Access to Care
There are those of us who live our lives with the hope that our pets will find us worthy. We spend the majority of our time giving gestures of thanks for all that they give us. We feel humbled by how little their loyalty costs, and yet we still want to offer them more knowing it will never repay all that they give us. The relationship between ourselves and our pets, with whom we share the most painful, joyous and raucous moments of our lives, is unsurpassed. Our pets are our truest, most trusted, most faithful companions. They give us so much without asking or expecting anything in return. Most of us would chose them over any other person, even those we call a relative. This, this single sentiment, has forged many a veterinarian to face arduous years of disciplined study and turmoil. Those quiet, unseen moments with them for that one soft purr, a gentle wag, a velvet ear and wet nose, for these we would, and do, give everything.
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Jenn and Johnny Cash |
This is a story of love and the dedication/devotion that all pet parents feel when their pets life is tenuously suspended on the precipice of life meeting end of life. Veterinarians, those of us in the sweaty, grueling, chaotic trenches of day-to-day medicine life forget this. We lose sight how much we are needed. How much power we yield, and how devastating the loss of our companions can be when we fail to live and deliver the purpose our knowledge and skills provide. There is the potential loss of a life with every patient we see. We veterinarians know that. We are so used to it that for some it is an acceptable, albeit an inevitable sequela that it permits a degree of indifference some call a "healthy boundary." It allows us to practice without prejudice and without emptying our own internal well so thoroughly that we can go on to help others. What we forget is what the loss of these patients does to their family. The void of losing their unsurpassed love, and the living through the phases of grief that loss requires. But, the real pain of too many of these situations is the cold, indifferent manner that we treat those coming to us for help. This is the place that vetmed has gotten itself to. We did not come here to be this. We must never forget why we are here, and what kind of legacy we are building as we walk each footstep of our professional life.
Within the week Johnny Cash's decline he was given 5 examinations, 2 ultrasounds, 4 full lab works, 2 internal medicine teleconferences, 3 x-rays, and two radiology reviews. Every person at our very busy practice was working to help him.
When his disease eluded us, and he continued to slip away, we knew we needed more help. We did for him what we would do for every case we cannot figure out fully, we referred him to those who could. In our part of the country the most competent place we can send a patient is the University of Pennsylvania Veterinary Teaching Hospital.
The veterinary teaching hospital is the foundation of all that a veterinarian holds as the building blocks of who we are and all that we hope to be. There is no other place that holds greater power nor greater minds. These institutions employ the most notable, credible and wizard-like masters. For the greatest medical minds of our world, these 30-odd colleges represent the best of our abilities and the fringes of our most modern advancements. They built us, each one of us, and for that we are forever indebted. They also hold unparalleled optimism for the cases we cannot heal. With great power comes great responsibility. This is where we sent Johnny Cash as our last hope to help him, and Jenn.
This is the communication sent back and forth over Johnny Cash's care. The first is Jenn's letter about her concerns and experience when she brought her very sick, very fragile, very much loved Johnny Cash to UPenn. What concerned her the most, as we look back on this, was how hard she had to advocate for her dog. How hard she had to insist on being heard, and how, if she hadn't been an "insider" and hadn't had me on the phone, 3 times during her stay at the hospital, she would have paid $6,000 to $12,000 to be given his diagnosis. Within the course of 4 phone calls (1 to transfer him in, and 3 while she was there) I, me the referring vet, had to repeatedly remind them to use the skills we were all taught. Listen to the history, listen to what the patient tells you during the exam and start with a presumptive diagnosis and a minimum database for that presumptive diagnosis. JC needed 1 abdominocentesis after an ultrasound and we had our answer. He came back to his vet and we helped him from there. All of this could have, should have, been done within a short time. We were very clear on our needs, hopes, and expectations. We just weren't heard.
What strikes me as the most unacceptable part of her experience is that she wasn't treated as the instrumental part of the patient care experience she should have been. This is a teaching hospital. The safest place for anyone to be. The place where mistakes are used as the crucial crucible of molding future veterinarians. It is the place where asking questions, challenging all aspects of medicine, and putting the patient above all else should happen. It should be encouraged. Nothing is more important than preserving the bond between a pet and their family. Nothing is above being kind when faced between choosing being right over being compassionate. This is another crucible of a veterinary teaching hospital.
Jenn's letter to UPenn after her visit;Good Morning,
I am sorry for the delay, as its been only a week since I lost my beloved dog and articulating our experience in a coherent manner does not come easy.
I do want to preface this email by saying that I have utilized both Ryan Hospital (2019) and New Bolton (2021) in the past and was incredibly pleased with my experience and the care that my animals received. We were treated with respect and compassion. This experience was so outside of the norm I know from Penn. As stated in Dr Magnifico's email, she had called ahead as the referring veterinarian to the Emergency Department hoping for a second set of eyes on the case. We were asked how far away we were to which we stated about 2 hours. Records were forwarded outlining all we had done in our clinic and Johnny Cash was loaded into my car on a stretcher. I kissed his head and promised that we were trying to help him.
I arrived at UPenn on 1/23/2024 around 3: 15 pm. The stretcher was loaded onto a gurney to take him back. I gave my information at the desk and signed all consents. Our stretcher was brought out along with the blankets that he had soiled.
Around 4:20ish I met with a 4th year student to give Johnny Cash's history.
Around 6:30ish I finally met with the attending to go over her assessment, more than 3 hours after we arrived. I was told that we needed to start "at square one" with diagnostics. It was recommended that fluid be pulled off his abdomen for assessment. I was told his pulses were low. There was concern for cancer and that he would need to go to the ICU. I was told a urinary catheter would be placed. I questioned this as he was not outputting urine despite being on fluids and was told this was to keep him clean. My estimate to start was $4,000 - $6,000. I was a bit in shock as we had called ahead to see if we could send him for a second set of eyes, along with record of everything we had done in our clinic over the prior four days. I wasn't sure why we would need to start at square one. When I questioned this I was told nothing was open at this time to do any diagnostics, ultrasound, etc.
I questioned why we were told to come up, two hours away, if there was no ability to provide the services that were requested. The attending told me that she would look through the referral log to see if there was anything recorded there, which she stated there was not. I was given the option to return in the morning when we could have the necessary testing which would eliminate the cost for overnight care and likely be around$2,000 but result in a total of 8 hours of driving with a dog who was in critical condition. After a lot of back and forth we agreed to at least pull off the abdominal fluid before we left. Some time around 7:30 pm his abdomen was tapped. Around 7:43 pm we were given the news that the fluid was septic. My estimate changed from $8,000 to $10,000 to start as he would need an emergency ultrasound and surgery. I made the decision to take him home to euthanize at our clinic in the morning.
As a pet owner, and someone in the veterinary industry, I have several concerns;
- I watched as less critical pets had histories taken quickly. They quickly met with an attending and were even discharged before I had even met with the attending. If my pet were so critical an ICU was recommended shouldn't he have been assessed before the easy "in and out" cases? (Specifically a Golden Retriever with an eye injury stuck out in my mind, (although there were others). Are cases not assessed for urgency? (Maybe if mine had he would have gotten the services he needed before clinicians left for the day?). Your own website states "Patients are seen on a medical priority basis. Waiting times for clients can vary depending on the caseload at the time of presentation. All patients in life-threatening situations are immediately brought to the treatment area, where the emergency clinician performs a physical examination and provides emergency stabilization." Given our timeline this does not seem to be accurate.
- I was told that my pet could receive "better care" in the ICU than what he was receiving at home overnight. Yes, my dog was hospitalized at home overnight, under the care of someone who works in the veterinary industry and under the direct supervision of a veterinarian. These were the exact words used, and they stung.
- My dying dog was given no pain meds, even when we knew his abdomen was septic and I stated he would be euthanized in the morning at our clinic. A dying dog who was septic was discharged and given no pain meds.
- A week later Johnny Cash's records have yet to be sent to Jarrettsville Vet, I am glad no next steps were hinging on this.
- While I could have likely come up with $4,000 I was told that the $4-$6k estimate was "to start" I work in the veterinary industry because I love animals, unfortunately a love for money does not align with a life in our industry. I do not have unlimited resources. $8-10k to start was completely outside of reachable, and I fear this would be the case for many. I know most of our clients would not be able to manage this
- I have read over your Client Rights on your website, (see here), Johnny Cash and I were failed at every bullet point within those rights.
School of Veterinary Medicine
Department of Clinical Sciences & Advanced Medicine – Philadelphia
3900 Delancey Street
Philadelphia, PA 19104
July 11, 2024
Dear Dr. Magnifico,
Thank you for reaching out and for your thoughtful message. We appreciate Jarrettsville Veterinary Center's commitment to providing compassionate care to all pets, regardless of financial constraints.
At Penn Vet, we share your values and dedication to the well-being of our mutual patients. We understand the importance of ensuring that every pet receives the best possible care, especially during emergency situations. Your offer to collaborate and find solutions to avoid euthanasia due to financial difficulties is truly commendable.
We will certainly reach out to your facility if we encounter any situations where financial constraints might affect the decision-making process for a pet's care. We kindly ask that you discuss estimates with your clients and notify us of any financial concerns when referring a client to us. As we have many clinicians that rotate through our emergency service, this will be a critical step in communications to ensure that the emergency care team helping your clients understand the terms of your support and that nothing is lost in the transfer of information. Having your contact information will be incredibly helpful, and we appreciate your willingness to financially assist clients in such circumstances.
Thank you once again for your partnership and for your unwavering commitment to the health and happiness of the pets we collectively serve.
Sincerely,
PennVet -Ryan Hospital of the University of Pennsylvania
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