Veterinary Ethics Bio

Kisses from Cookie

I was asked to do a podcast from the Vet Ethics Committee. With that I had to add a bio. ChatGPT helped. It was an odd way to add an unknown perspective to a life I have outside of the clinic and its reach. Here's what I submitted...

Dr. Magnifico is an innovative veterinarian and passionate animal welfare advocate. She hopes to continue to build a legacy of being known for her commitment to an innovative, ethical and a patient-centered approach within veterinary medicine. She sees every animal, and their caregivers, as being worthy of compassion and is committed to preserving and maintaining the bonds we have with the pets we call family. She is currently specializing in the management and treatment of FUO/blocked cats by utilizing a minimum database, managing costs with outcome and budget as the starting point, and never giving up regardless of the obstacles presented. In essence she practices the way her patients need her to; the old fashioned way when integrity, loyalty and trust were all paramount to longevity and viability.

As the owner of Jarrettsville Veterinary Center, Pawbly.com, founder of the Pet Good Samaritan Fund (a 501c3) and Not One More Pet, Dr. Magnifico operates with a strong ethical foundation, prioritizing compassionate care and client education. A key area of focus is finding solutions to economic euthanasia, where financial barriers often force difficult decisions for pet owners. By offering a spectrum of affordable care from the onset, Dr. Magnifico ensures that every animal, regardless of their owner’s financial situation, has access to the veterinary services they need, thereby preventing unnecessary suffering and premature decisions.

Dr. Magnifico is an advocate for fair access to care, transparency in treatment options, and informed consent in every facility, in every case. She has proven that you can do good and do well in your practice. For every act of kindness, good will, and pro bono care the return has doubled. She shares her cases, challenges, and obstacles on multiple social media outlets and has built an Army of change who support others in kind. It is possible to be ethically driven and financially successful. She has also proven that it is also possible to wear your grubby, fragile, intense heart on your sleeve and be peacefully content within your practice. It is possible to be the vet your little girl self dreamt of becoming.

With a dedication to both medical innovation and ethical integrity, Dr.  Magnifico works to shape a future where veterinary practices are accessible, sustainable, and rooted in compassion for both animals and their families. 

Thank you again for considering me and for all that you do to help others.

With gratitude,

Krista

The Ethics Of Choosing Welfare Over Profits

One.

There isn't one hour of any day that we don't discuss the financial impact of veterinary care and its influence on the pets we share our homes with. 

The strategy for balancing care and cost is to prioritize animal welfare and focus on providing the most effective, cost-efficient care possible. This may involve recommending alternative treatments or procedures that are less expensive but still effective, or working with clients to develop a treatment plan that meets their needs and budget.

I have been asked to give a talk on ethics in vermed to the SVME, or, Society of Veterinary Medical Ethics. Now maybe every veterinarian doesn't spend as much time in the veterinary mire as I do, but, every veterinarian, heck, every human is muddling through this minefield every day.

For me it comes down to who I am. Why I am here. What veterinarian did I set out to be all those years ago. The years when I was small, helpless, feeling overlooked in a world of other meek beings who were always at the mercy of someone bigger and stronger. The perspective of need was the place I dwelled. I was alone in a world that had other creatures around me in the same bucket of existence between luck and mercy. I grew up primarily on a farm. For all of the beauty and joy it held there was disease, suffering and death. I was never a child to go quietly into the night. I was, as those around me taught me to be, resourceful, resilient, and determined. Every dog, cat, sheep, horse, bird, bug and other showed me how to be at one with my surroundings yet waiting for fate to come challenge you at your most vulnerable. I learned this at a very early age. I learned value was relative. It came with a perspective that dictated fate based on the pocketbook, whim, and emotional value its own placed upon them. I also learned too early, that I had little to say in matters of care when a bill was included. When our dogs found porcupines and cried in the laundry room all night awaiting the vets office to open. When the cat got stuck in a fence but wasn't worthy enough for surgery. I never accepted that my dearest companions were any less worthy than any other being around us. I failed miserably at state fairs, thanksgiving dinners, and any other event/entertainment that allowed animals to be used for amusement or waste at our expense. I was shaped by so many instances of seeing the world differently because the animals who insulated my life brought love and I couldn't be a part of cruelty to any of their brothers or sisters. 

I was, and remain the same girl. The girl who looked so deeply into the eyes of her sheep and horses that she saw a reflection of herself within them. At least a reflection of gentle kindness she wanted to be. Those moments of companionship for comfort were my first biology, anatomy and ophthalmology lessons. I was learning as I was being cared for and to them I owe lifetime of debt.

When medicine came I knew that I was here for more than a professional reimbursement. I was here to put them, their health, happiness, and liberties above profit and gain. For as much as vetmed emulates and follows human medicine we have lost the connection that binds us so passionately to our professions purpose that we cannot be dissected from it. My mission, the seed of the soul of who I am and why I am here is so metastatically entwined with how I practice that I would walk away from medicine before I would surrender her to it. There are few cases where a humans life is endangered by my patients, these are the choices that I struggle with. The behavior cases, the rabies suspects, the ailing parents who cannot manage their pets care and cannot see that they are incapable of seeing the part their forgetfulness plays in their pets lives. These are the ethical dilemmas I call my minefield. These are the places I cannot tell if I am enabling cruelty albeit disguised as loyalty and ownership.

If human medicines primary ethical obligation is to the patient, why then can't mine be the same? Why would I put a Standard of Care above the ability to provide care? Why does money always find itself at the root of all evil?

If this profession wants to reap the benefits of following in human healthcare, all of the advancements, miracles and yes huge profits then maybe it's time to remind ourselves why our clients are willing to seek, and yes, pay for them. Maybe it's time to remember that our clients come to us because they, just like the little girl I was, and am, want to protect the being in their lives that give it peaceful acceptance and purposeful worth. Maybe it's time to gaze into our clients eyes and see a reflection of ourselves as we want to be seen.

Cookie. How I adore this girl.
Addisonian. The purpose lies within

The physician’s first professional obligation is to his patient, then to his profession. His ethical obligation to his community is the same as that of any other citizen.

The Avenues Of A Legacy

We are open from 8 am to 8 pm Mon through Thurs. On a typical day, I'll pick yesterday as an example, I see about 11 appointments in 30 minute slots and then as many emergencies as call and need to be seen. Yesterday 3 vets, all working a 12 hour shift, saw 17 emergency same day fit-ins.

At 745pm a 9 year old up to date on its annual exam and vaccines presented for an acute onset of lethargy, inactivity and inappetance. Within 1 minute of the physical exam my gut told me this dog was in trouble. It is the gut feeling that you get with experience. I spoke to the owner. I had to have a quick, frank, troubling conversation without any diagnostics to lean on.

"I am worried about your pup. We are dehydrated, the gum color is mucky, and our belly looks distended and is painful. I think you need to go to the ER." She shook her head in agreeance. 

"I just knew something wasn't right." She replied.

"Ok, I am going to go make some calls."

I called the two local ER's both are about 30 mins from the clinic. 

In the days of the ER's opening and inception the primary objective was to honor the referrals of the local general practices. We were the bread and butter of their business model. There was an understanding that if we referred it meant these cases took priority and needed to be there. The acute episodes of milder emergencies would be deferred, or wait. Last night when I called to transfer both places refused to take the case.

I called both of them the next day to try to understand.

I was given very different answers, neither I expected, from the veterinarians who are the medical directors.

The first ER told me that when they say they are full they are full. Hard stop. She did add the perfunctory exception. "We always take the euthanasia's. We don't want to make them wait." Now, it might sound like an act of basic compassion, and in some cases it is, but, it is the easiest money a veterinarian makes. If you cannot make room for patients that are trying to live but dying, versus the dying and can't afford other, then I am skeptical. Disturbed. Irritated. Do I understand the reality of over extending and over burdening an engine? Hell, yeah! There are times where I know I cannot add one more case to the day without repercussions. There are moments that I want to run screaming from the building, ripping my scrubs from my body to be thrown in the trash as some last desperate act of freedom. But, then I remember who I am and why I worked so hard to get here. And, so it remains that many of our emergency patients won't, can't, refuse to go elsewhere. 

The other provided an apology. "We always take veterinary referrals. It is our first obligation." Well, thank you. Thank you very much. I reiterated that I would only send them on after we were unable to provide care. I also promised to go over expected costs and scenarios so the pet parents wouldn't be caught off guard. There is a painful reality to being sent elsewhere with a potentially dying pet and then being given the news that you cannot afford to be here. You have no options and the vet that you knew and felt you could trust has been responsible for it.

The subject of emergency care at our general vet practice is a harried history so long that it bears context and consequence to discuss it.

Jarrettsville Vet has been around for over 80 years. A long, long, long time. Over that time we have been the place for all things animal related. We have seen the transition from farm animals as our primary patients to dogs and cats that are now provided every luxury a human has. We have grown from a clinic with 2 exam rooms renovated from a single story home, to an 8 exam room facility open 7 days a week. We have done (almost) every surgery imaginable. Open chest, transfusions, horrible accidents, wounds, and cruelty. We have worn every hat from every specialty because we had to. We can transform from a bleached, pressed, white coat to a trauma center in seconds. We are still the people of the place this has always been. A rural, humble, practice built upon longevity and honesty. 

We, the team at JVC, has learned together that there isn't much we cannot do. We are never alone in our cases and we never abandon each other. Maybe that is the marrow of a legacy that 80 years grants you? Maybe it is just the collective fabric of a group that has always understood their place, their importance, and the legacy that time and dedication grants you.

Resting

 

Resting

I don't own a comfortable chair.

...something is unsettling about becoming settled.

"no rest for the weary" meets "idle hands," and all the bad lot that follows.

I have always run along a timeline. Able to see the hourglass sands finding their way to gravities desires and not complacent in its calling my name aloud. Running so fast the destination is as obscure and fleeting as the journey. The days fly by as the clock with its unyielding and unforgiving schedule gets fatter, fuller, and more demanding. Most days I wake up on Monday only to find it Thursday afternoon. 

While I don't have a soft inviting chair, I do have a cloudy resplendent bed. It is the only place I go to rest. The rest is, well, kinetic chaos to complete a task list that includes peaceful compassion to allow every living thing to flourish. I don't seek accomplishments only a dreamers canvas. There has to be sleep even in the obsequious near absence of relaxation.

Wally. Cats and hair ties.. 

Over the top is what best describes it. Over the top is what describes it all. Every last moment is so full I cannot ever look back with regret or remorse. I filled every day with all of it. Every intention to be as full as it could be. Ask hard questions, look for challenging answers. Never walk away from someone or something you can help with. Push so hard there is just a wall that reminds you this is the end. Doesn't everyone want their end to be simply because there was no gas left in the tank?

Maybe being a veterinarian, the profession with the highest suicide rate, the most compelling reasons for death, is exactly the place to know how fragile it all is. Maybe seeing the reflection of your own soul in the eyes of every other soul that comes to you is the best mirror. Maybe this life was meant to be so full of need that you didn't have time to ask yourself if you ever needed the bullshit that floods social media. Maybe the billionaires seeking more stuff are so lost the clutter is a way to fill a hole that just gets bigger from indifference? Maybe the secret to life is living it in all of its hardship while you make the moment last just a little longer than everyone else can by giving it all away.

Perla, pyometra

I'm not wishing for anything other than what I have. I wouldn't do a single second of it any differently. I am, however, looking for a more peaceful plod through it all. A way to be grateful, purposeful, and feel alive. I don't want to go back, do it over. Find the pieces easier the next time, but it would be appreciated to not feel so worn out by Friday. There is the key I am missing as I chase the sands through the bottle neck to settle in the shore of time.

The Insulation of Greed.

I routinely post the same content on multiple social media outlets.

For the last 15 years here's what I have noticed.

The more we become insulated as a society, community, country, (the list goes on), the harder it is to relate to others who are not in our position. I also believe that some of us choose to take from those who have less as we (believe) we all have to fight for the same pieces of wealth.

Why does such a divide exist when there is so much wealth around us? Why would we choose to take more, deny more as we continue to try to insulate ourselves from some unknown fear? We are not living in poverty. We have a home, clothes, possessions, people who love us and yet we spend so much time and effort trying to deny others the same? It is so difficult for me to understand.

I recently chose not to put up a flagpole because I am not going to be told to fly the flag for a domestic terrorist who made friends with the like, and not lower it for those who actually do deserve a military honor. I would have lowered it for Jane Goodall. A universal symbol of unity, peace, and kindness. My husband and I have both worn a uniform and sworn an oath to the constitution. We have more right to posting that big flying flag in black and white with "We the People" etched on it than all of the white men in trucks who paid to have it put there and never once took a second to contemplate protecting justice, tranquility, general welfare, but merely to defend their bunker of assault weapons that has only made school children more afraid, and likely to die from mass casualty shootings. I could go on, and on. 

Jarrettsville Vet has created this sanctuary for its people. We are a wide brush safety net for our patients and clients. When I post about the despair present in vetmed. The collateral consequences is insulation that despair happens to others. Routinely people show up at a veterinary medicine facility and cannot afford much, if any, of the treatment plans offered. 

When I do put up a post about economic euthanasia in vetmed on our JVC facebook page it gets no views. It feels like it is not relevant. It makes me wonder if I am insulating and fueling the indifference?

"Hope is about action." Jane Goodall. 

Hope is not wishful thinking. It is observing a problem, rolling up your sleeves and working hard to achieve the thing you are hoping for. I am hoping for compassion, kindness and sharing all so that we all can thrive.

To all of those I work with on a day-to-day basis in rescue you understand. Encouraging people to go to the shelter, save a life without a breeders lineage tree, (and price tag which for reasons I find mind-boggling insinuates that they are "more desirable," "less likely to have X-Y-Z problem" (which is total idiocy) is arduous and exhausting. The fact that people think they are getting a better guarantee of anything (insert hypoallergenic, no behavior issues, special, etc. with a higher price tag is ludicrous. Rescue people, vet people, know this. The idea that shelters/rescues house animals with hidden defects is also fundamental biased, prejudiced, and wrong. I had a recent equally ridiculous discussion with a person upset that they couldn't take one of the kittens we were helping "for free" and would instead have to adopt them through a local rescue for $150. I tried to remind them that $150 adoption fee is a $350 savings from the price tag of care through JVC for three cat visits, vaccines, spay/neuter, deworming. They could only see "free" which leaves me to question whether that kitten was ever going to get any care after possession. Live a day in the trenches of rescue, factory farming, puppy mills, deforestation, genocide, and let me know how safe you feel.

Here is the post I put on JVC Fb that got no traction. On a rescue page, professional outlet it received both comments, shares, and scrutiny because it is relevant and relatable.

The Recommendation

Many decades ago I was in your shoes.

I see in you exactly the same character flaws. An unwavering blind ambition so strong it can best be described as a rip current. The kind of underwater force that you don't see coming and have to give yourself into it to in fact save yourself from it. A force of nature. An untenable belief that is so powerful you bend to it so as to hopefully not be broken by it. This is what magic, miracles, and civilizations arise from. This is what medicine needs as its nidus to become its next iteration. This is what heals, compels and inspires those that follow us.

In my shoes, so many years ago as I set forth to build my own career, I called it blind ambition. It was my most valuable asset. I grafted it to my compassion and I let it take wing. To this day I am still this girl. A creator of possibilities among a sea of sharks who will never dream of being anything else. They can do them, I am sticking with me. She will carry me on journeys to far away places. She will keep me grounded when the civil war around me beckons me to dump my kindness and throw stones along with the masses. She will be the girl saving the wrens, the bees, and the poppies in the fields. She will never be alone, and she will never seek harm for personal gain. There is comfort in the little beings who need me. Whatever you want other people to know about you is reflected in your belief in yourself and how you live your life.

It is impossible for me, or anyone else, to define, defend, or promote you in any capacity that should ever matter. Life is just that way. A long road of bumps, pit stops, sunbeams breaking from clouds, and trees to find that place that you belong simply by the terms you define it to be. Never consider another opinion, or definition to where your place belongs. Never ask for a letter to remind you who you are not, nor care if they provide it. You are all you ever need to be. Just keep putting one foot in front of the other, and do good. The world will welcome you and you will find your place.

P.S. IF I can find my original letter to the vet school I will post it. I am sure I have not strayed from its gravitas, but, I hope it remains buried. I don't need to look back to remember where (or who) I want to be.

Skipping on repeat.

 It’s 1:51 pm Friday. I am getting into bed. Wearing the attempt I had at 10 am to go for a run and have a day that might include more than one item from the to do list. 

I’m going to disappoint myself yet again. 

It’s time for bed. Time to give in and admit defeat. 

I lose Friday. It is taken. Collateral damage to the price of Sunday through Thursday. The day that the lord needed to rest. The human equivalent of Monday morning disease the work horses of the early 1900s faced. When men went to work in the factories from Mon through Friday and arrived home to plow a field sat and Sunday. The consequences were horses that tied up by Monday. You have to pace yourself to avoid the painful reality that you are not the athlete you once were. 

The current anguish of my body is this. Everything is worn out. The stuffing is misplaced. The blood isn’t carrying oxygen to the eyelids. They hang like old velvet drapes of a widows cave. Too cumbersome to open. Too frail to collect the edges and fasten in place. They have given up hiding the frosted lens that only seees shadows and ombré. 

The week is a blur of still images slowed to a pause. The names, diseases and dilemmas have all bled together. I ask myself the same questions. I don’t know if I can answer truthfully to most of them hem any longer. 

Yes I did my best. 

No I didn’t abandon anyone other than myself. 

Yes I might be burnt. 

No I don’t want your advice. Maybe this isn’t the bottom. 

Yet. 

And still the world goes on around me. Inspite. Or despite. I have no intentions that I can write down and hold fast too. Just the music of a dance I taught myself long ago. I make the same motions on the same stage. Day after day. Expecting something to be different and never changing any pieces. The definition of insanity fueled by longing within the chaos. A poet or the muse? Does anyone know? Is there any point in asking? 

I’ll get dressed again tomorrow. Tie the slippers. Don the robe and smile once more in the sunshine that skips on repeat. 

Frippie

The reviews are in

There is a freedom to growing up. The kind that allows you to just stop caring about others and their opinions. Somewhere along the tripping path of life you realize that no one really is as invested in you as your worry permits. Your hair, face, body, intellect, all of the juvenile judgements that you might cast upon others just don't have to stick back on to you. 

Raffles and Birdie say hello

Veterinarians are a precarious bunch of perfectionists. We spend our whole lives making the voiceless matter. We spend countless days and nights bemoaning their fragile existence. We have only ourselves to blame, to hate, to lean upon. It is a pedestal of flower petals ready to take light in the breeze at any given moment. We exist in this place of pure emotionally driven action items. We seek comfort in a life that cannot make any decisions for themselves. We have power so crushing it dictates a suicide rate that is alarming in its own peaceful existence. There is no greater accolade than a pet parent who is made to feel good, whole, expunged and exalted in executing their power to provide a peaceful passing. Never has anyone been so grateful as when we provide a goodbye from all that we have been built and trained to avoid. Imagine that? Being beloved most at the time of your talents failings? How does one not seek warmth in indifference with these?

I have been conditioned to abandon accolades as equally as I have been castigated for advocating for the patients their parents no longer see worth within. It is a tango of twisted maneuvers you never master. While so many veterinarians now seek the avenue of at home euthanasia as a safe place to meet the professions challenges, I wish on many a day that it was not an option without a committee. That if the standard of care is to mirror and break the monopoly of advancements open to the two legged, non-furred beings then why not our own furred families? Where is the line for compassion and responsibility? These days it seems to lie firmly in the haves taking from the have-nots. Where is the morality in this?

With the open market of society comes the feedback. The reviews that the big guys can buy, bury, or expunge. The divorce of annulments that leaves whispers among parishioners as to whom was responsible?

Why does it even matter anymore? For every 1 star there are 10 other 5's. .. and yet Mr Google will send me an alert each time our name is brought up and the vote is sent. Each time I go there, in an attempt to clear an inbox, and face a judgement of some encounter with so many intangible variables it makes you pause to consider your intentions. 

If our work, our lives, our purpose and our value is representative of those rankings I take great soalce in knowing I was never going to be a 5, or an A+, or a perfect 10. What would the point be in any of them? Who wants to leave a life behind never knowing the heartbreak of a lost love? Who needs a crown when you can have a callous from tying too many sutures to save that splenectomy? Where is the bed of exhaustion if you don't sign up for that 150 pound gelatinous uterus slipping through your fingers like slime? Who among us came here for the yellow brick road and not the forest of the path less traveled?

Contentment

To all of you who know who we are, and love us in the midst of our worst days, I say a big Thank you! To the rest I hope that you fall flat on your face and just ask yourself how lucky you are to be there? We all spend time there so why not be prepared for the upside as the down makes her debut.

Here are some of the reviews I saw today;

"These folks are incredible. They saved my cats life today when I thought all hope was lost. I was an absolute mess in their office and they showed me compassion, empathy, patience and professionalism. I could not afford emergency services on a Saturday to save my cats life from a severe urinary blockage, but they squeezed me in anyway just to look him over. After believing my only option was euthanasia, and being there right when their office closed on a Saturday, they managed to pull together resources to help and the entire staff stayed late on a weekend to help my baby survive. I'm so grateful. What's even more amazing, this is not the first time they have showed me amazing compassion. During Covid, my elderly female cat died. Being the only office in the area open during lockdown, they squeezed me in then too, despite that cat not being a patient of theirs. She passed in the car on the way there, but when I arrived they took her body, checked her over, and placed her lovingly in a special box for me to bury. They didn't charge me a dime for that care. I can't say enough good things about them. I'll never take my babies anywhere else."

The reviews that matter are here

There are some 1 stars there too. 

They, most of them, came from the time I refused to euthanize a puppy. Or called Animal Control for a possible neglect case. Or, spoke out about a pup who waited days dying at home when help had been offered days before. When a client stormed the clinic, got a peace order against them and then had their whole family slam us online. There is no way to stand up for something and not have to face the crowd who doesn't like what you have to say. 

I call it integrity. But, the reality is that there are a lot of people who just get angry and become keyboard warriors behind a fake name or account. They can have their two seconds of feeling powerful and being a bully. But we all know that your dog knows who you really are. It's only that opinion that keeps me up at night.

The Self-Inflicted Damage of Economic Euthanasia

With all of the layers of dismay present in vetmed, (and life), today it might be the perfect time to start asking some very hard/challenging questions. It might be time to start questioning the accepted excuses and practices others have told us are "just part of the job."

My beloved Raffles

For me, 20 years into private practice, it is time to start asking if economic euthanasia costs us all too much? Is it even ethical? Is breaking everyones heart and denying our patients value worth what we are asked to concede for profitability?

Now I know some of you are going to start chiming in about suffering, and your God complex, but, if you want to practice medicine without the liability and responsibility ownership provides than I would ask you to be a pet parent and a consumer before being the judgemental pessimist with the ability to end a life that might be the most important part of another human beings life?

The degree of conflicting inconsistencies and our redirected aggression because of the pitted opposition between profits and compassion is crippling. We know this, we just don't admit to being able to change, or even influence it. How did we become so powerless to the forces that motivated us into this profession? How did we lose our inner purpose to meet others agendas?

Butterfly

We, ok, all of us in the small animal arena, came here to save animals. To make the lives that comfort, console and inspired the longs days, and nights, of study worthwhile. We accepted the debt, the dedication, and the sacrifices vetmed asked of us. For too many these sacrifices brought with them concessions. Maybe a contract with a boss you never really meet? A doctrine of numbers to adhere to. A whole bunch of subliminal whispers that taste like Kool-Aid and wash over your soul seeking solace.

How did we get a place where a pyometra surgery in a middle aged, mid-size dog at a big corp specialty can be $18,000 while the experts at the HVHQ clinics call it a spay with a $200 price tag? There is no way that any of us would tolerate being the pet parent/consumer on the other end of this quandary and not be pissed off when we cannot produce the 18k and weren't told the $200 option existed. I have hundreds of similar examples. Each one fiercely and furiously debated on both sides. The problem is that within each is a pet who likely was someones everything. The bigger problem is that this part of the equation is not held as the ultimate factor in deciding how to get the care that matters to the pet parent. If you think economic euthanasia is an acceptable reality in vetmed than you would be offering it before you offered a treatment estimate with a comma included. Any profession that wants to tout itself with the ability to provide organ transplants, dialysis, pacemakers, and every other medical specialty has elevated their own sense of power to a place that cannot also include death by lack of transparent, full disclosure options at the onset. (,, and where is that social worker who works only for the patient?). The dichotomy and incongruity has cost us the most important part of any medical toolkit; trust. I'm not even sure we can trust ourselves anymore to look into each patients eyes and see the power their presence brings to our own humanity.

With the passing of Jane Goodall it is even more clear. Every single life holds the power to shape everything that follows. There is no greater value than life and we are all equal in our reliance upon each other.

Nexus

I wonder how many of us really challenge the inherent inconsistencies we get asked to swallow? The foie-gras of the corporate stockholders expectations? Is it possible to wear your vulnerable heart on your sleeve everyday and still know we are a hero because of it? Do we see ourselves as the little girl facing the posturing, charging bull, head on fists squarely on our hips, chin up and mocking; "I dare you to budge." Is it possible to pay down that debt without surrendering your soul in the process?

I know it is. I know it is possible to challenge the ethics of bebarking, declawing, terminal surgeries, adoption of the lab beagles after the study is complete, and feel good about the life after the normal accepted practices are abolished and retired. Our vet clinics can still be financially secure if we don't provide the ear cropping/tail docking. We can save ourselves as we decide to "do no harm." So many of the once "acceptable" practices have fallen into the history books. Why now can't "economic euthanasia" fall away with them?

Can we all join our collective hopes together and start a wildfire of change in the current climate?

Maybe only because we haven't felt broken enough, angry enough, brave enough, or kind enough?

Cookie

Note To Self

 I sit in the morning inhaling coffee in tiny breaths. Whispering to myself as a calling. A gentle internal reminder just to see if the systems are still running. Neglecting the cylinder count as a small way to permit a flaw here or there. Collateral acceptance snuggled in permissive acceptance. I try to be understanding to the engine that reminds me it is showing its miles.

My Birdie reminding me to relax more than I let myself.

Reality blankets like an insulator. Deep, silencing, unyielding. A tight jacket that hugs back like a finger trap. The more I struggle the harder it embraces. There is no feedback that permits relenting.

..And so I sit quietly. Appearances of acquiescence. A body that ages as the soul stirs lifeblood back in. 

Found on the side of the road with head trauma, blindness, pain and fear.
Her rescuer named her Angel. She, over 5 days, has made an (almost) full recovery.
They remind me that miracles are everywhere if you will let them in.

The daily sequence of hours that exist between coffee at my kitchen table, and the cat purring on my pillow each night are fraught with too many needful souls. Furr-iously feverish with chaos sprinkled atop. It is the life I always dreamt of. The life I felt most honorable, needful, and absolute within. The place where mattering means everything. A shadow of credentials accrediting the mastering of a skill. Those three little letters, punctuated to add significance. Bold, erect, commanding, at the end of the name I was born with. They, well, they were and remain, the epitaph I got to carry my entire veterinary professional career. If you are very fortunate you get to write your own obituary early on, and build that legacy as a path you adorn with good intentions and not feel so burdened by clearing the road for anyone elses foot traffic. 

The professional degree was the bait. But, it brought with it a fear that the years of repetition, the endless one note of the same tune, might produce some degree of boredom.

Stripes, Baby Ketchup, and their girls. Reminding me to take joy in being a part of their story.
There is nothing more that I cherish than being able to see them all grow up together.

The highlights are the same. The stories repeat themselves time and time again. Some with nuances that remind me to be a constant student. Others with a pat of reassurance that practice has brought mastery, and others are a harsh, painful, albeit earned reminders that there is work left to be done. All of the repetition remains welcomed. All of the wrinkles were earned. All of what is behind, ahead and around mine for the pile in my nest. 

P.S. I just celebrated 20 years at Jarrettsville Vet. It's a milestone that I had always hoped to reach. When you find your place you can call it home.

What Every Parent Hears on the Summer Road Trip. I Gotta GO!

Plodding through a mostly piddly-wet day there are a few cases that are blog worthy to share.

It was a typical busy (but not crazy) Monday. We had our token half dozen urgent phone calls before 9 am, and I went into work with half dry hair.

Magpie reminds me that all work and no play,,,

 

There was one blocked cat to see at 9. I used to get all in a tizzy over the dreaded "blocked cat call." But I have learned that about 50% of the time it is a cystitis, or urinary tract infection and not the life-threatening half dead fully comatose cats of every vet students nightmares. For those of you out there that do not understand the gravity of having a blocked cat think of how terrible you would feel if you had to pee and were unable to. As much as this sounds like psychological torture it is made even worse for your kidneys and heart. If your bladder is unable to remove the urine the bladder will expand and expand until it either ruptures (a very very bad thing to happen, and also equally life-threatening) or your heart will eventually stop beating due to the toxic accumulation of potassium in your body.

SO, important take home message to everyone out there: If your cat seems to be visiting the litter box frequently, and/or is only able to produce a small amount of urine, or if you ever see your pet urinate and it isn't a light yellow color (really any other color is bad, not red, not pink, not orange, not brown), or if your pet is vocalizing (indicates they are in pain) in the litter box (or any other place your pet is eliminating), then go to the vet immediately! If there is any way you can bring a urine sample (ideally a free catch from the source urine sample) then bring that too.

When vets say "free catch" we are speaking about you catching a urine sample as your pet is urinating. The best sample is a mid-stream catch. I know it sounds silly, and virtually impossible but it can be done. I think it works best of someone takes the pet out on a leash

My favorite story of urinary tract infection is the year that we had our first snowfall in late October. The next two days after that fluke 12 inch snow fall I saw 6 clients who all came in telling me that "they were outside with their dog and when they peed they noticed that the snow was pink." ( I guess we need to start telling kids to not eat the yellow or pink snow?). Those pets all probably had infections for months and no one ever noticed until the snow fell.

I know it sounds gross and silly but we all really need to pay attention to what is coming out of our pets. I will ask you to describe every item that comes out of every orifice. If they vomit I need you to describe how it happened, (i.e. did their stomach contract? did it look like the food just fell out of their mouths? what did everything look like, your pet, the product?) This is all very important information. Your pet's treatment plan and long term prognosis is based to a great extent on the information you give us.

The 9 am blocked cat turned out to be a diabetic. I knew as soon as I saw the medical chart that this was probably not a blocked cat.


OK, let's review diabetes. Diabetes happens when the pancreas gets overwhelmed by trying to digest all of the sugar in the body. (This is the very very simple version). For cats we see this in obese, overweight cats being fed a dry food. It is an acquired disease. These cats show up at the clinic as having one of a  few complaints; 1. drinking excessively 2. and/or urinating inappropriately, 3. unexplained weight loss, 4. loss of vision. In all cases a diabetic cat drinks excessively and because of this urinates excessively. It is therefore, almost impossible for a diabetic cat to have a urinary blockage. they are the most flushed pets on the planet. BUT, what diabetics do get is chronic infections. The diabetes is an immunosuppressive disease. These guys are far more likely to get concurrent infections that the normal healthy adult cat. So, right off the bat I suspected we had a cat going to the litter box excessively and only producing small amounts of urine because there was a urinary tract infection.

A blood glucose test (459, waaaay high), and an un-palpable bladder, (it was too small to find), suggested my hunch was correct.

Just rescued after being hit by a car

I focus a lot on cats. They are the underdogs (pun intended) of my community and profession. People spend far less time and money on taking care of their cats than their dogs. Cats are also much better at hiding a problem, so those problems are often magnified by the time we see them.

Please follow me and please see the many other blogs I have on blocked cats, or FUO, feline urinary obstructions.

If you are passionate about cats, access to affordable veterinary care and want to help please join us at Pawbly.com and the Pet Good Samaritan Fund

Veterinary Pearls 2025 Edition

I just celebrated my 20th year in practice! Quite a milestone!

It has been speckled with so many memories, hopes, fears, obstacles, challenges, and, most importantly peaceful purpose. For everything that I ever hoped this place, and my place with in it, has cost me, (and be honest living, breathing, furious working, well, it costs you), it has paid me back twice what I put into it. I am exhausted almost all of the time, therefore with the current currency exchange, I still count myself the luckiest person ever.

There is now a calm sense of accomplishment to add to my dusty degree. Something that wraps the responsibility that weighed heavy with a hug of reassurance that it really did all work out just as it was supposed to. For me, that is what the Pearls of Practice are meant to convey. The outline of a recipe to make your magical creation, your legacy, your life's work, your own. 

I am adapting this to you, from this; it is the original version and it can be found here. 

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

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. 

The best pearl I can offer is this;

Start with a moment about thinking of who you are. Who are you as a person, pet parent, 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 YOU. It takes courage and bravery to be a great veterinarian (and human). If you know who you are it is easier to defend your inner voices of conflict on the hardest of days. Stand up for your patient and yourself among the dark days that medicine invariably delivers. You are everything your patient, your profession, and yourself ever needs you to be right here and right now. It will never be an easy job, or a painless profession, but, all the hopes, dreams, and magic all lie right here. In this place. You should be as proud today as you are 20 years from now.

Cookie. Perfection in a purpose.

Start every appointment, surgery, interaction and crappy moment with pause. Take pause and sit on the floor with the puppies. Whisper into the frightened kittens ears that you are on their side. Take a moment to think about your surgery patient. How afraid you might be in their place. Never rush a moment that you need as much as they do. Euthanasias are sacred. It is about them, and their family.

Pearls are pivots posing as a overlooked routine. To help provide context to them let's start at perspectives. The 20 years of time and the macroscopic viewpoint it provides.

I have to start here. I have to start at the end. What life really needs to teach you is to start at the end. Make all of your small moves and tiny steps as a direction that started at the destination. Medicine should always start there. Every piece of advice, kindness, spirit and thought starts at the end. 

Hope for the best, prepare for the worst.

The ending for all of us is a goodbye. There are so many clients whose lives become arrested at goodbye. This one act, the one that vetmed allows as a true end to suffering that human beings cannot put themselves above, is a curse as much as it is a blessing. There is a time in my career where I am going to walk away from euthanasia. There are cases today I have to say no to. People hate you for the no's. They want you to make them feel good about the goodbye, when often it is hard to do when your allegiances lies with your patients who deserved a chance. A diagnosis. An analgesic. Another pet parent. (A string of pearls for another day).

Never euthanize a patient because it is;

•  Closing time.
•  Cheaper. Economic euthanasia is a business practice for practices focused on billing not building (borrowed from a colleague). Nothing costs you more than selling your patients short. 
•  Easier than a work up.
•  What the client thinks is the best treatment option and you feel uncomfortable with it. Looking back these were the times I wished I had become a nail salon technician, or florist. Truly, nothing has cost my soul more than feeling like I was abandoning my patient for the sake of the (non-existent) relationship with my client. There are days I wish euthanasia was no longer a "treatment" option. There are days that I know I love my patients more than their families do. This is what I love most about myself. This is who I am, and I never abandon her. Being the most liked vet doesn't amount to squat if you don't like yourself.  See more on this with Honeys Story here.

Seraphina. One of my WHY's

Live 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 and vet med, (or 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, like the people who we will also be helping 10-20-30 plus years down the road. It took me awhile to realize this, that these new faces were faces who others before me knew, and cared for as they help guide through the quick/easy and long/tragic waters of pet care and veterinary medicine. 

Here is my advice for all of the middle parts of this life.

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

 A

      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 thoughts 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. 

I    It's ok to not know. It is ok to say that. How often do vets and their big britches say "cancer" and condemn a patient to a death sentence minus the shadow of diagnostics. 'Tis better to be honest than the lynchman wearing the crown. 

      Keep everything you do as a practitioner relatable to the rest who are not. Big words, big diseases, and the lofty pretense of knowing better than your client who "has done their own research."

·       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 you, not them.

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.

          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. Don't 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 phycologists/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 don't 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” 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. A client who wants too many refills, or pills, or is a new client with a drug addicted pet is a red flag. 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. Don't freeze a rabies suspect. CYA if an owner refuses to submit for rabies. Tis better to lose a client because they don't like then then because they died after taking their rabies pets home. (We have a lot of rabies,, did I ever tell you about the TNR cat?).

Scan for a microchip for every new pet, or every pet period. We provide them at cost and I tell people "I hope you never need this, but, things happen. House fire, house is broken into, car accident with pets onboard, kids forget to close the doors, cats break screen windows, fireworks."

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. In some cases I send them to be given the bad news I am not sure of. No surgery outside of spay/neuter, or treatment plan should be without a written offer to seek a specialist, but, all of them should include some sentence about coming back to us if they cannot get help elsewhere. 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. Apologize when warranted, 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 there 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. It takes time to know 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..