tiniest modicum of sense to avoid moving vehicles.
• Don’t give your pet any human medications or supplements without first consulting with your veterinarian.
• Don’t let your pet get into illicit drugs.
• Check out the ASPCA Animal Poison Control Center website for a list of poisonous plants to keep away from pets. Big ones are lilies for cats (including Easter lily flowers in floral arrangements this spring) and grapevines for dogs.
• Don’t keep any rodenticides (rat bait, mouse poison, gopher bait) on your property, even if you think they’re out of reach of the dog. There are various types of rat bait, which cause fatal hemorrhage, fatal kidney failure, or fatal brain swelling. Call an exterminator or use old-fashioned mouse traps.
• Don’t keep snail/slug bait (metaldehyde) on your property. Let the snails eat your hostas, or put out small saucers of beer to trap the snails. (We vets don’t want your dog drinking beer, either, but mild intoxication is preferable to fatal muscle tremors, seizures and hyperthermia.)
• Use only “pet safe” antifreeze.
• Don’t let your dog ride in the back of the pickup truck.
• Don’t ever leave a pet in a closed vehicle in the summer.
• Don’t feed your pet real bones. Real bones can break teeth and perforate intestines.
• Keep your pet on year-round parasite prevention (heartworm, intestinal parasites, fleas and ticks).
• Don’t let your pets eat these people foods: grapes, raisins, onions, garlic, chocolate, macadamia nuts, or anything spicy or fatty.

MMS Awareness

MMS is Marley and Me Syndrome. Marley and Me, the book, was a great favorite with many of my clients. This book basically gives an account of a yellow lab’s life with all of his faults. Most lab owners could tell similar stories as read in this book. Marley was not as unique as one might think and that is why I hated this book. For me, a veterinarian, it was like listening to a client for a long time—hours, days.

To be clear, I love stories about pets: short stories. I love to hear one or two anecdotes about my patients as I examine them. It is what adds flavor to my day and usually makes me smile. There is the dog that separates out his kibble, by shape, and then eats one shape at a time. There is the dog that brushes his own teeth if you give him a tooth brush. There is the hound who decided, untrained, to monitor his owner’s glucose and wake her if she dropped too low. Who wouldn’t love hearing about all of these cool things?

People who have MMS usually are talking about a dog, have no time restraints, do not rely on communication for an income and are possibly lonely. They usually relate one story after another and another and another, with no room for me to excuse myself. They rarely relate anything unique—they are stories of regular dog behavior, like Marley, that the owner does not realize is common. If you are worried that you may be bogging your vet down by some MMS, here are the signs:

Your vet quits asking you questions.
Your vet is painfully smiling like a baby with gas.
Staff randomly enter the room, repeatedly, asking if anything is needed (the staff is flagging your chart, I promise).
Your dog is no longer nervous and is in fact curled up and is snoring.
A visit has lasted 40 minutes longer (or more) than the 15 minutes for which you were scheduled.

I am sure that there is rehab or a pill out there for MMS sufferers. Admitting the problem is the first step….

Truth or Consequences

A veterinarian of my acquaintance related the story of a new client visit. Middle aged male owner with a dog. The tech who had led the client to the room and performed the usual temperature, respiration, pulse count met the doctor in the hall as she headed toward the exam room.

“The pulse and respiratory rate are up, but he won’t tell me anything. No history. No nothing. I’m sorry. That’s all I have.”

“Well….he’s a big help. OK, thanks. Not your fault. Hang close while I talk with this guy.”

The doctor enters the room, the client standing next to the exam table, the mixed breed thirty pound dog in repose upon it.

“Good afternoon Mr. Quiet. I’m Dr. VBB. Pleased to meet you. So, what’s up with Friskie today?”

“You tell me.”

“Excuse me?”

“You tell me. Show me how smart you are.”

A moment’s pause as the doctor regrouped. 

“OK, Mr. Q…Is Friskie sick, or do you think he has been injured?”

“You tell me.”

“Excuse me for a moment, please.”

The doctor leaves the room and wanders over to the receptionist’s desk.

“Mr. Quiet…Did he give you any reason why he brought his dog in today?”

"Nope, not a clue."

Dr. VBB walks to her office and then back to the exam room. She re- enters the room and Mr. Q is standing there, arms folded across his chest. She plops the old snow globe onto the exam table next to Friskie. There is no water in the globe. The large crack in the glass is obvious.

“See….it’s broken. My crystal ball is broken. So you have to help me a little here, Mr. Q. Why did you bring in Friskie today?”

“You are the second vet I seen today. The last guy couldn’t tell me anything neither. You people have a lot of nerve charging us for the nothin’ you do.”

“The best doctor in the world is the veterinarian. He can’t ask his patients what is the matter-he’s just got to know.” 

“What?”

“Will Rogers said that. Smart man, Will Rogers. But he had that one wrong. We don’t ‘just gotta know’. We need a little information to help us figure out what’s wrong with our patients. We are not psychic. And we don’t have a crystal ball. Now, if you won’t give me any information about Friskie, I’ll just thank you for wasting my time and move on to my next patient.”

“I think Friskie has cancer.”

“OK, what is Friskie doing that makes you think he has cancer?”

Mr. Quiet finally rattled off the list of things Friskie was or was not doing that suggested he wasn’t quite right. Dr. VBB asked a few questions, which Mr. Q answered. Then the doctor did her physical exam, noting that the poor dog’s gums were pale and his pulses were in fact too rapid. The doctor got permission to run some blood tests and take an abdominal radiograph. Mr. Q took a seat. 

The blood count showed anemia, and the odd cells present suggested a hemolytic anemia. And the spleen was enlarged on the xray. Friskie had immune mediated hemolytic anemia. Very serious, but treatable. After treatment, Friskie is doing much better now. 

Veterinarians are quite skilled at reaching a diagnosis when a patient like Friskie shows up in our office ill. We utilize three sources of information. We take a careful history of the problem from the owner, perform a thorough physical exam, and reap the answers that our tests can yield. These three sources of information feed into our brains and generally a diagnosis flows out.

If we get bad information, if the owner for instance, gives us bad information, we get sent down the wrong path, and that does not help. What we need from owners are their observations, but not their conclusions. Pardon the ego, but we are better equipped to form conclusions once we have the three sources of information, than the pet owner armed only with their knowledge. That’s what all those years of training, and retraining, and experience nets us. But the real skill we acquire over the years is the ability to coax observations out of a client who only wants to give us their conclusions. 

One of my oldest friends, and most difficult client, is a retired physician I’ll call Dr. R.  He was a skilled physician, but through all the decades I’ve known him, he has never noticed that his knowledge of human medicine doesn’t always translate well into veterinary medicine. Each and every time he has brought an animal to me with a problem, he has already reached a conclusion about the cause of the problem, and of course, already laid out his preferred treatment. And over all these years, and all those pets of his, he has yet to be correct. And no, this has not altered his style one lick.

Many years ago, Dr. R brought in a kitten he had found. The little tyke was not doing well, and he had that all figured out. He had even picked out the antibiotic he wanted to use. All he needed from me was to be the source of the drug he wanted. I of course, wanted to do an actual physical exam after he told me how the kitten was acting. The heart murmur surprised me, for I had never heard such in a kitten. I was convinced the poor thing had a birth defect, a heart problem called a PDA. I had heard the classic sound of a machinery murmur.  Dr. R didn’t believe me, and off he went with his kitten. 

The phone call came a few days later. The kitten had died with classic signs of congestive heart failure. Dr. R thought it was pneumonia, and he was going to show me the error of my ways. Would I be willing to do an autopsy? Meet me at the clinic.

Tiny thing on that big table, with the big light shining down. Dr. R standing beside me as I opened the chest. The lungs were severely congested. And right there, at the top of the heart, that extra blood vessel that is a patent ductus arteriosus, and it kills by causing lung congestion. Dr. R wasn’t convinced, but there it was.

Years later he called. He thought his old poodle had suffered a stroke. Bring it on down, and I’ll take a look. 

“So, why do you think FIFI has had a stroke?”

“Well, it’s obvious. She has been eliminating in the closet for a week. She won’t go outside to poop or pee, but does it in the closet.  She clearly isn’t acting right. She must have had a stroke.”

My physical exam was normal. All the blood tests were fine too. I gave him call and asked a few more questions. Turned out FIFI didn’t want to go through the doggie door to the back yard. And so she was pooping and peeing in the closet. 

“Anything happen to FIFI in the back yard recently? Could she have been spooked by a raccoon or a coyote? Did she get injured by the doggie door?”

“No, of course not.”

“What happens when you let her out the front door?”

“Haven’t tried that. What’s the use; she’s had a stroke.”

“Let me know what happens when you let her out the front door.”

Turns out, FIFI was just fine in the front yard, and this continues to this day. Don’t know what spooked her out of the back yard, but I doubt it was a stroke.

Las Vegas Baby!!

If you notice that posting is a bit, um...light, that is because a large number of us are in the process of converging on Las Vegas for a vet conference. I heard a rumor that some might even be wearing a VBB t-shirt. Yes, we have t-shirts.

Those of us that were not able to ̶g̶o̶ ̶b̶l̶o̶w̶ ̶a̶ ̶w̶a̶d̶ ̶o̶f̶ ̶c̶a̶s̶h̶ ̶i̶n̶ ̶a̶ ̶c̶a̶s̶i̶n̶o̶ attend a really huge continuing education conference will try to make up for this.

Animals DO feel pain (with bonus guest post)

A big peeve of mine is people saying that animals don't feel pain. I don't understand. For example someone comes in with a dog who is only using 3 legs while one is just hanging there. After an assessment, imaging studies are recommended along with some pain medicine. "oh, he's not in PAIN doc, he just banged up his leg." Seriously? That makes no sense.

Anyway, apparently old doc VBB is not the only one who is regularly frustrated by this. Here's a good one from the VBB mailbag:

--
A young adult intact human male did not want his male dog to receive any pain medication before or after the neutering procedure - he said the dog did not feel pain. We discussed it for a bit before I gave up and said how about I neuter you and you tell me if you want some pain medication??

He still didn't want the dog to receive analgesics. I told him he didn't have a choice. The dog is being neutered, and will receive post-op analgesics!
--

We at VBB central are pleased our reader's patient will not have to experience a gonadectomy without analgesia. Too bad our reader didn't have a chance to demonstrate on her client.

BTW, over the counter medications are not really medications.

Dear Great Dane Owner,

Maximus is a beautiful dog, really. But at 8, he has long passed his salad days and is currently sliding down the other side of the hill. It is understandable that he is having a bit of trouble getting up and down lately. A dog of his breed, at that age, is like a man closing in on 85.

While I was glad to make recommendations a few months ago about increasing his fatty acids and starting some massage therapy, I am more than happy to add in a non-steroidal pain medication to the mix. The NSAID panel didn't show anything that would bar him from starting rimadyl, previcox, or one of the other approved NSAIDs. Now, for the difficult question: is Maximus on any other medications? Tylenol, Ibuprofen, aspirin? God forbid, Naproxin? Ok, no. Great. Any supplements besides the fish oils? Oh, vitamin B? Ok, that is fine. Now are your sure that there are no other medications that I need to know about? No prescription pills that you have lying around? No one else could be giving him any medications, right? *insert explanations of how the medication works and risks, etc*

Thanks,

Dr. Repeatable Questions

*************** One Week Later************

Dear Great Dane Owner,

Maximus is now here blowing out black tarry diarrhea and vomiting blood. What part of the question "Is he taking any other medications?" did you fail to understand. I even gave you the benefit of the doubt by asking about specific medications. See, when I ask if Max has been taking any aspirin, that means *aspirin*.... Not too hard to understand. I even used short words, just in case. You even got written instructions of what *not* to give him

So, how in the holy hell do you fail to mention to me that Max has been getting his prescribed anti-inflamatory medication AND aspirin AND prednisone that you had laying around from some skin disease from 5 years ago? What do you mean you gave him an extra dose of each when he started acting nauseous? How does that even make sense? Oh, since you bought the medications over the counter, you thought that they didn't count as medication?

I am sorry to tell you that Max is pretty sick now. The signs point to a bleeding and perhaps perforated ulcer. Things have suddenly gotten much more critical and much more expensive.

Thank you,

Dr. I didn't realize that OTC meds were not really meds

Being Charitable

There was a news story here the other day about a cat who (somehow) got himself frozen to some driveway. Apparently he was there for 24 hours before he was rescued by an employee of an animal shelter.

The long and short of it is, the cat was taken to a local veterinary clinic for care, and despite significant hypothermia, he appears to be doing well.

On this news website there is an area for readers to leave comments. And in the comments section, one reader had left a message fundamentally asking the veterinarian to donate services and such in order to offset the bill.

I’m not sure why, but this really irked me.

I thought about it carefully, and I think the reason I was put out by this was because the vet was called out in a public way to donate his time, expertise, equipment and supplies in order to offset the cost of care of his patient.

The person who commented made no mention of donating money to the cause... he just called on the vet, for all intents and purposes, to reduce his fees for the cat.

Now, we all know that most veterinarians are a giving sort... and I think it’s likely that the vet in this case will probably donate some of his time and try to manage the expenses as much as possible, but I ask, why should he feel obligated to do this?

It made me think of the hypothetical situation of a person (let’s call him VBB) walking down the street, and he stumbles across Hungry Homeless Guy (HHG). VBB, being the kindly sort, elects to offer help to HHG, so he picks him up, and helps HHG walk to the local restaurant. And it’s a good restaurant, too. Not McD’s or some other crap food, but it’s a nice steakhouse, with a wine list and such...

So, anyhoo... VBB and HHG enter the establishment and meet the Fancy Restaurant Owner (FRO). VBB explains the situation, and then demands that FRO feed HHG at FRO’s expense. Because VBB has no intention of paying for it himself, and after all, FRO has all the stuff required to feed HHG.

Doesn’t seem right, does it?

I guess the point is, if you choose to be a 'Good Samaritan', man-up and be the Good Samaritan! When you ask someone else to pay for your 'charity', you end up not being charitable at all.

Taxi service ?

During the usual nite in the ER, we get the chocolate eating dogs & the HBC pets & so on. We had a lady call about her sick dog & I overheard the receptionist talking to her.

Recep. listens to the story about what the pet is doing. Lady asks her for directions to our ER. She gives her detailed instructions.

The lady then tells her she doesn't have any transportation. Recep tells lady to call a cab or friend. Lady wants to know why we don't have a pickup service for these situations.

Oh, she doesn't get paid till Friday.

head/desk.

V is for Vomit

Ah, Valentine's Day. The day when the phone rings every fifteen minutes with someone worried that their dog may have ingested a toxic dose of chocolate. Usually the dog is fine, rarely there is something to worry about. The dose makes the poison, after all. I think back on past Valentine's Days and remember lots of vomit. Most people think about flowers, candy, candlelit dinners, that kind of thing - me? I think of vomiting dogs. See, either they ate the whole damn box of candy with wrappers and everything and puked it up themselves in my office, or we're actually worried about a toxic dose but they don't have the courtesy to puke on their own and we have to make them puke. Either way, there is puke involved. Yay.

My beloved made me a super-sweet video for V-day this year. Jazzy background music, cute pink swirly animation, and some awesome pictures of us, and the kids, through the past year. At the end of the video, a little animated cartoon of a dog vomiting up a pile of brown stuff with flecks of red foil wrapping.

Awwwwwww. He knows me so well!

Happy Valentine's Day to you!

"A Day in the Life" Haiku

Where is my coffee?
Careful balance to prevent
Surgery jitters

Cute Frenchie puppy
Umbilical hernia
At least no murmur

Diabetic cat
Now has nasty U.T.I.
Hope I can treat that

Sad parvo puppy
Getting worse. Pink juice is best
For you, little one

Dark when I arrived
Worked in windowless building
Dark when I go home

Date night after work
Me: “I think I smell like cat pee”
He snorts, “Yeah, you do”

When the Cost is Too High

Virtually daily, veterinarians everywhere are faced with clients that can, or will, only afford so much for their animal. I don't like to take an owner's finances into consideration when I make a recommendation because I try to base my plan of action on what is best. As one of the clinical professors at my school always told students: don't try to x-ray your client's wallets. As he once shared, it is sometimes the old farmer in the overalls and no T-shirt that will pull out a roll of $100 bills to pay for his sheep dog's surgery. And, sometimes the person with the Coach bag, iPhone, and Lexus will decline everything and just want a single shot to "fix" their dog.

For several years, I worked at both a general practice and at an emergency clinic. I would often have cases that went back and forth between the two clinics. One of these patients was a cat named Hercules. Actually, it was Hercules II. Hercules I had died after being attacked by a dog. Hercules II was almost identical and the family kept a close eye on him. He even went outside on a leash. However, one day he got into some rat poison that the owners had forgotten about that was hiding in a kitchen cabinet.

The owners were able to get him treated in time and after a month or so on vitamin K, which is an antidote to one of the main types of rat poison, Hercules II was back in fighting form. He spent his days lounging with the owners, an older retired couple that loved him very much.

About a month after he was past the rat poison episode, Hercules escaped from the house. When he got scared, he ran out into the road where he was no match for a passing truck. By the time the owners found him, Hercules was almost dead. When he got to the day practice, the vet there initiated treatment and found that Hercules was not stable enough to be alone overnight. The owners were not wealthy, they were not even middle class. And they were retired, so they had no real income. The veterinarian, who knew these things, offered referral to the ICU overnight facility but did discuss his poor prognosis and gave an estimate of cost for the transfer. The owners wanted to go ahead, no matter the cost.

When the owners brought Hercules into see me, I recognized them. They were very sweet, but also very minimally educated. Trying to explain all of the injuries and treatments that Hercules needed to have a fighting chance took a very long time because the owners didn't really have a concept of basic anatomy or biology. Trachea was reduced to "breathing tube," and muscle was reduced to "meat." I tried repeatedly to give them an idea of his chances and the cost of care, even just beyond the initial stabilization. Hercules had to have a chest tube placed and I feared that he might have a pneumothorax caused by ruptured bullae (where the air pockets in the lungs break open and leak air from the lungs into the chest) and a ruptured trachea as well.

I knew that these folks didn't have the money but they wanted to pay with a credit card. I wasn't worried that the clinic wouldn't get paid, but I was worried that the family would have a hard time paying off the credit card company. I was also worried that Hercules would not make it and they would owe tons of money and have no cat.

The first night turned into a few days of hospitalization. Hercules developed new problems and got progressively worse. At each stage, I discussed euthanasia as an option. I knew that even with radical and expensive surgery that his chances for survival were minimal. I tried to explain it to them, but they hung on to that 10% chance of survival. I gave them an estimate for cost of care, cringing while I did it because I knew that they were going to say yes. When I openly discussed euthanasia as an option, they wouldn't consider it. I even offered to keep Hercules completely doped up while he succumbed to his injuries so he could "pass naturally."

By the morning of the surgery, Hercules had gotten considerably worse. His glucose would not remain normal and kept dropping, possibly indicating a septic infection (infection in the blood). He started having seizures and no matter how much glucose we pumped in him or how much valium he received, it kept on happening. His kidneys were failing, which also might have been contributing to the seizures. These things made him a terrible candidate for surgery.

I called the owners and told them to come out at once because I was fairly certain that Hercules would not make it much longer. When the owners got to the hospital, I rushed them back to see Hercules. He was comatose by that time, either from the drugs to control the seizures or the disease process itself. As I placed him in the owners' arms, they asked repeatedly for me to do something to help him.

Once again, I had an internal war going on. If the owners had been millionaires, I would have still given the same advice: euthanasia. But these people, who could not easily afford what we had done already, wanted to go even further. They absolutely refused to euthanize. Their daughter and son in law had come with them to visit. I pulled them out of the room to try to explain what was going on. They too only wanted to press forward, saying that cost was no object.

I left the family to visit with their pet, telling them to alert me if there was a problem. About 10 minutes later, I heard them screaming in the room and ran back. Hercules had another seizure and then started agonal breathing. At that point, I knew that nothing we could possibly offer would help him. I explained that he was dying and offered to ease the passing with some euthanasia solution. This was a last ditch effort to try to help the owners more than it was to help the patient. Hercules was beyond the need for the injection, but I thought that if the owners had some control over the situation, they might feel better. However, Hercules was gone before I was able to leave the room.

Frankly, I was torn. I felt horrible for the owners. I knew they had poured their heart, soul, and wallet into saving their kitty. I knew they felt guilty because their miracle kitty (which is what they started calling him after the rat poison incident) had escaped the house and gotten hurt. And even though the referring vet and I had been totally honest and upfront about the chances for recovery as well as the cost, I personally felt guilty.

I also felt relieved: the cat was no longer suffering and I didn't have to spend anymore of the owner's money in what I felt was a futile battle. I was relieved because I was also tired...mentally tired to trying to explain the same thing over and over again and getting no where. It sounds awful when I write it down.... I didn't resent the owners for either not being able to understand or just not being willing to understand the situation, I was just plain tired walking that line between offering the top plan and making it plain that euthanasia was an option. Looking back on it, I like to think I would have offered the same thing to a wealthy person. I might not have felt quite as guilty about them spending the money, but I would have offered the same thing. The case still haunts me and it colors every end of life discussion I have with clients.