Thursday, May 31, 2012

A Dramatic Scene


CLIENT: [holding leash attached to large fuzzy dog] hey doc, nicetuh seeya!

DOC: [entering room] Hi there Fuzzman! What brings you in today?

CLIENT: Fuzzman's a real mess, doc. Take a look at her back.

DOC moves in close to Fuzzman and begins to examine her back. CLOSEUP of Fuzzman's back reveals a golf-ball-sized inflammatory ruptured cyst. DOC squeezes the base of it and caseous material begins to be extruded.

CLIENT: oh god, that's really gross. Doc, is that the grossest thing ever? Omigod that is gross. I'm starting to feel sick.

DOC: [looks up at CLIENT] are you ok? Do you need to sit down? Let me get you some wat-

CLIENT, who has suddenly turned white and begun dripping with sweat, slumps down onto the floor.


Friday, May 25, 2012

I'm not your bitch. Shame on you.

Why the hell do you even bring your dog in to see me if you aren’t going to let me do anything?

I don’t want to have your depressed, dehydrated, vomiting and bloody diarrhea dog in my hospital if I can’t help him. You telling me he has This or That disease which you have diagnosed based on a prior experience at another hospital of which you did the same thing to them. You didn’t get a diagnosis then so telling me that is what he has now holds no water.

Declining every single frickin’diagnostic except my exam gets us just about nowhere. Your dog is vomiting. He is not in shape to take oral medication. He is too dehydrated for your requested subcutaneous fluids to help him much. They are a step in the right direction but your dog is dying while his body can start to absorb them. And then you declined even that anyway.

Thank you, thank you so much to allow me to give him an anti-vomiting injection. At least that will help him a little bit. I feel so sorry for your poor, poor loving dog that you do not deserve. Do you know how much is of a hole it puts in my soul to see such a wretchedly sick dog and not be allowed to help him?

When I send home the information on your invoice that your dog is very ill and needs diagnostics and IV fluids and medications or he may get sicker and/or die, I mean it. When I ask you to either take him to another hospital or reconsider our recommendations I’m doing that for the dog. It’s not for me. Well, yes it may assuage my guilty feelings for not calling animal control on you immediately. But I really do want to help you and the dog. I’ll give you a brownie point for not yet being rude to me. That’s why I haven’t fired you. But my poor receptionist is struggling with trying to help you while doing her job as a go between. No one here wants to see or know a dog is suffering. It deflates all our staff to see this. It puts us one foot closer to the grave.

Telling me that you’ve spent thousands of dollars on diagnostics on this dog is incorrect according to the medical records. Yes, when he bloated about 5-6 years ago you had the cost of the surgery. However you’ve not spent any bucks at your prior clinic, the animal ER or here since then for the chronic vomiting that has occurred. We discussed on your first visit here the recommended diagnostics to help determine what the problem really is.

Now your dog is suffering. He has one or more medical conditions which are making him suffer. You need to buck it up and do the humane thing. Either let him go or get him some help.

When you call me the next morning and ask for oral medication for what is your new diagnosis of him and tell me he is eating and drinking forgive me for declining to participate in your delusional world. I cannot accept the liability. I myself would not even be trying any oral medicine or food or water on a pet that is retching his guts out and has a nasty bloody diarrhea. So I cannot give you any guidance since you are not listening to me. Although I have not fired you as a client I figured you would have fired yourself.

Lady, I’m a doctor, a doctor for animals. I’m not your bitch to get the drugs that you think he needs. I know what the rule outs for your dog’s condition. I know how to rule out the incorrect ones and help lead to the true diagnosis.

Your job as the owner and caretaker for this poor pooch is to get real, stop fooling yourself and recognize that your dog needs a hands on doctor like me. Your job if at all possible is to have prepared for his medical needs. If you haven’t done that then you should get real about the suffering you are putting him through because you are unrealistic. You should prepare to ask for help from your family, neighbors, friends, clergy, pawn shop, etc. or to say good-bye to your dog. Why should your dog suffer because of you?

Now, some of the readers here might want me to understand the economics. I do. This is not about economics, it’s about priorities.

What this is about is that you think you can direct me to get the drugs you think her dog needs. Lady, I’m not your bitch. If he has a chance to recover the lack of proper care will have caused some permanent damage to his kidney and possible other tissues. How do you do that to such a great soul? Shame on you.

Tuesday, May 22, 2012

Reverend Love

I think it is time for another memorable character story. Which would you like? There have been several memorable characters drop by our practice over the years. They’ve enriched the experience.                                                                                                                          

The Reverend Love was a +/- 400 year old man, slight of build and quiet of demeanor. He headed up a tiny church, about the size of your garage, in the old, poor, unsophisticated end of town. He was polite in the African American lived a lifetime in a prejudiced society and didn’t make waves kinda way. I was a child of the 60’s love everybody kinda guy, and he tolerated me. He had attended this practice for years before I got here. He smiled a lot, but you could see the weight of a world’s mark in the stoop of his shoulders.

Reverend Love had two backyard German Shepherds. Back in the early 70’s there were only two kinds of dogs in our practice. The Poodles lived indoors, and the Shepherds lived in the backyards. Backyard Shepherds were expected to keep folks out of the backyard, because without one, people would drop by and borrow things from your house and yard, and they never did bring em back.

Training such a dog involved about any unspeakable abuse that would turn a dog irredeemably vicious. He might have a doghouse of sorts, or not. Under the porch would do. These dogs ate what they got, which often was what was left after a big family was done eating. They would, often as not, attack and maul your own kids, so you kept the offspring out of the backyard. Sometimes the chain was long, other times kinda short. Just enough to reach the fence, and any fool stupid enough to jump over, but not long enough to hang themselves. That kind of chain.

The clever dogs wouldn’t bark if someone walked up to the fence. All you’d hear was that chain dragging, and then it would stop. The dog was waiting for you to hop in. Right there. Sometimes he’d sniff the crack between the boards. Can you spell deterrent?

Back then a rabies vaccine was good for two years. The county dog license, for which you needed a rabies vaccine, ran from Jan 1 to the next New Year’s, and they granted a grace period through the end of February. So we gave lots of rabies vaccines in February. The backyard Shepherds got out of the yard once every two years, to get that vaccine and thus their license. They didn’t behave well once out of the confines of their yards. For $6 a dog, I gave a physical exam and a rabies vaccine. Filthy, screaming, un-socialized, untrained, terrified, psychotic dogs who had never set foot on a floor or walked under a building’s roof were dragged by their chain, shitting and pissing, into the exam room for their turn. The owner often carried something stout to smack the dog.

The nastier the dog, the more cursory was my physical exam. My goal was to survive. I didn’t approve of the switches and clubs, but if the owners at least tried to hold their vicious dogs off me, I appreciated that.

Reverend Love was a mere wisp of a man, and both of his backyard Shepherds were 90-100 pound dogs. No way could he keep either from killing me if he brought them into the exam room. But he had worked out a system that worked every time. He’d come in without a dog, pay for his two vaccines, and then quietly inform me that he’d knock on the side door when he was ready for me.

The old hospital sat on the corner of the main drag and a side street. We had a front entrance on the big street, and a side door by the other. Near the side door stood a power pole. About ten minutes was all it took. A quiet knock on the side door meant that Reverend Love had his dog ready. And I’d step out, syringe at the ready.

Picture an ancient dented listing Ford pickup truck sitting at the curb (actually, we didn’t have a curb, but who’d admit that?) with one lunging snarling barking wild-eyed insane giant German Shepherd straining at the chain holding him in the bed of the truck. The truck would rock from side to side, the chain clattering. I awaited the “PING” sound of a chain link parting, knowing it would be the last sound I would ever hear, save for my brief futile screams.

The other dog was tied rather snugly to the power pole with a length of chain. The thick leather collar on the dog’s neck was cinched down directly to the pole, and then the good Reverend would sorta wrap the dog around the pole and then run the chain clean round the dog and pole, oh 30 or 70 times until the dog could not so much as twitch the tip of its tail.

“I got him ready for you, Doc.”

All I had to do was find a hind leg muscle between the loops of chain, and complete my task. My physical exam consisted of a quick verification that the dog was still alive. Which I confirmed readily by listening to the sound, the deep throaty growl of absolute hatred and frustration that escaped from the dog’s well-confined throat. I never looked into his eye, for that would be a vision of Satan himself, and I didn’t need to meet that dude yet. I didn’t so much hear the growl as feel it as it reverberated through my kidneys. It chilled my blood.

“Thanks Doc. Give me a minute and I’ll get the other one ready.”

Moments later, another soft knock on the door, and another sound effect machine from a Stephan King movie awaited me, tightly confined to that power pole. One more quick poke through the wall of chain, and then back indoors to sign two rabies certificates.

“Thanks Doc. See ya in two more years.”

Thanks your own self, Reverend Love. You be the man!

Monday, May 21, 2012

Humane Duty

I talked with a friend tonight.  I know her through multiple sources: she lived with my college BFF's family , she knows the people at my family's barn...etc.  And my 6 year old daughter has loved her since the first meeting.  This woman, newly graduated from a college with a great horse program, is a wonderful instructor.  My daughter has taken one lesson, and though she fell off due to over balancing, has ID-ed the reason she fell off (horse tripped and she was too far forward), wants to go back and correct the problem.

Recently, we stopped in at a local place.  After seeing their stallion standing in a stall in at least 12 inches of manure, a horse with a swollen eye/emaciated (glaucoma or cancer), and the lead instructor riding without a helmet and with a 5 inch shank bit (for every pound you "pull," the horse feels twice that per inch), AND the horse was behind the bit, it assured me that this was not the place where I could sub some lessons for my daughter.  Oh and the mini-horse had such over grown feet that I would tern them as elf feet.

I was lucky enough to take college classes in equine production, training, physiology, and teaching riding lessons.  I know how to start a new rider.  I know how to build up an advanced rider.  In addition to being a vet, I can do these things....if only I could afford a pony for my daughter.

So, I talked to "daughter's riding teacher" tonight after my daughter found her name in my phone and called her.  And we shared stories of riding without helmets.  Things that are, to us,  as uncomfortable as getting in a car without a seat belt.  We talked about horses (and other animals) that needed to rejoin the great grape jelly bean in the sky and we talk about the stupidity of riding without a helmet.  I have come off of a horse so many times that when I started having seizures and my neuro guy asked about head injuries, I just laughed.  Most of the injuries occurred with a helmet.  So, good there.  But some were when I was futzing with my helmet and it fell off.  There are so many times that I would have been dead without a helmet.

Distance be damned, I will drive my daughter to my friend who cannot even get on a horse without a helmet vs the place where the woman rides with no helmet, a 5 inch shank, and the horse's head behind the vertical.  Because my daughter loves her for her artistic and crazy colored hair....  and I love her because she believes that true equitation covers all disciplines and she believes in effective riding.

And this is true for your vet.  Just because everything looks ok at first glance and parents tell you that thinks are great, find someone that you really trust.  If they are far away, that is a pain, but it is likely worth it.  Because I will choose someone that will give my daughter what I would like to give.  Common sense, forward thinking, and workman like riding.  I want her to be safe, but on the cutting edge of equitation.  I want her to be able to ride anything.  I guess as a parent, I expect some perfection.  Ok, maybe a little over-reaching.

Thursday, May 17, 2012

That trapped feeling

Being in exam rooms with clients is nervewracking.

No, seriously. It looks easy, right? Examine the pet, chat happily with the client, make cute jokes with their kids, it's all fun and games. Mm, no. Being an introverted, self-conscious sort of person, I get more than a little stressed being stuck in a small room with one or more people hanging on my every word. One of the main reasons I never considered being a teacher-the profession of much of my family-is that a roomful of eyes on me, all day long, has always sounded like a scary way to spend my days. No matter how much I like the client (and in spite of the prickly misanthrope I come across as, I really like most of them), I always feel relieved when I can get out of there, beat it back to the treatment room, and pull myself back together.

Now, any vet will tell you that some clients make you feel more trapped than others. There is a subset of pet owners who just spend a little too many of their waking hours obsessing over their pet. Did he just wink at me funny? Is our tap water going to give him cancer? I just had a fly in my kitchen, will it give my dog any exotic diseases?

So thusly I found myself, late in the afternoon, trying as kindly as possible to extricate myself from an exam room. The owner in question is one of the nicest people I know. Her dogs are lucky to have her. She has taken stellar care of them through some terrible illnesses, and to be blunt, has spent money she really couldn't spare in order to do so. One dog is having some issues that are probably not serious, but there's a slight chance they could be. So, lots of questions. What if she does this? What is a symptom of that? Should I let her do this thing? How often? Knowing her ongoing anxiety, I spent all the time she needed, answering them all. Finally, we were done. Score! About to be away from these prying eyes, it's late in the day so I can finally be in my car and away from all of them. Well, one more, actually. As we're talking, another client is waiting right next to the room for his own dog, and he's been waiting awhile.

I've made it to the doorway when she thinks of one more thing to say. I pause at the doorjamb and eke out more answers. My hand absently touches the little hole in the strike plate, the place where the bolt from the doorknob goes into the doorframe. I poke the knuckle of my pointer finger into the hole. Why? I don't know. Like Mount Everest, it was just there, and my slightly overloaded brain was making me fidget. I move my hand away. But my knuckle doesn't budge.

Huh? I look again. My finger is stuck in the hole. I wiggle it a bit, flex it a little differently, but it's still there. I'm STUCK TO THE F*&^ING DOORWAY, in front of this owner, and right next to another one. This time, I don't just feel trapped. I am trapped. I've run out of that few seconds one has when one can still play it cool, and I finally have to choke out, "I'm stuck. I can't get my finger out of here."

The owner, bless her heart, at once turns her obsessive caring in my direction. She crosses the room and blurts urgently, "Oh no! Are you okay? Are you sure? Here. Here's some soap from the sink. Maybe I can lube your finger up with it. No? Are you sure? I think it will work." But just then, I manage to turn it just right and pull it out, if not very gently. I shake off the pain, thank her kindly, and finally retreat to the blessed isolation of the treatment room.

And then, immediately walk back up front, introduce myself to the gentleman who was standing right next to this little tableau, and review his dog's exam findings with him. He never mentions the previous scene, and neither do I. It's the elephant in the room.

In case you wondered, my finger is still kind of sore. The staff is still laughing. The whole thing was immortalized on our security tape. And if the second owner thinks I'm such a flake that he'd prefer to see a different doctor next time...he hasn't said so yet.

Wednesday, May 16, 2012

Half Grown Crow

From across the room it looked like it could have been a half grown crow. The guy said it was a crow, and he likely knew more about birds than I do, so let’s call it a crow. I took a class in avian medicine once, maybe third year of veterinary school, so that would be 42 years ago. Any twelve year old kid who watches Animal Planet on cable knows more about birds than I do. The only birds I have any interest in show up on a Thursday in November or in that red and white box from the Colonel. And I’m not even sure I can legally work on wild birds without some government’s silly permit. So I didn’t offer to take the bird off his hands.

The guy showed up with no appointment, walked in with this black bird clutched in his paws, and said, “Here, I got a rescue for you.”

“I’m sorry sir, but we don’t see birds. There is an avian practice just a few miles in that direction, and a wonderful wildlife rescue and rehab place a half hour the other way. Here are their phone numbers.”

That would be my receptionist. After thirty years, she knows what I do here, or more importantly in this case, what I don’t. People do show up with baby birds fresh fallen from the nest from time to time and she sends them to the wildlife rescue place. They are world class good over there. And the avian practice the other direction is a tad better than world class. The doctor there wrote the book that the world class places read to learn about birds.

I have no qualification to diagnose or treat birds, don’t wish to do birds, and legally and ethically likely shouldn’t even try. So when this guy didn’t buy into my receptionist’s assertion that we don’t treat birds, I reinforced the notion by looking him in the eye and telling him I don’t treat birds. That’s my reality, it’s the truth, and it seemed the right thing to say at the time.

But guess what? Not good enough.

I’ve known this guy for several years. He is a primitive, but has always been tolerable, despite my sense that some irrational anger lies just below the surface. We’ve gotten along OK when he’s been here in the past. On this morning he asked if I remembered the big dog he brought in a while ago.

“Doc…remember that big dog I showed you that you said had a big cancer in his belly? Well, not long after you saw him he just dun up and died. Imagine that.”

I was thinking that I figured that one right. I believe that was exactly what I told him the dog might do, but he was kinda intimating that I wasn’t much of a doctor onna counta that dog dying and all. And then he glowered at me and spewed out, “Unless this bird’s got a hundert dolla bill tied to his tail they won’t do anything to help him here.”

And he stomped out the door. The bird ended up in the bushes behind the clinic where this guy dumped him, and he squealed tires leaving the parking lot. So my assistant went out, caught the bird and found it a nice box, and on my lunch hour I drove it that half hour to the wildlife rescue place. They said they’d try to help it.

So I’ll go to the bank tomorrow on my lunch hour instead of today. And I will call the rescue people in a few days to see how the little bird is doing. And if I can remember this guy’s name I will pull up his chart and send him a nice letter suggesting he go insult some other veterinarian the next time he needs help, for I have lost interest in trying to remain civil to him.

Monday, May 14, 2012

Nerd Humor.

Explaining the humor is inversely proportional to the amount of humor generated.
I am a nerd.  Or a geek.  Or both.

Thursday, May 10, 2012

PTSD and the vet- true, but not funny

This past month has been a trial of various medications in order to allow me to overcome being anxious about dealing with clients.  I have a therapist, a couples counselor (because this kind of thing makes your spouse crazy), a primary care internist, and the psychiatrist.  The actual diagnosis is being worked out, but this is a marathon and not a sprint.  So, cost THIS week of therapy: $205 for the combined therapists and @$290 for the psychiatrist.  I get a small break next week: one therapist is out of town.  Oh, insurance covers NONE of this so it is out of pocket.

My PCP, therapist, and psychiatrist all agreed that I have PTSD.  The psychiatrist mentioned that there are two main types: several small instances (non-combative) vs single/multiple combative PTSD.  She thinks I have both.  I had a boyfriend in junior high that abused and threatened to kill me and my whole family.  He held me hostage with threats against his own life, attempting suicide when I broke up with him.  Less than a year later, my father died when I was 16 and in a new school.  Two big traumas.  Then all of the little money grubbing digs, all of the rich doctor heartless jokes, all of the animal abuse, euthanizing 10-30 patients a weekend on emergency.  The fear of never knowing if when I told an owner "I have a 90% chance of saving your dog, but it will cost at last $2000 and might go up from there," what they were going to say.  Some would hug me and tell me to go ahead, then send thank you cupcakes. Some could not afford it and I euthanized their dog, but still got a nice card and sometimes bakes recriminations.  And some called me a thief.  And some just yelled at me.  And when you have PTSD, all your limbic system processes is that all of things that stand out are the traumas.  And you have constant cortisol release.  And then your hippocampus shrinks.  And you become angry and at its most base form, anger is fear.  I was paralyzed when picking up the phone.  I was paralyzed going into exam rooms.

Given my previous history, I would have been better off going into pathology or anatomy or research.  But I am an adrenaline junky...jumping horses goes along with that, diving competitively goes along with that.  I despite what my doctors think, I believe that I am high functioning ADD.  My psychiatrist says that my brain just works differently and that I have a busy brain.  It makes me good at solving problems, but does not help with the mundane things.  I can diagnose and manage several severe medical cases, remove a spleen in 10 minutes, and start treatment on an animal my techs show me through the surgery window and I am closing the splenectomy.  However, I cannot clean the house.  I can cook a fabulous meal without a recipe but I cannot repeat it.  I can create pictures that make people cry.  I can give lectures and create inventions, but I cannot work through the mundane task of patenting them.  Talking to a single client picking up the phone is trauma inducing.  Giving a grand rounds lecture to an entire human hospital staff makes me high for at least a day.  Instead of a wall that only lets a few things in, my mind is a colander, letting all sorts of things in and out.  The box that all the exec want people to think outside of does not exist in my world.  And even though my doctors all agree that this a 4 D way of thinking makes me a wonderful doctor, it makes me a shitty wife, and a less than mundane mother.  At this point, I am agreeing that polygamy is a good choice...if I could have a wife that did all of that day to day perfect would that be?

I am finding my way in this new world of purely capitalistic veterinary hospitals, where so many hospitals are competitors and not colleagues.   And so many hospitals are being bought by corporations.  I am navigating the land mines of the big box companies forcing pharmacist, with no veterinary training, to sell veterinary drugs that they *MIGHT* learn about through the hazy filter than is their rep (and do they know what they can trust, do they know about the interaction of Comfortis and Ivermectin products??.)  I am trying for education rather than anger.  I have already given one pharmacology CME, might as well charge Wally World for more.

And I am fighting this battle with suicide.  Veterinarians have one of the highest suicide rates in the to dentists.  Money problems, easy access to drugs that kill, a feeling of helplessness, of being devalued....those all come into play.  PTSD and the unending anxiety also

So you vets and human health care might have some PTSD too.  ED medics, nurses, and doctors are at risk.  Be safe.  Get your help.  I am mortgaging my future to do so, because without this help, my future will be in the state run loony bin or in the ground.

Yes, it is a downer post.  But it is true to my life.  Off to watch more TED talks and work on my next lecture.  If I get my grant, it should gain some national attention.

Tuesday, May 8, 2012

Spreading some sunshine

OK, we've been a bunch of Debbie (and David) Downers. Never one to turn down a challenge, I'll rise to the occasion and spread a little sunshine here.

Like my esteemed colleague before me, I'm a HUGE fan of puppies. Big, slobbery ones! Silly, clumsy ones. I love watching them grow, as they come in for their puppy visits during the first few months of life. I'll go out on a limb and say that furthermore, I love it when I'm able to provide good care and support for that dog during its entire life. I'm just old enough now that I've euthanized some of my first "new puppy" patients, and while I wouldn't say that part of it is FUN exactly - it's meaningful. It's important.

I also love it when a pet comes in feeling awful, and I can intervene in some way, and the pet leaves feeling better. Really, that's what it all comes down to for me.

Cat abscesses! I love cat abscesses! Stab those suckers and watch the nastiness come spurting out like Old-freakin-Faithful.... gotta love a cat abscess.

Oh! And showing kids cool stuff - like, mites on a slide under the microscope or something. Although that one time the mites were getting it on led to a troubling series of questions given that they weren't MY kids and I wasn't really sure where the parents wanted me to go with my explanation.

Hearing people's stories - yes, it's true. I don't hate EVERYONE. When someone gives me the honor of sharing their story with me, I really value that. Of course, that's assuming that their story is not complete and utter bullshit. Because those stories, I could do without.

OK sorry, I guess this blog post is a little longer than my sunbeam tonight. Still, the take home message is, yes - there's still a bright side. It's not all bounced checks, drug seekers, and assholes.

Shed a Little Positive Light....

One of our readers asked a very good question.  They wanted to know what are some of the shining lights in this profession - what is it that we still enjoy?

So I'm challenging the authors - including myself - to pull up our bootstraps and try to come up with some positive thinking for a few posts. 

Let's see...

I'll never get sick of puppies.  Even when they are naughty.  I love their breath, their fat little puppy feet (like those of dachshunds), their clean, perfect little ears (like baby hound dogs), the way they smell (except their butts - those don't smell good) and the way they are just these fresh, new perfect little beings.

I love how dog feet smell like Fritos.  They just do.

I'll never get sick of kittens.  Even when they are naughty.   Their complexity that is perfection in a tiny little killing machine.  Even when they wouldn't hurt a fly.  The way they will stalk and hunt and jump straight up in the air at seemingly nothing.

I'll never get sick of my senior pets.  Especially the ones I've known for their whole lives.  There's just a special place in my heart, even when they are old and grumpy and want to bite me.  In fact, I get more worried when my old grumpy patients quit being grumpy with me, because I know they are trying to tell me something.  I know those signs well.

I love some of my really good clients, who never refer to me as "just another vet" but rather call me their friend, hug me, tell me to take a day off, and show genuine concern about MY life.  Like I do theirs.  I am honored when I see their pets as puppies, spay or neuter them, nurse them through illnesses, and then get to ease them with their passing to the other side.  There honestly is no greater honor than that.

True, there is a lot of negativity with this job.  Many of us more seasoned vets are jaded - dealing with the public with the level of emotion that we do, it wears us down.  And sometimes we feel really tired.

But yeah, there are some really cool things about it.  Like those darned Doxie feet.  I'll never get sick of those.   :)

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.

Saturday, May 5, 2012

Late Night, Can't Sleep, Ruminations

“It’s never the doctors or the scientists; it’s always the barbarians at the gate.”

There are two kinds of people. One group is young and they know in their core that the world should be made into a perfect place, and they are angry as they view the reality of the world and thus observe that it IS far from a perfect place.

The other group is old, and they’ve been watching the world for a long time, and they’ve noticed that it is far from a perfect place, but they have concluded that the world will NEVER be a perfect place.

This notion is as good as it gets if you’re looking to explain the half filled glass and how it is perceived. One group is optimistic but frustrated. The other group is frustrated and figures the world is going to hell in a hand basket.

I am no longer optimistic. I’ve been young, and now I’m the other. So this clouds my thinking in a predictable manner, so bear with me.

I have some holes in my education. Setting out to become a veterinarian exposes the student to plenty of science and related disciplines. But in the rush to master these areas, some of the philosophy, economics, language, education, history, literature, etc. get left behind. Folks often slap me upside the head when I express an opinion derived from my observations rather than any actual study of these important fields. I’m not truly qualified to talk of the human condition. I’m a reasonably deductive person but that is no substitute for actual expertise in any of these fields. Try to remember these last two sentences because hopefully I’m going somewhere with this thought, but this is opinion, not science.

One of my deductions regards my impressions of education in this country’s population. Taken in its simplest form, education should expose students to a certain minimum amount of plain old information, which forms a foundation for more learning and allows the student to rise to two legged transport. And then from this platform, a student can branch out into specific areas with more specialized learning to master.

This is the ole “what to learn”. We cannot forget the more necessary “how to learn”. For when formal education ends and life begins, the how to learn thing becomes far more important, because this is what arms each individual to continue learning after formal schooling ends.

As this old guy looks hopefully to the next generations, the glass is looking very nearly empty, because my deductions suggest serious deficiencies in both the “what” and “how to learn” in education these days. Now, the experts in today’s education system and the folks who encourage them would disagree. Perhaps we might address my conspiracy theories at some other time, These are only my deductions, so take three times daily with a grain of salt.

The products of this education system are no more stupid than my generation, but they often are shamefully less educated. Thus unarmed, some lack understanding of, and respect for, those mysterious elements in life they missed in their education. You know, things like the work we veterinarians do. It is no surprise to me that there is one important reason we veterinarians face such vitriol from people who act like they don’t understand the difficulty and cost of the work we do. And that is simply because they don’t understand the difficulty and cost of the work we do. The folks responsible for their education didn’t prepare them to handle such complex notions.

And sadly, these people don’t even know what they don’t know.

Of course, if their expectation might be that the world can be made a perfect place, the complex, difficult, and costly work we do should be provided for free to everyone. We might suggest that perfect is far from obtainable, but again we face an education system that seems to be leaning toward the economic models that favor everything free to everyone, so this is small wonder.

Another of my deductions, take at your own risk, is that there are two kinds of people. The HAVES and the HAVE NOTS. The HAVES get all the breaks, have all the money and all the power, and they stay up nights plotting ways to get more breaks money power from that other group, the NOTS. The NOTS of course suffer a lifetime of abuse at the hands of the HAVES.

This is another one of my conspiracy theories, but don’t you wonder why this sense of HAVES and NOTS has become a core concept in the education of today’s youth? Again, no time for this argument now, but could one of the reasons we veterinarians encounter such vitriol from some really angry people possibly stem from the notion that they consider us to be HAVES, and they are relegated to NOTS status. Not their fault, but certainly ours. Because that’s what they have been taught.

Small wonder we become money grubbing thieves to some folks when we think we are simply dedicating our lives to a really difficult task. We think we are the good guys who are trying to help, and some think we are the enemy.

Thursday, May 3, 2012

Presenting complaint haiku

"His poo-poo smells bad."
Are you fucking kidding me?
Like YOURS doesn't smell?

"My dog laid an egg."
No it did not, you're confused.
That's a placenta.

"I think she hates me!"
I'm so sorry to hear that.
And, I'm not surprised.

"She pees on the floor"
She's 24, ma'am.
She only has one nephron.

"He ate my homework,
and I need to turn it in."
Here! Take him to school!

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.


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!

Wednesday, May 2, 2012

Doing It For Free

You walked into my clinic - not an established client with a relationship - but someone who rarely sought any care at all for your pet.  You told me your pet was "up to date" with vaccines but you couldn't provide any proof.  (I have to take this information at face value even though it can potentially put my entire staff at risk) 

You told my receptionist you could pay for the exam.  We believed you.  So I stopped what I was doing with my established, paying client and ran to your emergency.  Just like I always do.

Your little dog was bitten by a bigger dog.   And it was badly, badly injured.  I informed you that its injuries were SO bad, that she needed to see a specialist or be euthanized.  I would get her stabilized and then send you to the surgeon.

You immediately said you had no money for extensive treatment.   Thank you for being honest.  You asked me to just put her to sleep because you couldn't afford treatment.  I thanked you again for not telling me I should treat for free and arguing with me. 


You lied when you said you could pay for the exam.  Your truth was that you had a pack of cigarettes in your purse and a look of crystal meth on your face.   I know that look.  I see it a lot.

So I had to pay for the exam, the euthanasia of your badly injured pet and the cost of disposing of her body because you had no money.  Zero.  None.   Because, yes, I do love animals.  And I hate to see them suffer.

I don't fault you for not having any money. 

But if you realized that this scenario plays out every single day in my practice, you'd realize how much money it costs me.  Actually, though, you probably wouldn't.  You have no idea and you don't get it.  You've made personal choices that don't allow you to take care of your pet. 

You expect someone else to do it for you.  And I did, because I care more for your dog than you did.  I could have said No and sent you to the shelter where they would have euthanized her for $25.  You wouldn't have been with her, holding her while she went to sleep.  You wouldn't have been able to sit in my exam room for an hour sobbing and grieving, making us all cry.

No, instead, I sucked it up like  I always do and I did what I could.  We humanely euthanized her and ended her suffering.

And you didn't pay me one dime.  That bill for the disposal of the body will be here next week,  and the staff who took care of her and eased her anxiety still got paid, and my good paying established client had to wait for a long time while I dealt with you.

I'm the one who didn't get paid.  I incurred 100% of the costs.

So the next time someone tells me I'm greedy or that I charge too much or that I don't care about animals....   Screw you.  You are misinformed, uneducated or downright ignorant. 

This scenario plays out every day in every veterinary clinic in every state of this country.  So articles like the one written below - are fantastic.  Keep pissing us off by making one of the most humane, caring, underpaid professions in the country look bad.  We are starting to congregate and realize that you are doing this to us and we are starting to fight back.