Thursday, July 15, 2021

Mass Removal On The Foot, and Neuter, German Shepherd Dog


This is Apollo. He is a recent rescue. He, like almost all of the rescues we see has a checkered past with more holes than answers. We know what we see in front of us.. male, young, intact and jittery with all of the newness of everything in his life.

He is in foster care as the rescue gets him caught up on vaccines, allows for time to decompress, acclimate and show his true colors. Let his fear assuage to his personality. 

This is the story of Apollo's neuter and mass removal.

I mention both as he was in need of neutering before he found a home of his own, and he had a mass on his wrist that had no accompanying information.

When dealing with a neuter the options are fairly straightforward and simple;
1. neutering is the removal of the testicles from the scrotum. It can be done as an open or closed technique. I  decide which based on size of the blood vessels needing ligatures. There shouldn't be a change in price and the preference is based on the surgeons 
2. scrotal ablation with the neuter. For dogs with excessive scrotal tissue (older dogs tend to have larger and more sagging skin). It's a cosmetic thing in almost all cases. In the trade we call it preventing "the flapjack."

This is Apollo's mass. Firm, raised, irregular and without any evidence of what it might be, or, what might have caused it. 

As with all masses on pets the only way to identify what it actually is, is to send in a piece of tissue of that mass to a pathologist. There is only guessing outside of tissue. If you are looking for more information on this please read this blog; When a Bump Causes You Concern, Slay It With A Diagnosis.

There are so many factors that go into a successful surgery. For Apollo's case we did a thorough pre-op physical examination. We also made sure his vaccines were up to date. I prefer that each patient be as calm and stable as possible. This includes physically (healthy based on exam and blood work), emotionally (all rescue pets need time to acclimate and adapt to their new surroundings). Too often these rescues are rushed in and out and back and forth to find placement as quickly as possible. It costs the pet terribly. Stress and its detrimental affects on the body are underestimated and too often overlooked. If at all possible give a pet time to go into surgery in the best possible place, happy, calm, relaxed and healthy.

The next part of a successful surgery is surgical planning. I start every surgery with the plan in my head. The order to which I will execute the surgery, the amount of tissue I want to remove, and the plan for how I will close the area after. You need to know where you are ending before you begin, and then you also need to be prepared for plan B, C, D, etc if the previous doesn't go as planned/hoped for/expected.

Apollo's surgery was a challenge because there is not much room on the wrist. I can't cut too deep, or wide, or have any extra tissue to close after I removed his mass. The mass extended both wide and deep. No room was left over to let me close the sides after I removed the mass.

The goal for every mass removal surgery should be discussed with the pet parents before the anesthesia is turned on. 

Ideally every surgical event is what we call a "one and done." Once surgical expense and event solves the problem. It provides both the diagnosis (meaning we removed a large enough tissue sample that the pathologists feels exceptionally confident in their diagnosis. AND, there are clean margins that prohibit the mass from being able to return. 

In all but the most exceptional cases we should never place our patients under repeated anesthetic events, NOR, require additional financial investments from our clients.

Too often I see veterinarians offering surgical services and NOT attempting to remove the mass in its entirety. It is a financial and emotional burden that is placed on patients and clients. 

What happens if the mass is malignant? Or, invasive/destructive over time? Do we require clients pay for surgery twice? Put our pets at an anesthetic risk twice, or more? Many clients cannot afford twice? Or, feel the case is not worth the diagnosis the partial mass removal has provided. 

Many of the cases that I see have been told the "mass is probably bad" i.e. likely cancerous, or, the pet is too old to put under general anesthesia. People are essentially discouraged from surgical excision of a mass for reasons that too often ;eave them at a place where they are euthanizing their otherwise happy older pet because the mass is now so large it is open, draining, and painful. 

I cannot even tell you how many dozens of older pets that we have given extra enjoyed months of time to because we just tried.. we tried, and SUCCEEDED, in the mass removal. See Spencer's story here.

Apollo's mass was in a tough spot: the lower leg. It was the size of an acorn on the outside of his wrist. 

I had to remove the mass and then make a large flap of skin above where I had removed the mass to close the hole the mass left behind. It is commonplace to close the sides of the site and leave a linear incision, but, the legs don't leave enough skin to do this.

The fear with an advancement flap is that everything you cut will die. Instead of a quarter sized hole of non healing tissue we have an area three times larger than the mass was.

After Apollo's surgery I placed a bandage. It serves a few functions;
1. Protects the incision.
2. Allows a few days for the incision to have very little stress on it with movement of the leg.

This is Apollo one week post op. The tissue is looking perfect! 

Here is the histopath results for Apollo;
Calcinosis circumscripta refers to a non-neoplastic nodular focus of
mineralization and is considered to be a localized subgroup of
calcinosis cutis. The cause of calcinosis circumscripta is currently
unknown, but the majority of cases most likely involve trauma followed
by dystrophic mineralization. In some cases it may be an incidental
finding in young rapidly-growing large breed dogs (especially German
Shepherd dogs). This lesion most commonly occurs at sites of previous
trauma (bite wounds, ear crops), over pressure points (footpad) and
other bony prominences (spine, elbow), and occasionally in the tongue.
There is no evidence of neoplasia, and etiologic infectious agents are
not observed in the examined tissue sections. The lesion appears
narrowly excised.

What makes this case so notable?

1. The rescue made decisions based on what Apollo needed first and foremost. Not cost, but care. His adoptive family knows what his mass was. They don't have to worry about what it might be. How it will affect his lifespan, and the cost of all of this as a new family member.

2. His mass removal BOTH diagnostic AND curative. Every case in every surgeons hands should start with this as the goal.

3. Apollo has the best chance at success for a future with known information. He's not a mystery of unknowns. We are filling in answers for him as we discover who he is. He has a solid foundation to succeed!

The cost of care for Apollo's case included;
i.v catheter $40
i.v. fluids $50
i.v. fluid pump $25
anesthesia $250 for 2 hours, it is based on surgical time
castration $150
nail trim $0
analgesics post op $50
laser for mass removal $220
mass removal $250
sutures $30
SQ fluids $35
biopsy $150
antibiotics $30

total $1280. Apollo received a rescue discount (not shown here).

Saturday, February 27, 2021

Investing Too Much. When, and Where Do You Draw The Line?

Perhaps I went into this for all of the wrong reason(s)?

Maybe not the wrong reasons, but, perhaps the expectations were unrealistic? Maybe there was too much of me in this endeavor for others? Maybe it's the other way around?

These are the questions I ask myself as I muck through the maze of my daily life as a veterinarian in general practice.

One of the many delightful faces of my vet life day

Yesterday I spent a long time, (to be honest 20-30 minutes), with a sobbing client as she dropped off her dog, Brunswick, for a forelimb amputation. She was, (as every single other amputation pet parent has ever been), reluctant to consent to this surgery. Of all the procedures that we do, and, for all of the many indications this procedure is recommend for, there is no other life-saving, pain alleviating surgery that is met with such pet parent reluctance and resistance. In my clinic over the last 15 years that I have been practicing, I would say that only about 1/4 of the pets who need this procedure, and, I believe would benefit immensely from, actually get it. Most pet parents will sacrifice the pet to spare the removal of a limb. There is this incredibly difficult and deeply rooted mental block on consenting to limb removal as a treatment option. We were at this place; sitting in the front office, debating whether to consent to cutting off the leg of her otherwise perfectly healthy and happy pup.

Brunswick is a timid 7 year old, 50 pound, mixed breed dog. She is a tawny brown with big erect triangular ears, a wide faced and her soft white body is liver spotted from neck to tail. She has a history of a mass removal from this leg that yielded a diagnosis of "lipoma" many years ago. That mass has returned, slowly growing within the armpit of her front leg. It is now pushing the limb out and away from her torso. It has gotten so large that it has exceeded her skins ability to further contain it. The underside of the arm was red, raw and ulcerating. The mass that has been slowly growing for years now is outgrowing her. The cold cruel eventuality of Brunswick's leg was lose the leg or lose her as she would soon have an open wound that would never heal but instead continue to erode her leg, cause her increasing pain, and chew its way up her neck and across her sternum. 

Brunswick walks front legged short stepped, cowboy style. It manifests as a limp. The mass is hidden from obvious view by her bushy hair. The dappled coat hides the magnitude of the mass until you pet her. The diameter of the upper part of her left front leg is easily twice that of her slender athletic right leg. Her demeanor is always stand-offish for a few moments, but, if you are patient, quiet, and gentle in allowing those few moments to pass she will warm up to you to flounder flop on her "good" side for a full belly reveal. It is her not so subtle invitation to focus your affectionate rubs on the tender fleshy part of her belly. She is easy to fall in love with. Her handicap simply reinforces her charm. Her mom adores her. She will tell you that "Brunswick is her first child." 

And, now,,, here we are. Sobbing. Crippled with fear and doubt, and stuck about what to do with it all.

Many conversations get to this point. That critical pivot point where biology, disease and prognosis has met the timetable of limited options. That juncture in a pets life where you have to choose? Are you a proactive parent seeking to gain as much time with your pet as medicine is able to provide? Or, do belong to the crowd that does not believe in surgical procedures for pets? Do you choose to invest multiple thousands of dollars, hours, and caregiving requirements to gain the precious commodity of more time with your companion. Do you value your pet as a member of your family? Are they one of your kids? Can anyone possibly speculate all of the twists and turns that lie ahead if you do, or don't, take action? 

Most pre-op surgical discussions go like this. 

In Brunswick's case we had already done multiple examinations. Two with me, one with the surgeon. At each time we (the "professionals") agreed the best resolution to this tumor was to remove the leg. There were about a dozen emails back and forth to discuss every possible question and concern. And,, yet,, here we were, crying at drop off. 

I sat with her and said; "I know how hard this is. Please do what you think is right. Not what anyone else tells you to do." I firmly believe that this needs to be said to every parent. The road ahead is too full of twists, turns, and potentially even life-threatening landmines. I should add the cost of care, but, for me it is not a part of the equation I will let decide options. If we believe a treatment option is needed we will find a way to make it accessible. (Note: we use multiple payment plan options to help people not let the financial burden be the deciding factor).

I try to ask myself who will benefit from these decisions? Who am I looking after? These are huge weighty decisions with dire consequences. I try to be unbiased, neutral, indifferent. I try to present facts, argue all sides. I soo often feel that I fail miserably at this. I am not ever able to remain indifferent. I am not on anyone's team outside of my patients and their family. It is the dark force that grips my soul surrenders my conscious heart at midnight.

Brunswick post op

Here's where the muck meets the sole. Brunswick needs this operation. She will die within a year from the mass if she doesn't have it. How do I advocate for that? A: I just have to be honest. Then I have to accept the consequences. But, I know Brunswick is loved and I know her mom is making this decision based on that. Seems silly to some, maybe? But that is always enough for me. I am not the vet for indifferent people who don't value pets. That I cannot do. That would kill me.

My pups; Frippie and Storm

These are the elephants I carry on my back all day every day. They remain cumbersome, consuming and catabolic even after I get home at night.

I didn't sleep much after midnight. That mystical witching hour.  My typical work day has me arriving home after 9 pm, a 12 hour day of work without breaks, meals or niceties logged in the record books.  My shear exhaustion leads me to literally passing out on a pillow having foregone the obligatory teeth brushing, face washing, moisturizing and evening medical supplement regimen. They are all tossed out the window for the sake of sparing my legs the 80 paces they would require. There are loads of nights like this. Wrung out dry. I enter home as this zombie-eyed shell. I sleep for 3 hours and the death cipher lets go her grip for the anxiety ridden stressed-out-Suzie to take claim. Its always this exchange of custody each night between the hours of midnight and 2 am. A shared custody battle as the sun sleeps. 

My Frippie always brings me a gift

Why does the day weigh so hard? Brunswick is one example.. this is another. This one happens too often these days. COVID has created a huge demand for puppies. None of them are being socialized appropriately and for some (often breed specific) it is causing potentially disastrous consequences.

The other emotional dilemma of my day was an 11 month old German Shepherd, (let's call her GS), who visited for a pre-spay exam with bloodwork. Her mom had brought her inside the clinic vestibule on a one foot leash to a tight prong collar. Even with moms double fisted grip she could not get GS to remain with four feet on the floor nor have any kind of focus. She had no control of her adolescent puppy, and, she knew it. She told me that she "doubted I would be able to get her blood." She passed my technician the one foot lead and watched us all as we struggled to lead her to the treatment area. All GS needed was a 5 minute physical exam and 30 seconds to pull a blood sample. These appointments are not charged for as they should only take 6 minutes to complete. That didn't happen.

GS was a happy, outgoing 75 pound determined to party firecracker. She was elated to be around people, and in absolute resolve in not sitting for longer than one split second for anything. She knew commands, and she knew how to decide to avoid them. She surged, jumped, boxed, and thrashed. She twisted arms, crashed heads, and started to lunge and bite to have her demands heard.

Our dinnertime excitement

I always stop here...... The three of us; myself, my technician, and GS. We all looked at each other. What to do now? Take a breath? Try a different tactic? All of the above? We took breaks. We tried treats. We tried calm quietness. I tried a large muzzle, just to see if that would settle her. Fifteen minutes into the endeavor and one thing was clear; Nothing worked. We were at the place where one of three things was going to happen;

    1. I lose my patience and I hog tie, muzzle and we pig-pile on her to attempt to bruticaine (brute-force-paralysis vet lingo), and see if she is so shocked by this she gives in.  I just turn into a cold hearted drill sergeant. Bark orders. Intimidate. Force her to be what I want her to be. Force her to hold this command until I feel she has learned who is in charge. Quickly restrain GS and get it done. Get the blood. Skip the exam. Smile and return her to mom. After all what she doesn't know isn't my problem. She can't claim naivete when she already admitted unruliness. Make friends with the owners, even if it  is at the patients expense. A lot of vets have learned this trick. Two faced. Sweet to people, not so much to patients. A bite will likely follow at some point. What the real consequence of this is; To hell with the next guy who has to deal with her.  Might work for some dogs, never works for shepherds. Shepherds are too intelligent, they cement resentment like dolphins. If I do this to her she will never again come happily into our doors.. She will start every future interaction with fear and aggression. A bite will follow at some point soon.

    2. I give up knowing the short game loss is worth the long term gain and we have a family meeting to try to find a way to make her appointments more enjoyable and productive. Her mom had already expected that today wouldn't go well. We come up with a plan for next time. This should include training at home with the family to allow others to handle her. Working with a trainer to help her focus on commands and execution of them with focus and safety. And medications to help bridge the gap as we work on training. 

    3. I just get bitten. No chance to compromise, or convince her that we are not trying to hurt her. She just explodes and bites as fast as she  can. She is done with us and she will remind us she is in charge. 

What happens when a "bite" happens? Paperwork, fear, and almost always the pet parents compounds the tragedy by isolating their dogs in an attempt to avoid future potential bite provocations. Muzzles, prong collars, yelling, over protecting orders and mounting anxiety across all fronts. It's a snowball. Attempt to avoid situations leads to a lowering of estimation of the pets perceived threats. They used to like everyone. They were puppies meeting a world of new sights, sounds and smells. Now they are guardians that bark at the door knocking, or, strangers. You can't take them out in public anymore because now they bark at everyone. Everyone is a perceived threat. They are 100 pounds and you cannot restrain that amount of determined muscle. They become isolated. We reinforce the idea that everyone is a stranger. I used to see them every two to three weeks. We had fun visits. Now I am the stranger. I ask for unreasonable acts of discipline and focus. They don't know me and they certainly can't see a reason to obey me. Hence the bruticaine and indifference. 


Who's fault is a bite? Well, for the huge majority of clients vets see daily they would say it is our fault. For every time I have handed back a shepherd to say "we need a different plan to make this visit enjoyable." I almost always get, "well, you don't know how to hold her. She is fine with me." Oh, how I long to reply; "Ok then you do the bloodwork and  the spay. I like my fingers and face." Or, "she would never bite me, therefore, you are the problem." 

Here's my advice; it is the advice that every seasoned pet care professional will give you. Train your dog to accept a muzzle. It is NOT a reflection of a persons failure. Nor the pets. It is a tool to provide assistance as we transition out of anxiety based fear laden actions and reactions. Every pet parent should openly and provide permission for a muzzle to be used if deemed necessary. Man-handling, bruticaine, that is not permissible.. ever (unless a pet is endangering another's life). How do we insure this? Trust. If you don't trust your pet care professionals ask to be present for all possible procedures. Ask, demand, insist that pre-anxiety medications be given. Set ground rules for care. Resistance is a flag for scrutiny. Leaving a practice because a person intervenes on your pets behalf is only going to hurt your pet. 

About 30 minutes after I aborted pushing GS any further I sent her home with a training plan and sedatives to try at the next vet visit. I chose to not push her, not exacerbate a bite, and not make it impossible for the next time. Here's what I got for that, a call from the husband saying "they had a bad experience with us and they are going elsewhere." I doubt I will ever see GS again. There is pride before a fall. There are Shepherds relinquished everyday because no one intervened on their behalf at this critical development time. And, worst of fall there are vets who get court orders to put animals down after a "bite" history deems them a danger to the public. Will the next vet push her so hard she bites? Or becomes passive aggressive? Or fears people so much she reacts with defensive aggression to everyone outside of her family? In my opinion she needs help. Will she  get it? It's one of the reasons I awaken at midnight with elephants.

Tex. His first puppy visit. My goal is to have every patients visit look like this.

The truth is that people pine as much as I do, if not more, on what to do for their companions. What is the right/best/safest/compassionate course of action to take? What will consequences for that looks like? Will I hate/berate/beat up/chastise myself for the action, or lack there of, I take? I have been in these shoes. At every moment of my professional life I remind myself that I am still that devoted pet parent who is in turmoil about what to do? Do I trust my own judgement? Do I have enough pertinent information to base my judgements upon? Is there trust here. Maybe GS's parents lack that? They just don't trust my call? The reality is that she is being set up to fail, not flourish, and her "bite" won't be on my account of failing her. 

Brunswick. One week post-op forelimb amputation

What these two cases have in common is that I did my best to make decisions, present options that were in the  best interest of my patients. period. I can fall asleep knowing that. The rest, the worry, the grief, the elephant on my shoulders that I failed them, their parents, or the relationships we have is the midnight hour that clutches my throat and drags me into the abyss of self-doubt of avenues from that first decision to "do no harm."

Magpie helps me motivate for another morning.

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Sunday, February 21, 2021

"I Just Couldn't Do What You Do." The publics misperception of why being a veterinarian can be painfully hard.

I was in a shoe store today. One I have been going to a few times a year for decades. I go there because they have fabulous shoes at affordable prices AND because they have dogs. Resident Shih Tzu's live here. (Not that I care what breed they are. I just love dogs). 

I am a veterinarian. Don't all veterinarians LOVE dogs?! (Well, most do. Another topic for another blog).

The store owner loves her dogs. It is obvious in so many aspects of the visit. There are dog toys strewn about the floor like this is a daycare center. Dog beds hidden under every clothes rack and a hidden home base behind the check out counter. The owner is a tiny little lady with jet black hair who wears clothes that I feel more aptly belong on a spit-fired little Italian godmother residing in central Brooklyn; The kind who knows everyone's business and points her finger, cigarette sidecar on bottom fish-hooked left corner lip, once tightly lines in fire engine red outliner. She is frills with razor edges. And, yet those little coiffed pups make her melt. My Italian grandmother Grandma Magnifico was a lot like this. Trying to look like she's still got it, tight (too tight) black velvet pants, overly shiny sweat jacket attempting to pose as formal dinner attire, not too chatty, always too skeptical of anyone she doesn't know, and yet loves dogs in a manner that almost makes her certifiable. My grandmother would find dogs roaming in Brooklyn, throw a leash over their head and drag them home to safety. In other words she stole them, yet always harshly believing she was providing them all a much better home. 

Back to my shoes..

Each shoe store visit is, and has been, the same. She never remembers me from the last time. I walk in, the dogs run to greet me, I bend down hoping the door has securely closed behind me and I say hello to each of them individually. I ask them, "how are you doing?" "What's new around town? Any new/latest shoe store gossip?" and, "if they have any selections to show me?" I treat them as people. This whole exchange is super vital to my shoe shopping experience, and, they in return spend the rest of  the time I cuddling with me. We are kismet. 

At some point their mom comes over, tells me that I shouldn't feel obligated to pet them, and that she will put them away if I need her to. I remind her they are the reason I come. And, she leaves me to shop.

Today was a snow day. Most of Maryland was closed. When I had to go out for a baby gift I just happened to see she was open. The store was otherwise quiet and empty. Today the conversation met its chapter two.

"Are the dogs bothering you?" As the black one jumped on the couch and sidled up behind me. I was trying on shoes and he wanted to be center stage.

"No, he's helping. We are doing fine."

"Oh, well,,,, if he is let me know." 

"Umm, ok, well, he won't I'm used to dogs all over everything. So, he won't intrude. I have no personal space when it comes to dogs."

I knew it as it left my lips. I said too much. "Yes.", "No.", "Ok." Those are the simple answers I should stick to.

Most vets I know, (I am going to say all but one), will never tell a stranger that they are a veterinarian. The "work-life balance" thing is important to preserve. We don't like being asked for advice. Although I don't mind so much as long I feel people really care about their animals. What I do take offense to is being the arm chair vet-quarterback to the people who think they want help in caring for their pets, but, just want to pass on responsibility. There's a difference between asking for help because you simply don't know, and, shirking responsibility for a pet that is exactly yours to be responsible for. You know the kind; They want to sound like they care so they don't seem like they might be perceived as a shitty person, but not actually go out of their way to do anything about it. That kind. They share their self-admitted stories of neglect, idiotic scenarios, and remind me to go back to my one word answers. Don't know what I am talking about? Let me give some examples of this kind:

    "I have this cat in my yard who keeps having kittens. I don't really want her. DO you know anyone who will come and take her?" I had a subcontractor working on our new clinic renovation, for which he was paid about $70,000 to do, tell me this. I fired him.

    "I had a dog once, she got hit by a car, and, eventually died." Thanks for sharing that one. Let's hope I never meet you again.

    "We had puppies once. They all died. My dad thought it might have been parvo. Or, maybe something got to them, like a snake bite." Umm,,,,

    "You know my vet told me that my dog should be on heartworm prevention. He doesn't really need it, does he?" 

Yes, I get these all the time. Stick to "Yes." "No." "Ok." Feign ignorance. Be a damn closed book for five minutes of your life.

Nope. Not today. Today I confessed, "Well, I have to love animals I am a veterinarian."

She stopped and withdrew her internal stoic stern governess sourpuss face to transition into an inquisitive detective.

"Oh, I could never do what you do. It must be so hard."

Once again I should have just nodded a reply.  A simple; "No" or even throw her a bone, just say "Yes." keep trying on shoes. Why do I have to open my mouth? Instead,, this happened.

"It isn't. I am only the vet to people who love their animals like you do."

Her sourpuss face looked like it bit hard on a lime. Her face collapsed inward. A black hole suction of air left the room, vortexed into her thorax and she left me feeling as if I was a freak.

It took me a few minutes to realize that her idea of "hard" was not my idea of "hard". She believed that every pet was loved like hers. That her rescues (one was) were all just orphans awaiting Daddy Warbucks and happy endings happen. It was the mortality part she defined as "hard" as if that was some aspect of life found only in pet dogs.

No, the hard part is killing pets no one wants. Or killing a pet that has a treatable condition. Or seeing how awful people can be. Suffering, yeah that's hard. Indifference that's harder. She didn't understand a thing I said in my brief two sentences. She 70-ish. What is the point of explaining how hard this job can be? She would have to live it to understand it.

My dog Storm. Rescued 2 years ago by our friends at Animal Rescue Inc minutes before he would have been euthanized. His family had dropped him off at a NC shelter the day before as they evacuated from Hurricane Florence.

No, there isn't one honest vet in the world who will tell you that the dying is the hard part. Life is unfair. Every vet knows that. Cruelty, neglect, abuse, indifference, disposable views of pets that kills you. That's "hard"er than anyone could ever know.

"She's just a barn cat." Apparently there is a breed known as "barn" (aka "outdoor") that requires no veterinary upkeep? (yeah, I never knew that either).

"He was a free puppy." (It's cheaper to get another than fix his vomiting/diarrhea/prolapsed rectum, blah, blah..)

I bought 5 big dog beds at TJ Maxx yesterday, (and when I say BIG, I mean 3ft by 4 ft and about 8 inches thick. They required a palate cart to move). At the check out the girl asked, "how many dogs do you have?" "Three," I replied, "but we have 23 dog beds in the house and a few are 10 years old and impregnated with dog smell no matter how much I try to wash. (How do you wash those big beds?) 

"Wow, that's a lot of dogs." (No, it isn't I thought). How can you afford them?" 

Shoulda shrugged. I didn't. "I'm a vet," fell out.

"Oh, that's such a hard job. I don't know how you do it?" At least she smiled at me with a genuine interest in my answer.

So what do you think? 

Do you agree? Do you think that my job is "hard"? If so, why? I would love to hear your perspective.

I really would love to hear your thoughts. Please share them in a comment below. (Just so you know they have to be approved by me before I post.. the whole FB video rant three years ago left me no choice. Vets can be vicious, just an FYI).

Here's where my head is headed next, and how this topic is related to where my current blog topic lies;

It's truly a matter of perspective. Isn't it?

Here is a FB post I saw today that reinforced the misconceptions of perspectives. It is a fellow vet in a FB page where vets share their vet life experiences.

"I was recently trying to buy a new home. Obviously, I haven’t done this much. Not many people do. I have 7 kids. So, we all went to the house to view it with the sellers realtor because that’s what the seller told me to do. My kids were respectful, took off their shoes but they are loud and excited (who wouldn’t be?). I got home and my husband and I discussed it and then called my own realtor to make an offer on the house. The sellers realtor was very offended that he took the time to show the house and then we chose to use a different realtor to represent us. Looking back, that’s an understandable reaction given the time and patience he took with us on a weekend to be able to work with our schedule and tolerate our noisy bunch. However, he then proceeded to make it extremely difficult to put an offer on the house-not communicating, putting in road blocks and in general being a jerk.

Here’s my point. I did not know enough about that realm to understand my actions were offensive. I apologized and followed all the recommended protocols after I realized my offense and was still given a hard time.

❇️ How often do we do this to our own clients? Do we think badly about them because they don’t know any better? How many times have I said on ER “Why do people expect x,y,z?” when we have not explained the situation thoroughly because we are busy and overworked and frustrated with the industry in general.

❇️ How much of the clients reaction has come from our own inability to show compassion (because, hello, compassion fatigue is a real thing) or explain the process in our industry to yet one more clueless person?

❇️ Is this their fault? Is it ours?

We ABSOLUTELY still have a**hole clients that expect too much and are unreasonable.

But...can we improve our outlook and communication and make some of those borderline pain-in-the-a** interactions maybe be a bit less stressful for everyone involved if we just show some understanding and forgiveness?

Just a thought process I had when faced with the same prejudices in another field."

...from a colleague on Facebook, Dr Jennifer. (Shared with permission). 

The questions keep rolling.. the answers,, well,,,

My kitty Magpie enjoying the sunshine.

Related blogs;

Losing My Beloved Jekyll. He came to me as an 8 week old puppy whose breeder owner had given him so much cow dewormer he prolapsed his rectum (he literally strained so much with the diarrhea it caused him he pooped out his colon). The breeder reasoned it was cheaper to euthanize than treat. He came home with me that day. Two surgeries fixed him.. He was my beloved dog for the rest of his too short life. He died of prostate cancer at 8. See this one too; Coming To Terms With the Death of My Beloved Dog Jekyll. 

The video rant that will mark me forever. And one of the reasons I am who I am. The Impact Of A Rant.

Drugs, Drink, or Die. The Shitty side of being a veterinarian. Here are some of the real cases that I think make my job devastatingly hard.

Don't Forget To Put Your Heart Into Every Euthanasia. How being a compassionate vet keeps us alive instead of stealing our ability to care.

The hardest part of being a vet is not being allowed to help those you know you can. This blog here.

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YouTube is Krista Magnifico, DVM. Meet my real cases and my real-life responses.

Monday, February 1, 2021

The Fortress You Retreat Within

 The house at the end of the lane is mine.

She's a little fortress of stone straddling a bank that tumults into a pond. She is a formidable villa whose skirts used to encompass all the land around her. She has been settled here for over two hundred years. Long enough to have seen dozens of families transition from new hope to old death. She has secrets. Mysterious hidden passages. Root cellars, caves, and an ominous presence fortuitous in its reassurances. 

I met her twenty years ago. She was a speck on the edge off a map. Her criteria fit; old, stone house with land, relatively untouched. There were peepers and Lily of the Valleys in Spring. Deer and abundant wildlife in Winter. Her location did not. She was alone on the edges of a place no one sought outside of being born there. Her charm was what stole me. She was as exact in her integrity as she was simple in her merits. She would also require a lifetime of devotion. Old houses are like that. They will you into bowing to their needs and enslave you in their necessities. It wasn't me so much that I was worried about, it was my city slicker husband. He had no idea what he was in for.

We bought this place with the single goal of never leaving. We were going to die here. Our final stop. I wonder how many others before me meandered down this lane and felt the same way? 

A fortress can serve as a refuge, or, it can become your enslayer. Perhaps a matter of perspective. Perhaps a toothless grin from wicked grandmother waving an apple.

COVID has found us. Arrived quietly in the night. Tickled my throat. Ended up swallowing us whole. A python of paralysis that inches you into their gut. It has been 14 days of isolation. The house and the virus suffocating us from all sides. And yet there is no answer elsewhere. No place to go and find better shelter. No welcoming relief awaiting us where the drive meets the world. We stay. Hidden. Quietly suffering watching the hope slip into snow falls, and simpler lists for the tasks of the day. 

In two weeks I have watched my husband erode. He is distant, vacant, empty. He resists everything. The bed calls him like a tomb. The worry has melted into anger. He is giving up. Letting the leeches in his blood suck away his resistance. I ask him "how he feels?" a mind numbing hundred times a day. I search for any sign of forceful intent. It is not there. We just lie together. All day every day as it melts unrecognizable into the next. A delirium of attempts to know what day it is, and how many we have  been here? 

It was our custom to ask each other at the end of everyday "what the best part of the day was?" I attempted to carry it into COVID. A last sense of routine to hold us together within. I had to abandon it a week ago. There is not one remarkable thing within these 24 hour loops, save for breathing. We are still breathing.

I check his pulse ox, his temperature, heart rate, rhythm, rate of breathing. His degree of dysphoria. I am certain that I can feel this bug worming a way in my brain. "Eating into my cribiform plates" as I rip the scalp from my head to wave off the headaches causing my blinding agony. He keeps repeating, "umm, ok, uh-huh." Some statement to a villain I cannot see beside him. An affirmation we are alone here save for the thief within us. 

I am a veterinarian. Trained and skilled at assessing my patients who cannot speak. Who cannot point or articulate the source of their dismay. I am certain that if a disease of this magnitude hit our pets as hard as this has hit us that (save for a few outliers)The  all of my clients would be ending suffering long before day 14. 

People don't survive this. Seems silly to those of you not in the midst of it. Or, those young enough to allow resiliency to shape the path. The elderly are sitting ducks. Incapable of escaping the life it steals as you are too tired to fight. 

The snow has covered the ground. Seasoned the salt and pepper to all white with a few remaining black trunks to jab the gravid sky. 

The dogs are so bored they have become bad. Annoyances with too much energy to direct in a manageable fashion. I used to tell clients about the many advantages pets breath into life. The stable regimen they adhere you to. The life their antics breathe. The optimism they shed. The youth they bind us to remain within. A pandemic magnified this. Everyone got pets. Everyone found their isolation someone in a wag and a purr. For as much as I have lost all sense of any kind of humanity holed up here away from the world they have brought me back every day. Perhaps just for a peek, perhaps for just a vivid moment, but, they have been all I had, and dare I say all I needed. A life line of a wet nose nuzzled under the covers of eternal slumber housebound in a snowstorm sobbing alongside a pandemic.

Tuesday, January 12, 2021

Pandemic Induced Decision Making Catalepsy

The Queen of the clinic Seraphina

I am at the point within this pandemic that I have decision making catalepsy. I am paralyzed by each new decision. The dilemma lies within being almost empty on identifying right versus wrong, or, bad versus worse, or even when to intervene any more. I am at heart a pragmatic decisive democratic leader. I got here from spending four years at a federal military academy, and then a decade serving in uniform in the private sector where rank determines everything from where and when you sleep, to where and when, you eat. I have for most of my life been embroiled in leadership roles. I am also a veterinarian. I am wired to care more about those less fortunate than I am my fellow human beings. This pandemic has forced me to reconsider, and, perhaps even abandon, each previous decision making argument as I attempt to decide how to navigate these ever emerging uncharted waters. The entanglement of my decision making process has become the angles of individual alliances and personal motivations that have been so unprecedented I almost can't tell myself where to settle my soul of indecision and burgeoning heart of consumed worry.

Remy. A little nervous at first, a marshmallow at "hello."

This COVID decision-making jungle began in March. The forced closure of most businesses left us with a simple question? Do we dare deem ourselves "essential" enough to stay open? Put the staff at risk of, well, ventilator dependent coma or even death? Am I that arrogant to consider my job that necessary? Is the pride going to come before the fall? I dug deep. Initially I opened the decision making process in true democrat fashion with querying the entire staff. We offered free passes with an indefinite leave of absence to any and every staff member who wanted it. They could play it safe. Stay home. Insulate themselves with their families. The safest maneuver possible. All were promised full acceptance and support to whatever decision they felt best suited them. I pledged to keep their position open until they deemed themselves ready to return. I secretly prepared myself for a skeleton crew. Endless days of paltry appointments from only the most dire cases to be shuttled in by their masked, socially distanced pet parents. We would sacrifice our bread and butter routine spays, neuters, vaccines, well visits, and, just buckle down for the most darkened days of our 80 plus year existence. Even at this bleak unknown place I believed we would get through this. Perhaps scarred, scathed, nearing bankruptcy, whatever may come, I would not let this ship be lost on my watch. If I could keep myself off that COVID causing ventilator I could go on, even alone if need be. I truly went there. Imagined myself in this place. Alone and yet still having my neon sign burning as an "open" beacon to the rest of the world huddled within their isolated and hidden homes.

The decision to stay open, with the Governors blessing, turned into a weeks long hysteria about whether our pets could contract, or even transmitting, the bug. The paranoia that this brought to each phone call was unsettling. The pictures of people in the COVID birthplace throwing pets out of high rise windows to eliminate the baby with the bathwater. That lecture of quelling paranoia was left to my previous 15 years of dealing with zoonotic disease. I wasn't going to fall into that rabbit hole of fear. I knew my enemy well enough to not placate to personal paralysis because it was simply a novel pandemic. I know corona. It's been around my office forever.

My Jitterbug. Always on duty, never under command.

The first round of COVID forced decisions left us down about 25% of our staff. Which was about the amount of business we saw decline.

March 2020 also coincidentally delivered us the ability to start our long awaited hospital expansion. It had been ten years in the making and waiting. A decade of hoops to jump through. A decade of personal saving and planning to allow us to grow into the clinic we had outgrown 15 years ago. A building permit was finally granted. The clock to begin, and complete, the project started ticking as the personal promissory bond was deposited. I had voted to wait the construction out and let the pandemic pass. In doing this we were risking a rare chance to do what we had been told over the last 10 years that we could not. We took a big chance, dropped a million dollars we had spent my whole career saving for, and jumped in. It has made me sick with worry every single day since. Every nail and every excruciating decision. I didn't know what the future held and yet here I am putting all my chips in the game. To this day, mid January 2021, I still think/fear, that I just put a bigger anchor around my exhausted neck to sink into the abyss of bankruptcy both deeper and faster. The dizzying list of decisions that a huge construction project brings are daunting. Some I made by the bottle, others I made by coin flipping. Most were whatever the builder wanted. I couldn't focus on them, so, I didn't. Not the way to spend a million.

As COVID was settling in with her 24/7 news coverage of bodies being amassed like war torn canvas clad victims housed in portable freezers, March also brought the news that my mom was now terminal with breast cancer. Fear took her over, the cancer ate away the rest. I had to choose between seeing her, assisting her with trying to function at any kind of basic level, and the exposure my job left me open to bringing back home to her. I took time off. I decided the little time I had to advocate for her was not worth the limited appointments the other vets could see without me. Of all the decisions I have faced within the last year this was the easiest. For three months we faced COVID and her debilitating disease that stole everything she had and left. We all faced decisions that left only two options with every decision. She was either sent away to die in some patchworked mandatory isolation from us, or, suffer at home as cancer insidiously pilfered the rest of her. Trying to find in home care options in the early days of a pandemic was impossible. No one would help us. I moved in to live at my parents house. It was quickly apparent that she needed more than this one human could manage. Three times we had to send her away to try to save her a few more months of time. Each was excruciating to debate, and final in its potential consequences. Every time she was taken anywhere we knew it might be the last time we might see her. How do you weigh that? In May 2020 my mom died in hospice hidden away, and still very much afraid, at home with her family. We have never had any closure after her final breath. I'm not sure we ever will. It's dull and faded and blanketed in an anger I still can't resolve. So many of the decisions I faced outside of taking time off for her were fraught with coffin calling cards. I have no idea if any of them were right? But we made them. Twisting her arm to get in an ambulance as C-diff ripped her guts out in a bedpan her frailty wouldn't permit her to get to. She fought the interventions and surrendered to the terminal.

Three months in, June, 2020, and the phone began to scream incessantly. The holed away humans began adopting pets in record numbers. These humans also began to place a much higher value on their pets who were at home with them and now their only source of companionship in keeping them company. The business surged and the risks of contracting COVID followed. As the novelty wore off the fears abated a little into monotony. Life was soo busy we couldn't watch the news with the same fervor. A sliver of silver lining found us.

Six months in, September 2020 and the staff, and world began to grow restless. You can only stay quiet for so long. People started traveling. Families began to scatter. By this point we had at least a half dozen self-quarantine 2 week hiatuses to disrupt the scheduling obstacles. We had at least 2 dozen people pending tests, some of which took almost two weeks to return. We had dozens of near misses. We were due, and our numbers were too big to insulate us from the bug forever. We split into teams to try to lessen the contact of the blow when our luck faltered. December advent delivered our first COVID positive staff member. The rest of the team went home with quarantine induced fear and chaos. The fear led to real-life mortality concerns. It was the harsh slap in the face that reminded us we were still vulnerable regardless of the masks, hand washing and curb-side service.

I had to decide what to do about a positive employee? I took the safest route I thought possible. We sent everyone who had been in contact with them home to isolate and hopefully contain the spread. We paid everyone, as we had done before. We calculated how many more home stays we could afford? We called the health department, our legal counsel and scoured the CDC for guidance. The NY Times had just run a section long special eulogizing the huge number of landmark businesses across the country who fell to the pandemics passing. Was I going to follow?

Where has paralysis cornered me? Here;

The vaccine is now eminently at our doorstep and another series of questions that need to be asked. How do I handle vaccinations? Silly, stupid me thought this one would be easy? We are all medical professionals? Aren't we? Isn't that our pitch to stay open as we call ourselves "essential"? Don't we all want to get out of this fearful place where a virus still has us by the neck? We are the vaccine giving kings of the world. Right?

Turns out a significant portion of the staff doesn't want to be vaccinated.

So,, do I take my personal opinion and force it upon others? Do I stay true to the devote liberal I am and let you do with your body what you want to? Isn't that what I stand for?, (well, as long as it doesn't hurt others. Isn't that caveat pertinent? And doesn't it apply?).

Every decision up to this point has been based on others over self. My mom, the staff preferences to stay working or not, making sure they are financially secure for whatever time off they might need, the multitude of ways the business might suffer at the expense of treasuring and coveting life. And, here I am now. I can force vaccination to be a condition of employment and risk losing people I deeply care about as I force my firm belief that we have an obligation to eradicate disease with all measures available. Stop the spread of disease by the same means and manner we do, pitch, force, and testify to being effective to the staff who doles it out to our clients and patients. What if there are pregnant staff members who should not be vaccinated among us. What do i, we, owe them? What about the conspiracy theory staff who don't believe the virus is real. Is that a religious pass?

Here is my list of pro's and cons. The forces pulling me one way versus another. The network of squabbling synapses causing my current COVID catalepsy;

I find a few things odd and unreasonable. How can we be a group of doctors and medical professionals and not believe in science backed preventative care? How can we be the single greatest distributors of vaccines to others and not participate in being vaccinated ourselves? How can we not call ourselves hypocrites and cowards? How can I possibly protect the staff if the staff isn’t willing to protect themselves? I certainly can’t take the ostrich in the sand approach. Just not look, not ask, and not care, if this virus hits is like wildfire and mows out everyone it meets. 

When all else fails in medicine we often defer to what's the “worst case scenario”. Shouldn’t we always be talking about and prepared for that? Isn't it both helpful and insightful when stuck at a crossroads of indecision and perplexity? 

So, let's go there.

What’s worst case scenario for us? The collective group of jvc? My thoughts on this question is not that someone will get sick and have life threatening or even life ending complications. That’s what it was before we had a vaccine option. Mine now is that someone at jvc will get sick or pass on illness to someone else and that transmission will affect others. I now worry more about not the individuals who made a selfie choice, because they now have a choice, but the collateral damage to letting the choice be made. We have multiple staff members (3) who are pregnant. What would I feel like if I didn’t get vaccinated (and let’s be honest the only people who don’t here are doing so out of selfish fears) and then it affects the mom's fetus? I’m not living with that. Part of being in a society, a family, a group as tight as we are, is agreeing to go along with what is best for that society. So for as much as I too worry about the first generation of a population receiving a vaccine I worry more about it others than myself. I will be vaccinated because I care about my husband and you all more than my business and myself. This for me is yet another incredibly difficult decision in a years long list of the same and I am not putting me or the business first. I’m putting you all first. You can choose what you feel is right for you. But abandoning science and the best interests of each other is not how I vote. 

Do I split us up into “vaccinated” vs unvaccinated teams? Leave the expecting moms in the most vulnerable place? Just take the "don’t ask don’t tell" approach. 'Cause that never benefited anyone? Just keep hoping? Praying? 'Cause that didn’t work with breast cancer in 2020. I am not sure. What I do know is that not making a decision leaves everyone vulnerable. And like every other medical issue we face with our clients ignoring it doesn’t make it go away. It just leaves you a prisoner to fate. What good is any medical knowledge if that's your approach  to disease? 

So who is liable? Me the person who let the unvaccinated work with the vaccinated? Let the pregnant employees work with the unvaccinated? 

Do I give monetary incentives? What does that say about us all? Are we at that place in society where baksheesh is the only way to get selfishness to take a back seat to population protection? Have we completely abandoned the notion that the sum is a product of the courage of the parts?

My obligation to this place where so much good happens, so much love exists, and so much healing is given so unselfishly is probably where I need to focus my answer. The answer is that this, like all the rest of the decisions behind me, is just another test to see if I can adult harder? Can I salvage my liberal democracy where people can be confident in living their authentic life and not see it as the selfish, myopic, obsession with individual-above-all in America?

Take a minor risk, get the vaccine, require the staff to unless they have a valid medical exemption.

And yet I sit here torn. Catatonic to Covid.

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