Rainy Days and Solitude

There is something universally consoling about the kind of rainy day that makes all the decisions for you.

The kind of rain that does not permit safe passage. Does not allow the outdoors to be anything more than a backdrop. The kind that measures the dogs bathroom needs by a stopwatch.

Today, god-granted, is one of these days.

Raffles

It is screaming rain in torrents. The house is my refuge and even unto this, my old stone manor, I am forced to check the corners, crevices, and crawl spaces for ingress. Nature, that Queen who fates us all, takes her time but always finds her way in. This house has been here for 200 years, and still her roots get washed every spring and fall. 

I am expected at the vet clinic soon. I had been trying to ignore my phone as it flashes the latest queries about my arrival time for the newly requested cases that never abate. The rain seems to insulate and buffer but it doesn't provide refrain from the rest of the pet world with their vomiting, diarrhea, and urinary blockages. Much to my dismay, and even with the fierceness of this wailing water, I can hide but I cannot evade. Biology might be the engine to nature, but Mother Nature will always be the dictator.

Magpie, Storm, Frippie

The cats have decided to nap the morning away. They take small eye opening breaks to peak out the windows, but return to their spots of sleep as the only souls around here who truly never care what day of the week it is, nor how much their parents have on their endless to-do-lists. I know how lucky they are to be here. Safe, warm, well-fed and beloved. For so many I see it has never been anything they know or can imagine. Even as I remain begrudgingly reluctant to face my impending day I am grateful for them and their care-free existence.

Nature reminds us that we are small, meek and transient. Just like the rain I will be a force today and quietly settled at home for a day off tomorrow. For now, it's time to pack up. Tell the cats that I hope they feel fiercely independent to make whatever decisions their heart desires, and to the dogs that maybe they can muster their primitive selves just long enough to remember to pee outside even if it means getting your paws wet. They seem to lack trust in me that they won't have to remain there long. I won't shut the door behind them. And, so I go out just to get battered by the rain as a small sacrifice that we are in this together.

Blocked Cats, UO, How Far Has Veterinary Medicine Fallen?

Blocked cats are my professional obsessive jam. The urinary blocked cats, this one disease which is almost always curable, (and, lets be real honest, how often can we say that in vetmed?), affects primarily young otherwise perfectly healthy cats. It is also the most egregious example of how far vetmed has distanced itself from helping the patients who need us most. In the olden days, (i.e. the days of my formative veterinary exposure, when the music was 80's pop and the hair was big), the vets that I worked for would have never-ever, ever, even contemplated turning a blocked cat away. It wouldn't have mattered whether it was 5 minutes until closing, or, if we had never seen the cat/pet parent before. Nothing would have stopped the vets of the days before the specialists, the fancy ER's, corporate ownerships and astronomically expensive off-shore vet schools from treating these cases, and doing it affordably. Vetmed was so honorable in those days that we offered help and asked for payment later. There was a foundation of trust, a pragmatic approach with integrity, and every vet knew that they had to treat or the guy down the road would. We never passed the patient by. We always had the practices credibility on the line. Every client mattered, and, therefore every pet mattered. Euthanasia was reserved for the cases that failed to get better after we had done our best to provide what our patients needed, never before. 

UO (urinary obstructed) cats are the best example I can give of how much vetmed loves money, and how horrifically we fail the most underserved and vulnerable among us. If I had one wish it would be that every single veterinarian loved this jam as much as I do. Every single veterinarian would see these patients as miracles just awaiting our healing hands and a little reconstituting from a slow iv drip. How can I help other vets see these cases this way? How can I inspire and motivate a whole profession to look deeply into the eyes of a treatable feline, remind themselves to invest all that we are, and save them all? How can I remind us to be kind, to be compassionate, to help people who desperately love their pets like family, and  save the world, just because we can?  

This is Figaro. This is his story. His life, his chance at surviving his acute urinary obstruction, and all of the accolades, frustrations, desperations, and phone calls his mom had to make to save him. This is what vetmed has become. It is also everything vetmed should be ashamed of having become. 

Figaro is a young, healthy cat who has been loved, cared for, taken care of his whole life. He has been to all of his vet visits, and his mom has done everything she was ever told to do for him. He was perfect and loved, until he was sick, very sick, and his mom rushed him back to the place she knew he belonged. The place where people would help him.

Figaro's mom noticed that he was not feeling well. He wasn't walking normally, and he wasn't eating or drinking. She called her vets office immediately and they told her to take him to the ER. Which is technically the right answer, and all too often the only answer most small, private practices, already too busy to stay on time veterinarians will give. The biggest problem with this answer is that this is too often a place that most pet parents cannot afford to utilize. Most pet parents walk into an ER expecting that the veterinarians will help them. Save the lives of the pets they adore, and be treated with hope, respect and compassion. This is what you will get if you have deep pockets. Financial stability and access to about $3,000 to $30,000. This is what vetmed is today. This is what all of the things that veterinarians, corporate ownership, and lust for profits, salaries and mental well-being cost. It just costs lives too.

Figaro's mom went to her vets office anyway. She knew them, they knew her and she wasn't comfortable being sent somewhere else. They left her in the waiting room, took her cat to the vet in the back and the vet palpated a full, hard bladder and knew he was blocked. She sent her to the ER.

This is Figaro's mom's letter about her experience. I asked her to write it because she is not alone. Figaro is one of so many that I see. Figaro's mom was just brave enough to share her side. She is a survivor, and now so is her cat. She is an advocate, a voice, and a beacon of hope that the profession will start to listen. 

Maybe if enough people start to ask themselves how their part contributes to this responsibility will will begin again to protect with compassion. We will do so because we can, and because we want to. Because this does save the world. It does pay forward, and it is what we owe those who came before us and those who will follow after us.

The ER did what they always do in these cases. They alert you to the cost of the exam. The technicians collect a history and your pet goes to the back for an exam. The exam reveals a hard, painful bladder that cannot empty. You are given an invoice with every possible diagnostic needed, every bad turn, and every worst case scenario covered. In the last decade the estimates for this have gone from $2,000 to over $8,000. 

Figaro's mom was given a $2,700 estimate.

I don't send people to the ER without warning them of the estimate that they will be given. Why? Well, because I didn't go to vet school to send my patients to a euthanasia based on economics. I didn't go to vet school to send my patients elsewhere to be denied care. I didn't go to vet school to send my cases to other places who aren't going to help them. I didn't go to vet school to have my clients feel ashamed, embarrassed, humiliated, and helpless. In some cases these otherwise young, healthy perfectly normal perfectly fine cats are euthanized as the most "compassionate way" to treat this disease. We call this economic euthanasia. In other cases the pet parents can only afford a quick unblocking and then they get sent home. This treatment option, although relieving the immediate problem, makes the next unblocking (you the ones I get asked to do a day or two later) much harder to do. 

Figaro's mom had access to $400. Her estimate at the ER was about $3,000. They, (to which I have to add that I am surprised and hopeful that this is the first crack in the facade of finding a way to provide care outside of the approved corporate income driven recipe), offered care based on the clients ability. Was it great care? No. Was it ideal care? No. It was a quick palpation to diagnose and a passing of a urinary catheter to remove the obstruction and then he was sent home. 

He was sent home without all of the care he needed. He was heavily sedated, poorly responsive and his mom had been firmly told that Figaro needed to eat a special diet, and only this diet, for the rest of his life. He was so depressed, chemically incoherent and incapable of walking, eating, or responding to her pleas to eat the food and use the litter box (therefore proving to her that he wasn't blocked again). 

Figaro's mom called her vet the next morning. They couldn't fit her in until the next day. She was so worried that he needed to be seen sooner that she started calling other vets offices. She called explained Figaro's dilemma and then added that she had no money left. She kept calling when everyone turned her away.

She called us and told us that she was worried he had reblocked. We told her to come in to see us immediately. It helped that I was at work and the staff knows that this is my jam.

Figaro was not blocked. He peed as soon as I gave his bladder a gently squeeze. He was gorked on the medications from the ER, and needed the extra time that the $2,300 would have gotten. He needed intravenous fluids, pain medication and an antibiotic. He needed the toxins that build up in the kidneys after you cannot pee to be flushed out. So that's what we did. Figaro only needed a few things from us. He didn't need a long stay, or an expensive list of invoiceable items. He was a cat who needed just a little more help, with a mom who needed help on how to take care of him. Figaro and his mom needed us to be what all of us should be. Helpful on their terms.

The next day we got a call from our local Animal Control. They wanted to confirm that Figaro had been seen by us?

Seems someone had dropped a dime on Figaro's mom for cruelty and neglect after she had failed to show up for the recheck appointment she said she would. 

Here is where Figaro's story takes its next troubling turn. What was Figaro's mom supposed to do? She knew he needed help so she reached out to the place she had always gone to. They sent her elsewhere. They sent her to a place she couldn't afford. Then they give her a discounted service that isn't enough for her cat, and then call Animal Control on her. They report her. 

If she hadn't found us it is very likely that he would have been in much worse shape the next day, or that they wouldn't have given her a way to pay? What then? Likely AC would have forced her to find a vet, or, bring him to the shelter to be euthanized. Figaro deserves better, so does his mom.

Our Office Manager called the ER to inquire about why they called Animal Control to report her. This is the reply they gave us.

I did call the ER to discuss Figaro.  I spoke with their Hospital Director.  Please see highlights below from our conversation -

 

• ER saw Figaro to unblock him
• Owner only wanted Figaro unblocked and wanted meds to go home. 
• Owner seemed untrusting of ER and did not seem to understand how critical a blocked cat can be. 
• ER discharged Figaro under the impression he would be seen at original vet office the next morning, however no Direct Transfer of Care was in place
• ER has a pamphlet that they give clients who are struggling financially.  The pamphlet includes resources and information for Vet Billing, they did try to point her in the direction of Helping Hands and let these folks know they should try to find a vet that accepts payments.  I am surmising that this may be where they get our information from, if they go to the VetBilling website and search for a vet in the area who participates they find us. 
• The following morning owner called as Figaro was not doing better, they were surprised that she was reaching out as she had told them initially he would be seen at her original vet office.  It was in that conversation that she told them that she did not have an appointment with original vet office until the following day, 8/28
• It was at this juncture that they did call AC for a wellness check - they were concerned that owner did not understand how critical Figaro was and that she had been dishonest in when he would be seen.  They were concerned he would not be seen at all.

What would you do?

What would anyone with limited resources and a pet they love who is in desperate need of help do?

How does this profession address these cases? 

How does the veterinarian, who is justly worried about Figaro, do?

It is with all of this in mind that Jarrettsville Vet has started to have these discussions.

This is the letter we are now using with clients when we can't decide what to do with a case that burdens our hearts, pulls our compassionate souls from our guts, and leaves us unable to sleep at night. 

“We care about your pet and your pets care.  We are concerned that there was not a follow up appointment after the veterinarian recommended it. Your pets condition was not stable enough to provide a dismissal of care. Please call us to arrange a recheck appointment or let us know if you found a recheck appointment elsewhere.

If you have any concerns about the cost of this care, or any future care here at Jarrettsville Veterinary Clinic please call and ask for me or one of the other managers. We will be happy to offer options for you and your pet.

We have called the numbers we had on file and sent an email to address you provided. We hope to hear from you by the end of business tomorrow. If not we will these concerns on to animal control to be in accordance with the state mandates. “

What do you think?

Here is what the ER has come up with to help cases that come to us.           

The ER is 100% on board to do this and do regularly do so with a Direct Transfer of Care.

• With a Direct Transfer of Care they will send everything in place.  They will suture in a urinary catheter, send IV, etc.  They also will not fill meds there as the client could fill cheaper at their regular vet.
• A conversation between doctors is what initiates the Direct Transfer of Care.
• In the past owners have said they were transferring to their regular vet and didn't, they had a pet return septic when a catheter had stayed in place.  Therefore they will not leave everything in place without that conversation.
• If one of our clients is in conversation with one of our doctors about transferring care it is important that our doctor reach out to the ER so the Direct Transfer of Care can be in place.

Here is the site for Maryland reporting of animal cruelty. 

So where do I go from here with my resolute disbelief of how far we have come, and how much we are enabling suffering for both our clients and our patients. Well, I suppose you will have to wait and see.