The devil wears cat hair...

We've all (well, most of us) read James Herriot's stories of veterinary practice in Yorkshire. The hills, the dales, the sheep, the cows, the hunting dogs, and the people who loved or at least depended on them for their livelihood. Not to mention the everpresent pampered pets :). Evocative tales to be sure - but not quite like what most of us are experiencing today. But readers, you are in for a treat.

The VBB mailbag recently received a wonderful story from a New York City colleague. I present to you here: The Devil Wears Cat Hair!

Yesterday, the most self-absorbed fashionista and her meek, henpecked fiancé brought in their senior cat in for a lion cut.  The cat was a shorthaired cat, so the lion cut request was a bit unusual.  We’re not groomers, per se.  We are a feline-exclusive veterinary hospital that does do grooming when asked.  Because these were first time clients and the cat was a senior cat, we told them we wanted to do a physical examination first.  He was fine; she was huffy, but agreed.  

Upon examination, I discover that the cat had atrocious, filthy teeth that required a thorough cleaning and multiple extractions.  I called the owners and told them that.  About an hour later, when we started to perform the lion cut, the cat (named Ferocious) began living up to her name.  We called the owner and told them that sedation would be needed.  He handed the phone to his fiancé, who immediately accused us of doing something bad to her cat. “She NEVER acts this way, so you MUST have done something”. 

Yes, everyone knows we keep a huge arsenal of cattle prods and tasers in a drawer, waiting to break them out as soon as the client leaves the building. 

In a fury, she decides to come over, her weary boyfriend in tow.  She sees, with her own eyes, as we try to take Ferocious out of the cage, that the cat is hissing and growling.  Again, the accusations fly.  I calmly show her the cat’s teeth.  She and her boyfriend cringe.  I suggest that we schedule a dental cleaning, and while the cat is asleep, we can do the lion cut.  It’s less stress on the cat, and better for the cat because things are done under one anesthesia – the cat only needs to be sedated once, not twice, which is in the cat’s best health interest – plus, it would save them the sedation fee that would be required to groom the cat today.  The boyfriend sees the logic.  The A-list fashionista is livid.  She wants the cat shaved, dammit.  Horror of horrors, the cat is shedding fur on her furniture!  Faced with the decision of doing what is best for her cat vs. what is best for her and her furniture, she unsurprisingly chooses the latter.  I tell them okay, we’ll start now, and you can come get her between 5 and 6:30; she’ll be fully awake from the sedation.   

The fashionista bursts a blood vessel.  “We can’t come at that time! We have a shoot this afternoon!  I can’t believe this!”  She throws her hands up, and orders her boyfriend to just take the cat so they can leave.  At the front desk, she’s bitching and moaning about what awful people we are.  “I should have just taken her to my own vet”, she says.  

Yes, that’s the same vet who saw the cat three months before, and who made zero mention of the cat’s horrible dental disease in his notes.  

I suppose these folks will never be back, and I’m overjoyed at the thought.  I just feel bad for the cat, because I know that they won’t do anything about the cat’s teeth until it somehow has an effect on her – the fashionista.  Like, if the cat starts drooling blood on one of her blouses. 

It reminds me of a time, early in my veterinary career, when I was doing an overnight shift at an emergency clinic. A yuppie couple came in at 2:00 a.m. with their puppy who was having diarrhea.  I asked how long it was going on. They said, “six weeks”.  Six weeks of diarrhea!  So why was it an emergency now, at 2:00 a.m.?  Because this time, the dog pooped on their bed.  I guess it’s only a problem when it affects the people. 

The real lesson to be gleaned from all of this is really for the boyfriend. The fashionista is his fiancé.  After ten minutes in her presence, I was ready to slit my freakin’ wrists.  He’s about to sign up for a lifetime of that.  Take my advice, buddy, and get out now.  Every avenue of pleasure you currently experience is about to be closed off the moment you mutter, “I do”.  It’s not too late to reconsider. 

Bear in mind, the same could be said to all potential future colleagues. Take some time to reflect on what you want out of life - it's not too late to reconsider. 

In which we look like idiots for no good reason.

A friendly and collegial veterinarian from a local specialty/ER vet hospital left us a voicemail regarding our mutual patient who apparently "stopped by last night" and "was found to be in congestive heart failure, which was a big surprise to the owner. I'll be in first thing tomorrow so feel free to call me to discuss this, or I will try to call you before I head home," she said on our voicemail.

So I looked up our records on this pet....and found that at her last visit, she had come in as an emergency to our appointment-only day practice, and informed us she had been dry heaving earlier in the day, and subsequently developed difficulty breathing. She wasn't in any particular distress at that moment, but we worked her in and saw her. 

The physical exam findings were very concerning. The dog had a grade IV/V systolic murmur, focused over the mitral valve area, and bilateral crackles were noted during auscultation of the lungs. She was breathing rapidly but did not seem particularly distressed. She had lost about 15% of her body weight since her last visit three months previously, without having been placed on a reducing diet. 

Our chest radiographs revealed an enlarged heart with an alveolar pattern present in the perihilar area right dorsolateral lung fields.

The owner was informed that we strongly suspected this dog was in congestive heart failure and that we would like to arrange for a consult with a cardiologist, an echocardiogram, or if the owner would prefer not to seek specialty care, we could initiate treatment after just a few more tests done in our hospital (we wanted to get an ECG, and some basic bloodwork).

The owner elected to take the dog home without additional testing at that time, telling us she needed to think about it seriously and decide what to do and how to budget for it. We explained that it would be ok to at least start some treatment without additional testing if there was a big money concern, just to try to make the dog feel better, but she chose to go home and promised to call back on Monday (this happened on a Friday). We gave her the emergency clinic phone number handout we have on hand for this type of situation and wished her well.

When we didn't hear from her that Monday we left her a voicemail. We left another one several days later, too. When we didn't hear back we wondered if perhaps the pet had died suddenly, and were very concerned for the next week, wondering if we could have helped more.

Then, about three weeks after the appointment here - the voicemail came, the voicemail in which the specialist cheerfully describes how our client went over there completely "unaware" that her dog was in heart failure despite having "just been in to see the regular vet, who didn't know what was wrong."

It is this type of scenario that keeps the bourbon people in business, is all I can say. I know the specialist probably realizes that clients aren't always telling the whole truth, and not all referring vets are morons -- but it is hard to hear this kind of thing anyway, and I do worry about being perceived as an incompetent moron by the specialists in these situations.

Where is the personal responsibility?

A dog limped into my office the other day and informed me that he'd avulsed his gastrocnemius tendon. Well, ok - he didn't actually SAY it with words, but it was pretty obvious from looking at him. Anyway, his person described the history:

Doctor, last night he was FINE! I let him outside, and he was out there for a while in our fenced-in yard. Nothing can get to him out there. He was out there for a while and then when he came back in, he was like this.

Pretty typical, really. So, I told this dog's person that I'd like him to see a surgeon, as I wouldn't be able to fix this here at VBB Satellite Office. She looked at me, apparently shocked beyond my expectation, and remarked "Well! Someone's going to have to pay for THAT!"

Now, I am not known in my social or professional circles for having any real degree of tact. I try to be sensitive to people's needs, but generally I say it like it is for better or for worse. So I replied "yes! Someone is going to have to pay for that, and I expect that someone will be you!." She was quick to correct me. "Oh no, this wasn't MY fault! I didn't do this to him!" and I explained that I in no way intended to confer blame on her, but simply financial responsibility for her pet. She reiterated that since she wasn't culpable, she was not going to pay, and she would be contacting the breeder because the breeder had never informed her that this type of injury could occur to a dog who was "just out playing in the yard."

I'm pleased to report that, in the end, the dog received the care that he needed. I have no idea who is paying for the care, though.

The usual suspects

Things I have been asked in the exam room this week:

Doctor, what's this on her bottom? (This question accompanied by owner's hand tugging on dog's vulva.)
Followup remark: oh, I thought that would have been more internal!
It left me wondering: what was this lady hiding in HER underwear? How would one have an internal vulva?

Doctor, I've noticed one of her nostrils is a little larger than the other, is that ok?

Doctor, when he pees, I can hear the pee hitting the ground. Is that normal?

Doctor, do you think he needs a fecal transplant from me?

Doctor, in people, do the anal glands just empty automatically every time we poop?

And finally, after a long discussion about why the dog on the exam table was unlikely to survive the next few days, let alone make it until mid-May when the adult child of the family would be home from school, during which I used the words "very painful" and "extremely unpleasant way to go," I got "OK Doc, but, before you put him to sleep - do you think you can trim his nails?" I declined to do that antemortem nail trim.

Bring back Miss Manners!

I have children, and one thing I try to impress on them is how very important it is to be respectful of other people's time. I teach them that they should not be late for school, for example, because it is disrespectful to the teacher and the classmates, who are either wasting valuable time waiting for them, or wasting time repeating something they have already gone over. My kids seem to have internalized this message and they are pretty good about making sure they are ready to go places on time now.

I wonder if other people's mothers and fathers do not teach their children this lesson, or if more people just really are that selfish these days....

I'm writing this on a Saturday night. I don't spend Saturday mornings with my family. I spend them with my patients, because I know how many of their owners are simply not able to take time off from work to get here during the week, and I want these pets to receive care. There are of course a finite number of these Saturday appointments. I'm not giving up my entire weekend with my children and spouse!

The 9:00 AM appointment today was for a "new puppy, 8 wk old pit bull." I was pretty excited to see it. But at 9:15, my receptionist decided to call the owner. Here's how that went down:

Receptionist: Hi, this is Katie at VBB Animal Hospital. We had an appointment for NewPup down for 9 AM today, were you planning to come in or...?
Owner: Oh. I thought that appointment was for 11 AM.
R: No, we had that down for 9 AM. Would you like me to reschedule it for 11 AM? That slot happens to be open.
O: No, I'm not sure yet if we are actually coming in at all. I'll call you back if I want the 11 AM, otherwise, just forget it.
R: OK, well, if you do want it, please call, or if you'd like to make an appointment for another day, that's fine too. Thanks anyway! Bye.

Really? I would be so very disappointed in my children if they treated someone this way. It's just the height of rudeness and so disrespectful, not only of my time, but the other patients who could have had that appointment at 9 today...

Please pass the alprazolam.

Lately things have been kind of getting on my nerves.

First of all, I do not believe it is ok for anything that has lungs to ride in the trunk of a car. Call me crazy, but this is my strong opinion. So, you know, I found it pretty shocking when my client came to pick up her in-heat bitch, and asked a staff member to carry the dog out to the car and *put her in the trunk*. I'm pleased that my staff member responded appropriately and refused to do this. So the client came inside and asked to speak to me, and told me she didn't understand what the problem was. Her mom's car, you see, has white upholstery, and she was afraid of getting blood on it. I honestly don't really remember the rest of the conversation we had, but in the end one of our towels went home with this lady and her dog, and the dog sat on the towel, and all was good (at least until they were out of the parking lot. For all I know she moved the dog into the trunk around the corner, but I hope not).

Second of all, there is the issue of names. Now, I'm not an idiot (shut UP!). I understand the concept of nicknames. Hell, I even have a few myself. But, in general, for official documents such as medical records, consistency in naming is important. If you, Dear Client, have a pet named Butterscotch, and call him Buddy for short - I totally understand, and that's just fine. However - if you have a pet named Butterscotch, and you register him with my clinic as "Butterscotch Smith," but then you take him to a cardiologist and register him as "Buddy Jones," because you got married or divorced and changed your dog's last name accordingly but never mentioned it to us, then I am going to get a referral letter from Dr. Cardio in regard to our mutual patient, Buddy Jones. And then I am going to search my database for a Buddy Jones, and I may or may not find one - and if I do find one it may or my not be the same age/breed/sex. And I will pull out my hair if I do find a matching signalment because hey - there's nothing in the notes about heart disease! And I will pull out my hair if I do not find one because hey, what WAS the name of the last dog I referred to Dr. Cardio? It's just all very frustrating. PLEASE, Dear Client - be consistent.

Third of all, we have the issue of emergencies. We all know that sometimes emergencies happen. When you roll into my parking lot while I'm walking out the door to head home to my family, and your dog is gasping for breath, guess what? I am going to run over and start helping you. If you walk in during my lunch break and your cat has blood pouring out of its rectum, I'm going to put down my quinoa salad and start working the case. HOWEVER -- if you walk in during my busiest appointment time and DEMAND that we see your dog RIGHT NOW because he has been licking a red spot on his foot for three weeks and it is now an EMERGENCY because you have to leave to get to the airport in 20 minutes or you will miss your cruise, well, GUESS WHAT? That is not, in fact, an emergency according to the Laws of the House of VBB! That is what we call a "client emergency," and if you are very very lucky, and I'm in a good mood and the stars are aligned, I'll accomodate you. But if I am busy with people who thought ahead and made appointments for their pets, I'm not going to make them wait past their scheduled time because you were thoughtless. Sorry. Just the way it is!

Tell me - what's been getting on YOUR nerves lately? And please pass the alprazolam - this chamomile tea isn't helping at all.

Diagnosis: idiot!

From the VBB mailbag, I bring you Dr. Happyvet's tale of woe:

Joe Doglover has a dog named Mutt. Mutt has had a few health problems for a while, so Joe takes Mutt to Dr. Happyvet.  Using her powerful diagnostic skills, Dr. Happyvet determines that Mutt suffers from “sickdogosis,” and requires continued treatment.   Treatment is prescribed, but sadly the Mutt does not improve, as Joe either decides not to treat Mutt, or forgets to give the medication. Instead, Mutt gets worse. 

Chart review reveals that sickdogosis  has been noted three times in the file. The last time Mutt was seen, sickdogosis was "discussed extensively with owner". Specifically, a treatment plan was laid out, with appropriate diet and medication sent home. Prices to further work up sickdogosis at external labs were relayed to the owner - the record contains copies of these estimates. A few articles regarding possible underlying diagnoses, additional medical treatments, management methods and possible outcomes of sickdogosis were sent home with Joe on multiple occasions. These articles were discussed while sitting next to Joe, and relevant points were highlighted in front of him. A summary was written on another sheet of paper and given to Joe, with a copy retained for inclusion in the medical record.   

After a while, Joe stopped coming in, and there were no additional updates on Mutt. A few weeks later, a records transfer request arrives at the clinic. Reason given?  "Dr. Happyvet is incompetent for failing to recognize that Mutt had sickdogosis."

          I don’t want to live on this planet anymore.

Getting Crispy Around the Edges

Burnout can be insidious. I noticed the signs in myself today as I prepared myself to call a client regarding the findings on his dog's physical exam. The dog had been dropped off for grooming & my exam had revealed some significant progression of the dog's heart disease. I could hear the conversation playing out in my head before I picked up the phone. I was sure it would go like this:

[ring ring]
Mr. Apathy: Hello?
Me: Hi, Mr. Apathy. This is Dr. VBB from VBB Animal hospital. I'm calling about Foxglove.
Mr. Apathy: Well, I'm at work. What do you want?
Me: As you requested at drop off, I did perform a physical exam on Foxy today and-
Mr. Apathy: Can we discuss this when I pick her up?
Me: No, Foxy needs additional diagnostics and treatments because her heart is-
Mr. Apathy: She saw a cardiologist six months ago. We already did the heart stuff.
Me: well, today she is having trouble breathing and -
Mr. Apathy: I'm not talking about this again right now. I'll discuss it at pick up.
[click]

I was so sure I would be having that conversation that I postponed making the call for probably an extra ten minutes. I got myself all worked into a frenzy internally. I'm sure I ground off some tooth enamel. However, after a few deep cleansing breaths I psyched myself up for it. I made the call.

[ring ring]
Mr. RealGuy: Hello?
Me: Hi, Mr. RealGuy. This is Dr. VBB from -
Mr. RealGuy: Doc! How's Foxglove?
Me: I have some concerns, and -
Mr. RealGuy: is it her heart? I know, I was supposed to bring her back to the cardiologist for a recheck in December, but I got so busy and she seemed fine. Is she in trouble now? I feel terrible.
Me: well, I think her medication needs some tweaking. I'd like to go ahead and give her some extra diuretics today, but I do want her to see the cardiologist as soon as possible too.
Mr. RealGuy: I was actually planning to take her next week, but they almost always can get me in same day. I'll call them right now and see if we can go there this afternoon or tomorrow.
Me: Great. I'll have her records ready to go for you.
Mr. RealGuy: thanks doc! See you soon!
[click]

I was of course really pleased that my patient will get the specialty care she deserves. I was also really pleased that I had a nice client interaction. I was DISPLEASED by the realization that I am starting to always expect the worst. This bothers me a lot. I don't want to be one of those old and crispy burned out people!! I want to be able to think positive! Or even be like the Whether Man from The Phantom Tollbooth, who said "Expect everything, I always say, and the unexpected never happens!" But to always expect the worst - well, it's draining. Any creative tips on dealing with burnout??

That's me in the corner.

So, this one client has been increasingly annoying for over ten years now, and try as I might to gently encourage her from seeking care elsewhere, she is frustratingly loyal to VBB Veterinary Hospital. There are a lot of things about her that annoy me, but hands down the most annoying thing she does is try to get me to attend her church.

In the time I've known her, I've gone from ignoring her church invitations, to politely saying "no thank you", to offering generic excuses along the lines of "I'm sorry, that's simply not possible," to explaining that I have my own place of worship that I prefer, and finally things got to the point where I said "please listen because I am only going to say this one time: I have my own religion. It is not the same as your religion. I not only am not interested in changing my religion, but I am also personally offended by your continued attempts to solicit my participation in your religion. Please stop this, or I'm not going to be able to be your veterinarian any more, and I'd feel terrible about ending our professional relationship over this." 

One might have thought that would put an end to the problem, right? 

Or, failing that, one might have thought I'd be cynical and jaded enough NOT to expect her to cut it out.

Sadly, one would have been incorrect both times, and I was bitterly disappointed that this client continued her attempts even MORE vigorously. Unfortunately the Boss Behaving Badly around here put the kibosh on the idea that I might fire this client...

So - imagine my response to this voicemail:

Hi Dr. VBB! This is Ms. Prossy Letize calling about my new little doggy. Well you know I don't get around so well anymore and I'm mostly in the chair all day, and little Barkmeister has taken to, well - you know.  He jumps up and [Sotto voce] humps me [normal voice again] for 20 minutes and I can't get him off of me!  What do you think could be wrong? Have I made some kind of mistake in his upbringing?  I don't really want to bring him in, unless you have some idea of what might be wrong with him that you could treat. Let me know what you think. Bye now.

Words fail me.

Please don't stand so close to me!

Despite my hardened cynical exterior, deep inside I have the heart of a social butterfly. Really. I enjoy chatting with people, when they aren't being stupid idiots, and the confines of the exam room don't usually provide cause for me to feel like my personal space is being impinged upon.

That said, life is full of exceptions, isn't it?

I wish I could post a sign on my door listing the expectations I have. To gain entry to my exam room, you must be:

1. Fully clothed. If it requires bikini waxing to prevent hair from curling up above your waistband, you are not fully clothed. If I can see your areaolae, you are not fully clothed. If I can describe the fabric and color of your undergarments, you are not fully clothed.

2. Reasonably clean. This isn't to say that I mind good clean DIRT, or anything. Accumulated layers of human sweat and filth that has not been showered off in who knows how long is another thing entirely. If you've been in the garden just prior to your visit, fine. If you've been gardening all summer and you haven't showered since Easter, step off.

3. Hands-off. You must be able to control yourself. If you feel compelled to touch everything within a 4 foot radius, including my vaccine refrigerator, my otoscope cones, my prize bandage scissors, and even my own personal body - you can't come in. Go away.

4. A Pet Owner: At this point in my life, I really do not have time to talk to you unless you have a pet. I do not want to be on TV. I do not want to be in the newspaper. I do not want to do a presentation at your 8-year-old's school. If you are in the pre-purchasing phase and you are serious about finding a vet in advance - ok, yes, I will speak with you. But if you are just here to "interview" me for your own personal benefit, guess what? I am totally not interested.

What are your exam room entry rules??

Left, left, left right left...

Learning left from right is something that children do pretty young. I'm not sure exactly at what age but I'm sure that by the age of 10, most kids have that down pat. Kids are also pretty clear on the concept of mirror images. They look in the mirror and raise their right hand and they see their mirror image raise its left hand. Pretty simple. My six-year-old demonstrated this for me last year at a school event.

So, what's the deal with the people who insist that their dog is limping on the left front leg, and then after a lot of back and forth and arguing and namecalling, finally admit that they mean THEIR left, and the dog's right?

I have a patient who came in about six weeks ago and saw a colleague. The appointment was booked over the phone as "check right leg - limping." On physical exam, the dog was found to be limping on the right foreleg. Rest & Rimadyl was prescribed after radiographs were declined and the exam did not reveal a specific cause. The dog went home and recovered uneventfully.

Two weeks later, the owner called again and told the receptionist that the problem was back. The receptionist said "his right leg again?" and the owner said "no, left," and the receptionist remarked that this must be a new problem. The owner then got irate and screamed that the doctor must have written it down wrong, because it was the same leg, and it was the left leg, because she was looking at him right now and could see it was the left leg etc. She eventually came in and saw another one of my colleagues. The dog was not limping on any of his legs at that time. Again, radiographs were declined. She argued with my colleague about which leg it was. She pointed at the dog's right leg and said "now, this is definitely the leg he's been limping on. The left one." My colleague explained that that was in fact the dog's right leg. The owner argued about it. There's really no need to describe the argument I'm sure. You've been there, right?

So anyway she called me today & told me the dog was limping on the left leg "again." I said her left or the dog's left? She said "they're the same left. Left is left." I reminded her that the past two times she'd pointed to the right leg. So she said "oh right. You guys go by HIS sides, not mine." And it made me wonder - why do people do this? I don't take my kid to the pediatrician and say his left leg hurts and point to his right leg because that is what I see in my left visual field. Why do people do this with their pets???

It's 5 o'clock somewhere!

Patient of mine with a chronic (many year) urinary tract problem (whose management I share with a University specialty team came in today for a cystocentesis). The patient was brought in by a person I have never met before. The person did not know why he was bringing the patient in, but arrived about 15 minutes before we opened and asked "do you know why I am here?" Luckily, I did! Yay, Dr. VBB. So anyway, I did the cysto and returned the patient to the owner. As I typically do, I said to the owner "Fluffy has a damp belly. Don't worry about it, she just has alcohol all over her belly." The person replied "wow, lucky her. I wish I did!"

OK! Whatever floats your boat....

Actual exam room interaction with actual client.

Me: So did you have any additional questions today?

Client: Yes. I seem to be allergic to her saliva. Is there anything we can do about that?

Me: Don't let her lick you.

Client: well I try not to but sometimes it gets on me and the allergy is getting worse. 

Me: What do you mean? you're not having any trouble breathing or anything are you?

Client: No, but I get hives and it's very itchy.

Me: Oh. Well, Local Reputable Allergy Medical Practice is just down the road and I highly recommend them.

Client: Can't we just give her something to make her have less saliva?

Me: No, that's not something I would do. 

Client: can't we give her something so I'm not allergic to her saliva?

Me: No, that's not possible.

Client: Oh. Well, I guess I'll keep making her miserable by not letting her lick me.

!!!

The High-maintenance Client

Ah, the high-maintenance client.

I’m talking about the one who needs every tiny detail explained beyond all reasonable expectation. The one who has his own list of differential diagnoses, and expects you to explain the diagnostic pathway of every single one on the spot during the appointment. At VBB Central, we have our share. I saw one last week.

This week, the dog was brought in for an acute illness which had resulted in significant dehydration, requiring hospitalization. During the office visit immediately preceding the admission, the owner not only regaled me with the details of every meal/urination/defecation/nap/wake/play/funny look the dog had in the past five days, but also insisted that this acute illness (which was most likely a viral syndrome) was in some way related to a deworming medication given to the dog the week before (even though this man had called poison control already). I told the guy I agreed with poison control that this was not likely due to the dewormer and explained what supportive care and treatment I wanted to provide. He agreed to go along with the plan, but had a list of followup questions as long as my exam table. Could this be due to Lyme disease? (Unlikely.) Could this be due to having eaten a piece of cheese last week? (Unlikely.) What if the cheese was moldy? (Was it moldy? No? Then who cares?) Is it possible this is because the vaccines were given one week after the “due date” on the postcard? (No.) Is this because of the abdominal ultrasound he had last month? (No.) How do you know? (Because that’s not a thing that happens!) Each question required not only an answer but an explanation. And then an explanation of the explanation. And you know, at some point, when you hear yourself saying things like “honestly, I’m not sure anyone has actually done a study to determine whether dogs with an isolated episode of hematuria 5 weeks prior to the onset of acute anorexia are more or less likely to have pancreatitis than a dog who presents with anorexia in the absence of a preceding episode of hematuria, but generally hematuria has nothing to do with pancreatitis and anyway we have a UA pending and if we see hematuria today we will address that,”  odds are that you are dealing with a high maintenance client.

This owner, btw, was also very interested in having me personally lay eyes on several baggies of urine and feces that had been dutifully brought in. LOVE that.

Just as I thought I could escape from the exam room and move the little dog back into the hospital ward, the owner put his hand on my arm and asked me to check the ears - because of course we should consider whether this could be related to the cotton allergy.

The what? “Oh, well, you know - after that bout of ear mites, I did some research and it turns out this breed is really prone to cotton allergy and I’m sure that’s what caused those blisters he had in his ears that time. Please mark his chart, doctor, so no q-tips or cotton gets used on him.”

You see, once in the past, this little dog had presented with a horrific inflammatory, ulcerative, blistering otitis. It turned out the dog ultimately was diagnosed with food allergies and had some secondary bacterial infection, but at the time of initial presentation, it was just terrible. The owner had tried treating the little guy at home first - with, variously, dish soap, alcohol, sweet almond oil, gentian violet, and a few other things that slip my mind at the moment - but all of the home care had failed to help his little buddy, so he presented the dog to me so I could get stronger medicine to treat the ear mites. Yes. The owner insisted that there were ear mites even after my cytology revealed that this was not the case. The owner then produced baggies of ear exudate he had allegedly been collecting at home and insisted that I look at them under the microscope. I did, and saw only cotton fibers and epithelial cells and some pollen grains. I have no idea where that stuff came from! On that day the owner agreed with (paid lip service to) everything I said, went home, and ignored all of the recommendations, which I found out when they came back in a few weeks later, having tried more harebrained home treatments that did not work. Eventually the ear problem was solved by a regimen of medication & a diet change.

So at that point, I couldn’t take any more and agreed to mark the chart. Then, when discussing the case with my colleague during our hand-off, I explained to her what had happened and why I’d done that. She said to me “oh, I can’t wait til this guy comes to pick up this dog - I mean, he was wearing jeans, right? And what kind of shirt did he have on?” I started cracking up. I mean, I hadn’t even thought of that. Plus of course the dog had been wrapped in a cotton towel when the owner carried him in. D’oh.

Anyway, this type of client can really suck the life out of me and kind of makes me hate my job.

What's the time?

I don't know about you, but I'm a busy person. I have 3 kids, 2 pets (8 if you count the ones in the tank actually), and a husband. I do more than just blog and practice veterinary medicine and take care of family matters. I'm involved with the administration of the kids' school, at our house of worship, and my husband's business. No, I don't know how I do it - but the important thing is, I do in fact do it. And when I'm doing it, I'm respectful of other people's time, because I know oh-so-very well how irritating frustrating - well, if I'm being completely honest let me just say how INCREDIBLY FUCKING ANNOYING it is when people act like THEIR time is more important than YOUR time.

Ahem.

Seasoned readers will see where this is going, I'm sure.

So, yeah. The other day I had scheduled myself such that the last appointment was 45 minutes before closing, because I had somewhere I had to be, and I wanted to be darn sure I'd be able to be there (so as not to waste the time of the other 12 people I'd be meeting, who were going to be waiting for my arrival).  Of particular note is that the pet who held that appointment was boarding in our hospital, and required an examination, but the owner had wanted to be present for the examination and "to discuss a few problems" the pet had, so the owner had scheduled this appointment for the time he planned to pick up the pet at the end of boarding. The appointment time rolled around and the client was not there. As is our practice, the receptionist phoned the home and mobile numbers on file to see if the client was en route. There was no answer. Fifteen minutes went by, and the client was not there. After 25 minutes had gone by I figured I'd at least examine the pet, and just discuss my findings once the owner arrived. As I finished examining the pet, we heard our voicemail pick up (it does this on speakerphone - we stop answering the phone 30 minutes before closing. This fact, by the way, is well advertised) and the voice of my client came through. "Hi there! Just wanted to let you know I *do* still plan to pick up Fluffinator, and be there for our appointment, but you know, I'm not going to be there til about ten after seven, so, you'll need to wait for me. See you soon!"

Interesting message, there. The thing is that our office closes at 7:00 PM. This appointment had been made for 6:15 PM. The client just expected that we'd be more than happy to accomodate a 55-minute late arrival time for an appointment, after our normal business hours, without even a please or a thank you. Honestly it kind of blew my mind because although I may vent a lot about how people are so FUCKING ANNOYING all the time, for some crazy reason I still expect that people will actually behave in a civil manner to me. I know, I know - I'm the crazy one. Well, if you can't beat'em...

So anyway, as it happened, the Big Boss Lady was standing there and I looked at her and said "listen - my findings are written up, you can feel free to stay and discuss with her, or not, at your pleasure - but I'm leaving because people are waiting for me and I don't feel comfortable making them wait." She was fine with that. She said she was going to call the client and tell her if she couldn't come in before closing, not to come til the next day. I'm not sure if she actually did that or not, though.

Just to be 100% clear, by the way - my physical exam of this pet did not reveal any abnormalities. If I had picked up something potentially dangerous, I would have notified the people waiting for me that I had been unavoidably detained. But I saw no reason to do so in this case, especially given the massive sense of carelessness that had oozed through our telephone's speaker with the client's message.

So, yeah. That happened.
Please join me in the comments section with your answer to the question in the subject line!

Insert witty title here.

Sometimes things happen, and I want to tell people about them, but I fear no one will believe me. Then I read stories like this one: http://jalopnik.com/5889727/this-man-rear+ended-another-car-with-a-sex-toy-in-his-ass and I realize that there is so very much crazy in the world, my stories are probably not that shocking to anyone who's paying attention.

So, anyway.

My poor beleaguered receptionist just doesn't seem to have learned her lesson. Despite years of experience suggesting she not do this, she continues to ask people "so, what's new?" or "how's everything going for you?" or some such, when they are in our waiting room. A couple of weeks ago, she asked one particular woman this question, and was unprepared for what she subsequently learned. It went down like this:

Receptionist: So, how's everything going for you?
Client: Well, you know, it's been hard since Rusty died.
Receptionist: I do know. I'm so sorry.
Client: The thing is, Cooper only ever peed when Rusty did. Rusty was housebroken, so Cooper was too. But now that Rusty's dead, Cooper doesn't know he's supposed to pee outside. So I have to teach him.
Receptionist: What do you mean?
Client: Well, I've had to start peeing outside so Cooper knows he's supposed to pee outside.
Receptionist: ...
Client: It was ok during that unseasonably warm week but it's been kind of cold the past few days.
Receptionist: ...
Client: How long do you think it will take him to figure it out? I need to have some landscaping done but I don't really want to be peeing outside in front of the work crew.
Receptionist: I think you should bring this up with Dr. VBB - that's above my pay scale, really.

Priorities

Yesterday we had to call the plumber out to our house to rooter the pipe that drains the washing machine. Apparently it was full of gunk, a.k.a. dog fur. The plumber spent about 15 or 20 minutes and charged us $350, which I didn’t have. I thought about all the things my clients have said to me over the years when presented with treatment bills for their pets:

• “If you really cared about animals you wouldn’t charge so much.”
• “You should name a wing of this hospital after me, for all the money I’ve spent.”
• “I don’t get paid until next Friday. Can you hold a check?”
• “Is that the lowest you can go?”
• “You vets are only in it for the money.”
• “I bet you drive a Porsche.”

For about a tenth of a second I thought about trying out one of those lines on the plumber: “If you really cared about washers you wouldn’t charge me,” or, “Think of my poor children! They won’t have clean clothes to wear to school!” But I didn’t, because I’m a decent person. Instead, I handed over the credit card.

For most people who claim they “can’t” afford veterinary care, it’s really that they choose not to spend money on veterinary care. It’s all a matter of priorities. If your priorities are an iPhone, shiny new SUV, and cigarettes, don’t try to make me feel guilty. I feel sorry for your pet that he is stuck with you as an owner, but I don’t feel sorry for you and your poor decisions.

And for the record, I drive a ’99 Subaru with 209,000 miles on it, having upgraded from an ’88 Blazer with 180,000 miles that couldn’t turn left in the cold without stalling.

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.

Unexpected kindness

Yes, we're a jaded, cynical bunch. We've heard a lot of the muttering about how we are a bunch of bitter, burned out, bad-example-setters. Whatever.

I read this blog post today. The pharmacist author experienced an unexpected kindness from his patient, in return for something he'd done that he really hadn't considered a big deal at all.

The post reminds me of something that happened in my work life recently. Some people brought in their elderly, decrepit pet in terrible shape, actively dying, and I put him down. I didn't think too much of it. I told the people how sorry I was. Even though I had people waiting for scheduled appointments, I took the extra ten minutes to talk to these people and tell them that yes, I did think they had done the right thing. I even let them hug me on their way out - both times that they came back in to thank me again, tears in their eyes.

They were so grateful for what seemed so little from me. I did not really feel like I'd done anything extra special. They sent me a lovely notecard the following week, too. I'm keeping it in my "I don't suck" file.

The Pet Problem

The Pet Problem is the headline of an article in today's New York Times, which of course all of us here at VBB central read cover-to-cover before office hours every day. It is required reading for this blog post, so, go ahead, click over there, and check it out. I'll wait.

No, really. I'll wait.


OK. Hi, welcome back. So, the problem of elderly people and their pets, and the mismatch between their life expectancies, is commonly encountered in the world of general practice companion animal medicine. In my experience, most very elderly pet owners love their pets and prioritize the care of their dog or cat above almost anything else in their life. The subject of what to do if or when the owner expects their beloved companion to outlive them is frequently raised in my exam room - along with the sad subject of what to do if Fluffy is going to die first, and the owner feels "too old" to get another pet. In the latter situation, I have been able on several occasions to match relatively healthy but older pets, whose owners have recently passed away, with recently-bereaved elderly owners whose pets have recently passed away. Talk about a feel good moment all around! But in the first situation, it's very difficult.

I have had owners ask me if I would be willing to euthanize their dog or cat, once they themselves have passed on. Euthanasia of a healthy pet is not something most general practice vets feel good about. Simply because the pet owner is old and dying, that does not necessarily give them the right to decide a pet should die. However, commonly, the elderly pet owner is him or herself feeling the loneliness that comes after one's friends and family have largely predeceased you, and the neglect when the few remaining family members you do have do not come to visit you or even call you to say hello. When your world is so small, and there is no one to see you and give you a hug every day, is it worth it? They may feel that for their pet, there is no chance of finding a new loving home, and therefore want to spare him that loneliness. I can understand that, but I have so far been able to convince my elderly clients that this is not the way to go.

I have had owners ask me if I would personally take their dog or cat. "Dr. VBB - you are so good with Timmy. You understand him. I would rest easy if I knew he could have a place in your home." I appreciate the sentiment, really. But, if I took home every needy pet I encountered, or even if I took home 10% of them, I would quickly find myself living in some kind of "Dogs Gone Wild" meets "Hoarders" scenario. This is not a practical solution.

If the pet is relatively healthy, rehoming through one of the local rescues is often a viable option. If the pet has special needs, it can be trickier, but I do my best to find a place for it by checking in with local colleagues and social networks, in hope of finding a match. Hey, it just struck me - "Veterinarian as Owner-Pet Matchmaker" would be an interesting elective, wouldn't it? Right up there with biochemical basis of disease!

Anyway. Sometimes we see the situation where it seems like the owner and the pet are in a contest - who's going to die first? We take the cat in for boarding while the owner's heart failure is treated in the hospital. The owner goes home, the cat goes home, then the cat comes back in three days later vomiting and dehydrated. It's in renal failure, this happens periodically. We diurese it and we'd be sending it home after four days but oops, owner is back in the hospital with pneumonia. We board the cat for a few weeks, then it gets to go home again. Then it comes back in. It's really sick, hasn't eaten in a few days, hey look, now it has diabetes. We get it regulated on insulin. We send it home only to have it bounce back again a few days later because the home health nurse taking care of the owner, who broke her hip and is recovering at home, can't give the cat its insulin. These situations become very very complicated sometimes. I think the worst is when the owner arranges for us to board the pet while they go into the hospital themselves, and then they die in the hospital, and no one tells us, and eventually, we call to find out what's going on and get yelled at by the grieving son or daughter who answers the phone for being so insensitive as to ask what arrangements have been made for the pet, "at a time like this." Not being psychic, we do not know it is "a time like this" if no one tells us. The guy who taught the Crystal Ball elective at my vet school was on sabbatical during my third year, btw.

I once had a client my own age who came in frequently with a very large dog. The dog was obedient to her and well-controlled by her, but had significant aggressive tendencies and was not safe to be around when the owner was not present. Unfortunately, this client was suffering from widely metastatic cancer. At times, she was not able to care for her dog due to her weakness while undergoing chemotherapy. I took care of this dog for about five years, during which time the owner had at least four or five brushes with death. We were able to board him successfully only by keeping him relatively sedated, which is really not optimal. Eventually, in this case, we did euthanize him when his owner passed away. She had asked me to do it, and I couldn't refuse. I did have to deeply sedate him via IM injection while a tech held him at arm's length on a rabies pole first, though. Very sad situation.

The idea of the pet trust is interesting. I'm not sure there are that many people who have enough of an estate to make this idea that popular. Including a pet in one's will seems like a good idea, although as pointed out in the article, that isn't completely binding.

Veterinarian readers - what kind of solutions have you come up with for your elderly clients who fear for the fate of their longer-lived pets?