Leave Funds Available For Euthanasia. The things vets say to each other that would appall the pet parents they serve.

On a Facebook page for vets to assist other vets I saw this comment. It stopped me in my tracks. It also made me question where this profession is at, and, whether we want to change our collective persona. It was also another reminder that the veterinary world that I live and work in is a far cry from what others do. 

Storm in his holiday cheer

There are numerous Facebook groups dedicated to vets helping other vets with difficult cases, and, of course the clients that come along with them. It is our international social media network for vetmed advice. This particular post, like many of them, was about a perplexing case with a client who had limited resources, or as we like to coin it, "financial constraints" aka no money. Most of these cases have the typical presenting facts; dog, age, breed, spayed/neutered, pertinent history, along with presenting owner concerns, and, veterinarians physical exam findings. This particular case involved a cat who was having trouble breathing. Scant details about patients history, (and/or details the vet thought the client was withholding to look better; think marijuana, drugs, illegal ingestion or access to stuff), and therefore vet really only had that and their physical exam findings to go on. This is an all too common scenario. People show up with a very sick animal and little-to-no details about how, when, why, or even last time the pet saw a vet. Think; umm? don't know how long the pet has been like this? Don't know when, or if ever, it saw a vet? Don't know if they could have gotten into something (like weed or toxins)? Don't know when they last ate, or, went to the bathroom? Or any tiny tidbit of relevant helpful information to assist in this case. Turns out the vet thought the chest sounded too quiet, (indicating there might be fluid in the chest making breathing harder, and hence, breath sounds absent). When a client without any money for things like x-rays, or a chest tap (to try to remove the suffocating chest fluid) the patient has little help of getting help because the clients didn't have enough money to allow for the most basic of diagnostics. It happens with almost every case. We make do with little diagnostic dough on a daily basis. It is almost impossible for me to try to explain how hard practicing medicine is when you don't have the liberty to run tests.. like any tests. Even the most basic/cheap diagnostic tests. Try to analyze a sick, almost lifeless non-verbal being with just your eyes, ears, hands, and nose. We do it all day every day. We also get convinced to guess so much that it too often makes us believe that we are truly very good guessers. I dare say we are too often cocky with our presumptive diagnoses as there is no one to prove us wrong. The clairvoyant diagnostician with no data to ever prove us a charlatan.  

What was most shocking to me about this particular post wasn't that people weren't giving the advice I give my vets (which is listed below), but, worst of all that one vets advice was to; 

"not spend all of the clients money so that they could no longer afford euthanasia." 

I suppose I am deeply and ethically perplexed that this is valid advice. I also wonder how many of us veterinarians live here in this place where mercy only comes with a price tag? And, why would we want to? Aren't we being both neglectful and hypocritical if so? Aren't we both absent in our compassion towards our patients (and no, I did not say client,, because we all know that we love to punish them), but also hypocritical in our own advice of "it's neglect if people get a pet that they cannot afford?" Can we really be so cold and cruel to allow suffering if it doesn't make us money? Don't we dish that judgmental sputum daily? Blame the pet parents when their pet gets sick because they couldn't prevent the preventable? And then deny them a compassionate end when they run out if resources to permit it? Aren't we complicit in promoting negligence that perpetuates suffering because we do not offer affordable euthanasia's? I know of some places that charge $400-600 for euthanasia. (It is $125 here at my clinic). If you cannot afford it, AND, (big and here!) if we truly believe that it is in the pets best interest to be euthanized, should we then be doing it for free? Are we really reminding each other that we should spare the $600 to help save the pet so that we can euthanize them profitably? 

Holy Crap where has this profession gone?

I don't (and won't ever) add the cost of a euthanasia into the cost of a patients care. I also don't list it as a treatment option. It's an option, as it should be for every living being that suffers in dying, but lets not elevate it to a "treatment". It is not the last line item in the long list of charges for both goods and services that I feel the patient will need to get better. After all isn't that our primary goal? Getting patients better? Aren't we all collectively responsible for helping pets get and feel better? No veterinarian should withhold euthanasia due to cost. And yet it seems we do? I have never even considered adding/budgeting/listing this on an invoice when a patient is at the clinic asking for care. As if the tally of the 'total cost of care' needs to include this? Is euthanasia part of our "care" package? I am not arguing that it isn't, but, I am asking why we make room for this at the expense of doing what we all came here to do? Am I asking for too much room? Too much compassion? (Yes, probably). I am asking for a sliding scale of care. You know the kind that gives you a "freebie" euthanasia when financially warranted after a client has exhausted the meaningful list of possible curative treatment options. A rewards program of sorts so that we can care for pets by making them better versus incentivizing euthanasia. How many times do we send animals home to suffer while they die because we used up all of the funds beforehand? Doesn't that sound cruel? How can we preach being ethical and responsible and then send pets home suffering for our economic gain. Let one vet get charged with intentionally cruelty when they deny affordable euthanasia. Then maybe our collective conscious would outweigh our judgmental pragmatism. How sad that it might come to this?

Frippie, sock thief.

When veterinarians wonder why the state if the profession has come to this place where we can boast of our astronomical suicide rates, or, having made the worst return on investment possible by profession decision, or, the fallen trust status we used to boastfully proclaim, it is no wonder that we struggle and suffer to the degree we do. We created it. We are responsible for it, and now we wonder how to repair it? 

To my fellow veterinarians out there.. (whom I suspect will be pissed at me for my publicly stating this viewpoint) argue with me all you want.. and, then ask yourself whose side you are on? Who do you serve? If you said yourself, then ask yourself how she thinks that is compassionate care giving to be proud of.. ?

Zeba and Honeybrook waking up from surgery. Kept in kind oversight by Michele.

The following is the list, (long, short, detailed, and just silly I suppose) that I wish my mentor had given me before I started practicing vetmed. This profession is too reliant on learning hard lessons. Trial by fire, and thrown in to see if you can swim. For a profession too settled upon self doubt in the face of loads of guessing prognoses, not to mention our imposter syndrome frailties alongside the suicide factor it isn’t appropriate any longer. We can, and need, to do better.

Home at the end of a long adventure in the park.

The vet practice I bought has had a 17 year history of this sort of practice owner advice. My advice to the vets who follow. I keep the list growing. Accumulating pearls of practice to pay forward. A playbook for the other doctors and our staff. It consists of permission slips, warnings, and some basic ground rules as we all try to live within this landmine filled landscape full of wet noses, heartbeats and heartbreak trying to keep healthy the most important lives in other humans lives. We are just like them. Us, the veterinarians and staff, and them, our clients. We love our pets as the lifeblood to our souls in need of companionship, purpose and joy. It is imperative to always remember this.

My Frippie sleeping guard over our tree.

To the veterinarians and staff of Jarrettsville Vet, I ask you to ponder these;

I would like to start by saying one thing that I hope you hold true and tight to your heart. You have to be brave enough to be vulnerable and courageous enough to fail. Too many of us let our fear apprehend us. Too many lives slip away because of this. Jump in! Challenge yourself and be both proud and hungry for the next. Invest yourself into every patient every single time. Sometimes you will walk away with only that. And that is always enough. The rest is short loved transient and holds little value.

Likability matters. In medicine it is the single first influence to motivate your success. Smile. Engage. Offer more than you have to, and, more than the rest do. You can risk vulnerability but the reward more than makes up for the soft spot exposure.

The secret to the report card (the summary of the pets visit that we send home from every examination); it is the measure of your time with your patient. Let it reflect it accurately and definitively. People need a tangible piece of the experience. It is also the ticket to the next stop in many cases. Let it be the road map for where you came from, where you are and where to go next.

I summarize the report card as having the following key pieces in each;

• Summarize the exam findings. 
• Provide your presumptive diagnosis, or worst case scenario. State them both. It is our responsibility to hope for the best and prepare for the worst. This is life, both happen.
• List the diagnostics or measures to confirm this. i.e. “our next step is blood work, xray, u/s. Etc”
• Provide guidance as to what to do next, i.e. “if this, then that.” I tell every client what I expect and when I expect it by. I also leave a timeline. i.e. “if the coughing isn’t better in 48 hours call me. If the coughing leads to open mouth breathing, or is intractable, go immediately to the ER.”
• Give estimates for the suggestions you make. Use the support tools provided to generate this estimate. 
• Talk about payment options. We all too often just assume people have excessive disposal income. 
• Help people understand the journey. Be the guide and the sherpa.
• Lay out the plan but keep the focus on the needed steps to getting their pets quality of life back. I.e. do not exhaust resources so that treatment is out of reach. It sounds scary I know, but, if you think a pet is dying and needs surgical intervention, or, medication to survive and resources are tight, skip whatever diagnostics you have to to allow curative treatment to occur. 
• Never paint a picture you can't back up if the case ends up being the worst possible scenario. Being caught off guard, or, letting a pet suffer because you didn't educate the client in what to look for is negligence and makes us complicit in that patients suffering. 
• CYA every day and every interaction. We are dealing with disease. Potentially deadly diseases where many can be passed onto humans. We also have this sticky situation of having to protect the people around our patients. Dangerous dogs, feral cats, zoonotic vectors, and human limitations to the "ideal at home treatment" plans. 
• Always be honest. It's ok to apologize. It is always right to make it right. In some cases I just say that, “what do you think I need to do to make it right?” There is a drought of admission of responsibility in vet med. This too must change. We aren't fallible humans when we cannot be honest and culpable. 
• Pro bono is allowed. Anytime or place that you want to help a patient (or even client) for the sake of helping we will support you. Take a free radiograph to look for pulmonary edema vs a met lesion if it means you can sleep better at night. There is a serious mental health issue in vet med... don't let the few scant dollars it takes to help you feel better about what you are doing here preclude you from resting just a little easier at night. These cases follow us.. the dark shadow. The grim reaper at 2 am, is there a price for these? Yes, but don't let a few give-away diagnostics be the culprit. I promise that what you give away comes back 10 times over. You can tell the appreciative and needy from the rest. And to be honest there aren't many who will take advantage of you when they know that you are here because you care about their pet with them.

Here’s where we fail people. We don’t explain enough. Talk.. talk,, talk… but try to be clear and concise.

Two of the 52 cats we helped to save in our most recent pro bono endeavor.

• Take good care of the staff, they will return it in spades. You may be in that white coat at the head of the line but there is an Army behind you.
• Clean up after yourself. You look like a jerk if you are too good to get dirty, or, think that you are above it. 
• Ask for help. It is available everywhere. Us (the other vets), our broad network of specialists and referrals. (Hey, psst,, did you know that there is a whole enormous group of specialists out there that can give your vet free advice? So, if they tell you they don't know what's going on, or, need help figuring it out ask them if they asked for help from the vet team that supports them. i.e. referral lab, online specialists, Facebook groups. The vets who invest and care will utilize these for the benefit of their patients. If your vet isn't one of these move).
• Don’t send out a referral without a head up as to what they should expect once they get there. Most often this is the price tag, but, it might also include diagnostics which they might be unaware of. Explain as much as possible. Call for estimates, then tell them they are welcome to come back to us if the options from the specialists don't meet their needs. 

Clarke. One of the many faces that I find purpose in this cause.

• Everything is offered a referral. Everything. If they don’t trust us, if they are worried to "don't know what to do paralysis", or, if the molehill looks like it might have a mountain of ugly behind it, CYA and refer. I have a "three times I try and then I punt" rule. If I can't figure it out within three visits I punt to a specialist. Or, I at least strongly encourage/offer. Everyone's time is precious. Further (brace yourself) we are not always such impressive/perfect guessors.

I hope this list grows. I hope that others add to it. Maybe we can all learn from each other and we don’t need to trip so often to remind ourselves who we are or what we are capable of.

Most of all I hope that we remember how powerful the love of a pet in our lives is. That we hold it sacred and feel honored to be caring for each other and giving as much, if not more, than we receive with the spirit of our pets unconditional love to guide us and serve as the inspiration for us to follow.

Jennifer, the Office Manager and our beloved clinic cat Seraphina.
For more on Seraphina read her story here.

If you are a pet parent struggling I am here to help. You can find me at my veterinary clinic Jarrettsville Veterinary Center in Northern Maryland, or, for free pet advice meet me at Pawbly.com.

References;

What is the ROI of your college degree?

Professions With Highest Suicide Rates

How Much Does It Cost To Euthanize A Pet.

Eluding The Arrow. When Life Narrowly Escapes Death. If Only By A Few Days

I have been repeating the following to myself routinely throughout the past days;

"There is nothing more precious than this day...."

I play this on a loop because my breath can't catch my fears for long enough.

Every moment of each recent day has been an egg-shelled goosestep frenzy. A holding of my breath as I cross my fingers and mutter a silent prayer for a reprieve,,, if only for another day. All the while knowing that my luck, and the mercy from above, is on short supply from an endless demand. Fate always wins. The house always calls its players home from rehearsal. I am not fooling anyone, surely not myself. The one who witnesses, awaits, and too often yields that fateful blow. No, surely I will not be provided mercy from deaths ever tightening grip. 

I know this, and yet I, like everyone else, sit here pray-fully begging for another skipped turn. 

Just one more hour, a sunrise, a day, perhaps the upcoming holiday, to be given with my dear boy.

His name is Charleston. He's 13. All grey faced and creaky. Bones jutting from a spine that used to propel him like an antelope. Stiff gaited and slow. He wags a slow paddle when you gleam a big "hello!" and whisper into his silken silvered ears,  "I love you." He is still there. 100% mentally intact. Feeling all of his wants, his impatient protests, and the pull of a cancer that is slowly ingesting him from the inside. He moans and flops, and reminds me to beg harder. Plead more profoundly. And decide where that line is that I always propose to stop at. The veterinarians compass is full of tricks. Tools of the trade to barter with the invisible veil of fate calling him home.

Today was a night of sleepless worry. He did well yesterday. We enjoyed a full day at home, uninterrupted. Last night he paid the price for not sleeping the day away as is his usual when I work 12 hours. He tossed, turned, moaned, whimpered, and panted in small short blows to a chest that has been compressed by fluid from a tumor leaking inside his heart.

He sleeps at the foot of my bed. His dry, violent coughs jolt me out of half slumber to try to assuage the beast that rises and screams within his ribs. It was a night that brought an awakening that we couldn't do this another day. It was just too cruel to hear him pant so fast and furious and still not be able to catch a good breath. 

When my husband awoke we talked about the logistics of putting him to sleep on his bed. In just a few moments he could be at peace. I could give him that. For all the pain it brought to me. I cried to my husband hating this part of my toolbox as much as I do. I truly despise this one last act. It is the most difficult thing I force myself to do. 

Why do I euthanize my own? 

It comes down to them. My beloved pets knowing that they left with me confessing the depth of my gratitude into their ears, their being. That I loved them beyond measure and I wouldn't let anyone else tell them for me at this last moment together. It makes me nauseous. Physically ill. I cannot eat, or drink, or let myself be forgiven for my failure.

I draw imaginary lines to not cross. 

Today it was oxygen and thoracocentesis. I was not going to put him in a caged oxygen chamber, alone. Breathe better my boy, but do it surrounded by stainless steel and a plexiglass door fogged with panting pleas to be freed.

Chest tap. Drain the fluid compressing his lungs and let the air back in. Why when the tumor is just going to replace it? Maybe it will take days, or weeks (fingers crossed), but, it will come back.

Nope we were going to be grateful for our time together and say our goodbyes. 

The cancer is in his heart, his bladder and his spleen. Nasty invasive fucker holed up in the heart. The one place I can't put my surgically gloved finger on and cut out. Tentacled, maniacal, bastard.

The sun came up. The windows filled with light. The puppies made their morning ritual jump up into our bed and kissed our hands. They wag and wiggle and nuzzle into the pillows. It is their subtle "good morning!" cadence. Charlie usually starts to stir after the puppies pop in. A long exaggerated guttery yawn. A shaking of his head and church bell collar charm cockatoo. He then stretches cat-like on the carpet and trots to the bedroom door for his chaperoned walk outside.

This morning, after a full night of fitful moans he did just this.

Walked outside, peed on the holly and trotted for his morning stroll.

He walked into the kitchen, sat on his bed, and ate the steak left over from last nights green-mile dinner.

I smiled a tear-choked nod to my husband and said,

"I'm calling the troops at the clinic and we are trying different meds and a chest tap."

And so goes the line. Nudged to the corner. Redefined in another day.

The words rattle in my subconscious. The pearls passed down from the weathered vets who taught me to live by these words;

"Let no patient die without the benefit of steroids, analgesics, and an appetite stimulant."

That was the recipe for todays reprieve. And a jigger of chest tap muddler.

and to the wise words of my fellow vet friend,, because it is true that we lose our "doctor brain" when it is our own pet, sedate for sleep. We all need it, and, that mercy comes without a guilty hangover.

For those who understand. For those who still grieve with loss. And for those pet parents who have walked down this road before. You are not alone. You gave a soul a life I know they are blessed and grateful to have had. Every dog should be as lucky as Charlie is. He was loved, he remains loved eternally. What more could one ask for?

Parting wisdom; Saying goodbye never gets easier. What does make it survivable is only knowing that there are lives ahead of me to take care of, and a sense of knowing I can add his footsteps to mine on the other side of this. My life is infinitely richer for having shared the last 13 plus with him.

I will miss you Charlie, everyday.

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).

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. 

Buster

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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"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.

Giving Up On Loving, The Ultimate Cost Of Grieving A Pet.

Watching People Ruin Their Pets.. When Do You Intervene?

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.