Monday, March 31, 2014

Grief and the Days that Follow Saying Goodbye

Savannah's first baby picture

It has been a week in a long 18 year story. Not days of vacation, but days of separation. I am still here and you are gone. Not to any place I can see you, carry your little flannel draped body under my arm, rub your velvet ears, or hold your little foot in my hand. There are no more kisses on my hand, sleeping in my arms, or days for me to thank god that I still got to share with you. I am filled with sadness and I miss you.

If the hardest thing was the acceptance of that horrible realization that you were better off away from the body that carried your free spirit for all of those years, the truth is that the act of putting your body to rest was excruciating. It took a leap off a cliff without being able to breathe. There was never a sadder moment, a more painful wound to open, or a decision completely my own that I wanted to flee and hide from more.

How your heart can duel with your sense of responsibility, obligation and selflessness I do not know?

After Savannah took her last breath, fluttered her last heartbeat and slipped her last moment from my life I cried in hysterics as all of the fear, doubt, pain and guilt drowned me.

The tears of exhaustion of months of interrupted sleep, clean-ups, and attempts to soothe a colicky child who answered only to the mysterious whispers that only she heard caught up with me, ambushed and overcame me. 

The grief of those first few days was crippling. As a friend said it best, “the loss was devastating.” And that’s what it is.

Trying to get through the first day was the hardest. I am thankful for my husband’s shoulder to lean on and my bed to lie in. What resulted was a meltdown of epic size. I know myself well enough to know that I need time, space and a place without interruption, away from the well-wishers, simpatico sentiments, or intrusion. I know that I need to be quietly alone as I try to cope with the grief of losing someone that my life revolved around. It has always been difficult for me to articulate why. Attempts to assuage my concerned friends, my protective slightly overbearing mother, and my staff (who thank goodness have seen me here before and know that a little note in my mailbox is the safest way to express a sympathy without sending me into an uncontrollable tidal wave of tears), can't be done in person, or over the phone. I need to hide away for just a little while. You have to be true to who you are. Take a few moments to sit with your memories, pay tribute to the memory of your loved one, and remember to breathe. There is always a sunrise and a tomorrow and a tiny sparkle of faith that time heals even the deepest most tragic losses. But for me it happens after I close myself to the world, and furrow under the sadness.

That first night:
It was a blur of tears of loss, relief, guilt, question, doubt, fear, and loss. All mixed and muddled together. I needed and took time to wallow in the murk. I knew I had to let her go, and yet I struggled to find some small justifiable, excusable reason to keep her. I was soo tired. She was a burden. A heavy, relentless, inescapable curse.

And yet,  I racked my head to come up with one more option to thwart fate for one more day. Maybe if I sedated her, let her rest a few hours, put her in the underwater treadmill, bought a harness, or cart to support her back legs, maybe..just maybe I could buy her another day.. Maybe I could buy two, or three? Or…maybe..??

Wouldn't it just be easier to go through life in the middle? I could go to work and take care of other peoples pets. Get a lick, a purr, a jumpy happy puppy, all on someone else’s time, and heart strings. No attachments, no highs or lows, just midstream easy street. How many of my clients walk out of their pet’s euthanasia mumbling this sentiment? I understand why when your heart is crumbled and hurting.

That night was so quiet. No rumbling and stumbling in the night. No drinks of water. No pausing of my sleep to listen for her struggles, whimpers, cries, snoring, and breathing. I haven’t slept in months. It will make you crazy. There is guilt even in my restored sleep that I would happily trade back.

The day after: 
I took a look around my home. Every single square inch is another reminder of a life my home has lost. The whole main floor was Savannah-proofed and I was stuck internally dueling over how long I could keep her shrine in the middle of our house before my husband realized what I was doing, and, feeling like a grief obsessed and crippled mom. 

Day two:
I cleaned. Keeping my hands busy keep my mind quiet and made the time pass.

That night it hit me, the house was unwontedly quiet. There are four cats and two dogs in our home now and they were mute. I realized they have been this way for...oh, I would guess.. a year? It has been that long since I could remember them playing in the house. And there was yet another line item on my guilt list.  My other kids have given up on me, stopped asking for attention from me because I was too focused on Savannah.

I started telling Savannah’s story to try to help other dogs. But when you make your personal story public there is an obligation to telling the whole story. When Savannah’s story ended I wanted to hole up and bury my grief in solitude and silence. But that too would be selfish. So on day two I sat down and spilled it all out.

Day three:
I collected all of the things she left behind that I no longer need.  Four bags of bedding, her fleece onesies, her lights, her harnesses, the bumper guards, the rugs, the pee pads, the night lights, the refrigerator full of food options, they all went away. There would never be a moving on if I couldn't move it out. It broke my heart repeatedly.

I walk by her grave daily, like it calls to me as if I still need to check on her. I hope and expect it to bring me a tiny respite of peace, and it fails me every time.

I have heard from friends , family, and people I have never met about how they followed Savannah’s ups and downs and how her story resonated with them. Finding her, having her be a part of every day of the last 18 years, and knowing in my heart that 18 years is an incredibly lucky blessing that many wish for but never get, sharing her story and the love, support, and kindness that it paid forward has been life changing.

Going back to work helped. I needed to get out of the house, get away from the time and space and vacuum of grief. I needed to give my overactive mind a time out. I needed to share my love for my pets with other pets. There is no grief a wet nose, a wagging tail and the soft fur of a purring cat can’t cure.

Day four:
I can stand again. I can almost talk about her without sobbing and I can feel more gratitude than sorrow.

Day six:
I found myself talking about Savannah and my grappling with how I knew when it was time as a client sat sobbing and holding her depressed anorexic end stage heart failure pup.

“Well, when I knew that there was nothing else I could do to make her feel god, or keep her living a happy life I had to make a very hard, very unselfish decision to let her go.”

She looked at me and said, “This is the hardest thing I have ever had to do.”

“I know.” I replied.
I gave her a big hug and together we put her sick and dying dog out of the pain and suffering that a very sick heart causes.

For all of those of you who have lost a pet I extend a warm hand to hold, a shoulder to lean on, and the promise that you are never alone. The love you give lives on, it never fades, and it never leaves you. If there is any way that you can look into the eyes of another pet you can perpetuate the love again do it for yourself, for another heart to heal, and for the memory of your departed. It helps, and your heart can fill again..that space of my heart that Savannah had is still there. But like my cardiology teacher taught me about the Frank Starling Law of the Heart, the size of the heart increases with the increased load placed upon it. So you see, your heart will get bigger and bigger the more you fill it..

Savannah and her best human friend dancing on the porch of our old house.

The original gang, walking the Virginia Tech campus.
I want to express my deep gratitude to my friends, family, staff, clients, and all of those that sent condolence cards, flowers, and even donations in Savannah's memory. I cannot express how much it helps and how grateful I am.


And from a dear friend;

Our 14-year-old dog Abbey died last month.

The day after she passed away my 4-year-old daughter Meredith was crying and talking about how much she missed Abbey.  She asked if we could write a letter to God so that when Abbey got to heaven, God would recognize her.  I told her that I thought that we could, so she dictated these words:

"Dear God,
Will you please take care of my dog? Abbey died yesterday and is with you in heaven.  I miss her very much. I 'm happy that you let me have her as my dog even though she got sick.  I hope you will play with her. She likes to swim and play with balls.

I am sending a picture of her so when you see her you will know that she is my dog.  I really miss her.



We put the letter in an envelope with a picture of Abbey & Meredith, addressed it to God/Heaven.

We put our return address on it.

Meredith pasted several stamps on the front of the envelope because she said it would take lots of stamps to get the letter all the way to heaven. That afternoon she dropped it into the letter box at the post office.

A few days later, she asked if God had gotten the letter yet. I told her that I thought He had.

Yesterday, there was a package wrapped in gold paper on our front porch addressed, 'To Meredith' in an unfamiliar hand.

Meredith opened it. Inside was a book by Mr. Rogers called, 'WHEN A PET DIES.'

Taped to the inside front cover was the letter we had written to God in its opened envelope.

On the opposite page was the picture of Abbey & Meredith and this note:

"Dear Meredith,

Abbey arrived safely in heaven. Having the picture was a big help and I recognized her right away.

Abbey isn't sick anymore. Her spirit is here with me just like it stays in your heart.

Abbey loved being your dog.

Since we don't need our bodies in heaven, I don't have any pockets to keep your picture in so I'm sending it back to you in this little book for you to keep and have something to remember Abbey by.

Thank you for the beautiful letter and thank your mother for helping you write it and sending it to me.

What a wonderful mother you have. I picked her especially for you.

I send my blessings every day and remember that I love you very much.

By the way, I'm easy to find.

I am wherever there is love.



Tuesday, March 25, 2014

How Do You Say Goodbye When You Can't Let Go?

This is how I will always remember Savannah.
Smiling, superior, divine, and splendid.

Savannah and her constant companion, Ambrose.

It is with a heavy heart and an ocean full of tears that I bid my dear girl goodbye yesterday.  

She has been my shadow, my companion, and my labor of love for 18 years.

Can't you tell who was always the boss?
She was always the brains of the operation,
Ambrose was the brawn of the bunch.
She could somehow convince him to do all sorts of naughty things
that I know he would have never dreamed up on his own.

Her favorite position to sleep in.
I always knew that she was content and happy when she faced the world belly up.

Savannah's typical view of the world,
"I'm in command and nothing can challenge my perception of this."

Savannah knew that I was her mom, she was at my heels at every step,
but I was never her favorite person,
Noah always was.

That smile was omnipresent.

The official Savannah and Ambrose family portrait.

If anyone doubts that pets share similarities with their parents all you had to do was see the two us of together. She was a stubborn, determined, un-waveringly demanding force until the end. Her body tried to continue to do the things that it had always done, but as the last few months stole her abilities she remained a reckoned fighter to get up, move on, and refuse assistance. She was tired, although her body had surrendered to the requirements of freedom to move, and she was pushing on to do things that her tiny frame could not answer to. It was impossible to keep her happy any longer. If she would have allowed me to carry her to eat, drink, and continue to live I would have done so. But her pride and resilience became the burden of her bodies inability to perform even the most basic of tasks. She was unable to walk anywhere except outside. She couldn't lift herself to get to the water, and her frustration manifested into screams of aggravation and exasperation. Even if I was holding her, she demanded her freedom, and I couldn't assuage this.

I have had to address the queries of on-lookers unable to understand that I knew her well enough to know when it was time to let her go. I was often left to defend my decision to others who I hope and believe had her best intentions in mind, but it made the weight of my decision more burdensome and more perplexing.

I knew yesterday when she tried dozens of times to get up and be her normal unencumbered self I knew I had to say goodbye.

She is one of the hardest cases there is. Her heart, lungs, organs, skin, bones, and body were in almost perfect order. She just landed that one last straw on her tired back and lost the ability to move herself around and she was furious about it.

I understood, I empathized, and I had spent the last year trying and exhausting every option for her. But there was nothing left to try. Nothing I could offer her, and no way to dodge the angel calling her any longer. Her body had surrendered, although she fought to accept it, and I had to let her go. There were no options left.

Every day has been a strict regimen of offering at least 4 options to eat every time she woke up or every 4 hours. I walked her through the coldest winter days and nights to try to salvage as much muscle mass as was possible. The terrible painful oxymoron of being a vet is knowing what lies ahead of each possible turn in the road and the binding ineluctable obligation to be the hand of healing, the parent, the paladin, and the hand of death. It wasn't until she was gone that I truly realized how small and fragile she had become. I don't even know how she lasted as long as she did on her bony body.

My husband held my hand as I let her go. It may be inexcruciably difficult to make the decision, but sitting next to her and sending her body away is the hardest task of my life. Joe offered to take her to the clinic, to spare me the pain and agony, but I told him that she would want to be here with us, and surrounded by those who love her the most. He said he was trying to protect the one he loves most, and all I could do is reply "that it's not about me."

He dug her grave, and we had a frigid cold service as he placed dozens of iris bulbs over her. She is at peace and I am left behind feeling grateful to have had 18 years and a lifetime of memories.

The house is ghostly quiet a day later. I have been holed up at home sobbing, replying with "Thank You's" to the dozens of friends posting their sympathies on Facebook, and doing the loads of laundry that removing her area of the hallway took up. I have four bags of towels, sheets, blankets, harnesses, jumpers, baby monitors, booties, baby food, cheap dog and cat food, pee pads, and throw rugs to donate.

I took down the tie out in the front yard.

Threw the repeatedly heavily cleaned after being heavily soiled rugs into the burn pile.

And spent the next day at home re-arranging every room of the main floor that had been "Savannah proofed."

I hear her whimper in the far corners of this now silent house, and feel compelled to follow my routine of spending every sleeping and waking second wondering if she needs me. There is the gnawing guilt, the sharp pain of grief, and the appreciable conditioning of a person who deals with loss everyday.

And I look around at Charlie, Jekyll, Jitterbug, Wren, Magpie, Oriole, and Strawberry who are all quietly sleeping and realize that they need me. I have had all of them on my back burner for a year while I took care of Savannah. I have some making up to do...

Jekyll and Charlie

Jitterbug, Wren, Oriole
and the puppies in their beds at the end of our bed.

My Wren.
Who cries with me,
who came over to me and Savannah last night while I said my goodbyes.
She sat next to us and kissed Savannah on the head.
She is the one who keeps checking on me,
and who reminds me that I don't have forever to dwell on this,,
there are bellies to be rubbed.

Savannah left a big impression on many people. I am grateful for the friends who are so supportive and generous with their kind words and strong shoulders.

Pets with Santa and VMRCVM 2003

If you are struggling with the loss of a pet, there are many wonderful people who can help.

Association For Pet Loss and Bereavement

"Tis better to have loved and lost than never to have loved at all.." Tennyson

Savannah's tale;

Update; Valentine's Day 2016. I miss my girl everyday. Those little velvet ears.. the patter of feet behind me, and the insistent demanding love and companionship. I was so fortunate to have shared so long with her. But I miss you always.. Love mom.

* End note; This post has spelling and grammar errors that I cannot fix.. I cannot stop crying long enough to convert the raw script into a polished edited post. I apologize.. This would require an unbiased third party.

Sunday, March 23, 2014

What "Does Lowest Effective Dose" Mean?

Sam, cruciate ligament rupture repair
There are a few key terms that veterinarians use daily that we mistakenly presume our clients are comfortable with and understand. One term that I use daily is "lowest effective dose" or LED. I thought it would be helpful if I explained what this term means, and why we use it. I use it most commonly when I am talking about NSAID's, or non-steroidal anti-inflammatory drugs. All licensed NSAID's have a label statement on LED, and label mandate is for LED.

We use this term when we are trying to customize a drug dose for a specific patient. I use it when I am treating a pet with a drug that has either a narrow therapeutic index, and/or for a condition that either will likely need long term management, and/or a condition that I expect to change with time and therapy.

Another cruciate ligament rupture repair.
I rely heavily on NSAID's with orthopedic surgeries.
NSAID's are useful for a whole host of diseases and ailments, but because they are so tightly protein bound they have a narrow therapeutic index. This narrow therapeutic index means that your pet needs to be given the exact amount prescribed, or less. Over dosing, even by a little bit, by giving a higher dose of the medication, or by giving it more frequently than listed on the prescription can be detrimental to your pet. NSAID's as a family are the most widely reported drug to the FDA by about a 1:5-10 ratio because of their common and sometimes very serious adverse side effects.

Daisy Mae

And her broken femur

The most common side effects I see in practice are vomiting and diarrhea, but I have also seen perforated gastric ulcers that caused severe illness and required emergency surgery. I have unfortunately also seen a dog die because the owner kept giving the drug days after their dog stopped eating and began acting ill. For these drugs I have a lengthy conversation about possible side effects, things I want the owner to monitor and be aware of, and I always repeat two things;

Post-op re-check

1. Only give the NSAID if your pet is eating and drinking normally.

2. If you ever have any hint of a concern that there is a problem DO NOT GIVE THIS DRUG!

Before I prescribe a NSAID I give the pet a thorough examination, take a detailed history understanding what the client is seeing, what they are concerned about, and how the pets condition might improve with use of an NSAID. I usually always perform a baseline blood and urinalysis. If there is a problem with the pet I want to know what their kidney, liver, urine, and red and white blood cell counts are before starting the drug.

Examples of NSAID's used in veterinary medicine include; Rimadyl (generic name carprofen), Metacam (meloxicam), Deramaxx (deracoxib), Previcox (Firocoxib), Onsior (Robenacoxib). 

Because NSAID's are heavily protein bound they need to be dosed based on lean body weight, (not actually body weight). Therefore use the exact dose (your vet will tell you what your pet’s optimal body weight is. (Hint, this is the number on the scale you and your pet should be working towards). That milligram size is the maximum amount of the NSAID that you can give in the prescribed time frame.

Post-op she barely toe touches with that leg.

The key to finding LED is understanding when the drug is working and then attempting to customize to the lowest effective dose your pet needs to maintain resolution of the clinical signs that your vet prescribed the NSAID for. So for instance, if your vet prescribes an NSAID because your dog is limping in the morning due to osteoarthritis or joint pain, we would like to get the inflammation to dissipate by using a week or two of the NSAID. You should see an improvement in the form of ease of rising, ease of moving the joint, and an overall improvement in activity level and comfort. It is very important for you, as the parent, to understand and appreciate the changes that the medication makes in your pet. Without appreciating these changes it is difficult to understand how to identify their lowest effective dose. For some of my clients I ask them to keep a daily journal that describes how their pet is doing each day. The daily journal entries should also include how much of the drug was administered.

One month later she is using the leg very well.

The game plan for LED is to administer the labeled dose and represents the maximum amount that can be safely given. I always ask for a re-check phone call, or update from my clients within the first week of using the NSAID. I also place them on our call back list so that we make sure that we are touching base with them at this critical time period. Most adverse reactions to NSAID’s seem to occur within the first week. This is done to assess efficacy, ensure there are no adverse effects, and to boost compliance. Once efficacy is confirmed go over a titration plan with the owner. The key is to decreasing an NSAID is to do it very slowly. Statistically about 5-10% of all patients need to stay on labeled dose, but most can go to about 25% below label dose. This saves the client money and protects our patients from the possible side effects. I remind owners to begin to look for recurrence of the clinical signs that brought the pet in the door in the beginning. How well are they still moving? Are they reluctant to use stairs? Or climb onto the couch? Or get up for all of the things that they used to  want to be a part of, for instance, when the door bell rings, when a loud car drives by, when the neighbors visit, etc. It is also important to mention that your pet will give you some indication of pain/comfort by their facial expressions and body language movements. For pets on tablets I recommend trying half the original dose on the same frequency. For dogs on liquid NSAID's decrease by 5 pound dose per week if over 20 pounds, or decrease by 1 pound per week if less than 20 pounds. When the clinical signs begin to recur it is time to increase the dose of the NSAID, this means go back to the last dose that controlled the clinical signs. This is your maintenance dose. If the dog at some point in the future has a return of clinical signs go back to the original prescribed dose for 2-3 days.

For the pet's who I do not think need the NSAID long term, like my cruciate repair surgeries, spays, neuters, and minor wound repairs or surgeries I advise my clients to use the NSAID for a short post-operative period of time (usually 2 days for a neuter, 4 for a spay, and 7 for an orthopedic surgery), and after this period I want them to try to skip a dose, or use half of the intended dose to see how their pet does. Over those next few days I want the pet to be asking for the NSAID instead of the client just assuming they need it and giving it. In my experience outside of the prescribed times listed above most pets do not need any further NSAID therapy. 

Getting better.

Our biggest concern is that a dog being titrated will exhibit clinical signs that the owner doesn't recognize and we have a painful dog. The journal is a helpful visual cue to help understand if we are using an effective dose and an effective drug. Pets should be monitored weekly until the maintenance dose is realized. After they should be monitored monthly. While your pet is on an NSAID routine examinations and blood works should be monitored. NSAID practice tips: Give NSAIDs only if eating and drinking. This means that the NSAID should only be given if the pet is feeling well. I want your pet to be pain free, but I also want your pet to be safe. The safest way to give an NSAID, a long term is to find LED and understand that your pet’s disease, ability to tolerate medication, and the treatment options will all change with time. 

The best advice; keep an open dialogue with your vet and never hesitate to ask for help in navigating the ever changing current and direction of the waters your are traveling with your pet.

I think that I am as happy as Daisy Mae is that her leg healed so well.
Daisy Mae had a serious fracture to her leg.
She required NSAID's for many weeks.
If you have any questions about NSAID's, or any other pet related question, you can find me and a whole bunch of other pet loving people at Please check us out and join our community. We are all about helping people take care of their pets, and we are free to use!

Or you can find me at the clinic, Jarrettsville Vet, or on Twitter @FreePetAdvice.

And as always, please be kind.

Many Thanks to Danny Joffe, DVM Dip ABVP who gave a talk on Metacam that was incredibly insightful and the backbone for this discussion.