How Rich Is Too Rich?

The question I often ask is; How rich is too rich?

There isn't is there? Isn't that what we are all expected to say?

"You go get whatever you can. Build your empire. Have it all." It is the country's theme song.

..until you see what this breeds. In vetmed, one of the newest frontiers to wealth, (who saw that coming?), there is no limit. The price point to everything is escalating. It seems to have no boundaries, just an endless horizon.

Dixie. 141 pound St Bernard with a 5 pound pyometra emergency that was $6,000 at the ER.
Our community posted her story and raised all of the funds to pay for her surgery.
She is alive because enough people cared to make it happen.

Twenty years ago I graduated from vet school. The vet school was nestled in a rural, deep mountain, poverty stricken area. The small animal practice I used for my own pets was in the very rough, country, mountainous landscape of deep Western Virginia.  I was a fourth year vet student in need of a tape worm medication for my elusive, reclusive, outdoor-escape-artist had found it in her heart to deposit flecks of white undulating larva on my bedspread that morning. I called, asked politely for the medication and was told to come down shortly to pick it up. The vet clinic was a bustling, wood-walled, throw back to 1970, the early edition. Orange counter, long ago broken glass partition and a matronly woman long absent from etiquette class restrictions handed me the tiny envelope of praziquantal. "Fifty-nine cents." she said when I asked for my cats medication.

I stood at the check out window dumbfounded and paralyzed. Surely she had gotten this incorrect?

"What? (long odd college student perplexed shock). "How can that be?"

She didn't look up at me. She sat multitasking the phone ringing, the busy waiting room. She was as sick of college students as the rest of the full-time residents in this mega-college stuck in the mountains.

I persisted. "Isn't there at least a dispensing fee?" Here I was arguing the best example of poorly managed vet practices. She wasn't amused. 

"Don't you understand that your salary is a reflection of this sale? That the only way we can bring the earnings of veterinarians up from exchanging chickens for pet care is by adding a dispensing fee to all of the medications you sell?"

"It's still 59 cents." 

I rifled through the change in my wallet and produced 2 quarters and a dime. "Keep the change." (Put it toward your 401K, I whispered. Smart-ass senior vet student one arm fisted protest in the air as I departed. Slightly proud of my college student frugal gain.

Scooter. Dying when he arrived. We managed him in the hospital on a diagnostic restricted plan. He is thriving now. His parents just needed help in managing his care. Help can come in the form of listening, donating time, asking for medications from the manufacturer reps, and just basic medicine.
He is 3 years old. He deserved this chance. He is a purring, biscuit making miracle. The first time I met him I fell in love. Every moment with him was an investment in my self worth. He reaffirmed my dedication. There is no price for that.

I bought Jarrettsville Vet a year later. It was a win-win for both parties. I am eternally grateful to have bought a clinic from someone who wanted it to keep its heart and soul alive. It was passed on to me to be its guardian. I truly feel that way. There was a decade of catching us up to speed on basic goods and services and the cost and value of them. I remember cat neuters being $15. They were real down and dirty raw bones. I was proud of that. Getting a Tom off the streets to help curb the tide of unwanted kittens was my singular goal. Profitability would have to come from another aisle.

Yesterday the neuter for Bo, a 7 month old male tuxedo cat was $187. It included being intubated, on general anesthesia, pain medication, a local anesthetic block, post op fluids, and an antibiotic (his siblings all have upper respiratory infections and he sneezed twice after his neuter). I am still really proud of that price. I don't know of any other for profit clinic that even considers turning on isoflurane for under $300. He was pain-free and given 5 star care. He had a well trained surgical technician with him the whole time. Further he was cuddled and loved from drop off to pick up. 

The standard of care for all pets has consistently gotten higher. The prices we demand for this has also increased. The blossoming of specialty care, the multitude of avenues that pet parents have available to them for their pets has also become accessible. There are specialty hospitals for dialysis, transplants and the equivalents to the most costly aspects of human medical interventions. It is truly astounding what your rescue cats and dogs have in the way of medical care, if you can pay for it. There are specialists topping 7 figures. It is not uncommon for a pets care to be over $20,000 at a specialty referral center. Whilst our portfolio of options for care have grown, our compassion for feeling ethically obligated to provide universal care has not. I would add that the perception of offering care to all simply because we can has diminished to a shockingly scant level. There is a pervasive feeling of pets being better off dead than lowering our profit margins to assist in their chances to survive. (And lets all be real honest here, those young cats survive against all odds with the most horrific injuries. Don't we all remember the meme about a cat broken in a million pieces and a paper bag? 

The vet school teaching of this goes something like; "Put a broken cat in a paper bag and forget about it for a few weeks and it will heal." After 20 years of practicing "save them all" medicine, I will tell you that it is true. The ones who die do so because of parasite anemia, bombarding of infectious disease, and a very very few from congenital defects. Of these the congenital defects are the only ones who should be dying. Modern medicine doesn't need its fancy modern frills to save the others. Heck, they may not even need medicine. They just need someone to care enough to help.

We are living in a time and place that breeds more selfish indifference. It is as deadly as anything else modern times will ever face. Every single human being needs to be asking themselves what every single veterinarian does with every case that we see.

My kitty Raffles. My constant, at home reminder of who I am.

Is this life worth saving? Is the question about why we shouldn't ever more than the money we need to encourage ourselves to answer this question with kindness and compassion in our hearts? And, what does this answer say about humanity and our part within it? 

Wealth, well, I suppose we all have our own definition for this. Me, well, I am just as wealthy as I was when the cost of a dewormer was 59 cents. I just didn't realize it until now. 

I was only poor when I saw the glass half empty. The really sick kitten as "replaceable" and "unwanted." I was only poor when I let the world remind me that this vulnerable soul of mine was for sale for a salary of someone else's profitability.

Shouldn't we all be asking the same questions? Isn't too rich that place where your ability to have an ethical compass is lost? I think that too many people in vetmed, and most professions, have lost their ability to be inherently wealthy by virtue.

Seraphina. The rest of my everything

Teetering

 Seems I teeter on the edge of more cliffs than I want to claim ownership of.

The brink of exhaustion. The edge of burn-out. The constant realization that I am not enough in any of the capacities I expect myself to be.

I accept that the dams break under my toes. I know that it will happen. I expect and brace for it. It has happened so many times that I am at a loss to find annoyance or dismay upon it.

"No Good Deed Goes Unpunished." I am fairly certain that I have titled this for more of my blogs than any other sentiments combined.

My Seraphina. She is my daily reminder, my touchstone, my beacon to remind me that kindness matters and has lasting resonance. Brought to us so injured we didn't know if she would survive.
See her full blog here.

You see the world is full of turmoil meeting unmet intentions. I am no different. I can hope for more, but in reality I am met with the same. A long list of too many moving parts to allow the engine to run seamlessly. Too many people too passionate about the pets in their lives that they have nowhere else to go. And, like a fool who refuses to accept the lessons previously presented, we open the gates. 

Yesterday a pit bull who could melt your heart with her cow-eyed pity abused, neglected and dismissed until someone found her by the literal train tracks at the near end of her rope. She needs a lot and she was found by someone who doesn't have a lot. The needs and the expectations far outweigh the availability and charity. She came to see me. Overall, if you can put the obvious skin defects out of focus, she is doing well. She needs time and stability, but she now has hope. That was my diagnosis. It wasn't good enough. They wanted the moon and the stars and to be the veterinarian writing scripts and filling meds she wouldn't benefit from. They wanted surgeries, social media posts about her terminal condition. They wanted me to be the wordsmith to the public plea for attention. No one is happy with kindness anymore. And so I was met with another bashing email. A public post about "disappointment" and another internal reminder to ask myself who I am and why I am here. And, maybe if it is time again to retreat into the darkness and shutter the gates.

Oreo. My clinic cat. They all start the same.
A cat no one wants because no one sees the value in them.
He is 100% adoring affection.

Yesterday there were 5 clients I got to spend time with. Five people who I know and adore and trust and feel honored to care for. And this one piece of self-righteous anger is the one who leaves me feeling half-empty. That's life I suppose.

Rainy Days and Solitude

There is something universally consoling about the kind of rainy day that makes all the decisions for you.

The kind of rain that does not permit safe passage. Does not allow the outdoors to be anything more than a backdrop. The kind that measures the dogs bathroom needs by a stopwatch.

Today, god-granted, is one of these days.

Raffles

It is screaming rain in torrents. The house is my refuge and even unto this, my old stone manor, I am forced to check the corners, crevices, and crawl spaces for ingress. Nature, that Queen who fates us all, takes her time but always finds her way in. This house has been here for 200 years, and still her roots get washed every spring and fall. 

I am expected at the vet clinic soon. I had been trying to ignore my phone as it flashes the latest queries about my arrival time for the newly requested cases that never abate. The rain seems to insulate and buffer but it doesn't provide refrain from the rest of the pet world with their vomiting, diarrhea, and urinary blockages. Much to my dismay, and even with the fierceness of this wailing water, I can hide but I cannot evade. Biology might be the engine to nature, but Mother Nature will always be the dictator.

Magpie, Storm, Frippie

The cats have decided to nap the morning away. They take small eye opening breaks to peak out the windows, but return to their spots of sleep as the only souls around here who truly never care what day of the week it is, nor how much their parents have on their endless to-do-lists. I know how lucky they are to be here. Safe, warm, well-fed and beloved. For so many I see it has never been anything they know or can imagine. Even as I remain begrudgingly reluctant to face my impending day I am grateful for them and their care-free existence.

Nature reminds us that we are small, meek and transient. Just like the rain I will be a force today and quietly settled at home for a day off tomorrow. For now, it's time to pack up. Tell the cats that I hope they feel fiercely independent to make whatever decisions their heart desires, and to the dogs that maybe they can muster their primitive selves just long enough to remember to pee outside even if it means getting your paws wet. They seem to lack trust in me that they won't have to remain there long. I won't shut the door behind them. And, so I go out just to get battered by the rain as a small sacrifice that we are in this together.

Blocked Cats, UO, How Far Has Veterinary Medicine Fallen?

Blocked cats are my professional obsessive jam. The urinary blocked cats, this one disease which is almost always curable, (and, lets be real honest, how often can we say that in vetmed?), affects primarily young otherwise perfectly healthy cats. It is also the most egregious example of how far vetmed has distanced itself from helping the patients who need us most. In the olden days, (i.e. the days of my formative veterinary exposure, when the music was 80's pop and the hair was big), the vets that I worked for would have never-ever, ever, even contemplated turning a blocked cat away. It wouldn't have mattered whether it was 5 minutes until closing, or, if we had never seen the cat/pet parent before. Nothing would have stopped the vets of the days before the specialists, the fancy ER's, corporate ownerships and astronomically expensive off-shore vet schools from treating these cases, and doing it affordably. Vetmed was so honorable in those days that we offered help and asked for payment later. There was a foundation of trust, a pragmatic approach with integrity, and every vet knew that they had to treat or the guy down the road would. We never passed the patient by. We always had the practices credibility on the line. Every client mattered, and, therefore every pet mattered. Euthanasia was reserved for the cases that failed to get better after we had done our best to provide what our patients needed, never before. 

UO (urinary obstructed) cats are the best example I can give of how much vetmed loves money, and how horrifically we fail the most underserved and vulnerable among us. If I had one wish it would be that every single veterinarian loved this jam as much as I do. Every single veterinarian would see these patients as miracles just awaiting our healing hands and a little reconstituting from a slow iv drip. How can I help other vets see these cases this way? How can I inspire and motivate a whole profession to look deeply into the eyes of a treatable feline, remind themselves to invest all that we are, and save them all? How can I remind us to be kind, to be compassionate, to help people who desperately love their pets like family, and  save the world, just because we can?  

This is Figaro. This is his story. His life, his chance at surviving his acute urinary obstruction, and all of the accolades, frustrations, desperations, and phone calls his mom had to make to save him. This is what vetmed has become. It is also everything vetmed should be ashamed of having become. 

Figaro is a young, healthy cat who has been loved, cared for, taken care of his whole life. He has been to all of his vet visits, and his mom has done everything she was ever told to do for him. He was perfect and loved, until he was sick, very sick, and his mom rushed him back to the place she knew he belonged. The place where people would help him.

Figaro's mom noticed that he was not feeling well. He wasn't walking normally, and he wasn't eating or drinking. She called her vets office immediately and they told her to take him to the ER. Which is technically the right answer, and all too often the only answer most small, private practices, already too busy to stay on time veterinarians will give. The biggest problem with this answer is that this is too often a place that most pet parents cannot afford to utilize. Most pet parents walk into an ER expecting that the veterinarians will help them. Save the lives of the pets they adore, and be treated with hope, respect and compassion. This is what you will get if you have deep pockets. Financial stability and access to about $3,000 to $30,000. This is what vetmed is today. This is what all of the things that veterinarians, corporate ownership, and lust for profits, salaries and mental well-being cost. It just costs lives too.

Figaro's mom went to her vets office anyway. She knew them, they knew her and she wasn't comfortable being sent somewhere else. They left her in the waiting room, took her cat to the vet in the back and the vet palpated a full, hard bladder and knew he was blocked. She sent her to the ER.

This is Figaro's mom's letter about her experience. I asked her to write it because she is not alone. Figaro is one of so many that I see. Figaro's mom was just brave enough to share her side. She is a survivor, and now so is her cat. She is an advocate, a voice, and a beacon of hope that the profession will start to listen. 

Maybe if enough people start to ask themselves how their part contributes to this responsibility will will begin again to protect with compassion. We will do so because we can, and because we want to. Because this does save the world. It does pay forward, and it is what we owe those who came before us and those who will follow after us.

The ER did what they always do in these cases. They alert you to the cost of the exam. The technicians collect a history and your pet goes to the back for an exam. The exam reveals a hard, painful bladder that cannot empty. You are given an invoice with every possible diagnostic needed, every bad turn, and every worst case scenario covered. In the last decade the estimates for this have gone from $2,000 to over $8,000. 

Figaro's mom was given a $2,700 estimate.

I don't send people to the ER without warning them of the estimate that they will be given. Why? Well, because I didn't go to vet school to send my patients to a euthanasia based on economics. I didn't go to vet school to send my patients elsewhere to be denied care. I didn't go to vet school to send my cases to other places who aren't going to help them. I didn't go to vet school to have my clients feel ashamed, embarrassed, humiliated, and helpless. In some cases these otherwise young, healthy perfectly normal perfectly fine cats are euthanized as the most "compassionate way" to treat this disease. We call this economic euthanasia. In other cases the pet parents can only afford a quick unblocking and then they get sent home. This treatment option, although relieving the immediate problem, makes the next unblocking (you the ones I get asked to do a day or two later) much harder to do. 

Figaro's mom had access to $400. Her estimate at the ER was about $3,000. They, (to which I have to add that I am surprised and hopeful that this is the first crack in the facade of finding a way to provide care outside of the approved corporate income driven recipe), offered care based on the clients ability. Was it great care? No. Was it ideal care? No. It was a quick palpation to diagnose and a passing of a urinary catheter to remove the obstruction and then he was sent home. 

He was sent home without all of the care he needed. He was heavily sedated, poorly responsive and his mom had been firmly told that Figaro needed to eat a special diet, and only this diet, for the rest of his life. He was so depressed, chemically incoherent and incapable of walking, eating, or responding to her pleas to eat the food and use the litter box (therefore proving to her that he wasn't blocked again). 

Figaro's mom called her vet the next morning. They couldn't fit her in until the next day. She was so worried that he needed to be seen sooner that she started calling other vets offices. She called explained Figaro's dilemma and then added that she had no money left. She kept calling when everyone turned her away.

She called us and told us that she was worried he had reblocked. We told her to come in to see us immediately. It helped that I was at work and the staff knows that this is my jam.

Figaro was not blocked. He peed as soon as I gave his bladder a gently squeeze. He was gorked on the medications from the ER, and needed the extra time that the $2,300 would have gotten. He needed intravenous fluids, pain medication and an antibiotic. He needed the toxins that build up in the kidneys after you cannot pee to be flushed out. So that's what we did. Figaro only needed a few things from us. He didn't need a long stay, or an expensive list of invoiceable items. He was a cat who needed just a little more help, with a mom who needed help on how to take care of him. Figaro and his mom needed us to be what all of us should be. Helpful on their terms.

The next day we got a call from our local Animal Control. They wanted to confirm that Figaro had been seen by us?

Seems someone had dropped a dime on Figaro's mom for cruelty and neglect after she had failed to show up for the recheck appointment she said she would. 

Here is where Figaro's story takes its next troubling turn. What was Figaro's mom supposed to do? She knew he needed help so she reached out to the place she had always gone to. They sent her elsewhere. They sent her to a place she couldn't afford. Then they give her a discounted service that isn't enough for her cat, and then call Animal Control on her. They report her. 

If she hadn't found us it is very likely that he would have been in much worse shape the next day, or that they wouldn't have given her a way to pay? What then? Likely AC would have forced her to find a vet, or, bring him to the shelter to be euthanized. Figaro deserves better, so does his mom.

Our Office Manager called the ER to inquire about why they called Animal Control to report her. This is the reply they gave us.

I did call the ER to discuss Figaro.  I spoke with their Hospital Director.  Please see highlights below from our conversation -

 

• ER saw Figaro to unblock him
• Owner only wanted Figaro unblocked and wanted meds to go home. 
• Owner seemed untrusting of ER and did not seem to understand how critical a blocked cat can be. 
• ER discharged Figaro under the impression he would be seen at original vet office the next morning, however no Direct Transfer of Care was in place
• ER has a pamphlet that they give clients who are struggling financially.  The pamphlet includes resources and information for Vet Billing, they did try to point her in the direction of Helping Hands and let these folks know they should try to find a vet that accepts payments.  I am surmising that this may be where they get our information from, if they go to the VetBilling website and search for a vet in the area who participates they find us. 
• The following morning owner called as Figaro was not doing better, they were surprised that she was reaching out as she had told them initially he would be seen at her original vet office.  It was in that conversation that she told them that she did not have an appointment with original vet office until the following day, 8/28
• It was at this juncture that they did call AC for a wellness check - they were concerned that owner did not understand how critical Figaro was and that she had been dishonest in when he would be seen.  They were concerned he would not be seen at all.

What would you do?

What would anyone with limited resources and a pet they love who is in desperate need of help do?

How does this profession address these cases? 

How does the veterinarian, who is justly worried about Figaro, do?

It is with all of this in mind that Jarrettsville Vet has started to have these discussions.

This is the letter we are now using with clients when we can't decide what to do with a case that burdens our hearts, pulls our compassionate souls from our guts, and leaves us unable to sleep at night. 

“We care about your pet and your pets care.  We are concerned that there was not a follow up appointment after the veterinarian recommended it. Your pets condition was not stable enough to provide a dismissal of care. Please call us to arrange a recheck appointment or let us know if you found a recheck appointment elsewhere.

If you have any concerns about the cost of this care, or any future care here at Jarrettsville Veterinary Clinic please call and ask for me or one of the other managers. We will be happy to offer options for you and your pet.

We have called the numbers we had on file and sent an email to address you provided. We hope to hear from you by the end of business tomorrow. If not we will these concerns on to animal control to be in accordance with the state mandates. “

What do you think?

Here is what the ER has come up with to help cases that come to us.           

The ER is 100% on board to do this and do regularly do so with a Direct Transfer of Care.

• With a Direct Transfer of Care they will send everything in place.  They will suture in a urinary catheter, send IV, etc.  They also will not fill meds there as the client could fill cheaper at their regular vet.
• A conversation between doctors is what initiates the Direct Transfer of Care.
• In the past owners have said they were transferring to their regular vet and didn't, they had a pet return septic when a catheter had stayed in place.  Therefore they will not leave everything in place without that conversation.
• If one of our clients is in conversation with one of our doctors about transferring care it is important that our doctor reach out to the ER so the Direct Transfer of Care can be in place.

Here is the site for Maryland reporting of animal cruelty. 

So where do I go from here with my resolute disbelief of how far we have come, and how much we are enabling suffering for both our clients and our patients. Well, I suppose you will have to wait and see.

Letter To UPenn Veterinary Teaching Hospital Seeking Access To Care

 Access to Care

There are those of us who live our lives with the hope that our pets will find us worthy. We spend the majority of our time giving gestures of thanks for all that they give us. We feel humbled by how little their loyalty costs, and yet we still want to offer them more knowing it will never repay all that they give us. The relationship between ourselves and our pets, with whom we share the most painful, joyous and raucous moments of our lives, is unsurpassed. Our pets are our truest, most trusted, most faithful companions. They give us so much without asking or expecting anything in return. Most of us would chose them over any other person, even those we call a relative. This, this single sentiment, has forged many a veterinarian to face arduous years of disciplined study and turmoil. Those quiet, unseen moments with them for that one soft purr, a gentle wag, a velvet ear and wet nose, for these we would, and do, give everything. 

Jenn and Johnny Cash

Johnny Cash was the beloved dog of our hospital manager Jenn. He was growing older and like most large shepherds, was struggling with issues associated with his breed and age. He needed help getting up, staying up, and his self- assigned guard duties pressure suffered as these progressed. Jenn was determined to do everything for him. During the course of almost a week he went from not feeling well to unable to stand, eat or interact. Over that time he was given an immense amount care from the staff of our clinic. When one of our own is not doing well the hive swarms around them to lend a hand.

This is a story of love and the dedication/devotion that all pet parents feel when their pets life is tenuously suspended on the precipice of life meeting end of life. Veterinarians, those of us in the sweaty, grueling, chaotic trenches of day-to-day medicine life forget this. We lose sight how much we are needed. How much power we yield, and how devastating the loss of our companions can be when we fail to live and deliver the purpose our knowledge and skills provide. There is the potential loss of a life with every patient we see. We veterinarians know that. We are so used to it that for some it is an acceptable, albeit an inevitable sequela that it permits a degree of indifference some call a "healthy boundary." It allows us to practice without prejudice and without emptying our own internal well so thoroughly that we can go on to help others. What we forget is what the loss of these patients does to their family. The void of losing their unsurpassed love, and the living through the phases of grief that loss requires. But, the real pain of too many of these situations is the cold, indifferent manner that we treat those coming to us for help. This is the place that vetmed has gotten itself to. We did not come here to be this. We must never forget why we are here, and what kind of legacy we are building as we walk each footstep of our professional life.

Within the week Johnny Cash's decline he was given 5 examinations, 2 ultrasounds, 4 full lab works, 2 internal medicine teleconferences, 3 x-rays, and two radiology reviews. Every person at our very busy practice was working to help him. 

When his disease eluded us, and he continued to slip away, we knew we needed more help. We did for him what we would do for every case we cannot figure out fully, we referred him to those who could. In our part of the country the most competent place we can send a patient is the University of Pennsylvania Veterinary Teaching Hospital. 

The veterinary teaching hospital is the foundation of all that a veterinarian holds as the building blocks of who we are and all that we hope to be. There is no other place that holds greater power nor greater minds. These institutions employ the most notable, credible and wizard-like masters. For the greatest medical minds of our world, these 30-odd colleges represent the best of our abilities and the fringes of our most modern advancements. They built us, each one of us, and for that we are forever indebted. They also hold unparalleled optimism for the cases we cannot heal. With great power comes great responsibility. This is where we sent Johnny Cash as our last hope to help him, and Jenn. 

This is the communication sent back and forth over Johnny Cash's care. The first is Jenn's letter about her concerns and experience when she brought her very sick, very fragile, very much loved Johnny Cash to UPenn. What concerned her the most, as we look back on this, was how hard she had to advocate for her dog. How hard she had to insist on being heard, and how, if she hadn't been an "insider" and hadn't had me on the phone, 3 times during her stay at the hospital, she would have paid $6,000 to $12,000 to be given his diagnosis. Within the course of 4 phone calls (1 to transfer him in, and 3 while she was there) I, me the referring vet, had to repeatedly remind them to use the skills we were all taught. Listen to the history, listen to what the patient tells you during the exam and start with a presumptive diagnosis and a minimum database for that presumptive diagnosis. JC needed 1 abdominocentesis after an ultrasound and we had our answer. He came back to his vet and we helped him from there. All of this could have, should have, been done within a short time. We were very clear on our needs, hopes, and expectations. We just weren't heard.

What strikes me as the most unacceptable part of her experience is that she wasn't treated as the instrumental part of the patient care experience she should have been. This is a teaching hospital. The safest place for anyone to be. The place where mistakes are used as the crucial crucible of molding future veterinarians. It is the place where asking  questions, challenging all aspects of medicine, and putting the patient above all else should happen. It should be encouraged. Nothing is more important than preserving the bond between a pet and their family. Nothing is above being kind when faced between choosing being right over being compassionate. This is another crucible of a veterinary teaching hospital.

Jenn's letter to UPenn after her visit;

Good Morning,

I am sorry for the delay, as its been only a week since I lost my beloved dog and articulating our experience in a coherent manner does not come easy.  

I do want to preface this email by saying that I have utilized both Ryan Hospital (2019) and New Bolton (2021) in the past and was incredibly pleased with my experience and the care that my animals received. We were treated with respect and compassion. This experience was so outside of the norm I know from Penn.  As stated in Dr Magnifico's email, she had called ahead as the referring veterinarian to the Emergency Department hoping for a second set of eyes on the case. We were asked how far away we were to which we stated about 2 hours. Records were forwarded outlining all we had done in our clinic and Johnny Cash was loaded into my car on a stretcher. I kissed his head and promised that we were trying to help him. 

I arrived at UPenn on 1/23/2024 around 3: 15 pm. The stretcher was loaded onto a gurney to take him back. I gave my information at the desk and signed all consents. Our stretcher was brought out along with the blankets that he had soiled. 

Around 4:20ish I met with a 4th year student to give Johnny Cash's history. 

Around 6:30ish I finally met with the attending to go over her assessment, more than 3 hours after we arrived. I was told that we needed to start "at square one" with diagnostics. It was recommended that fluid be pulled off his abdomen for assessment. I was told his pulses were low. There was concern for cancer and that he would need to go to the ICU. I was told a urinary catheter would be placed. I questioned this as he was not outputting urine despite being on fluids and was told this was to keep him clean. My estimate to start was $4,000 - $6,000. I was a bit in shock as we had called ahead to see if we could send him for a second set of eyes, along with record of everything we had done in our clinic over the prior four days. I wasn't sure why we would need to start at square one. When I questioned this I was told nothing was open at this time to do any diagnostics, ultrasound, etc.

I questioned why we were told to come up, two hours away, if there was no ability to provide the services that were requested. The attending told me that she would look through the referral log to see if there was anything recorded there, which she stated there was not. I was given the option to return in the morning when we could have the necessary testing which would eliminate the cost for overnight care and likely be around$2,000 but result in a total of 8 hours of driving with a dog who was in critical condition. After a lot of back and forth we agreed to at least pull off the abdominal fluid before we left. Some time around 7:30 pm his abdomen was tapped. Around 7:43 pm we were given the news that the fluid was septic. My estimate changed from $8,000 to $10,000 to start as he would need an emergency ultrasound and surgery. I made the decision to take him home to euthanize at our clinic in the morning.

As a pet owner, and someone in the veterinary industry, I have several concerns;

• I watched as less critical pets had histories taken quickly. They quickly met with an attending and  were even discharged before I had even met with the attending. If my pet were so critical an ICU was recommended shouldn't he have been assessed before the easy "in and out" cases? (Specifically a Golden Retriever with an eye injury stuck out in my mind, (although there were others). Are cases not assessed for urgency? (Maybe if mine had he would have gotten the services he needed before clinicians left for the day?). Your own website states "Patients are seen on a medical priority basis. Waiting times for clients can vary depending on the caseload at the time of presentation. All patients in life-threatening situations are immediately brought to the treatment area, where the emergency clinician performs a physical examination and provides emergency stabilization." Given our timeline this does not seem to be accurate.
• I was told that my pet could receive "better care" in the ICU than what he was receiving at home overnight. Yes, my dog was hospitalized at home overnight, under the care of someone who works in the veterinary industry and under the direct supervision of a veterinarian. These were the exact words used, and they stung.
• My dying dog was given no pain meds, even when we knew his abdomen was septic and I stated he would be euthanized in the morning at our clinic. A dying dog who was septic was discharged and given no pain meds.
• A week later Johnny Cash's records have yet to be sent to Jarrettsville Vet, I am glad no next steps were hinging on this.
• While I could have likely come up with $4,000 I was told that the $4-$6k estimate was "to start" I work in the veterinary industry because I love animals, unfortunately a love for money does not align with a life in our industry. I do not have unlimited resources. $8-10k to start was completely outside of reachable, and I fear this would be the case for many. I know most of our clients would not be able to manage this
• I have read over your Client Rights on your website, (see here), Johnny Cash and I were failed at every bullet point within those rights.

As humans we have evolved to love our pets as a part of our family. We love them in many cases more than we love many humans. We often grieve their loss more than that of a human as well. Somewhere along the way many in the veterinary industry seem to be capitalizing on this love and in turn emergency care is becoming out of reach for most. If this care is out of reach for someone in our industry I fear what that means for our clients.

I am grateful that I brought my dog back home. He was taken in for an emergency exploratory surgery at our clinic as a last effort to save him, and although that was not possible, I did get my answer (diagnosis) and with that came peace in letting my beloved companion slip away peacefully. I was only given this because I work at Jarrettsville Vet. My heart breaks for the average pet owner who would have had to make the decision to let their pet go amidst an impossible starting estimate, never knowing the diagnosis. 

While we worry about mental health in our industry the reality is there is a pet owner who is more often than not, loves their pet at the other end of the leash or the carrier who deserves to be treated with compassion as well. I hope relaying my experience somehow helps others; I have the unique perspective from both ends of the spectrum - someone in the veterinary industry and a pet owner.

Thank you for your time,

Jennifer

There were two phone conversations that occurred as a result of this letter. One with the UPenn social worker to better describe the care and client experience Jenn received. The second phone call was with the Emergency Hospital coordinator and an ER clinician. It was not helpful to Jenn, nor in any way reassuring to me that what happened to her and Johnny Cash, wouldn't happen again this evening. There was an apology for Jenn's loss, a defensive posture that he was well cared for at their facility, and a lot of excuses and firm language that they are compassionate, AND that they do offer a spectrum of care with affordable options being given when clients have financial constraints, and hurtful commentary from two veterinarians who want to stand by all of the reasons Jenn's concerns were wrong. It was a shocking phone call that further reinforces the state of veterinary medicine in this country.

After we got off the phone with UPenn and after we had put all of our thoughts, grief and taken the time to bring Johnny Cash's case into the learning and call for concern with the state of vetmed, we decided to write an open letter to all of the referral centers around us.

Jarrettsville Vet never puts a pets ability to have a chance at a treatable outcome, and a clients ability to have hope, behind anything other than our mission to Always Be Kind. This is where medicine starts. Where it lives and the only place it can succeed. There needs to be a better place for the conversations to start then the estimate. 

The letter reads;

Dear Referral Facilities,

    We hope that this letter finds you well. We are writing in regards to the patients and clients of Jarrettsville Veterinary Center. It's our hope and goal to honor our promise to stand by them in doing what is best for their beloved pets.

    We understand that emergency situations can arise unexpectedly and we want to ensure that the best care is provided to our clients/patients during these times. We also believe that every life is precious and deserves to be treated with compassion and respect. For this reason, and any other, should a decision ever need to be made to euthanize a mutual pet due to financial constraints please reach out to our facility.  We want to make it clear we do not condone this type of practice at our facility.

    We are dedicated to providing the best care possible regardless of financial constraints. We believe that every pet deserves a chance at a happy and healthy life. We will work with you and our client to find a solution that is in the best interest for all involved. Dr. Magnifico is happy to include her email and personal cell phone number to the DVM's and practice management staff to offer help when needed.

    Kindest Regards,

    Krista Magnifico, DVM

    Owner Jarrettsville Veterinary Center

This letter was sent to about a dozen referral and emergency practices within a 2 hour drive from our clinic. As of today we have received these affirmative acceptance replies; 

The UPenn Ryan Veterinary Hospital and Mason-Dixon ER in Shrewsbury, Pa. and the Animal Emergency Hospital in Bel Air Md

This week I tried, again, to refer a patient to UPenn. I was not able to provide the transfer without an authorization that the client would be able to afford the projected estimate even though, as in the case above, the diagnosis, diagnostics, and treatment plan were unknown. They, once again, and as they have previously, were more concerned about sending a client with financial security to allow for the full spectrum of possible care, then helping a patient/client in need find care that mattered to them. 

 

School of Veterinary Medicine

Department of Clinical Sciences & Advanced Medicine – Philadelphia

3900 Delancey Street

Philadelphia, PA 19104

 

 

July 11, 2024

 

Dear Dr. Magnifico,

 

Thank you for reaching out and for your thoughtful message. We appreciate Jarrettsville Veterinary Center's commitment to providing compassionate care to all pets, regardless of financial constraints.

 

At Penn Vet, we share your values and dedication to the well-being of our mutual patients. We understand the importance of ensuring that every pet receives the best possible care, especially during emergency situations. Your offer to collaborate and find solutions to avoid euthanasia due to financial difficulties is truly commendable.

We will certainly reach out to your facility if we encounter any situations where financial constraints might affect the decision-making process for a pet's care. We kindly ask that you discuss estimates with your clients and notify us of any financial concerns when referring a client to us. As we have many clinicians that rotate through our emergency service, this will be a critical step in communications to ensure that the emergency care team helping your clients understand the terms of your support and that nothing is lost in the transfer of information. Having your contact information will be incredibly helpful, and we appreciate your willingness to financially assist clients in such circumstances.

 

Thank you once again for your partnership and for your unwavering commitment to the health and happiness of the pets we collectively serve.

 

       Sincerely,

        PennVet -Ryan Hospital of the University of Pennsylvania

I will be reaching out once again to UPenn to discuss the practice of putting estimates at the gates. The estimates are formulated based on the referring veterinarians findings and suspicions. This estimate is based on many possible scenarios and presumed diagnostics, with presumed treatment plans. All of understand that this is difficult to cement into a narrow dollar figure. What it costs most clients is the fearful restraint that a large dollar figure, a potentially looming poor prognosis and the healthcare plan starting out, and being presented with financial influence at the welcome mat is both unkind, uncaring and costing care we can in all and every case negotiate and compromise. It seems, with all of the recent cases that we have sent, that the gates ability to open rely on the opening estimate. How can a learning institution practice medicine to train its students who will provide care to all kinds of clients with the admission set at worst case?. If they truly want to provide all clients options and follow the standards we were all taught, then these estimates have no place in greeting clients and patients BEFORE they are seen.

I have been a private practice veterinarian and practice owner for 20 years. There has never been one case that we have not helped in a manner that doesn't put the patient first, and the client feeling as if they are the at the center of everything we do, and that every patient has a team based approach.

There are many points of Jenn's letter that I understand as a veterinarian that are harder to explain to a client. The timeline. A clients idea of the passage of time is very different from the veterinarians. While I try to stay on time, Keep every client apprised of the time I am taking and explain/excuse why it is taking so long. It is inevitably impossible to be able to complete a complicated case, with all that we have to do, discern, digest, diagnose and report. Time in the clinic, on the floor, with a difficult case seems like seconds while the client is sitting for hours. We are always. always running behind, over extended, and never is there a moment where we sit down, relax, or eat, drink, or even pee. I will give them the time frame. I empathize.

The idea that any of us read every piece of paper, every diagnostic, each step another vet has taken, well, in reality we don't. We don't have time. And, after all, everyone, every other vet is is a charlatan. Don't waste your time reading over some half-wits work,, they couldn't figure it out, why waste your time looking at what they did.

No, what really lights me up is that they treated her like she was just another client. Just another replaceable mom, with another dying pet. She is a mom who loves her dog. She is the client we all worked so hard to get into vet school so we could take care of. She is the medium of all of our dreams. She almost walked out because they couldn't/wouldn't see her past their estimate. What an utter failure to even attempt to be anything of value. It doesn't matter what you are capable of if you cannot remember why you are here.

I welcome an open dialogue with UPenn, every ER, and every person who seeks help for the pets they call family. 

Please share your story of your pets care at Pawbly.com storylines section.

Tomato Sandwiches

In the closing days of July I can be found eating one singular thing in mass quantities; a tomato sandwich.

A soft, squishy, spongey white bread cradling thick slices of our own garden grown succulent watermelon-wet purple tomato. If I can sacrifice my inherent impatience I hold I will adorn it with three things; nayonaise, (the veal denying version of the fantastical Miracle Whip of my saccharine-sour youth), bread and butter crisp pickles, (homemade always), and elephant ear-sized leaves of basil, (the only other thing we grow). Summertime is about so many luxuries. The tomato sandwich is mine.

The Summer days begin with tomatoes as my morning coffee's spouse. Breakfasts are followed by a lunch a few hours later by my some-assembly-required sandwich, or else the soggy mess demands a spoon. I close each day with the only meal I yearn to have waiting for me when I get home after 9 pm work-weekdays. 

They never fail to fulfill, and I never tire. Those juicy thin skinned plumm-ey bombs so succulent and drip-ey messy you need to indulge over a skink, a towel, or with a bib.

By the time October rolls around our tomato vines have withered, the fruits shrunken and toughened. My belly is satiated and I resume the internet search for "clinical signs of toxic doses of lycopene."

todays bounty

(P.S. I would have included a photo of my breakfast tomato delicacy,, but I ate it too fast).

Tomato sandwiches are my lustful Summer mealtime desire. They remind me that there cannot be balance when the season is so narrow, and the yearning so insatiable. Who wants to try to be disciplined when you wait a whole other calendar to get back in season? Me, Nope, I will eat as many as I can for as long as I can, year after year. Summer and tomatoes, (Purple Cherokee's to be specific). What could be more perfect? 

Could it be that one good, no, great, (those Cherokees are that), thing marries one with another if you simply choose to recognize it as such? Summer sun and all that its bounty blooms.

prepping for another sandwich

Maybe the marriages are all that we need to look for? The ways in which one magnificent indulgent joy comes from a tiny place that everyone else overlooks.

Maybe if I can alter the perspective, just a teeny bit, I can marry one spectacular triumphant savor into the other parts that aren't so fanciful on the routine basis?

I imagine painting them as works of art. The color is so deep and robust

There is no balance in veterinary medicine. Nor, is there any longer a balance worth seeking. I live my veterinary work life in the maximum height and depth of everything I do. I chose this life, (or, it chose me. I cannot discern the difference any longer). It is the price of being me... so much passion for so many things and just a few trips around the sun to accomplish all that lies ahead. I don't know why people seek balance. That place where nothing swings, or moves, or gets felt for all that it beholds. We are veterinarians. The grittiest of the professions. There is no glamour here. There is no fortune to be won. There are quiet, voiceless badges of courage and lives that will never repay you for the impact that you have delivered. There is perfection in knowing that you can change a fate just because you set your eyes upon them, took a moment to listen, and decided that every little life has unimaginable power to heal another human. Our pets mean everything to us. They are the guiding influence on so much of our daily lives. They hold the calm presence that makes all of the inescapable turmoil of the rest of our lives worthwhile. I am so lucky to not have banal ordinariness about. 

Our clinic Queen, Seraphina

Do any of us want to live with just our toes in the water and not still want to dive in? Don't we all want to feel compelled to jump in, immerse ourselves in the glorious wonderfulness of that one thing that is just soo good you kind of get obsessed with it? That is my kind of balance. The balance of a veterinarian who knows what she loves and still loves it too excess. 

What are your favorite season based delicacy? I would love to hear about them! 

When I Get Lost.

 

Alvin. A true example of how much we adore our pets. His story here

The most obvious place to start when you are lost is back at the beginning. Therefore, I go here.. Back.. Back to the place I last remembered knowing my way. Having a direction. A footprinted fossil. That old place to call "start here."

It is all I know to do when the map has been lost, the sherpa abandons, and the world reminds you that you are merely a speck. A tidbit of dust. A fleeting, insignificant blip on a timeline too immense to even contemplate comprehension. Me, the bag of aging flesh with so much determined compassion that even this reality is dismissed.

Retracing my steps as I attempt to resurrect my direction, (albeit a direction with accoutrements like “purpose” and “fulfillment”), I remind myself cautiously that I know, admit, publicly, that I have never chosen the easy path and I am fraught with a conscious empathy that propels me. This small character flaw is a burden. At times it has led to compulsion, but along that path I was moving in a  direction I believed in, and with it I had always gotten to somewhere. After a few decades of kinetic acceleration the directions have become more cumbersome. The world seems to close in, and be far less welcoming. Age, has privileges which lessen the compulsion for manners, but, you pay for that in diminishing opportunities. Gravity clutches your intentions and suffocates them into mortality. You can't get to the previously proposed destinations with the same vigor nor timeframe, but you don’t give a damn, so it all balances out in the end. Problem remains there just isn't a calendar with a timer counting down to designate END, so you plug away hoping it isn't aimless, fruitless, and depressing as hell.

Garfield. The reason in everything that I am and who I still dream of being.
His story here.

Maybe it's mid-life? Maybe it's inertia calling my bones to pivot? Maybe it’s the reflection of those around me nesting and preparing for a hibernation I'm not prepared for?

The conundrum remains. I am lost and searching. Fueled by frustration and losing a voice in the mass of bigger fish this world has to fry. My little cause lost in earthquakes, tsunamis, wildfires, and genocides in Africa, Gaza, and Howler monkeys falling from the skies over global warming induced desiccations. How do these compare with the with blocked cats, pyometras, and nasopharnygeal polyp looksies being fined out of emergency care? I don't know, I lost my map. 

There isn’t a megaphone big enough to hold my tune next to that cacophony of desperation the rest of the world is grieving. Yet, my plight, my purpose and my internal quest for recognition and empathy in animal welfare and companion animal needs remains as steadfast as ever.

The lost part was also my beginning. No one goes to vet school to change the world. It’s a futile fight in a world of humble hardworking blue collars. Purpose exists in heartbeats for utilitarian use. Sure, dogs and cats have gained a bit of status with their handbags, service vests, and bedfellow pampering, but, vet school, is equal parts food and pushing the limits of biology and financial cushions. I went to vet school with an agenda. I went to attain credentials to argue with bigger guns than the fodder could muster. A worldwide awakening of public opinion ripe for disruption. My hope was to be a pioneer on the frontier of acceptance that the pets we call family could earn some status that provided rights and consequences when infringed upon. Cruelty comes in many forms but the worst is the mass cover-up with just how poorly these beasts are treated, and how little value their lives hold for the food supply to remain cheap and domestic. No one likes to see suffering. The Styrofoam and plastic wrap allow it to be bacon versus Babe. Dogs and cats aren’t much better off. They are considered property in the eyes of the law. Replacement value for your four legged furry kid is about $100. Pain and suffering if they are killed or tortured are unlikely in the lobbying world of minimized liability the vetmed profession defends. We, the collective veterinary profession, lure out incredible medical advancements and opportunities out one side of our mouth when we recommend MRI’s, stem cell therapies, cloning, or organ transplants and protect liability with "property" status out the other. It is an unsustainable mixed message against a public so bound to their companions. We provide some pets month long stays in ICU's and chemotherapies with price tags now hovering around $50,000 and up. While others are bred to be mute lab-rat beagles. Compliance their greatest asset, yet doomed to die unnamed. The Auschwitz inhabitants of our day. We offer. We profit, and we refer to our own knowing price tags that begin at 10k lie ahead. We admonish when parents aren't prepared and yet we defer responsibility when heartbreak is delivered. We, the lowly GP's, always offer “economic euthanasia” as a mandatory treatment therapy option. We offer this to make our clients feel empowered and compassionate as the last true gesture of kindness to alleviate suffering we hardly ever have firmly diagnosed, nor been specialized to treat in its maximum effectiveness. We know you will get another pet. We also know it is much cheaper to replace than treat. We did this. We are responsible for that mathematical reality, yet, we judge and castigate when it happens. We are even so egotistically privileged that we feel good about recommending euthanasia as a benefit to our treatable yet priced out of affordable options within the bullet points of acceptable treatment options that we have now made this a lucrative part of the profession. (And people wonder why the profession is plagued by self help via iatrogenic euthanasia?). We kill ourselves as an option to seeking compassionate resolution to unanswerable dilemmas.

Pickles and Geisha. Rescued by a client who cuddles them like they are the most precious lives anyone of us has ever been privileged enough to be entrusted to protect. 

There are veterinarians so fed up with the anger of negotiating between need and availability, options and finances, or the endemic corporate structures of avoiding on call and surgery, they can either head back to training to specialize, expose themselves to most often kind side of medicine; in home euthanasia, where your clients always speak nicely to you and show gratitude or wash out and switch professions.

There is no map for this place. This crossroads of incongruities. This place where we have to be human in places of lost humanity. The place where greed greets celebrity. Kindness is annihilated by power hungry egos. It is dizzying to know where to go at times. It is harsh to look in the mirror and ask yourself if you can dissect the problem  from the solution when you know you live within both as a matter of necessity and survival.  

I'm still fighting. Fighting to refrain from accepting the self protective blank faced indifference that permits clients who can't pay to be turned away with some excuse about everything being “their fault.” Or, the litigious liability paranoia that defends our patients as being replaceable within the big scheme.

Sparky. Rescued within minutes of being euthanized, and hours after his owner surrendered him.
His owner was told he would be given less than a day to be rescued as the shelter did not have enough space to keep him longer than that.
That smile says it all. 

I don't know if I will ever find that yellow brick road. Or, the map I had predicted so long ago that would lead me to tranquility. Or, even my self-proclaimed Utopia of purpose driven bliss. Maybe mankind is so inherently flawed these just aren't possible? But, maybe, just maybe my path lies right here at my feet. The inherent perfection of the pets I call my companions. The wet noses of the patients I know to be my purpose. These beloved companions who love so completely and unconditionally they inspire me to keep marching on.

Lil D. Rescued from an online ad. Transferred to her foster mom in the WalMart parking lot.
22 toes (2 shy of the world record) and now living her best life in a home she confidently calls her own.

Where did I leave that torch and megaphone?

Cooper. Waiting for me to leave