The Train Wreck and the Captain

The cops came by for a visit last night.

The example in real-life of how to handle an unmanageable escalating crisis when words have failed you.

People are so much like the pets we take care of. You can tell the ones that are going to be the problems, heck even the ones who are outright dangerous, if you stick around long enough and use your Spidey-sense acutely enough times.

We have a few pets who just aren't their best selves when they get stressed or overwhelmed. In the people world I can use the recent example I had on a commuter train from NYC to my hometown station of Lancaster Pa. Just outside of Philadelphia at about 5 pm the train came to a stop. Shortly thereafter the announcement came over that there was "a trespasser struck on the tracks" and the train would be stopped until further notice. Oddly, (although this is my life so I dare not say coincidentally) this had happened to me a few months before. The train had stayed paralyzed for 3 hours. I was with two friends, we were all seated together, and I passed this along to them. We commented and giggled about how smart we had been to pack goodies from our weekend trip and settled in with our books, tarts and trashy Netflix series. The hours passed. No news of relief came. 

Sometime after about 8 the announcement notified us that another train would meet us and we would switch over to them. It was dark and trains are trains. Visions of cowboys, Indians, and stowaway-runaways started to swirl. It was a new adventure for the story book of the life and so we kept on idly seated. Mutterings of a train parked next to us began to pass through the car. It was so dark outside that you had to be seated at the window seat and press your head against the glass to make out the dark silhouette. No announcements came so we all stayed seated lost in our own distractions. Half an hour passed and the door to the car in front of us opened. A small young business suited woman walked in. She was holding her phone and announced too loudly that her friend was also on this train, many cars back and the train had already been evacuated. Had any of us been alerted? Her voice was too loud and too panic stricken to process without scrutiny. She didn't understand why we all looked at her blankly and so within seconds she said, "If you all don't get up and start running I am," to which the nerve of panic hit the passengers. Two of us in the car of what must have been about 80 seats stood up and told her to calm down. The staff would come get us and we weren't going to start a stampede to get off a train that was parked god only knows where. 

She didn't like the answer she got. She demanded again that people start heading aft and swiftly.

Again the two of us took charge and this time challenged her with restraint. She was impatient and lacked authority. She is the patient zero of mobs where people are crushed and die. She is not the person you want directing life rafts.

A few minutes later we were directed to start moving and the night was long and a bit harrowing, but we made it home safely.

My two traveling companions this trip were my two surgery technicians. The two girls I rely on more than anyone else to help the patients at my clinic at their absolute most vulnerable and most needy. Many of the patient I take to surgery are scared, stressed, debilitated, and some are even dying. If I don't have a team that can listen, follow, and still be ready to jump into action when they see danger looming our patients will suffer and perhaps expire. We are a team with clear objectives and unique talents, but, we are also aware of each others responsibilities and protect the team as much as we protect the individual. You cannot teach this without living it to reinforce it.

I do see my role, my profession and my life in this light. I am the leader, the fall guy, and the example. 

Last night at the clinic I was called to come and help diffuse an angry client. He was refusing to pay his bill because it was over the estimate provided. To summarize as I have to defend others whose prices are often seen as being exorbitant for vet care, this was a dog who could not be safely handled with a dog bite wound three days old who the owner also wanted to have neutered while under anesthesia to repair the bit wounds. The cost of his invoice was $660. We fit him in as an emergency within hours of his phone call. We kept the dog for half of the day to manage his care safely for everyone involved. We performed an hour long surgery to clean and repair the wound that was half of the dogs back leg, which included a drain and multiple suture packs, and we neutered him (in the hopes it might help avoid another dog fight down the road). 

The estimate provided was too low for the degree of the infection we found when we could safely examine it under anesthesia. He was here at 730 pm (we close at 8 pm) stating it was "our error and therefore he shouldn't have to pay for it." To add fuel to this he was driving a Cadillac that was about the same size as the train car I refer to above that was brand new, and stated that he's a lawyer. He was so rude that the techs had to call me after he "excused" them for talking to him about our mistake.

I met him in the reception area with the itemized invoice in hand. I attempted to discuss the definition of estimate and the degree of unknown findings that every surgery can bring. He interrupted every sentence two words in with lawyer tactics meant to intimidate, bully, and prohibit answers that weren't going in his favor. When I stated that I would not continue until he was willing to let me finish a sentence he began to name call. In the course of our 10 minutes he called me "stupid" "arrogant" "Karen" "liar" "irritating" "annoying" and "holding his dog hostage for payment." I had at least 5 employees behind me listening. After it was apparent things were just going to keep escalating, and I was absolutely intolerant of the name calling, I directed the receptionist 5 feet behind me to dial 911. She looked at me frozen. I guess she thought I was bluffing? 

There have been dozens of staff meetings where we have run through this fire drill before. I wasn't bluffing, and she wasn't dialing. So I picked up the phone and dialed it myself.

Here is my advice for situations like this;

1. You cannot diffuse a bomb, but it is super helpful to recognize that it is ticking in front of you before it goes off.

2. Train your staff to use the chain of command and make sure whoever sits at the top does it willingly and is capable. Vetmed needs more fire drills for these situations..

3. Have witnesses if you think it is safe to do so. I have to admit that when the dispatcher asked me if "I thought he was carrying a weapon?" I had to pause. I replied "I don't know?"

4. The dispatcher asked me if I wanted her to stay on the line until the police arrived. I paused again. The all too empower woman in me never wants to ask for help in holding my hand,, but the inability to foresee the future and the potential train wreck that might happen because of this left me answering very humbly, heart pounding in my throat, "yes, please" in a voice that cracked as the words came out.

5. The "caution" pets have treatment options. Short and long term behavior modification tools that the profession has long been addressing. We can refer to behaviorists and trainers. If we can intervene early enough we can save the victims of bites, attacks and surrenders and euthanasias. People,, yeah,, I think the cops have to deal with too much mental instability outside of their wheelhouse. I am empathetic beyond measure for the situations they are asked to intervene upon. And to the Sherriff last night who was also treated so disrespectfully (and of unknown relevance, was the Black officer, if you can hear this I am sorry for how you were treated, and I applaud (grateful) you kept yourself together. I could see you wanted to pound his face into pudding also).

There are inherent strengths a woman (yes, I am going to go here because I exist here) has. We are super good at keeping our place. I hate this about myself at times. I am just as capable (likely more so in the case of an emergency) and yet I stood there quietly and took his abuse. I have never in my life allowed another person to verbally berate me like this. It is the single part of last night that is not to be forgotten. For this I am glad I had 5-7 women who I take responsibility for watching.

The police arrived and he made sure to intercept them first to give his side of the story only to end up treating them (almost) as poorly as he treated me. I gave him enough rope to hang himself and he took the bait. He told the Sherriff he "needed conflict resolution" training multiple times, and as he was being escorted out of the building, to "stay in his lane" as he ordered him to leave. The girls erupted in stifled giggles to that one. They turned their backs to the door to cheer together.

The night ended at after 9 pm with him paying the low end of the estimate only, (you know to "teach me a lesson)." And me telling him that he was no longer permitted on any of the private property that Jarrettsville Veterinary Center owns and a police report to document it.

I am home this morning reminding my blood pressure that worse things in life will come and I have girls to raise, and, a clinic full of pets to protect so I better get my shit back together before I step foot back at work and try to lead a Calvary again.

P.S. Of the many threats this former client made to me last night they included; social media, YouTube, and community page smear campaigns, along with word of mouth public humiliation. Good Luck to you,, I am sharpening my pen as I drink my coffee and type away.

P.S.S. This is my personal blog, It is entitled appropriately. I often write raw, unedited posts in an effort to shed the burden this life and the difficulties I struggle with airing out. For the horrific statistics vetmed suicide has shed light upon, we really all are struggling to stay alive.

Death Of A Lobster

 

It's said that the lobster sitting in the pot as the water gets hotter around him doesn’t recognize his own imminent impending demise. The gradual boiling of the lifeblood giving rise to a peaceful slumber, pain free. Whilst the brown pincher-ed self screams as it meets the inferno being drowned in the cauldron boiling to his final crimson curtain. I, like most veterinarians, spend a disturbing amount of time obsessing, questioning, and seeking peaceful death. We are the worlds pre-eminent experts of dying peacefully. We have more experience than any other earth bound shepherds. You, me, all of us in the companion animal side of vet med get no dress rehearsals, no free pass, no second chances at the delivering death if we cannot make it pretty. It's really a twisted request when you think about it. A conversation I have had to have too many times. How to make this passing peaceful and welcomed. Truth is the body, any and all, do not want to surrender. We have to use inordinate amounts of seriously concentrated narcotics to trick the heart, lungs and mastermind of it all; brain, into letting their primitive and archaic, hard-wired and determined to preserve at all other costs self to take pause and trip up just long enough that it cannot restart or resume. Our organs are prehistorically programmed to keep on beating, breathing, and firing even under the most intense of insults. Death isn’t supposed to be quick, easy, or pretty, no matter how much you desire it to be. Accept that. It is what has kept you alive through all of the accidents, injuries, diseases and disasters a lifetime endures.

But let's get back to my lobster.

Does anyone plan for their blushing oblivion? What about the life we live in between the here and the thereafter? Surely lots of us veterinarians do. Right? I mean how else can we euthanize one, two, or even three or four patients a day and not get smacked in the face so repeatedly that we don’t start asking ourselves if we are living the life we chose, or just living the life outside of the cauldron.

This morning I stood in the shower long enough to turn my own fleshy peach Crayola exoskeleton into a blushing burnt umber. Winter is here and I remained frozen between the day I had to face and the numbness of turning the hot water a little at a time toward scalding. There is the ocean and the fire and chasm of indecision between the two. 

If you don’t know vet med in its own current state of matter it's a hellish inferno. A secret kept so dark that it is reduced to a statistic instead of a biography. That shower for me each morning is my threshold between the two worlds. The world I sit quietly and creatively trying to exist within and the black hole vortex of the clinic which I am both immensely proud of, inherently petrified for. Because of these I am unable to break free from it. It’s a glue trap of purpose wrapped in good intentions. It is as consuming as the soaking sauna that lobster marinates within. Unless you live it it is hard to fathom. We all love what we do and hate what it does to us. We all came here with such fierce conviction to become a veterinarian that it captured us within its hopeful dreaming. And yet we all wish for the day we are independently wealthy enough to walk away, bags packed, scalpels silent, and yet knowing as we look back from our recliners that the notches in our belts had meaning and value.

Today I leave my sanctuary home to drive into work to check in on Harper, the Dalmatian who arrived so down trodden I feared for her ability to survive another few days. The dog who was so charming she smiles. Her dad was a tough nut to crack. The lobster debating his own destiny. He was intent on managing this mysterious ailment, the one who had her not eating for 5 days, on a scrawny budget. I begged to run diagnostics. They came back over 24 hours, not the 1 hour his timeframe based on budgetary constraints was based upon. I had an ultrasound and xray telling me that her gut was at an all stop. She was 2 years old. She may need an emergency surgery if my guess was obstruction. That starts at about $800. I asked him to go to the ER for overnight care. He couldn’t afford that. I asked him if she could come back to us first thing the next day. He said he wasn’t going to be able to do that. I took a long pregnant dare-I-step-here pause,, and,,, these words came out of my mouth. “What do I have to do to try to save her life?” I had already offered a payment plan. When that was refused I offered to take care of her pro bono. That was refused too.

Why did I do all of this? It was that smile. That Harper grin that I had only known for a few hours, and this gut feeling that there was a mystery to solve and a patient I could save. That nagging, gnawing knowing that this patient was not to be let go back into the ocean.

We agreed to leave her overnight. She settled into her cage as I walked out the door at 9 pm. I was fairly certain she would look much the same 11 hours later  when I could start her on i.v. fluids and wait for her blood work to return from the lab.

The next morning the fluids ran. She perked up just a little bit. Her blood work arrived from the lab mid morning. And there it was,, my answer,, Addison's disease! Of course!

TREATABLE!! Wishes of little girls dreaming to be their own James Herriott take up the bugles!

I called to report that I was fairly certain I had her diagnosis. I gave him the budget for managing this under best case scenario. We agreed to try the injection for the treatment. I told him that if we were correct on our diagnosis she would look like her old self in the next few hours. He ok’d the $200 injection of DOCP.

He came to pick her up at the end of the day. When he came in to see her she smiled, wagged and bolted toward him. We all cried. We were all so grateful for two lobsters who wouldn’t let the tide carry us into the cauldron.

 This is a profession of emotional turmoil so intoxicating it can kill you. It is a minefield of emotional decay that breeds indifference for your own survival. There are lives in the balance at every 30 minute appointment slot. It is not for the meek, or the dreamers, or the lobsters with the rubber banded pinchers outstretched.

Its been 5 days. She is back to being her happy, energetic, adorably endearing self. I, well, I am out of the shower and headed back to the frying pan clinic. Another notch in my belt.

Harper

P.S. Harper is about 40 days into her Addison's disease and doing very well. Her story has a happy ending because there is courage, determination, and an emotional investment in everyone involved with her care. We are going to save her on a tight budget. Although it is never ideal, it is exactly what her case requires. We all come to the vet with a heartful of pain, burden and extenuating circumstances. Harpers family needs Harper and I am here to help. 

We All Pick Sides

 At 24 years old I was a First Officer assinged to the Cable Ship Global Mariner docked and home ported in the great bluw color city of Baltimore Maryland. I worked the midnight to 8 am shift. I loved it for all of the reasons the rest of the deck offiers disliked. I was on my own and didn't have to put up with the frontal and not so obvious displacement of my sexual status and the marimtime inducstries disgruntled attitude towards it. 

There was never a moment that I felt appreciated, needed, wanted or safe. 

I slept from 3 pm to 11 pm, woke up, put on my khaki uniform and wished the world a sleepy few hours as I mae sure the stumblers made it up the gangway safely. There were rounds to be made every hour. Fires to be kept absent, and kitchen songs to sing me midway through the shift into the dawn

I had discovered running at the Academy. The only way to get off the Academy grounds was to use your own two legs. It was an escape as much as it was a freedom.

Running got me acquainted with the edges, periphery and genuine life of Baltimores less touristy spots. I ran every day before lunchtime for the rest of you. Hours of weaving down back streets, front streets and main streets. I watched the seals dance in their circular pool as the fish defrosted behind the scenes. They were my good morning colleagues. They reminded me that I had a calling elsewhere and a job to do to help propel me to pastures later. On one of these days I ran by a little bar on Fort Avenue. It was a sailors bar. Raw, unadulterated by fresh paint, and a feminine touch. Dark, quiet in the daylight, a parlor for spilling sea stories and alter egos after dark.  This particular morning the clean up was underway. The doors were open, the interior was dark, and a small black and white ball of fluff was launched out the door onto my traveling sneakers. A meow erupted. A scant piece of fur had vocal cords and a preference for kinder foregivings. I abruptly stopped, scooped and back tracked. To this day I have an impossible time seeing cruelty unfold in front of me. I cradled that kitten like he was Faberge glass. I pleaded for the only home he had ever known to consider offering him a short reprieve. Seems he had made a friend or two there. A hand out as his affirmation of acceptance. And the management wouldn't have freeloaders. 

My life at this time was four months aboard the Mariner and four months in Blacksburg awaiting a slot to open in vet school, or a call back to sea.

I had a decision to make. I could leave this tuxedo on the streets on Fort Avenue, a busy raucous place, or, I could find him a happier ending than his head smashed under a tire, or by some angered bar keep. There was a local shelter. I knew it well. It was a place I had volunteered at for years. The current daily kill numbers were above 70. This kitten had three days to find his owner or he was sent to the freezer to be picked up and disposed of as land fill. 

These are the moments that make the WOman. 

This one moment was where I had to decide who I really was and how I was going to answer harder questions down the road.

I don't remember how I secured that kitten into my running clothes and made it the mile back to the ship, but I did.

I kept him in my room for the two months it took to get my discharge papers,, until the last day aboard. I was called to Capt Kelly's office and had my ass handed to me. He was so angry at me, and looking back for very good reason. I headed home with my kitten, who by then I had named Boots, and left for vet school 6 years later.

There are always sides to pick. That day I chose his. I chose to be kind over being right. 

In the many years that have passed between my first day with Socks and my last case at my veterinary clinic just the other day, it has occurred to me that there is a degree of courage that being a vet for the patients requires. 

Vet Pearls. The Advice I Would Give To A New Veterinarian. 2022 edition

I have been keeping a list of "veterinary pearls" since the day I started practicing veterinary medicine. It is intended to be the list of tips and tricks I have learned, (some the hard way), to help you become the best veterinarian to all of your patients, and to maybe avoid some of the missteps I have made. 

I start every exam with a hello (to my patient first, of course).

Here is my partial* list of veterinary medicine pearls that I have learned over the last 18 years of practice. (*Note; I come up with new ones every day, so we are going to keep this list alive for the next new grad, or, the next bovine/equine practitioner we hire,,, or, just for laughs when we are 95 and in our rockers waiting for the next Jell-O delivery from the house staff)… 

I want to start with a moment about thinking of who you are. Who are you as a pet parent, a pet care advocate, and a veterinarian. Hold on tight to that person. You will be challenged and tested and ultimately your ability to care for others depends largely on your ability to understand who you are and stay true to her. It takes courage and bravery to be a great veterinarian (and human). If you know who you are it is easier to defend her to your inner voices on the hardest days. Stand up for your patient and yourself among the dark days that medicine invariably delivers.

Seraphina. One of my WHY's

The best practitioners take pause, think about our goals, and then use all of the tools in their vet med tool box (thorough exam, look, listen, smell, feel), and then; 

Remember to always listen first. (full transparency,, I have not mastered this one so I place it at the top). 

With a clear head  (try to) never formulate an opinion until after you listen to everything. Keep an open mind and open plan, as you listen carefully. many clues lie here. Jot down a list of things to keep in mind,, then do your exam,, then narrow and focus the list.

My puppies,, reminding me to play

 Alive in “worst case scenario-ville” "WCS". There are times where this is what the world gives you. If you are prepared for this, and if your client understands this as a possibility, they won’t be blindsided… But, be careful, some people use this as an excuse to apply the brakes too early and bail. Worst case scenario lifestyle. Vet med, any med, is about this. (Human medicine does an absolute shit job of this. They could learn a whole lot from this side of medicine if they just talked to people openly and honestly. No dialogue, no direction given to patients and a whole bunch of specialty focused volleying for ridiculous amounts of time). Here we talk to people, treat them like family, and help guide through the quick/easy and long/tragic waters of pet care and veterinary medicine. 

help clients understand your thought process and concerns/fears. Medicine is about mediating a patients needs and constructively manipulating a clients wants. It is an art. It is the stuff we are left with as the challenge we seek when the medicine gets boring, (which on some days does happen). 

·       always be accessible. Our JVC email is on every report card. For some patients I give my business email for better accessibility and a more timely follow up.

·       always document a plan, and provide best and worst case scenario framework. Everything in writing. People get overwhelmed and confused, and too often our words, and brains aren't the same as theirs.

·    Report cards are part CYA, part summarize exam, (list presenting concerns, what we are doing about them, what we are doing today, what we will do tomorrow if needed, and what their responsibility is (i.e. recheck, drop off samples, follow up, “if not better by ___, then we ____ ) and 100% documentation to deliver intentions, investment in care, and accountability. I also list the items they declined as a reminder of where we chose to go, and where I am going to recommend we go back to if needed. 

Keep everything you do as a practitioner relatable to the rest who are not.

·       Always close a report card with a personal note. For example;  “Thank you for bringing Fluffy in to see us today.” Or, “have a wonderful Summer, we are here if you need us.” Makes all the difference in the world. We always send home a report card. People can’t listen and comprehend everything they hear from us, and most of them do want to be excellent stewards of their kids needs. Gentle reminders, highlights of exam findings, and written plans (most especially for the late Friday appointments with the (likely feared) critical cases save lives, and help people who are emotionally over taxed.

·       Utilize and use the techs to help guide you. Ask their opinion, provide feedback, and help them to learn. They are as eager to learn something new as we are. The techs are your lifeline and your liability. Always hope for one and prepare for the latter. Never, I don’t care what the scenario is, use the excuse “the tech told me to” the state board fries your ass, not theirs.

Oliver.. A great reminder as to why I care so much

·       Every euthanasia is the most important moment of your day. Take the time it needs. Provide the guidance the client needs. Tell them your plan. Ask them their preference. Be gentle. Discuss the difficult cases before you have one. Don’t make it easier for you, make it easier for them. My personal opinion and protocol differs from others. Ask why? Ask yourself which you would prefer? Tell the receptionists to light the candle at front desk. Tell the other appointments waiting for you that you are taking your time to say goodbye. They will understand.

·       Understand your threshold. For me this is reminding clients that I am doing the best I can and dealing with a huge array of cases, including euthanasia’s. If they are being vocal, impatient and demanding I talk to them in person. I remind the complaining/impatient clients that the other case I am taking care of might be the most difficult moment a person ever has to face. Be patient and compassionate and ask them to do the same. They will empathize. If that doesn’t quiet them down tell them they are being referred to the ER so they don't have to wait for you any longer. We are about compassion first. Every single time. And I also usually remind them that at some time they will be in that persons shoes and I am an elephant I never forget. Your threshold exists on many levels; skill, expertise, ability, and emotional. 

Do not ever allow anyone to influence the emotional well-being of our staff. Bad clients exist and they are excised,, like cancer, its curative. People can be emotional and have a bad day but they cannot, and will not cost us a staff member. I am very firm, and completely unafraid to get rid of toxic people. It is one of the most overlooked and vitally needed pieces in our profession. How many vet care members work with leaders incapable of controversy, confrontation and allow others to suffer from caustic interactions and behaviors (internal or external) as the price tag. Think about why the suicide rate is what it is and what your part in protecting the peace is?

My rabies quarantine kittens; Raffles and Birdie.
They remind me that the most rational, and expected decisions can bear the heaviest price tags.

Know who you are and what you are capable of. While I firmly believe that all of us are here to help, and we cannot be afraid to practice outside of our "comfort" box for the benefit of our patients and their parents, your soul is yours. Take a soul that you still like to your grave.. 

The courage to speak out when needed, and the compassion to put your patient first. 

·       Surgery; you will develop your own preferences and habits. Every choice has a consequence. Here are my mandatory requirements;

1.     Every patient gets a full exam and a full review of the medical record. Read the previous medical record notes. Look for reasons to not do the surgery. You will need these for some cases. It is not uncommon to have to call an owner the day of surgery to discuss a new PE finding, ex heart murmur, increase in estimate, overbooking, emergency needs to bump an elective, etc. The patient comes first. I would rather apologize and postpone vs call after bc the surgery went sideways.

2.       every patient gets a planned course for surgery. If you need to change the plan call the owner to discuss. For example, I overwhelmingly request an iv catheter for each potentially difficult spay. I also use propoflo when needed. This is charged to the client and might double their bill. I explain why and get authorization before eating the charge which I will do, and allow all the vets to do if it helps your peace of mind and provides a better chance at a safer surgery.

3.       intubate whenever needed. (for me this is everything, except maybe, the cats who are so fractious you worry about a safe recovery).

4.       gown and glove for anything extensive or in a cavity.

5.       cap and mask at all times general anesthesia is on. Techs included.

6.       formulate an exit plan before you grab the scalpel. Dont worry about how to make it look pretty after you have a hole and no skin left to close. Closure is the devil to margins,, a patient with a rough post op recovery will negate all the work you did.

7.       expect your mass before you schedule a mass removal. I run by the ethos that if you are asking me to do it you owe me the right to see what you are signing me up for. with that go to number 12.

8.      dentals are like pandoras box. if you aren’t ready for the booby prize don’t open the box. every dachshund dental sucks.. every single one. even the ones who are 2 years old. Know how to do an oral-nasal fistula repair (two ways) before you find a dachshund on the table and blood dripping from the nose.

9.       PDS is $$$$ know when to use it and when its too $$$ to use. Suture choice reflects ability. 

10.      Every surgery is documented with all relevant and needed details. We have a surgery form to help.

11. post op care matters at the time of surgery. I rarely use staples. and I rarely have pets come back for suture removal. think about why. .

12. my favorite surgeries are the ones no one else wants to do and no other option exists. think blocked cat, foreign body, mass no one else wants to do. the life saving knife changing magic and miracles only happen if you try surgeries. Have I told you about Spencer, or Mufasa, or Maddie? 

•         every ADR old/older dog has cancer. palpate palpate palpate,, then xray... blood work gives you less clues than the PE does. Do it last.

Saffie,, rehomed 3 times for inappropriate urination.
She had needs no one cared enough about to help resolve.
Another great example of my WHY.

Who's hands belong where? I do not want anyone pulling medications off the shelf expect a vet. Mistakes happen. Have someone double check every drug, and label. we are going to start labeling our prescription areas with general doses to help avoid this. Further, I try very hard to run the fine line between encouraging people outside of their normal duties to learn and grow, but, I cannot put them in a place where they cannot manage the WCS consequences. think about a jugular on a cat that causes a tear in the trachea.

Cystos are a big worry for me. Never do a cystocentesis on a pet with a possible neoplasia of the bladder "seed the abdomen". What are other tasks beyond the techs ability to foresee disaster?

cremations. Have we ever talked about the catastrophe of mislabeling a deceased pet?

Hope,, and her pre-Christmas counter surf.

•         Rectals are part of a routine exam. You will learn this when the pet you saw 3 months ago presents for pu/pd and then you find hypercalcemia, and then you rectal. I see too many AG abscesses after the pet has been here for an APE within the last month. How do we explain that to an owner?

•         Never refer until you have done bw, rads, rectal, and offered u/s. do everything we can do here before you send.

•         Know what you are sending a client into before you refer. i.e. neuro ivdd, cost is about $10-15k. If they are not prepared to spend this, and do sx I am not sure what value sending them has? But,,

•         We always offer and document the benefits of referrals to specialists.

Rosie, first visit, first vaccine,, and a not so subtle reminder of the harm we can do,
even with the best of intentions and training.

•         call people often.. after every sick patient visit, after surgery, and when you think they might benefit from hearing your voice. I am not the most talented diagnostician that ever got a DVM degree, but damn I am invested in my patient and clients care. I go to bat for them. I make hard phone calls. I demand help for them when they need it (and can pay for it), and I am very comfortable not being liked by my peers. I am not here for them.. I remind them of that when they challenge me. (Have we ever talked about my license threats?).

•         Know the cases that take extra TLC/emotional and physical burdens from clients. Like IVDD, MG, ME, DM, etc. these cases stay alive only if their parents can manage them, and because we hold their hands for the first two weeks (or as long as needed) of adjusting to the new life of a special needs pet. We are the clinic that takes care of our patients even after they pay and leave the clinic. 

Reminder; not all pet parents are created equally. I have some clients who cannot read, or write, or have language barriers, or physical limitations, or families that put pressure on them to dispose of the pet,, there are so many conversations outside of medicine that go on in exam rooms. (Have you realized that we are part vet and part phycologist/emotional support advocates).

•         No cosmetic surgeries here.. no excuses,,, no pressure from owners. If you are not sure why ask me.. I am happy to discuss. (small exception; the polydactyls who live outside and cannot retract their multiple stacked dewclaws. These eventually grow into the foot pad,, they should be removed at spay and neuter).

•         hard work is our credo, heart-felt-compassion is our purpose in practice.

•         Give estimates to everyone. Document it on their go home report card and on the alert or appt        schedule. If the client seems uncomfortable about it discuss why and itemize. If it comes down to  inability to pay we will find them help. We have lots of options available for this. But we need to know before the fact. People feel like a failure if they cannot afford their pets care. We do all we can to provide support and guidance for pet care regardless of cost. Use the GSF if needed.

My Wren. She came to me a speck of a dying tid-bit. 
I refused to let her die. In some cases it takes medicine and a refusal to let it win.

There is an ethical obligation to being a veterinarian that I fear the profession is discarding. We owe every patient and every client the right to chose the treatment plan that is best for them. Many places offer "Gold Standard" care as the proposed "best" treatment plan. This is always the most expensive. There is no list of options given. There is one option. If it is refused a second, less costly, option is given. The amount of time, guilt, shame, and patients we lose from not putting the pets care at the clients/parents/owners choice is quite honestly unacceptable and unethical.

•         Take photos and add to MR if helpful.

•         Measure lesions, or have owner measure at home and keep track.

•         Have owners keep a journal for things like DM/BG, seizures, episodic events (v/d), litter box, cardio respiratory rates, etc. I love to give owners homework. It keeps them engaged, provides a way for them to participate in pet care, reinforces what I want them to focus on, and what clues I am asking them to search for. 

 Demos in the clinic are the best way to educate and owner and empower them to participate in their pets care. We have tech appointments for insulin admin, sq fluids, ear cleaning, nails, tooth brushing, ear hair, anal glands, etc etc. Charge techs do these. Arrange in advance and tell them what you need them to demo. No Qtips in ears! 

 Microchips are guardian angels. I scan for them at each visit and I expect every JVC patient has one. The  rare exceptions are the clients who "don't want their pet back if it gets lost?" I don't even know what to say to these people out loud.. they have a note made in the alert section.

•         The "vaccine only" clients. We have a few of these. They go home with a detailed description of why we  recommend what we do, and what they are not eligible for if their pet gets sick. Ex. KC, CIV and  boarding. Young children and HW RX. No one can decline rabies without your consent. If they do tell them you will call AC to notify. I always call AC to notify. (Its called professional CYA). Flip side, the "I dont vaccinate people" they are given a written statement that says "We reserve the right to deny services based on vaccine status." We do not board if the client declines rabies or lepto. 

•         Abuse cases. Document everything. Ask to take photos, ask to take a video. I always do this with the client present in the room. (PS ask me about the emaciated Coonhound case and the guy who went postal beating his dog at the front desk). These happen, sadly they happen in the cases you weren’t even considering this to be the case. The nurse who intentionally starved two of her dogs to death before we realized she had Munchausen by proxy?

River and Rosie,, who remind me why I love to be a small town vet.
I belong here because of these relationships. Some of the most meaningful in my life.

•         Cat vaccines and the tail. Read the AAFP guidelines. All cats get vaccines in the tail.  

We have staff meetings every other month. i am hoping that you will add a “pearl” (ideally a relevant one from a recent case) for every meeting.

•         you can always give out my email. Initially it will help build client comfort as most of them know me, don’t take anything personally.. we built a co-dependent practice the flip side is people got a little spoiled.. they (everyone) is less confident with the new kid..

•         always be humble. We are vets. We get peed on for a living.

Three view chest rads for every suspected neoplasia case. Rads for every case that your gut tells you to be worried about. Often clients need, and deserve, a quick answer to a tough, and/or expensive case.

TP always goes with PCV,, even if the techs don't want to, or, forget to do it.

Fat cat, weight loss, peripheral neuropathy, plantigrade walk, check BG first,, don't wait for that blood work to come back the next day. For the DM cats, I try to diet reverse them before start insulin. If they are not at DKA try canned DM, W/D watered down, no dry, and give them time to make their autologous insulin,,, or start at 1 unit and canned only diet. I have had a few that got off insulin for good, and lived much happier healthier lives.

Drugs.. ugh,,, the chasm of worries that these bring. Try not to give too many and overwhelm an owner, or drown out your ability to know whether the subsequent clinical signs are the patient or the meds.. and be careful for those seeking medications too often. When all else fails write a script and have the human pharmacies collect personal info. I am weary about tramadol prescriptions. No one overdoses on valium... but we have  safer options for people to not abuse. Watch the staff and the drug logs. It is a nightmare every clinic has to worry about everyday. 

when all else fails and a client is getting to a place where we cannot predict or influence the outcome pull out your cell phone and push "record" and call 911.

Take selfies.. and laugh with the results,, then share them.
Joy is as contagious as it is inspiring.

weird kittens can = rabies. We have stories to confirm. there is a fine line between helping all of the orphan kittens in HarCo and massive rabies exposure. Kittens with rabies die within 2 weeks, and usually within a few days. dont freeze a rabies suspect.

Scan for a microchip for every new pet (or every pet period). 

The Health Dept people and the Animal Control people will have your back. Lean on them whenever needed.

The use of a muzzle and removing a pet from a room need permission from the owner first.

Never argue. It's not worth your time, and it never solves anything. There is a place where we "keep them happy to keep them quiet" and, "pass the buck to someone else." Take a pause and remember your purpose. Always go back to that.

Offer a referral for everything. Its CYA and SOC. But, don't send anyone without giving them an idea of what it is going to cost them. Nothing worse than sending a referral to someone who cant do anything when they get there. (For both parties). In many cases I recommend going just to help them understand options, but they often can't afford treatment there. No surgery outside of spay/neuter, or treatment plan should be without a written offer to seek a specialist. Humans have that rackett of CYA solved.

Eating charges for having peace of mind. I would much rather have you be comfortable in your plan than saving a client money. If you need a diagnostic to help you sleep at night do it. We will either provide it pro bono or use the good sam to help. Answers without compensation are how we learn and live with the cases we stumble with. Rx. give the agonal cat a free radiograph to help make a suffering pet have peace.

The pets that save our lives.

 Step up for the staff anytime and every time they need it. No one ever gets bullied or intimidated. Ever.

Learn to pay attention to gut feelings and red flags. people are crazy. and crazy things happen.

One of the most important things to learn is how to protect yourself and minimize liability. What really helps is being likable, documenting everything, and knowing when to bail. A person who is unkind is never worth salvaging. Walk away. Call me, and let them go before they try to hang you.

Accidents and bad cases happen. Never lie. Always learn and be humble. you are human. The worst asset of anyone is to never admit failure and to not be honest. There are lots of vets who forget to be honest and have integrity. Admit mistakes, say sorry, and be kind. you can't expect others to do it if you can't.

Don't be afraid to jump in every single time. Be honest with your client, expect honesty back from them, and jump in.

A smile and a card save the day often. Learn to start difficult conversations with things like: "what do you think is fair?" "what do you want me to do?" "what is it going to take to make it right for you?" Write down everything. I prefer to have these exchanges via email to be able to add them to the MR without verbal interpretation or miscommunication. 

Remember yourself every day. start with a plan for work life, end with a plan for home life. they are codependent and equally important.

Don't confuse vacation with CE. They are separate entities. They require separate packing contents and medications.

Know where your loyalties lie. Never confuse the order. It will lead you into places you can't explain your way out of. For me it goes like this;  

• patients first. my passion and professional skills are centered on them.

• staff second. these people will have your back everyday. they will sacrifice for you if they believe you would do the same for them.

• client last. If they love their pet as much as we do they will understand and support your obligation to pets first.

• as with every rule their are exceptions. public health is our responsibility too.

• safety, patient, staff, client.. and always be ready for a mishap. Did I ever tell you about the time a technician got stuck with the sedation for a euthanasia, and then they called me as she was passing out? Or the time the feral cat got loose in the treatment area, hid under the xray and then attempted to be extracted by the only people in the clinic not vaccinated for rabies. Guess who was bitten? Guess what that led to?

A kiss for luck,, it can't hurt..

When I first started I had a tough time understanding the spectrum of presenting issues/diseases/severity. That took time. In general (ok I am failing to think of an exception,, wait,, cardiac,, there's one!!). I am now much better at seeing the imminently dying as such,, what the worst ear looks like vs the mildest, the dying of suffocation (did I ever tell you about the kitten on the exam table suffocating and the new vet in the back looking at a textbook for "orthopnea". I happened to be walking by the room and saw the cat on the table wide-eyed, open mouth blue and I just rushed in and took her to oxygen while we figured out the rest. (she had been hung by her collar on a stair rail.. we did an emergency tracheotomy and sent to ER,, she lived there for 2 weeks trach tube in, and a nice phone call from the sx about how to place the tube better the next time). 

Did you ever hear the story of the 54 cats we saved from the hoarding case?

Edema (peripheral) look for cardiac.. but I have had a few that turned out to be cancer way down the line. Rutin 500 mg and massage  and keep looking for the answer. Maybe old dog not moving, ie not circulating.

Lameness, the only emergency is a CF luxation.. time matters here, everything else can do rest NSAID (do SA055 for all suspected long term NSAID patients). People are much happier if you approach these in a cost sensitive manner. Offer rads and bw upfront, but set up a plan; 7-14 days rest w NSAID and then if not better rads. Small dog lux patella, mid-lg; cclr. Bilat CCLR’s look like hips. Cause significant lameness. Last note on ortho; in discussing CCLRs I have had people listen to me discuss the dx and tx plan (surgery is really the best and only way to restore best function) I have had people want immediate euthanasia. So, deliver gently. With this; be very careful with your words. Most people want their pet to be happy and healthy and not have any indication or permission to “suffer.” I never use this word unless I absolutely believe that euthanasia is the only and kind option. (remember the blue hypoxic cat). Eminently dying is one thing, guessing and recommending euthanasia is another. Tread very carefully. I honestly believe that the plague of SA vetmed is our non-chalant cavalier attitude in recommending euthanasia. Every pet deserves a diagnosis before we try to unburden ourselves from the detective work of getting this. 

Access to care and caregivers. The foundation of the community vet practices, the James Herriott model, is this. We are here through thick and thin and for both the short and the long haul. This isn’t a model of get what you can while they are here regardless of the bridges you burn. Where my fear in vet med lies isn’t in our ability to diagnose, or diagnose at any affordable price (seriously becoming an endangered species), but to retain the affection a parent has for their pet. This is where we are shooting ourselves in the foot. We are dismissing the importance of this in the longevity of this profession.

Hazel,, and her magnificent overbite.

These are from Micheal Shaer’s book, Clinical Signs in SA Medicine; they are timeless and precious;

1.     Treat for the treatable.

2.       Assumptions lead to trouble, therefore don’t assume.

3.       Always interpret clinical information within the context of the patients presentation.

4.       Avoid tunnel vision. 

5.       Treat your patient, not just its disease.

6.       Avoid overmedicating. (and be ready for these medications to change over time).

7.       Be honest with yourself. (and equally honest with your peers, pateints and clients. This is why I document everything, refer everything, and CYA in every single scenario.. its my healthy, be prepared for WCS (worst case scenario) paranoia).

8.       Don’t postpone todays urgencies until tomorrow. (i.e. exploratory, splenectomy, GDV, bloat, CF luxation, Addison's, hemoabdomen, blocked cat, humane euthanasia, analgesia in every single case!)

9.       Common things happen commonly. Look closely at your patient; they will usually tell you what is wrong. 

10.     Look closely at your patient; they will usually tell you what is wrong.

11.     Never let your patient die without the benefit of the silver bullet, (steroids). Human med does this well.

12.     When you hear hoof beats look for horses, but don't forget about the zebras.. (Addisons!, acromegaly, insulinoma, OSA vs CCLR, what about bilat CCLR vs hip dysplasia). 

13.     Never sell the basics short. (PCV/TP. BG, HR, RR, temp) so important! and go back and listen again, (pe, hx).

14.     If you don't think you won't find it. Cats are soo good at this.. every constipated cat is a bigger problem.

15.     Never let biological specimen go to waste. I.e. every sick pet gets a full cbc, chem (electrolytes and calcium are so important!) along with a fecal, urine (think ketones) and tick panel.. not knowing is negligence if you are not looking.

16.     Disaster lurks whenever a patients problem is "routine."  Ex. the patient who goes into shock after a vaccine. I have had two cats die after a neuter. 

17.     If its not getting worse, give it a chance to get better. Ex the URI kittens,, don't bombard them with abx. start with one ( I usually do clavamox drops, then doxy, then azithromycin), but, I give them a chance bn each to get better.. usually they need a little TLC, time, stability, deworm (first time you see them!) and good food.. their immune system will catch up. caveat; eyes worsening = asap meds! 

18.     Don't stray too far from the patient,, the diagnosis will eventually appear. (This is written by an IM specialist,, oh the bliss of always getting to a diagnosis! real-life tip here;; life isn't so blissfully easy in the trenches.. the patient often gets better and we often don't know what the problem/disease/diagnosis was). 

19.     Don't give your patient a disease it doesn't deserve to have. Be careful who you explain and describe your patient and their clinical clues.. ex; (for me) the "caution" dogs can be used in a court as documentation that they are "dangerous" also pit bulls as a breed. 

20.    Don't let technology make you decerebrate. Ex. Don't use amylase and lipase values to diagnose, same with T4. 

21.     The necropsy is the clinicians trial by jury. I am never afraid of the truth,, I just hope that I was kind, compassionate, and honest with all involved. We will someday leave our professional lives, it won't be without stories to tell, some we win and some we don't, but we are honest the whole way through. 

22.     The wisdom of experience should never be ignored. What we lose in mental acuity and new advances with age we gain in experience and gut to compensate. 

23.     The diagnostician should always ask themselves 2 (I say 4) questions;

1. Where am I with this patient,
2. Where am I going.
3. What does my client expect
4. What does the patient need now

24. If the patient isn't going where you expect it to be going, then go back to square one.

25. In order to successfully treat a cat, you must think like a cat. There is no anger, frustration, poor words or struggling with a cat,, (or dog). Stop, take a break, talk to the owner, try again later,, oral ketamine, oral gabapentin, kitty magic,, no one suffers here. The cat is always in charge,, we just try to convince them that they want to participate in our treatment plan

26. Avoid the pitfalls of the red herring. Labs are part of the story, the patient is the director, follow the patient, not the labs. Ex, every blocked cat has azotemia, often the worst you will ever see,,, ignore it. Same with hypercalcemia, it has to be repeated to be valid (except with Ag mass, thoracic mass, evidence of neoplasia elsewhere).

27. If they can't afford the Ivory Tower, then offer them a chance. Affordable care and access to it is every patients right.

28. Know thy patient. They are a whole package, with unique needs, and abilities,,, in my opinion it is more important to know your patient then your client,, and the best clients (parents) want for their pets then themselves.

29. Nobody wants to pay a big bill for dead animal.. while i agree in essence i do feel that it is better to accept a tragic ending with a degree of resolve that we all tried to the best of our abilities. 

30. What matters is not so much what you say to a concerned client, but how they perceive what you have said., (or "likability")

31. Diagnostic cloudiness will soon be replaced by clear skies - be patient. The difficult diagnosis patient can lead to frustration and sometimes wrong decisions. If it is not a life threatening problem, give the disorder time to unveil or refer to a specialist.

32. Better that the dying patient expire in the hospital than during the car ride home (or to the ER because you didn't see them). 

33. You must have cognition to be a competent clinician, (oh lord the number of things I can list with this one.. the utter exhaustion that makes you not competent to do that exploratory, or surgery, or even another exam,, the aging DVM who cannot perform at the level needed and needs to find another avenue within vet med, the elderly who need the techs to push the euthanasia solution)..

34. To prognose you must first be able to diagnose. Giving the wrong diagnosis will certainly cause a domino effect on all subsequent actions for your patient. Better to know why a certain action must be taken rather than to regret that it was taken. Me; Don't give a patient a death sentence you cannot back up from every single angle,,, we diagnose death sentences too often and with too much conviction. 

35. The toaster effect; Just as toast pops out when it is done, a patient will eat, bark, and be frustrated to be caged when they reach their turning point for recovery.. nothing makes my heart beam like a parvo puppy screaming for food and freedom!

36. To cut is to see; and to see is to do; to do is to cure. Get in there and try to save a life that is dying in front of you. There is great power in being a clinician if you are brave enough to jump in and try.

Never sink to the standards that make other people safe. Never surrender who you are because life hands you a challenge.

Get out alive and intact is more important than out of debt and liked.

Be vulnerable and find the strength in that.

You are never alone. We are all here for each other.. me, well, I am always here.

Be brave and know it will serve your patients in the best way they cannot ascertain without their freedom and liberty bestowed. It will serve you better than compassion. You cannot have one without the other.

Be the leader when you need to be, but always the student.

Be the ear before the professor.

Be the shoulder before the pen or the sword.

Be safe, you are your best advocate for those we are advocating to serve.

Hamilton,, let your heart decide

Analgesics accompany every patients peri-exam period and post-departure journey.

I have learned to never turn away someone without giving them something. Pain meds, nausea meds, app stimulant, my email, a resource page, a hug, a report card that says “we are here to help.” I have lost countless nights sleep over knowing a pet is FUBAR and telling them so, only to have them walk out without anything to help. Hospice, dying at home, and dying without medical interventions are all acceptable. Give them something for the sake of the pets suffering. “Tis better to die trying than to fail absently.”

Grin, smile, and jump in.
Let me tell you about Harper.

And to close I would remind you to think about your weakest link alongside your pet care goals. The one thing that you have to protect to get out alive (you and your patient). There are two to three souls in every case that need protecting, prepare to defend, fight, and even compromise the financial goals, the ideal care, and anything else you have to so that there can be an ending everyone can live with. Your weakest link might be the list of diagnostics that the owner cannot afford to do. Or, the list of diagnostics that don't leave you with anything treatable anyway. It might mean we lose the ability to run tests for the sake of saving funds to provide a treatment plan. It might be the time you don't have to sit with someone who needs reassurance that they are doing the best they can. It might mean the staff member who needs to be allowed the chance to fight for a case to help them feel a part of our cause. And in some cases it is you, losing sleep, feeling like an imposter-syndrome failure because life just isn't fair and the cutest, youngest, sweetest animals can die from horrible diseases that break your heart. Keep your heart on your sleeve and lead with conviction in the most honorable cause there is. Make magic happen with fierce determination and compassion coming first. 

...and good luck,, I am always here for you..