Dying With The Absence Of Intentions

"Two options," I usually start with telling clients that they have two options for their pets care when they come to see me. The operative word here is usually. I should have started this blog by saying "used" to. I used to say that there were two options when at the clinic. And here's why I now need to stop assuming there are only two options,,,

My pups play in the last rays of Summer sunshine and humming fields of daisies.

On Sunday I saw a client with a dog who looked like she had already passed away. A lifeless mass of fur laying without any sign of life. Her name was Lily, she was emaciated, laying on a blanket on the floor and not responding to anything happening around her. She appeared as a dirty, dusty, weathered coat of dull black poorly draped over a boney protruding skeleton of what a dog used to be. She could barely lift her head. She was so weak, sad, and weary looking that I assumed if she wasn't already gone she was surely here to be put to sleep. Where I had not previously realized that there are more than two options when at the vet clinic, I have learned that you shouldn't ever assume a pet parent sees their pet with the same veterinary trained scrutiny and collective experience to guide your prognostic indicator as I possess. So many people are so deeply emotionally embedded in their pets lives that they can't see their pets suffering, death, or the looming vultures of either at the cost of breaking their own hearts to say goodbye. There are times where I have to explain this in painstaking, emotionally devastating detail. On this particular Sunday I had two dogs who had arrived at the exact same time, and looked to be in the same predicament. Both were old big black dogs who couldn't stand, react, or show much of any signs of existence. They were dying, and they had been here in this pitiful state for quite some time. I also had about 20 other patients waiting to be seen. It was a Sunday. We are open for walk-in appointments for 2 hours, 1-3 pm. It was a bright idea (or so I had thought) about 15 years ago, or, as we all measure time now, before COVID changed vetmed into a war zone. Since COVID my Sundays have become the "open-to-all-neighborhood-ER." It's insane. Every single Sunday. It has gotten to the point where almost all of the people I see are non-clients, and all of the say the same thing; "I've been waiting for the ER to call me back to say my turn is up in another 12-24 plus hours." If these dogs have looked like this for over a day (and let's be honest I know they have) then the face of vetmed is no longer wearing a compassionate white coat. 

Our clinic vagabond, Saffie. Mostly trouble, occasionally demanding attention,
and almost always sleeping on the job,

The two women who sat behind Lily as she was slipping into her coma were sisters. Lily had been diagnosed as a diabetic over a year ago. The medical record was a list of missed appointments, phone calls left without follow throughs, and proposed diagnostics that hadn't been done to manage her disease adequately. Diabetes is a disease that leaches persistently. It can be managed with a huge amount of effort on both the clients and vets parts, but, it is a slippery, encumbering beast. Even people do a miserable job of managing their own diabetes and they have endless easy wearable tools to help monitor and guide them. Dogs get diabetes from eating crappy food and being too sedentary. It is incredibly difficult to convince a diabetic junk food addict couch potato to eat better and exercise. Old dogs/new tricks, the analogy is applicable. The two sisters loved Lily, it was obvious from the beginning. They never looked away from her as I spoke to the tops of the backs of their heads as they bowed over her stroking the dry brittle coat. (To this day I am not sure what their faces look like?). I could hear them sobbing. The assumption that Lily was here to die was so pervasive that the front staff had immediately placed the party of three in our comfort room, (our less veterinary medicine looking room that has real furniture in it). It also has its own entry and exit and a long bench for multiple family members to congregate.  There are two crystal light fixtures and multiple boxes of tissues. 

Hamilton

Lily didn't move as we carried her from the comfort room into the treatment area. She had lost over 20 pounds since her last visit which was many months ago.  Her breath smelled like nail polish, her eyes were not registering our movements, the foreignness of this place, or the sounds that made it so obviously worrisome to the other patients. She just lay on the stainless steel exam table absently.  I stroked her head and whispered into her ear that she would be "ok." While she is my patient and I have work to do on her, samples to collect and observations to assess her condition, she is also a heartbreaking site to see and a dying girl to protect. In this moment, in the place where patients are away from their families, on a stainless steel table, weak, and dying she is all I am here for. All I have ever strived to be, become, and exist as. At this moment she is one and all. The singular soul that mine is devoted to. It is at these times that I wish our hospital was like those old episodes of ER. The scenes where a caring, kind nurse stands over the patient clasping their hands and telling them calmly that they "will be alright." Why can't I have someone who tells my dying patients that? Someone to just be the angel and not the judge, jury and executioner too? 

In the treatment area we quickly discover what I had already presumed; Lily is massively dehydrated and her brain and body are being intoxicated with polluted ketones, which will slip her into a complete coma and kill her imminently. She needs immediate and aggressive help. She needs a highly trained veterinary emergency facility that can treat her for a minimum of 3-4 days, and even with that her prognosis is abysmal. She is too far gone and too sick. I tell her moms this. I do what I very rarely ever do, I tell them they should alleviate her suffering and say goodbye. They tell me that they have no money to do anything past $500. Lilly needs about $10,000 of care. I try to ease their grief and pain by saying that even with this it is vey unlikely she can survive this with much quality of life. They tell me that a transfer to the ER is impossible because of the cost. I leave the room so they can spend some time with Lilly and process what I have said. I move on to the other 19 cases waiting for me.

The war room,, aka treatment area.

I came back some time later to a very quiet room. 

Lily's moms weren't able, or ready, to say goodbye. So we did what we could for her. We gave Lilly all of the quick patch band-aids that I could. I dumped a massive amount of fluids under her skin, gave her an antibiotic, anti-emetic, and an injection for pain. I essentially given her all of the options I had without being able to hospitalize her. I had given them instructions to continue her insulin and they had agreed to bring her back first thing the next morning for more care. 

Lily, her moms and the mass of 19 other cases came, and went, (both black dogs went home). Although I leave the clinic for the evenings at home, it never leaves me. I carry it, the weight of every patient, their plight, and the families who love them with me. I dream about them. I wake up with surges of adrenaline coursing through me. I head to work each day ready to slay a dragon that medicine is and fate wins at. I prepare for battle everyday knowing I buy time, never destiny.

Vela. Our latest rescue effort. 
Her story to follow soon.

Lilly did not show up the next morning so I called to check on her. I had expected that they would tell me that she had passed away over night. Instead they told me that she was up, eating and walking, and therefore they wanted her to stay at home. I was so relieved to hear this, and yet, worried for what today, tonight and tomorrow would bring. I begged them to bring her back to us to run some blood work, give her another round of the medications we had done the day before. I reminded them that these had helped, and without them she would be back where she was 18 hours prior. They said that they wanted her to pass at home. They didn't want anymore medical interventions. It seemed that they were very upset that I had helped her the day before and that they no longer wanted interference. 

So here I am at option number three; People show up for care at your vet clinic, but, they don't want your help. Since when was this an option? Why did they drive over to the hospital, check in at reception, wait in a room, wait for me to explain her condition, agree to all of the treatments we gave her, and then get angry about it all 24 hours later?

I was dumbfounded on the phone. I could hear the anger in their voices, the betrayal that they felt I had provided them all. I paused. That long pregnant, my brain can't quite process this, pause. I offered them financial assistance to get Lilly some much needed medical care. I got back more anger. We were both doubling down and Lily was going to lose another round.

While I understand passing at home, hospice care, and the deep swath of divide we all feel about the act of dying, I also feel compelled to speak on behalf of the patients I have who cannot. In some cases I have to remind myself that I am bound to picking sides. I have to chose humans over my patients if there is a viable fear that the patient might impact the humans life.. (think rabies, aggression, etc). Then there are the cases I can't discern neglect and cruelty within. Do I honestly feel that Lilly is suffering? Yes, 100%. Do I feel her moms can care for her? No, even though they love her so much. Does the degree of love supersede the obligation to put our pets well-being above our own? Can passing at home without any kind of pain management ever be peaceful? Fair? kind? I don't know? I didn't know for Lilly. I told her moms that. 

I do think that a key part of my job, and everyday,
is kissing every dog and cat I come across.

They hung up on me. And then they went public and called me some really hurtful names. 

Maybe its me who needs that nurse holding my hand?

P.S. I have changed names and details.,, I feel that I have to, this is a diary on display. 

Affordable Options Are Everyone's Right.

Heather
Harford County Humane Society surrender

For a huge part of the pet owning population the ability to find affordable care for many aspects of their pets health is unattainable. Many cannot afford to make good routine nutritional choices, attain routine veterinary care, provide little to no vaccines or preventatives, and even more cannot begin to find affordable options for complex disease(s) or emergency care. The size of the chasm of need increases significantly for people as the small choices for basic care grow into more complicated health concerns.

The reality of the intensive side of veterinary pet care, and by that I mean; emergencies, life threatening disease or conditions, or pet care that requires specialists, referrals or hospitalization, is that if you have deep pockets you can, and will, get state of the art unimaginable high quality specialized care. The state of veterinary medicine is at the point where amazing things are possible when clients have access to immediate funds.

In the real-world of this small animal general practitioner there are too many cases where the degree of assistance and the altering of prognosis with the likelihood of cure is directly proportional to the power to pay immediately.

Let me explain. Many difficult cases require more than one vet visit and more information than our eyes, ears and nose can identify at the initial visit. Running tests and making repeat visits to the vets office are needed to find the critical clues that help lead to the answers your pet needs to provide optimal care and prognosis. These can be expensive. As the wallet shrinks these key critical pieces for a best case outcome scenario fade.

In some cases I cannot even get close to a diagnosis. Without at least $500 I often can't get a narrowed down list of possible rule-outs to allow focused effective meaningful care. Seasoned trained well established vets dole out a boat load of convincing "educated guesses" when we are presented with pets who need answers and pet parents who don't or can't pursue diagnostics. It is sad and true that huge numbers of fates are decided on "guesses" educated or otherwise.

Even in the few cases that I can almost 100% definitively diagnose for less than $100 or $200 dollars, let's say for example DKA, fractures, blocked cat, obstructions, pyometra, GDV,  IVDD, neuromuscular disease, toxins, cancer, behavior cases, (the list is endless), I cannot provide cheap AND prognostically favorable answers for less than $500 (plus). It is always a dance of managing expectations, resources, and open honest communication, and always, always, trying to figure out a way to keep a pet in a home and happy on all sides. It is why so many vets learn to walk away indifferent.

I believe that vets are an integral part of a pets quality of life. We are their advocate for all facets of their care. Why then is it that we shirk away from guidance when there are financial constraints? How on earth can denying affordable options help maintain our credibility and integrity? If there is a pet care problem there are ALWAYS options. There are even affordable options. Perhaps they are not attainable under our roof but shouldn't we be obligated to provide them regardless? Is withholding affordable options a part of who we want to be? My clinic provides clients in need with resources of low cost spay/neuter clinics, vaccine clinics, surgical facilities and trainers, even though  we provide all of these services under our roof. Why do we do this? Because ultimately our patients shouldn't have to pay for our inabilities (vet AND parent included).

Our most recent endeavor is to curb the need for shelter surrenders of our patients.

Undoubtedly there are many sides to the problem of why people surrender to shelters. There are many sides that I cannot help. Of them I cannot convince a pet parent to love their pet. I cannot build a bond between a person who doesn't want to make a place in their heart or family to care about them. I cannot convince someone to not be evicted, or not rent an apartment that won't take pets, etc. BUT, I can help in behavior and health care issues that might cause some loving pet parent to consider surrender, abandonment or economic euthanasia because the cost of care is too great.

PetFinder.com's  Top 10 Reasons for Relinquishment*

Dogs:

1. Moving (7%)
2. Landlord not allowing pet (6%)
3. Too many animals in household (4%)
4. Cost of pet maintenance (5%)
5. Owner having personal problems (4%)
6. Inadequate facilities (4%)
7. No homes available for litter mates (3%)
8. Having no time for pet (4%)
9. Pet illness(es) (4%)
10. Biting (3%)

Cats:

1. Moving (8%)
2. Landlord not allowing pet (6%)
3. Too many animals in household (11%)
4. Cost of pet maintenance (6%)
5. Owner having personal problems (4%)
6. Inadequate facilities (2%)
7. No homes available for litter mates (6%)
8. Allergies in family (8%)
9. House soiling (5%)
10. Incompatibility with other pets (2%)

Jarrettsville Veterinary Center can help with some of these. Here is what we are doing to help the pets in our community;

• Providing shelter for pets from excessive heat or cold for free. 
• Providing payment options when care is denied elsewhere. 
• Providing care when euthanasia is the only affordable options given, or, even taking surrendered pets when our clients pass away. 

We will do it. We can help and we will. Coming soon we will offer a pet food pantry and Pet Savings Plan to help our clients prepare for the rainy days every pet will at some point face.

This is our latest offer of assistance;

Dear Local Shelters/Rescues,

At Jarrettsville Veterinary Center we have a deep desire to help animals in need.  We want to be part of the solution in keeping pets out of shelters.  According to the ASPCA approximately 7.6 million animals enter shelters nationwide every year.  This number is shocking and we would like to do something to help with the problem in our community.  We are reaching out to the shelters and rescues in our area and asking for your cooperation.  When a pet is surrendered due to the owner’s inability to pay for the pet’s veterinary care we ask that you ask one additional question.  Please ask who their veterinarian is.  If Jarrettsville Veterinary Center is mentioned or listed on a vaccine history as the center where the pet received care please contact us at 410-692-6171 and ask to speak to Jennifer Taylor.  We would like to see what we can do to assist the owner and their pet.

Thank you so much for your cooperation in this matter, as a team we hope to help our patients who may find themselves in unfortunate circumstances.

Warm regards,
The staff of JVC

This is Heather. She was surrendered by her family to our local shelter. She is 3 1/2 years old and has not been treated for her diabetes diagnosed over a year ago. She was very, very sick from her neglected diabetes. Without immediate care she would have likely died within a few days. She was 113 pounds at arrival. This is almost 30 pounds more than she should be. If it weren't for the shelter staff calling us and our ability to help her she would have been euthanized. Somewhere someone failed her. This disease is avoidable and treatable. A lot could have been done for her to keep her from being surrendered. She needed to be given dietary options. Affordable, over the counter, options. She needed to be shown to how to be treated for diabetes. Affordably. She needed more than her family could provide. She is one of those pets in our community we are responsible for. We owe her more than she has been given and we will help her find her second chance at a new and healthier life.

Our goal is to offer options to help people so surrender or economic euthanasia isn't a needed option. Pawbly and Jarrettsville Vet are here for this purpose. We hope that you will join us in helping pets in your community. Education and options are often all that are needed to change and better the lives of those in our communities.

More on Heather soon.

If you would like to help a pet please join us at Jarrettsville Vet for one of our fundraisers, like Pets With Santa. Always the first Sunday in December. Or visit us on our Facebook page. You can ask me questions about your pet on Pawbly.com. It is free to use and open to anyone. I am also on Twitter @FreePetAdvice and YouTube.

Coot, our resident clinic cat, and I steal a snuggle selfie

Related Blogs;

What Are You Building? Leadership in a Compassion Based Clinic.

Medical bill madness: what if human medicine was like veterinary medicine?

Economic Euthanasia.

Veterinary Rescue Shaming and The Frank-Starling Law.

Rescue Economics. When The Expense Costs You Your Ability to Care.

Wellness Plans, Savings Plans, and Surprises.

Jarrettsville Veterinary Center Protocol for Clients with Financial Constraints.

Compassion Fatigue. When the candle you are burning at both ends consumes you.

Sunday March 11, 2012

I had the 1 to 3 shift today. I am the usual vet on Sunday's..

When we, (or rather mostly me), decided to open for walk-ins on Sunday's I got looks of "Oh My God, She Is Crazy!," and "God, she better not expect me to work on Sunday's" back from my associate vets. They wanted no part of Sunday duties.

But I decided to open anyway primarily for two reasons:

1. I knew my clients would appreciate it. I remember before I was a vet and my vet saw walk-in's on Sunday's. There were many a Sunday that I thanked the heavens above that she was available for me and my pets who always seemed to prefer to get sick on Saturday evening or Sunday morning . I never once had to go to the emergency room and a lot of that was because my pet's problem could be addressed by my own vet in a few hours, and I was lucky!

2. My husband and I needed to be at the clinic for a few hours each week. That used to mean that we made a special trip into the clinic to get "business bologna" done together either late one week night or over the weekend. Few things were more painful for me each week then going back to the clinic for another 3-4 hours after I had just left my hectic day behind. So we collectively decided that I would go into to see whatever walked in, and he could piddle around doing whatever he needed to do on Sundays. (This week his task is to try to figure out why  the toilets begin to run on their own, and try to fix the leak in the tank of one of them. Exciting!)

Some Sunday's (or every Sunday during football season when the Baltimore Ravens are playing at 1 pm) are very quiet. We use this time to catch up on cleaning and re-stocking, and each others family life. While others, like for instance today, are very very busy. On the days like today, Joe doesn't get anything done. He has no chance to get caught up on JVC stuff because I call him down to the floor to help out. He has been known to answer phone calls, book appointments, hold dogs and cats for diagnostics, take x-rays, keep clients company, and do ALL of the heavy lifting, (like the 150 pound plus dogs that need x-rays, or can't walk). He has become quite the well trained technician!

Last night was the clock change. The advancement of the clock one hour had most of us feeling like our already sleep deprived day was starting especially early because we had some people waiting for us at the door at noon.

I arrived at the clinic at 12:05. There were already two cars, (one of which had the 2 passengers inside of it sleeping, I shudder to think how long they were parked there waiting for us), out in the parking lot waiting for us to open up.

Both cars were worried clients with sick cats, who were very grateful and releived that we are here on Sunday's. (Oh, how I vividly remember that feeling).

My first appointment was with Boomer a very large, long haired, grey and white domestic long hair. He is diabetic, and thankfully a very good patient.

This is Boomers wound. His tail is lifted straight up and goes to the 1 o'clock position. His left anal sac is abscessed. It is the red circular wound. His anus is just to the right of the wound at the 2 o'clock position. We shaved all of the surrounding hair away.

He was brought in for a wound that his owners found near his rectum. Because he is a long haired cat we trimmed that hair around the wound. I always warn owners that the hair trimming is a very necessary thing because all of the hair precludes us from being able to see and treat the wound. But it also makes that wound look about a thousand times worse than it did when they walked in the door. Trying to treat a wound with hair in it is almost impossible.

Turns out after we shaved all of the surrounding hair that Boomer had an anal gland abscess. We see this much more often in dogs than cats.

For various reasons the anal sac (the correct term is sac, because it is a "sac" and not a "gland") does not empty as it should normally with each defecation. Because some of this anal sac secretion material is retained the sacs begin to over fill over time. At some point the sac(s) become(s) impacted and they begin to wear through the skin surrounding them until they rupture. Most pets with overfull sacs and/or impacted sacs will lick, scoot, or bite at the perineum (anus area). Some pets will also chase their tail, (because they are trying to reach their anus) or have difficulty or are painful when defecating. The skin around the sac can only stretch so much, after it is stretched to it's limit, the sac ruptures. And the pet now has an open wound, (but finally some relief from the pressure of the sac being full).

If we see a pet with an impacted sac we first try to medically manage the wound. Many people want to treat the impacted sac like a boil and lance it. PLEASE don't do this. A wound by your anus has a very high likelihood of becoming infected, and nobodies butt is that clean. We often use warm compresses of an antibiotic solution, oral antibiotics, and pain medicines to treat these. In most cases we can stop the impacted sac from becoming infected and rupturing.

It was too late for this for Boomer however. His left side anal sac had already ruptured. Based on the degree of tissue damage around the rupture I would say it ruptured a few days ago. His infected anal sac might have been made worse by the fact that he is a diabetic. We know in both human and animal medicine that diabetics have a weaker immune system and are more susceptible to wounds and heal much slower.

Boomer was given some SQ fluids, an injectible antibiotic because his owners weren't confident that they could pill him, and an injectable pain medication. We sent him home with a shaved butt, an antibiotic solution so they could try to give him warm compresses twice a day, and an e-collar just in case he starts to lick his wound.

Boomer being a very good boy. This is even after we shaved his sore butt, cleaned it and compressed it. He is getting some SQ fluids now. Mom and dad lend a helping hand on the right, my technician gives him his fluids on the left.

Just like your butt, your mouth is full of bacteria too. So licking wounds just adds more bacteria to an already infected infection.

I will keep you posted. He needs to be watched closely. I am concerned his butt will have an especially difficult time healing because of his diabetes.

Today I also saw;
FIV positive cat that the owner found last week after having been missing for 8 months
a sweet happy black lab with a broken toenail
a very sick cat who was unable to walk because his feet were so infected, and he was blind with both of his eyes full of blood, (great case!, but I am still not sure what is wrong with him),
a yellow lab who parents were away for their first vacation in 5 years, They just got home to find their dog not eating.
a very thin hyperthyroid cat who is vomiting
A severely jaundiced, very sick young black lab,

See how many great stories and cases I have yet to talk about this week! All of those cases in 2 hours. THAT'S WHY I LOVE SUNDAYS! You never know what is going to come in and I helped a lot of very sick pets today.

Stay tuned!