Just don't do it.

Public service announcement: if you make a video of your pet being put to
sleep, and show it to your gynecologist at your next appointment, your
GYN will immediately call her veterinarian friend and tell him all
about it, and they will mock you a second time. It's one thing to want a record of Kitty's passing for your own personal viewing, or maybe to share with one of Kitty's loved ones who was unable to attend the last vet visit (although in about fifteen years of practice, not once has any of my own clients made such a recording!). But showing the video around to all and sundry smacks of "Kittycat snuff video" to me. It's just not socially acceptable.
Trust me.

To Break A Heart

I tell my clients that the last thing they want to do is to make my day interesting, for boring, even tedious, is generally better for their pet’s health and happiness, and as a consequence, theirs’. Bring me another flea bite allergy, another simple gastritis, yet another cat peeing outside the box. I do this all day long. Sometimes during the worst allergy season of the year, it seems like I could record my first office call of the day and then simply leave, for my staff could play the recording for each subsequent client, and it would fit. Sure, I’m being useful on days like this, but it’s not all that compelling for me. And after all the years, I’ve gotten these simple, routine things down pat. I’m helping, but I’m not all that interested. I’ve done this all before.

In this profession, when you are helping, doing the job, and just fixing the simple things, you can go home at night with some degree of satisfaction. We all know that the average day will not bring those overwhelmingly ecstatic moments that you might want to experience doing this. But usually we can look in the mirror without needing to explain to ourselves why we do this work.

Sometimes we get to deliver puppies, or remove the cancer that would kill and toss it away in the bucket. The simple application of the correct medication can affect a cure. And on occasion, when the need is evident to all, we are blessed to deliver the gift of a humane death to a beloved but aged four legged companion. On such days, we done good.

And then there are the days like this past Friday. Mrs. Greatclient has been visiting this practice since before I arrived, and I’ve been here four decades. She can rattle off the names of forty-five years of her dogs, fond memories all. Decades and generations of dogs that she has presented, for both routine care and problems large and small. Not wealthy, but employed, so she fits into the better half of my clients, she has always done the best she could to keep her dogs happy and healthy. So she brought Brandy in that day to see if I could discover what had gone wrong with her.

It’s been a long year for Brandy. A boxer, she’d been a rescue dog, relieved of her duties in a puppy mill to move in with the Goodclients. At best we have an estimate of her age. But she is a doll, always a joy to work with, a patient companion for their other boxer who is a bit shy. One never goes out without the other. And Mrs. Greatclient and her husband dote on the two of them. This spring, when Brandy came up lame on her front leg, and I couldn’t get to the root of the problem, I referred her to a surgeon friend of mine who has a knack for fixing such things to see if he might help. Turns out Brandy has two bad knees, and two bad elbows, and they aren’t candidates for surgical fix, so the right combination of drugs and supplements have been applied, and they have worked wonders so far.

Then last week Mrs. Greatclient called because Brandy just wasn’t herself. ADR. She ain’t doing right, Doc. Brandy just lacked energy. She wouldn’t eat her regular food, but would only take treats from the hand. She drank a ton of water, but didn’t want to play long with the other dog. You could look into her eyes and see something was amiss.  Something, but nothing in her history suggested any particular problem.

I could sense her lack of energy, but Brandy’s physical exam was unexciting. I couldn’t tell what was wrong from that. So I pulled the blood tests, and without suspecting anything exciting, I sent them off to the lab.

The results came back via the fax machine the next morning. Liver enzymes OK. Blood glucose OK. Kidney numbers OK. Serum proteins OK. Red and white blood cell counts OK. Electrolytes OK, except for the calcium, which was way high. That twitch in the hair on the back of my neck…. For now it had gotten interesting. And like the brilliant soft-spoken detective of a mystery novel, I set my thinker to work.

An elevated calcium level by itself generally doesn’t cause major havoc in a dog’s body, but the things that raise the calcium level can. Calcium is the smoke, and I needed to find the fire.

A bunch of things can go wrong to raise blood calcium levels. A long list of bunch. In this job you mentally go down the list. The first three or four most common causes are malignancies, the answer we were hoping not to find. Then you run into the kidney failures, various poisons, monstrous dietary mistake, major hiccups of the parathyroid glands, and few other rare and weird things. Many of these answers would be tragic too, but some were repairable. And since my physical exam and the first set of tests hadn’t turned any problems I could blame, the mystery deepened.

The first thing to do is make sure that the calcium level truly is that high. Sometimes somebody mishandles the blood sample or the lab’s machine screws up. No point going all bonkers if the number is simply a mistake. So we repeated that test on fresh blood, and added in the second way of counting up the calcium, just to confirm. Both were elevated.

I also took the opportunity to recheck some of Brandy’s body parts, her lymph nodes and that rude grope around of her belly that I had done earlier, just to make sure I hadn’t missed anything. And I snapped on the rubber glove for the rectal exam that should rule out one of those cancers that can raise calcium levels. No change. These parts all seemed fine.

Another test, a check of parathyroid hormone levels was needed next. This hormone is responsible for raising and lowering calcium levels, to keep things at the right level. When it goes wrong, calcium goes wrong. And while she’s here for that blood draw, let’s take some radiographs of her chest and abdomen, just to rule out some things. Mrs. Goodclient took time off from work for this visit, so we must get a much accomplished as we can.

My wife, who happens to be my assistant, called me when the films were developed. I hadn’t found anything nasty to this point in Brandy’s workup, so I was hoping these would be normal too. 

They weren’t.

You can’t see the lymph nodes in a dog’s chest when they are normal. When they have grown to the size of my fist, you can’t miss them. Lymphoma. Lymph node cancer. I’d found the fire. So I also drew the job of telling Mrs. Goodclient. 

She wasn’t surprised, for I had prepped her for this eventuality. Ya can’t ignore the statistical probabilities in this game. I was trying very hard to find something I could fix, and instead found the bad thing I can’t. My heart sank, but this was nothing compared to what I landed on her. She nearly collapsed in grief, and had not my wife rushed into hug her, so the tears could blast out and defuse some of the internal explosion, I feared I might be calling 911.

The next day I fielded the phone call. Was I sure? Can we do some surgery? How long does she have, and how much will she suffer? The questions that always accompany the sinking in of such news. I answered each as best I could, explained those frustratingly few things we can do to help her precious friend. 

All that schooling, all those years of practical experience, all my best intentions, and the best I could do is try to break her heart as gently as I could. You don’t want to keep me interested. Sometimes I don’t want it either.

In which I *obviously* don't know what I'm talking about.

(ring, ring)

Client: Hello?

Me: Hello, this is Dr. VBB calling, am I speaking with Mr or Ms Message-leaver?

Client: This is Dr. Message-leaver, who are you and why are you calling?

Me: This is Dr. VBB from VBB Animal Hospital, returning your call about Fluffy. What can I do for you?

Client: My wife must have called you. Hold on.

Me: (holds on)

Me: (plays a turn in Words with Friends)

Me: (signs a few faxes & puts them in the outbox)

Me: (plays another turn in Words with Friends)

Me: (changes my Facebook status)

Me: (puts line on hold, releases a barbaric yawp, picks up line again)

Me: (plays another turn in Words with Friends)

Client's wife: Hello? Who's calling please?

Me: Hi, this is Dr. VBB returning your call about Fluffy. What can I do for you?

Client's wife: Oh. I wanted you to talk with my husband, the doctor. He says you don't know what you're talking about.

Me: Excuse me?

Client's wife: He read the label on that medicine you prescribed and it says it is approved for use in dogs. Doctor, I don't know much about this but I know Fluffy is a cat and not a dog.

Me: Yes. Of course. As I explained in your take-home instruction sheet, we are using that medicine in an extra-label fashion. That means that it isn't approved for this particular use, but that's ok. I'm within my prescribing authority to use it, as long as I've explained to you the potential down-side, and why we are using it, and I believe it is appropriate and you agree the benefit outweighs the potential risk. You said you understood this.

Client's wife: well, my husband says you don't know what you're talking about. Here, talk to him.

Client: Hello? What's going on?

Me: (sigh) your wife says you have a concern about Fluffy's prescription.
Client: What are you talking about?

Me: Gosh, well - I guess that depends who you ask. Your wife tells me you think I don't know what I'm talking about. That's what I'm talking about. Did you have any questions or concerns about Fluffy's prescription?

Client: No.

Me: Well, ok then. If that's all, I'll let you go. Have a nice-

Client: wait a minute. Are you the one that sent home the dog medicine for our cat?

Me: yes.

Client: Why would you do that?

Me: I'm using it in an extralabel fashion because there is no approved cat medicine for Fluffy's condition. 

Client: Well I'd prefer you used cat medicine.

Me: Sir, there-

Client: I'm Dr, not Sir.

Me: Excuse me. Dr Message-Leaver, there is no medicine approved to treat Fluffy's condition in cats.

Client: I don't believe that for a minute.

Me: Well, it's true.

Client: why would that be true? Do cats even get this disease? if they did, there would be medicine for it. At least some kind of clinical trial.

Me: The thing is, most drug companies aren't interested in going to the expense of obtaining approval for drugs when the market is going to be really small, and the profit very low. In human medicine I believe they call them "orphan drugs," right? But I've read a lot of studies about the use of this drug in cats and talked to some experts and I think it's fine. It's not like there is anything approved for use in cats that would be helpful here.

Client: you think it's fine? why should that mean anything to me? Who the hell are you?

Me: I'm Dr. VBB and I'm Fluffy's doctor, unless you'd like me to send Fluffy's records elsewhere. Would you prefer to seek Fluffy's care elsewhere?

Client: (silent)

Me: (plays a turn in Words with Friends)

Me: Hello?

Me: Dr. Message-Leaver? 

Client: I still think you don't know what you're talking about. (hangs up)

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???

Take Home Exam

“What do you think a passing grade should be? Let’s call this earning a C on your own report card. What does it take to earn a C?”

“Well…that would be getting it right all the time. Every time. Never making a mistake, always knowing the answer, knowing the diagnosis….. saving every patient.”

“That? For a C?

What then would it take to get an A? To give yourself an A?”

“I have no idea.”

“Don’t you think that’s asking a lot of yourself?”

“Of course. It’s crazy. But that is what is expected of me. And that’s what I expect from myself.”

Now, thinking like this will put you on the couch in front of a shrink eventually. Usually sooner rather than later. And there I sat.

Years later, in my early 40’s I took up target shooting to help me relax. Every Saturday afternoon, after I closed the clinic at noon, I’d head over to the pistol range with my trusty 22 Ruger. And I’d burn up hundreds of rounds of ammunition seeking that quiet feeling in my head that came about with the zen like concentration that target shooting demands. I fired a gun, surrounded by dozens of like-minded citizens all firing their guns, seeking quiet in my head.

My target was glued to a bit of cardboard roughly 20X 30 inches hung 25 yards from where I stood. The black bull on paper in the center was 4 inches in diameter. My task, if I chose to accept it, was to place 50 bullets inside that 4 inch diameter black dot during one ten minute firing period. After each firing period, I’d walk down range during the ceasefire and replace the center of the target with a fresh black circle, and then cover my mistakes, those holes punched through the paper outside the black circle, with masking tape. And then I’d start all over again.

I counted only my mistakes. After all those Saturdays over all those years, I had one target saved, thumb tacked to the garage wall over my workbench, which had only three holes outside the black. They were in the first ring outside the black, mistakes by less than a quarter inch. In all those years of Saturday afternoons, this was the best I ever did.

Having spent all those hours at the range, standing next to guys who were happy when they consistently hit the larger cardboard backing, I was proud of that target.

Showed that target to my mother once. She grimaced a bit, and sliding her finger lightly, in turn, across those three holes that were my mistakes, as if she were moving something across a smart phone screen, she quietly mentioned that if I had simply moved those three shots into the black, that it would have been pretty good. No C that day.

Expectations. Set your expectations too high, and you are often disappointed. Set them too low, and you stand to underachieve and disappoint. And when your expectations don’t match exactly with others’ there may arrive conflict.

Picture the fresh doctor, finished with the 8 or 10 or 12 years of college, heading out to save the animals and help their people, and pumped full of expectations. She has built a tremendous knowledge base, reworked her brain to assemble thoughts like a doctor, practiced her fingers to hold strange tools and modify flesh for good, and she expects…

Our fresh doctor expects to communicate seamlessly with her clients, asking the right questions and receiving in turn vital information about their pet. She expects to examine her patient and gain much useful information, so she expects the pet to be well behaved. She expects to utilize all that wonderful technology available to her profession to yield even more important information, and then she will feed that into her computer of a brain and she will then know what is wrong with every one of her patients, and how to fix it.

And then she expects the client to encourage her to proceed to fix her pet just as good as new. She expects to be paid for all this effort, talent, skill, and investment at a level where she won’t have to take a second job to support herself and her family. She expect to face the mirror and praise herself for a job well done.

Inevitably, her expectations may run head on into a thing called reality. The doctor will not be able to meet all of her expectations, for not every case will have an easy answer, or any answer at all. Not every answer is a fixable problem. And not every patient, nor every client, will be a willing participant. (See rest of this blog)

The doctor is now susceptible to that corollary of expectation, disappointment. Which often transforms into disappointment in herself. Long nights staring at an uncaring ceiling, frustration while filling in that stack of medical charts at the end of the day, and putting the done ones in one small pile, and the un-done ones in the taller mound. Sense of failure and self-incrimination. That rising dump of fear in the gut when facing one more trip into an exam room filled with questions ya just caint answer.

It’s not possible to earn a C in this racket. And forget ever getting an A.

And when you sit in the chair in the dark, late on a lonely night, with nonsense on the tube and not ever enough bourbon in the glass, and you think of those times when you failed, and the grief that left with the clients who left, and the tears come and the shivers that wrack your body, and you cry out for forgiveness because you cannot be perfect, and none comes. Well, then you know why the young ones question why, and then chose another way to spend their lives that doesn’t involve the pain and the frustration and the sacrifice. For why would anyone chose to do this?

Size matters

Your dog is big. So are you, really - I mean, you're about 6' tall & relatively muscular. I'm not petite by any stretch but you're bigger than I am, and your 100 lbs of aggressive guard-dog could definitely take me down. So, in the size contest - points to you.

You came in asking me to run some tests. Happy to oblige, but it's not clear which tests you want done. When I saw your dog last week and spoke to your wife, I referred her to a specialist. I subsequently spoke to the specialist to advise her of the incoming referral and discussed your dog's history and recent findings. The specialist told me we had done all the tests required so far & nothing further was needed. This is why I asked you which tests you wanted, and when you told me that "the specialist says we need a full blood panel - whatever that means - just do all the bloodwork you can," I got somewhat confused. That's when you told me you'd spoken to two specialists and it was the second one - not one I had spoken to - who recommended the "full panel." So I started to explain what various tests are available, which ones we had already run in the past six weeks, and which others might or might not be useful at various stages, and that's when you decided your innate size advantage wasn't enough. You had to make me feel even smaller. You had to tell me that I was obviously being obstructionist, I was obviously trying to prove that I am smarter than you are, that I was obviously feeling defensive because the specialist made recommendations I didn't understand, and that you should probably just leave without doing any tests.

It's funny the way you intended that to sound like a threat. You know. As if somehow, removing from my office a dangerously aggressive dog who does not actually require any tests to be done is going to ruin my day. GUESS WHAT? I didn't want to see this dog in the first place, and I don't want to take your money for tests that we don't need to do, so leaving really makes no nevermind to me. In fact, I'd prefer it....

What's sad though is that it did kind of ruin my day. I feel like a failure. I failed to communicate effectively. Your experience here was not positive. I replay the incident in my mind and I don't know how I could have done anything differently. I mean - I could have just smiled and said "full blood panel? Sure, no problem!" and then run a gazillion tests for no particular reason - but that feels really wrong to me.

Lennie

This bit was written about ten years ago, as two separate essays which I glued together here. I apologize for the obvious disorder. It's a bit tedious, but there is a point to this. 

"It is a fearful thing to love what death can touch"---unknown

Battered and bruised, the knight in shining armor lay on his back in a vast arid plain just downwind of Constantinople. The battle had moved on, but he would not. You don’t go far as a knight without your horse.

During the first Crusade, the armored knight was state of the art when it came to projecting military force in faraway lands. Educated, highly trained, and lavishly equipped, a knight perched upon his horse was almost invincible. Clad in interlocking iron plate from head to toe, he was protected from scimitar and arrow. His lance and sword made quick work of any opponent on the field of battle that was not similarly protected.

His horse was huge, weighing in at nearly a ton and leaving tracks the size of dinner plates. It was armored nearly as well as its rider and was trained to leap into the air to kick out at foot-soldiers that attempted to surround and unseat the knight.

Each knight had a cadre of men who supported him in the field. Their job was the care and feeding of this weapon system. They polished and repaired the armor and weapons. They catered to the horses. They helped prepare him before battle and nursed his wounds after. They peeled a grape for the knight if he that is what he wished.

But perhaps most important, they hoisted the knight onto his horse. For with the weight of all that metal, the knight was not able to climb aboard his own horse. In fact, his armor was so heavy, he could barely walk.

When the enemy managed to knock our knight from his horse, he became as helpless as a desert tortoise that has been rolled over on its back.

Peering out through tiny slits in his helmet, our knight couldn’t see much as he lay on the ground. He hoped he would be rescued by someone from his side of the war, but that was not to be. The voices he heard were Saracens. And they were not happy voices. 

The only gaps in the armor’s protection were the eye slits, two small ear holes, and a couple of joints at the shoulder and elbow that allowed the knight to move, which explains the Saracens’ affection for their daggers. The long, thin blade was just the ticket for extinguishing a non-believer clad in armor.

I can imagine how it must have felt to be trapped in that iron coffin, hapless, helpless, and hopeless, just waiting for the inevitable dagger in the eye. That’s how I felt when I finally realized that Lennie was going to die.

Lennie never really had a chance. When some kids brought him to the clinic he was a homeless, malnourished, undersized waif of a kitten. He had lice, fleas, and mites. And some sadist had left cigarette burns on his belly.

He found a home with my wife and me, and he tried his best to be a kitten, running all over the place, wrecking stuff, and getting underfoot. He harassed the other animals mercilessly, but in a few weeks we started seeing him curled up, sleeping with the big black and white cat, Orion. And he slid into any lap that was available. He was a great kitten, and he wormed his way into all of our hearts.

Lennie scattered toys all over the house, and we tripped over him in the kitchen and every time we tiptoed to the john in the dark of night. His litter pan was in the bathroom and he liked to join in whenever anybody was busy in there.

About the time the burns finally healed, Lennie started slowing down. He didn’t play as much and his hair began looking rough. And he was filling his litter pan with awful stuff.

I made sure he didn’t have any parasites and we changed his food, but the problem continued. Lennie wasn’t growing like he should either, but I chalked it up to a bad start in life.

Three months into his time with us he really started looking poorly. He just kind of lost his spark. I was ready to take him down to the clinic for the important tests when he just fell apart one morning. He suddenly lost his balance and staggered all over the place. I knew what was wrong before the tests even came back.

The virus had been in him all along. The best minds in veterinary medicine have come up with no cure for this one. As the doctor in the house I knew this, and I had to tell everyone else.

Like an un-horsed knight, I knew that despite all I could do against the right enemies, it would not matter against this one.

Our home is still full of animals, but it feels strangely empty. I still watch where I step until I remember I no long must worry about a kitten underfoot, and when I find one of his toys it drives a dagger into my heart.

Lennie, we miss you. Wherever you are, I hope you get a better start next time.

In 55 years of living and over thirty playing doctor, I've seen many really neat animals come and go. Some stuck around a long time, and some left way too soon. I brought this kitten home not just to rescue him, but to give my wife a few much needed laughs, as she is mired deep in an on-line masters program that provides far more stress than joy. And he did that, in spades. Watching him play and her giggle made this whole mad world go away for just a little while.

She used to call me in the middle of the day merely to tell me about the new toys she made for him and how much fun he was having. We both knew he wasn't all right at least a month ago. She kept asking me what was wrong and I kept avoiding answering her.

Once the vestibular and cerebellar stuff kicked in I couldn't dodge anymore. His lab work was pretty classic FIP. The drugs bought him about three weeks. He still had a head tilt and mild ataxia, but he forged his way through those little impediments without complaint. And she tried to drown him in love, even though she knew he would be leaving soon.

Through the whole course, I couldn't look in the mirror. I am supposed to be a doctor, after all. I brought this little life into our home to please my wife, and now look what I was doing to her. When the crying and seizures started at 4AM yesterday, I ran down to the clinic to get the stuff and let him go quietly while she held him in her arms.

Tomorrow, when the rain will have stopped and I can get home before dark, we will bury him out back in the little grove of redwood trees next to Sabrina, our old calico weirdo. She survived three bouts of hepatic lipidosis over the years only to run into carcinomatosis. I had to put her down last Monday, and we buried her last Wednesday. It's been a long two weeks.

Looking back on a lifetime of pets and patients, I have nothing but fond memories of the special ones. As I tell my clients, those are the memories that remain with us, when we lose all this painful stuff. Soon enough my wife will be able to laugh again as she recalls this little guy, and I will get back to what the gods actually let me do, which is to save some of them, and help their people through the rest. And we will be ever so grateful for the time we had with Lennie. It was a gift.