Saturday, November 28, 2015

Cat Abscess: What to do when they aren't healing.

This is Chaussette.

She came in to see me because she was "lethargic, not eating, not playful, or acting like herself, and she was much more vocal than normal."

To me these were all very important clues that she was not feeling well, and particularly I thought the vocalization was her very smart way of demanding help and attention. Those cats are very very smart and will tell you there is a problem if you just listen and pay attention.

Always listen to your cat!

So began my exam of Chaussette; Even though her weight was normal, her mucous membranes were normal, she was walking fine, could open her mouth normally, and seemed to look normal, she had a fever (104.8 F, normal high end is 102.5 F) and a large mass on the left side of her neck. The big clue was the big mass on her neck.

She was also an inside cat.

The mass on her neck was painful to the touch and had a tiny area of a scab.

Chaussete had what I find most commonly on cats with no other history of trauma, no access to poisons or toxins, and a hard mass.  With the careful prick of a needle she had puss under that hard mass. She had an abscess. An abscess is an infection that has buried itself under the skin, or within the body. It is significant because it can be harder for the body to fight on its own and remain hidden from our view.

For those of you at home.. If your cat is not acting normally check them over from top to bottom, nose to tail. Let your hands be your eyes. If your cat has a mass it is important to see your vet. I do not ever recommend that you lance or open up the infection on your own. Here's why; It might not be infection. Don't poke without knowing your anatomy and worst possible scenarios.

Even after I was pretty sure it was an abscess I did not lance the wound and I did not open it up. Why? Well, I know people want to pierce an infection to let stuff out,,but,, it might also be allowing stuff in,, and the wound was very large. Too large for me to do much with while she was awake and in obvious discomfort due to a big festering wound on her neck.

Here is where a good discussion with your vet can make a big difference!

Chaussette's options were;
  1. Gold Standard; Bloodwork done to assess degree of infection, organ function. Costs range from about $25 (PCV), to $300 USD for full CBC and chemistry. Chaussette was a young healthy cat. This step was not going to change our treatment plan (infection  needs to be addressed). 
  2. Silver Standard; Placing a drain under general anethesia. Pre-operative blood work is recommended. General anesthesia cost $100, drain placement $40, pain medications and antibiotics about $40-$60.
  3. Bronze; Try an antibiotic to see if that is all that she needs to heal her wound. 

Chaussette's mom wanted to try an antibiotic first. I discussed that it might work, but, I was a bit worried that based on the size of the wound it might not be enough? She elected to try a 7 day injectable antibiotic. I gave it a 50:50 chance. We talked about monitoring at home and the next step should the wound not resolve. 
Chaussette's initial treatment plan included;
1. Examination $50
2. SubQ Fluids $25
3. Injectable Antibiotic $50 (7 day dose).
4. Injectable NSAID $13

About a week later Chaussettes' mom called. She wasn't eating again and the bump was still there.

OK, time for Plan B. (Every prudent vet has a Plan B. Further, every vet talks about Plan B before it is needed!).

Chaussette was given subcuticular (sub q) fluids and injectable non-steroidal anti-inflammatory to help with the fever. We also started her on a different antibiotic. Any cat with a high fever is reluctant, if not down right adamant, about NOT eating. 

Whenever it is possible I provide as much of the immediate treatment plan as possible in the hospital. It might cost a little extra (you can always ask your vet about the cost differences), but, it gets those cats feeling better much quicker, and it can be awfully difficult, as well as down right dangerous, to pill a cat who is cranky because they do not feel good. It is especially difficult in Chaussette's case because her wound is on the side of her  face and it will be hard to not touch it when you are trying to open her mouth to pill her.

I gave Chaussette

The next day Chaussette went under general anesthesia and had a drain placed. The drain is a small flexible piece of rubber tubing that extends from the top of the wound to the bottom. The plastic tube (called a Penrose drain) stays in place with suture at either end. The drain allows us to flush an antibiotic solution under the skin to eradicate and kill the infection that has been hiding out under the skin. I usually put an e-collar, sweater, or bandage very loosely over the surgical area so the cat won't be able to scratch, lick, or pull it out. The worst thing that can happen is that a pet

Cost of treatment plan number 2;
1. Re-check appointment $30
2. Sub Q fluids (to get break her fever and get her comfortable for surgery the next day) $25
3. NSAID $12
4. Injectable Antibiotic, different and (stronger than first) $10 (one day dose).
5. Anesthesia $125
6. Drain Placement $75
7. E-collar $8
8. Daily oral antibiotics, 10 day course $32

The drain was removed about a week later and Chaussette abscess is now finally resolved.

Important tips for drains;
  • We use the drain to flush a medical grade surgical solution around the plastic tubing.
  • An e-collar is used so that Chaussette won't pull her drain out.
  • The drainage should considerably subside over 24-48 hours. It should be gone by day 5.
  • The drain must be removed within 2 weeks time or the plastic degrades in the body.
  • Drains should only be used when the infection has abscessed and doe snot respond to conventional methods.
  • Keep the area clean and dry. These patients MUST be kept inside and under close supervision.
If you have a pet question you can find me, and a whole bunch of really talented helpful pet people at Pawbly is free for all to use and open to anyone who loves and cares about pets and animals.

If you want to discuss your pets case with me you can find me at Jarrettsville Veterinary Center in Jarrettsville Maryland. 

I am also on Twitter @FreePetAdvice, and I have lots of helpful videos on my YouTube channel.

Wednesday, November 11, 2015

Veterinarian Position Available. The JVC Veterinarian Guide Book

Wouldn't life be easier if we all were given little instruction manuals to help guide us along our path in life?

What about simplifying life into parts? Say, work life?,,,,

What if there was a color by number map to follow from 9 am-5 pm? The quintessential Garmin for our day to day work life?

Here's what my veterinary work template would look like;
  • Arrive at work. Say "Good Morning!" to every person and critter you meet. 
  • Glance at surroundings to make sure they look and smell ready for a full day of patients. For instance, pick up syringe cap beside waste basket. Throw in trash.   
  • Walk into first morning appointment. Smile and greet Mr. Jones. Remark to him that Monster is looking better today. Pat Monster on the head in passing. 
  • Help over burdened client at check-out counter. Offer to carry Mrs. Granny's 30 pound bag of litter to the car for her. And, ask if she remembered to check Fluffies urine after last months urinary tract infection?"
How awesome would it be if I could install a little step-by-step programmed guide into the day of every one of the employees at Jarrettsville Vet? You know, just as a little nudge to guide and prompt them to remember manners, be friendly, and be the advocate for excellent pet care?

OK, so maybe no one really wants a little recording of me nagging at them the whole time they are clocked in to work? It is a little Big Brother meets "mother you're driving me crazy!"

And, yet training manuals have become a universal standard operating tool to train, advise, and guide employees daily. In the veterinary hospital setting we can either provide weeks of shadowing on another employees heels, offer  written bulleted lists to memorize and regurgitate, or a combination of these.

I think I have learned that a new employee is a bit of hiring on a hunch, listening to your gut, asking probing open ended questions, offering a bit of rope to see if they help someone or hang themselves, and yes, providing a tool kit, safety net, and being a nosy, hovering, overhead nagging mom.

Call it matriarchal leadership, ownership responsibility, due diligence, etc.. it's all the same. I, as the owner of Jarrettsville Vet, have an obligation to my family, my patients, my staff, and my clients. Without direction and oversight our ability to meet both our own and our clients expectations, as well as provide exemplary care to our patients, is limited, if not impossible. I have to be a mom. And every mom will tell you that this is not an easy job.

The bigger and more successful my practice has gotten the longer my list of 'mom duties' has grown.

Luckily, every mom has kids who grow up and mature and require less oversight. I am incredibly fortunate to have four veterinarians who are the epitome of professional, talented and compassionate. I have 4 kids I never have to worry about. (OK, complete disclosure; one was in a terrible car accident recently and I worry about how to keep all of the wheels turning in the face of tragedy, illness, absence and crisis. A moms worry is never ending).

Such is the prologue to this blog....

Jarrettsville Vet has hired two new vets! We are welcoming two new graduates into our family. Dr. Hensler will start in late November and Dr. Knouse, who will start in June 2016.

Like ever other new family member who joins a bustling finely tuned, (although sporadically chaotic machine), there will be a transition and change. With this in mind, I thought that it might be helpful if I put some of my pearls, hard lessons, triumphs, expectations, concerns, fears, complete paranoias, pet peeves, and hard lines on paper. (And, because I have this compulsive flaw to make all of that public, why not share it with the rest of the world? Really, I am sharing it because I have to set my new kids out into the word and I am a bit petrified of these kids making the same mistakes I made. Maybe this will help our clients be a bit more understanding of the newbies?).

How do you start a training manual/instruction guidebook? Maybe the best place to start is to reiterate at our most basic principle and core value?
  • Help people help their pets. Jarrettsville Vet helps pets. Above all we are a place centered on kindness coming first. The first, and most important piece of advice I can give is; should you not know what to do ask yourself "what is the kind thing to do?" and then, do exactly that. Everything else is secondary. If you abandon this principle you will lose our soul in the muck of all the other clutter and in the end you will also lose your ability to walk away with a sense of purpose. Abandonment of this will tarnish the hard work it took you to get to where you stand now. 
  • Be honest. No matter how terrible the plot gets your integrity, the greatest gift you give yourself, is on the line. Never surrender that to anyone. And never convince yourself that the consequences over shadow your integrity.
  • Work hard. There is no escaping this key ingredient in the the recipe for the success in life.
  • Be true, true to your patients first. They are who you work for. And, then be true to your clients. Too many vets get this misappropriated. Your clients will find you if they believe that you hold their pets life and happiness above all else. (I am not even going to add the little asterisk that reminds us that pets are property and human safety is paramount. I hope you already see the oxymoron in this?).
  • Never stop being a student. After a decade in practice you may have mastered spays, neuters, and sick kittens, but you will not ever master the art of human communication, emotional turmoil, and the pathetic financial compensation proportionate to educational burden. Be a student who learns from others, cases, mistakes, and pass along what you pick up along the way to empower the others around you.
  • Give everyone the benefit of the doubt, but be prepared.
  • General practice small town veterinary medicine is about finishing the marathon, not winning the sprint.
  • Get out alive. When all else is in question don't give up everything else in life.

Day to Day Pearls;

  • Trust is the cornerstone to being entrusted with a pets care. Look people in the eye.
  • Say "Hello," with a smile and eye contact to every person in the room.  Walk into every appointment with a "Hello." Introduce yourself. Shake hands if you want. You are going to make an impression, make it a good one.
  • Greet every pet that greets you! Acknowledge your patients. Introduce your self to them too. Making long term relationships work happens if you extend yourself to others.
  • Use your brain, your hands, your gut, your eyes, your ears and yes, your nose. These are the most important tools of your trade. Your successes and failures along with your experience will be built on these. Don't start any appointment with a textbook, rule out list, or notes! You will miss important clues if you don't keep your mind open and your brain picking at the puzzling case at hand. Books should be off limits until after you walk out of the exam room!
  • Diagnostics are life lines as you try to unravel the pieces of the puzzle. Use them sparingly. Talk to clients about your exam findings and why you want to take the next step to help understand their pets disease.
  • Give estimates of cost with each step. Your client doesn't know you and they need to trust you.
  • A pet that looks bad should be presumed to be in bad shape. I once had a new grad walk out of a room with a "trouble breathing cat" without the cat. That poor cat was suffocating and the vet was on her way to back of the clinic get a tech to help retrain it. That cat would have been dead in 5 more minutes had I not seen him on the table suffocating. True story. She left shortly after. Walk into every room expecting to be an ER vet. You are always an ER vet, like it or not.
  • Ask for help if you have that tiny little voice in the back of your head telling you to "proceed with caution." You will not be alone here and you are surrounded by amazing technicians and staff.
  • Call the cops if you are afraid. Seriously, never engage in a fight  (verbal or otherwise). Pick up the phone and dial 911. People forget that there is back up right down the street.
  • If you have a tough case and it is bugging you and you think that a radiograph will help you and your patient sleep better at night, do it. The revenues generated by a few simple diagnostics are not worth your compassion fatigue burn-out. Run them, don't charge for them, take it out of the Good Sam Fund, whatever.. Learn to protect and preserve your psyche.
  • We can make anything possible, you have limitless tools to help. Use them
  • Walk away from every appointment only after asking your client if they;
    •  have any other questions?
    • Need anything else?
    • Tell them the long and short term plan
    • Give instructions for expected resolution,
    • Next steps needed if the problem does not resolve within __.
    • Leave your contact information. I leave my email, or cell phone, for clients I am worried about.
    • Thank them and say that it was nice to meet them.
    • Provide a Report Card/Take Home Form to all clients
  • If your client doesn't leave with saying "Thank You" to you, there is a problem. Go figure out what it is. Face all potential problems head on as soon as you recognize them. My nice way of saying "make it right" and CYA.


Behind the Scenes; Pearls of Practice;

  • It is far safer for everyone if you and the techs hold the patients.
  • If a pet is scared ask the client to wait outside. Often a pet is protecting the client, or, they get away with intimidating behavior around the owner. Diffuse the situation before it escalates.
  • Pay attention to body language. A wagging dog tail is willingness to engage. Not friendly or curious sign language. Licking lips, tense body composure, and anxiety cause injuries and a client and patient who will be reluctant to return.
  • If a client insists on holding, makes demands you are not comfortable with, or escalates an encounter, walk out of the room and take a breathe. Take a moment to think. Don't be forced or intimidated into anything. I have stopped appointments when horns get locked. You are responsible for everything that happens under our roof. Live in worst case scenario world, and be prepared for it. A fractious dog and a demanding pushy client are setting you up for the worst experience of your professional life. I promise your pride will survive if you walk away and say "No."
  • Euthanasia's. Remember it is always about the pet. I know that no one wants to miss a vein when performing a euthanasia, but, taking a dying pet away from a grieving family is a question for you to ask, not the tech. Lay out a plan before the pet arrives, or talk to them when they do arrive. Talk about the procedure, ask about their concerns, sign pertinent forms, and check out before you touch their pet. Sedate a scared pet, take your time so that the clients don't walk away grieving more than they did walking in. Alert the staff that there is a pet passing away. Keep the clinic as quiet as possible, provide time, support, and compassion. 
  • You do not work for a person, You are the vet you want to be. The person you dreamed to be. If you do not feel right about doing what is being asked of you share your voice. I will not euthanize a treatable pet. We have placed pets in homes, treated pro bono, and moved monumental mountains to hold this pillar of care true. If you still think that the impossible is not possible stick around a while. The more we try to make miracles happen the more commonplace they have  become. There is no room for skepticism, laziness, excuses, or disposable views here. 
  • Everyone puts a little skin in the game. If you want to help a pet, or a person in need, we will support you. We ask in  return that everyone participate by putting a little personal skin in the game. Discuss expectations early on. 
  • Give stuff away. It builds trust, diffuses pointless exhausting arguments, and keeps clients coming back. I do most re-checks free of charge. I also have a '3 second waiting room' rule. If I have seen the pet before and it takes me less than 3 seconds to dismiss worry I give a 'free visit' pass. Tiny bug bites, tick scabs, broken toe nails, better safe than sorry worried parents who just need to hear us say that "it will be ok, just watch it," don't need a $50 visit charge. I appreciate their proactive nature and they appreciate not being punished for it.
  • Treat each client the same way you would your friends and family. If you are successful in doing that they will become a friend for life and you will cherish this above all else.
  • JVC is not all about the money. We all deserve to be paid well for our time and talents but we never take advantage and we never use scare tactics to elicit compliance. 
  • Give options. Lots and lots of options. Recommend 'Gold Standard' for the best care possible to be provided to your patient. Be honest about cost, prognosis and expected course of recovery. If 'Gold Standard' is not feasible talk, offer, and work until you get some treatment plan in place. Do not abandon your patient because of any obstacle. Find me if you run out of options. Practicing medicine successfully is about effective client communications and negotiations.

Going Home At Night;

  • Check on every staff member. Check that they are OK. Say "Thank You" for their help.
  • You are in charge of the people, pets, and property. If someone or something isn't working step up and say something. The staff is expected to follow your leadership at all times. I recognize that no one likes confrontation but you have to keep this place running smoothly and sometimes that requires being a mom.
  • Check on every patient. Make sure that all treatments are done.
  • If a pet is not calm, comfortable, and stable send them to the ER. They should not be alone at night, and no staff member deserves to come in to find a deceased pet. It is not fair to anyone.
  • Lock up, be safe.

I have your back. Every single step of the way. Call me, or Joe, or Diedra.

This is the first job of the long hard journey you worked so hard to achieve. Be Brave, Be Compassionate, and Be the dream you always imagined yourself to be.

Welcome To Jarrettsville Vet Megan and Lindsey!


Related blogs;
Living and Working in the Land of Liability.

The Power of the First Impression.

Which Kind of Vet Would You Be?

How Do Our Perceptions Lead Us?

Compassion Fatigue.

Olivia,,(who is looking for a home).

If you would like to talk to me about your pets care or needs you can find me on Pawbly is a free online community dedicated to helping pet people provide the care and support they need. It is free for all to use.

If you would like to meet me in person I, and our stellar vets, can be found at Jarrettsville Vet in Harford County Maryland.

I am also on Twitter @FreePetAdvice.