Permission in Veterinary Medicine. When Is It Not In The Best Interest Of The Patient, and Why Not?

 

The start of today's NYC 10k

Permission is one of those words that come seasoned with disdain. It’s a word spiced with hierarchy. Flavored with rank, status, and inherently poised to provide unwritten, un-equivocated submission to being less than, therefore in need of,,, permission.

It’s a silent caste admission. A way to assert while it sentences subservience. 

Hamilton. One of our best examples of compassion and not needing permission.
When you are unwanted its not relevant or pertinent,, at least to me.

Permission in medicine, the human variety, occurs at almost every level of care. Today I was running a race and right in front of me a fellow runner was broadsided by a bicyclist going about 40 mph. He hit her so hard that she was sent flying and landed like dead weight on the asphalt. She was unconscious for 20 minutes. In that time three doctors rushed to her aid (2 md's and a veterinarian from N Maryland). Without any consent her clothes were cut off and she was hooked to a defibrillator. We held her hand, kept our fingertips on her pulses and called an ambulance. Passerbyers flocked quickly and everyone was directed to keep clear. We placed her in a neck brace, slipped in an i.v. and began collecting vitals. It took 5 minutes to get an EMT and 20 for an ambulance. She was still barely conscious as she was transported into the ambulance to be brought to the hospital.  This is how we would all want to be treated. Right? A freak accident occurred, people immediately jumped in to help, and life saving care was not given one second to allow for a poor outcome. This is how it should always be, right? There are things we can do to help with pain, disease, and even immediate emergencies and we help? Well, let me tell you about vetmed. Vetmed is all about consent from the first second to the last. Consent requires permission. Permission is the crown wielding the fate.

Permission is where fate meets traffic signage.

Permission in my experience rests on spousal influence. I wish I could feel that permission rested on ethics, soul designation, and the inherent irreplaceable value that is the truest level of devotion and companionship any of us will truly have,,, but it isn't. It is so often about control. There are broad sweeping generalizations I could pepper in here, (most apply spot on), and much makes reminds me daily to be so grateful I have financial independence. Control/permission, the lot is an ageless reminder to women that their voice carries a 2/3 vote. It’s the acceptance that the purse-strings are provided with a budget in mind. It’s that one thing that drove me to not becoming my mother. Permission is that one last vestige of inequality that manifests at the vets office. Permission is as venomous to me and a chastity belt and a maiden name. I have given up asking for permission. It places me back, mentally and emotionally, into a time and place where skirts were too tight and white gloves were fashionable. Permission implies ownership, deference, and allowance for others that is far too generous.

Permission was something my mother needed too much of. She was resentful because of it. And I learned to never want to be in her shoes. It is quite simply the reason I went to vet school. I see it a lot, (too much quite honestly) in my day-to-day vet med life. It makes me seethe inside. It breaks me, daily. Why, why do so many of us need permission?

I have been married for decades. I know the difference between conversation and negotiation and compromise and permission. Permission denotes control. When it comes to pets, their lives, and the precarious place they hold value, permission turns into earnest negotiation and pleas for mercy.

..end of the 10k. Frippie and Storm are happy to see me!

It’s a high wire act founded upon compassion and rooted in property replacement values. Very rarely does permission for care hinge on sparing from pain. Occasionally permission to treat manifests around a lunatic discussion of perceived appropriate care. Last week it was the trapped barn cat caught on the vet clinics property. Small, frail, afraid to blink, or move a muscle and the neighbor who believes he is a wild animal and therefore does not deserve veterinary care. He will either be eaten by a predator, injured by a rabid animal, get and possibly infect other cats with FIV, or continue to live his life full of fear outside. They feed him by the way. They refused to give me permission to vaccinate, neuter and provide flea prevention. I am reminded of the saying about “good fences” although how many of these are cat proof?

Jeezy,, he loves me,, he loves me not,, it kinds goes like this with him.

Permission to provide pain management post operatively was a battle for the first few years of practice. I had to absorb it into the cost of the surgery to make it appear as if it wasn’t a line item that was negotiable. Permission for analgesia? Yeah, not under my scalpel. Permission is the most precarious part of vetmed. It may not seem so obvious but it is. Permission to help is often used as a wedge to drive price points. I admit I do this too often. Where I am strong in my ability to not show, ask, or desire permission my deference to advocating for a patient’s well-being lies in my willingness to negotiate anything for my desire to obtain permission. I will wheel and deal more cunningly than a used car salesman. I will wager the house to heal. I do it daily. I have amassed coffers of contributions so large there isn’t anything I can’t give away for free. I have turned my disdain for seeking permission into a black and white disclaimer of empathy. Still with this there are those who won’t provide care regardless of whether or not they have to pay for it. That’s the ultimate control. The ultimate heartbreak, and the ultimate reason I am not a veterinarian to all, in spite of all who need one.

Peggy. Allie's rescued kitten

Personal Note; please remember what the title of my blog is. It is my diary. The place I put everything I try to sort, package, and categorize when it lays bubbling under the surface of a profession I feel so passionate about and the lives of the patients who cross the threshold of my small town vet practice and eat away at my heart for the plights they face. I have come to be paranoid about euthanasia requests. Not because I don't feel they are warranted in so many cases, but, because they are also totally unwarranted in far too many. I have come to despise permission and the inherent control it inflicts.